Thesis (PhD (Microbiological Pathology) --University of Limpopo (Medunsa Campus), 2010 / Background: Azoles and polyenes are antifungal agents used for treatment and/or prophylaxis of C. albicans infections, and a high increase in antifungal resistance in clinical isolates of C. albicans in HIV/AIDS patients has been reported. Five genetic clades were described among C. albicans isolates using DNA fingerprinting methods (clades I, II, III, SA and NG). Although these clades have been described, little is known about their phenotypic characteristics, and not much is known about antifungal resistance with regard to each of these clades. The widespread use of fluconazole has led to its increased resistance reported world-wide. Resistance to fluconazole can be caused by point mutations in the ERG11 gene or overexpression of this gene, however, not much is known about the contribution of these mutations and over-expression to fluconazole resistance among different clades of C. albicans, and whether mutations or over-expression are clade-related. There is evidence to suggest that phenotypic switching may play a significant role in the ability of Candida strains to survive under adverse conditions and perhaps cause more severe forms of disease in the immunocompromised host (Vargas et al., 2004). Only limited studies on the relationship between phenotypic switching and fluconazole resistance of C. albicans have been done, and not much is known about this relationship among different clades of C. albicans. Objectives: This study undertook to investigate: (1) the induction of antifungal resistance among South African C. albicans isolates belonging to different clades, (2) the contributions of mutations in the ERG11 gene to fluconazole resistance among C. albicans isolates belonging to different clades, (3) the contributions of over-expression of ERG11 gene to fluconazole resistance among C. albicans isolates belonging to different clades, (4) and the relationship between fluconazole resistance and phenotypic switching among C. albicans isolates belonging to different clades. Study populations and Methods: To investigate the induction of antifungal resistance among South African C. albicans isolates belonging to different clades, a total of 100 C. albicans isolates (20 from each of clades I, II, III, SA and NG) were used. These yeast isolates were obtained from surveillance cultures on patients attending HIV/AIDS clinics in the Pretoria region. Resistance to fluconazole, miconazole, amphotericin B and nystatin was induced in all 100 isolates according to the modified National Committee of Clinical vi Laboratory Standards (NCCLS) broth microdilution method. Survival and retention of resistance among fluconazole resistant (n=100), miconazole resistant (n=100), amphotericin B resistant (n=100) and nystatin resistant (n==100) isolates after two years of storage at -80oC was determined in the presence of highest concentrations of each antifungal. To investigate the contributions of mutations in the ERG11 gene to fluconazole resistance among C. albicans isolates belonging to different clades, 30 isolates were used. These consisted of 3 isolates with induced fluconazole resistance and their 3 matching fluconazole susceptible isolates from each of clades I, II, III, SA, and NG. DNA was extracted, PCR performed with a high-fidelity Pwo DNA polymerase), and PCR products sequenced using BigDye® Terminator v3.1 Cycle Sequencing Kit on the GeneAmp® PCR System 9700. Obtained sequences were compared with the published ERG11 sequence from a wild-type, fluconazole-susceptible C. albicans strain (Lai and Kirsch, 1989). To investigate the contributions of over-expression of the ERG11 gene to fluconazole resistance among C. albicans isolates belonging to different clades, 30 isolates were used. These consisted of 3 isolates with induced fluconazole resistance and their 3 matching fluconazole susceptible isolates from each of clades I, II, III, SA, and NG. RNA was extracted, cDNA synthesized and Real time PCR performed on a Rotor-Gene 6000 instrument. Relative gene expression of ERG11 gene among resistant isolates, relative to susceptible isolates was quantified after normalization with the 18SrRNA house-keeping gene. To investigate the relationship between fluconazole resistance and phenotypic switching among C. albicans isolates belonging to different clades, 30 isolates were used. These consisted of 3 isolates with induced fluconazole resistance and their 3 matching fluconazole susceptible isolates from each of clades I, II, III, SA, and NG. Primary and secondary cultures were prepared on Lee’s medium agar supplemented with arginine and zinc, and containing phloxine B. The switched colonies were counted and colony morphologies viewed and photographed. Phenotypic switching behavior and different colony morphologies obtained between the resistant and susceptible isolates from different clades were compared. Switch phenotypes among fluconazole resistant isolates in different clades were compared. Switch phenotypes and MIC levels among fluconazole resistant isolates from different clades were compared. Results: Resistance to nystatin, AmB, fluconazole and miconazole was successfully induced in all of 20 (100%) C. albicans isolates from each of clades I, II, III, SA and NG. When survival and retention of resistance were determined, all 20 (100%) fluconazole resistant vii isolates from clades I, II, SA, NG, and 19 (95%) from clade III survived and retained their resistance. Of miconazole resistant isolates, all 20 (100%) isolates from clade I, II, and SA, and 19 (95%) from clade III and NG survived and retained their resistance. Of AmB resistant isolates, 12 (60%) from Clade NG survived and retained their resistance; 9 (45%) from Clade I; 8 (40%) from Clade III; 7 (35%) from Clade II and 6 (30%) from Clade SA survived and retained their resistance. Of the isolates resistant to nystatin, 12 (60%) from clade I survived and retained their resistance, 8 (40%) from clade II, 10 (50%) from clade III, 11 (55%) from clade SA, and 15 (75%) from clade NG survived and retained their resistance. No mutations associated with fluconazole resistance were observed in all isolates from clades I and II. Mutations associated with fluconazole resistance were observed in 33.3% of isolates from each of clades III, SA and NG , and some of the mutations observed in resistant isolates from clades III and NG were novel. A total of 50 novel mutations that have not been described previously were observed in both fluconazole resistant and susceptible isolates from this study. Previously described mutations, which were associated with fluconazole resistance, namely, D116E, K128T, V437I and E266D were also observed in this study. When relative ERG11 gene expression was quantified among fluconazole resistant and susceptible isolates from various clades, over-expression of ERG11 gene was observed in 66.6% of isolates from each of clades I, II and SA, and in 33.3% of isolates from each of clades III and NG. When the relationship between fluconazole resistance and phenotypic switching was investigated, phenotypic switching was related to resistance in 66.6% of the resistant isolates tested from each of clades I, II and III, and in 33.3% of the resistant isolates tested from each of clades SA and NG. When the switch phenotypes and MIC levels of resistant isolates from different clades were compared, stipple was the most common switch phenotype observed in all clades, and it was associated with the highest fluconazole MIC levels among isolates from all clades. Conclusions: The results of this study showed that resistance to polyenes and azoles could readily be induced in C. albicans isolates from all clades, and that induction was not claderelated. The ease with which azole and polyene resistance could be induced in this study can hold serious implications, especially in HIV/AIDS patients who are already immunocompromised, and in whom azoles/polyenes are mostly used for C. albicans infections. viii The study also showed that mutations contributed to fluconazole resistance in isolates from clades III, SA and NG, but not clades I and II, showing clade-relatedness. Novel mutations were observed, and their contribution to fluconazole resistance is at this stage not known. Genetic analysis of these mutations needs to be studied further to determine their significance to azole resistance, especially in C. albicans isolates from HIV/AIDS patients in South Africa. The results of the study showed that over-expression of ERG11 gene contributed to fluconazole resistance in isolates from all clades. However, over-expression was observed in more isolates from clades I, II and SA, and in less isolates from clades III and NG, showing clade-relatedness of ERG11 over-expression. The occurrence of over-expression of ERG11 gene in these clades is a cause for concern, especially in HIV/AIDS patients with OPC, as the increased expression of ERG11 allows for the cells to persist within the host, which in turn leads to the subsequent development of other more stable resistant isolates. In this study, phenotypic switching was found to be related to fluconazole resistance in isolates from all clades, with a high number of switch phenotypes occurring more in isolates from clade II as compared to others. This suggests that isolates belonging to this clade may survive better under adverse conditions than isolates from other clades. These results suggest that further study of differences between different C. albicans clades may be warranted, and that isolates from this clade need to be studied further. The stipple phenotype was found to be the most dominant in isolates from all clades, and was found to be associated with the highest fluconazole MICs levels. These findings suggest that the evaluation of colony phenotypes and their antifungal susceptibilities in C. albicans isolates may be useful in therapy. Recommendations: A continued analysis of clade-specific phenotypic characteristics of C. albicans isolates is recommended. Pathogens that can potentially infect HIV-infected individuals need to be studied to subspecies level in order to improve treatment of these patients. Continued antifungal surveillance is needed to predict the evolution of resistance in a particular population and to take timely measures. Evaluation of colony phenotypes and their antifungal susceptibilities in C. albicans isolates is recommended as this may be useful in therapy. Genetic analysis of the novel mutations observed is recommended to determine their significance to azole resistance, especially in C. albicans isolates from HIV/AIDS patients in South Africa.

Fungal infections have a significant impact on the world population, with estimates of over 1.6 million deaths a year. One contributing factor is the increasing number of fungi resistant to the current clinical treatments, including the last approved family of antifungal compounds introduced into the market over a decade ago. This is driving the search for new antifungals with different biological targets. A new potential antifungal occidiofungin, is a cyclic glycolipopeptide isolated from the soil bacterium Burkholderia contaminans MS14 with a broad spectrum of activity against both human and plant pathogens. Kill kinetics demonstrated that this compound is fungicidal and activates the cell wall integrity pathway at suboptimal dosing as determined by Mkc1 MAPK phosphorylation studies. As three of the four classes of currently available antifungals target ergosterol or ergosterol biosynthesis, the bioactivity of occidiofungin was assayed in the presence of ergosterol containing DOPC vesicles and was shown to retain antifungal properties. Occidiofungin was also found to have a similar activity profile against the S. cerevisiae -1,3-glucan synthesis mutant, indicating that it does not share a target with the fourth class of antifungals. Stability testing showed occidiofungin retained in vitro potency in the presence of human serum, across a broad range of pH and temperature conditions, and was resistant to gastric proteases. Based on cell morphology, occidiofungin did not target a specific stage of the yeast cell cycle, however cells were smaller in size and acquired ‘dancing bodies’, both properties of apoptosis. This was confirmed with data showing concentration dependent increases in DNA fragmentation, reactive oxygen species, and extracellular localization of phosphatidylserine. In addition to these findings, cells deleted for the yeast caspase gene exhibit a 2old resistance to occidiofungin. While SEM showed no morphological differences between treated and untreated cells, TEM did identify a thinning of the cell wall and inclusion bodies in cells treated with occidiofungin. As a stable fungicidal compound that induces apoptosis in yeast, occidiofungin has a great potential to become a new candidate drug for clinical use in treating fungal infections, including those resistant to current antifungals.

Aspergillus fumigatus is a filamentous saprophytic mold that is found abundantly in the biosphere. A. fumigatus is also an airborne human pathogen and is considered the major cause of aspergillosis, infections caused by inhalation of conidia. In immunocompetent individuals, the spores rarely cause any harm as they are cleared by innate pulmonary defences; however, in immunocompromised patients, the host immune system can fail to clear the inhaled conidia and aspergillosis may develop. Indeed, aspergillosis represents a major cause of morbidity and mortality in these populations. Aspergillosis is commonly treated using triazole and amphotericin B (AMB) antifungal agents. However, the increasing prevalence of triazole resistant strains and emergence of AMB resistance has become a challenge in treatment. To further expand our knowledge on the mechanisms of antifungal resistance in the species, we tested previously known or associated genes for antifungal resistance as well as investigated novel mechanisms via multiple genome-wide association studies (GWAS), which used a total of 211 genomes from A. fumigatus strains in 12 countries. Our results identified many novel mutations related to triazole and AMB resistance. Specifically, using stepwise GWAS analyses, we identified 6 and 18 missense variants to be significantly associated with itraconazole and voriconazole resistance, respectively. A linkage disequilibrium analysis identified six additional missense variants associated with triazole resistance, with two of these six being consistently associated with pan-azole resistance across subsets of samples. Furthermore, examination of known mutation sites and genes overexpressed with triazole exposure found a total of 65 SNPs implicated in triazole resistance. For the AMB study, we identified a total of 34 mutations associated with AMB tolerance using a GWAS. Subsequent analysis with 143 progeny strains, generated from a laboratory cross and genotyped with PCR-RFLP, identified epistatic interactions between five of these SNP sites that impacted growth in different concentrations of AMB. With the expanding immunocompromised population and increasing frequency of antifungal resistance, our results will help in investigating novel resistance mechanisms in A. fumigatus and in expanding the molecular diagnostic toolset in resistance screening, to enable rapid and accurate diagnosis and treatment decision-making. / Thesis / Master of Science (MSc)

Aspergillus fumigatus is a globally present pathogen capable of inflicting debilitating and life-threatening opportunistic infections in individuals, primarily those who are immunocompromised. Diagnosing A. fumigatus infections is often difficult, leading to a delay in treatment which can greatly impact patient outcomes. Furthermore, our lessening of antifungal development combined with increasing resistance generates a feasible scenario where only last resort options are viable. This has prompted the World Health Organization (WHO) to declare this pathogen a "critical priority" due to increased resistance and rising mortality rates. Azoles are utilized as primary treatment options for Aspergillus fumigatus infections such as voriconazole (VRC), itraconazole (ITC), and posaconazole (POS) with a reserve of Amphotericin B (AmB). In the past two decades, the emergence of resistance to azoles has contributed to a 90% mortality rate in resistant cases globally. In this report, we investigated the MedChem Express (MCE) Drug Repurposing Compound Library (4,226 compounds) in conjunction with itraconazole at 0.06 µg/mL against A. fumigatus CDC #738. After the initial screening, we identified compounds known to be antifungals or antiseptics and deselected them. The remaining thirty selected compounds were evaluated through published literature and clinical trial data to determine those candidates with favorable characteristics/properties. Criteria for candidate selection consisted of evaluating the compounds; plasma concentration peak, the time to reach peak, protein binding, oral availability, and drug class. Six candidates were ranked the highest of the previous round –surprisingly 50% of those compounds were HIV drugs, cobicistat, elvitegravir, lopinavir. The remaining three selected compounds are penfluridol, rilapladib, and rolapitant. The combination of itraconazole (ITC), posaconazole (POS), and voriconazole (VRC), with the identified compounds demonstrated promising amounts of synergy, in resistant and susceptible isolates. Further investigation revealed novel properties of ITC and POS when in combination with our compounds of interest. Rilapladib was able to reverse POS, ITC, and VRC resistant strain(s) to a sensitive profile. Growth kinetic assays demonstrate potent anti-germination properties not seen before in the sub-inhibitory doses of azoles. This work demonstrates that high-throughput screening as a viable technique to identify robust antifungal synergizers, allowing for tenable translation to a clinical setting. / Master of Science / Aspergillus fumigatus is a worldwide fungal organism capable of causing disease, particularly in immunocompromised individuals. Infections primarily occur when individuals inhale spores that can remain dormant until the person's immune system is weakened, via disease, cancer, or prescribed drug for surgery. When the immune system is weakened, the spores are more effective at lung colonization. Aspergillus fumigatus infections can be combatted with voriconazole (VRC), itraconazole (ITC), or posaconazole (POS). However, in the past two decades, some fungi have started to develop resistance to azoles, necessitating the use of amphotericin B (AmB), a highly intolerable and final treatment option. In this report, we challenged A. fumigatus CDC isolate #738 with compounds from the MedChem Express (MCE) Drug Repurposing Compound Library (4,226 compounds) with itraconazole at 0.06 µg/mL, an ineffective concentration. We selected combinations and compounds that negated 90% of fungal growth those combinations that contained a known antifungal or antiseptic agent; once identified we deselected any known antifungal or antiseptic agents. The remaining selected compounds were evaluated for favorable drug properties, by reviewing published literature and clinical reports to determine those candidates with favorable characteristics/properties. The combination of ITC, POS, and VRC with the identified compounds demonstrated antifungal enhancement in resistant and susceptible isolates. We observed the reversal of resistance to POS, ITC, and VRC in several isolates when the drug combinations were applied. This demonstrates the importance of evaluating approved and under current review drugs to identify novel properties to aid our dwindling number of effective antifungals. This study provides promising combinational therapies for further evaluation in combating resistant A. fumigatus infections.

Candida albicans is a fungal microorganism found on the human body and in the environment. An opportunistic pathogen causing local and systemic infection, this fungus is one of the leading causes of nosocomial infections. More alarming is its growing resistance against the limited number of antifungals we have for treatment Candida infections. An area of current research, termed polymicrobial interactions, focuses on how different microorganisms interact with each other for limited space, nutrients, and survival. The current study focuses on attempting to inhibit planktonic and biofilm growth stages by using the benign bacterium Alcaligenes faecalis, previously shown in our lab to kill C. albicans. Under a variety of growth conditions and phases, co-cultures of A. faecalis and C. albicans have demonstrated that the bacterium drastically inhibits all forms of Candida growth. The results of this study may provide information on potential new therapeutic targets that Alcaligenes may employ in inhibition of Candida.

No description available.

Dermatófitos são um grupo de fungos intimamente relacionados, que tem a capacidade de invadir tecidos queratinizados como pele, cabelos e unhas de homens e outros animais causando dermatofitoses. Os agentes envolvidos nessas infecções pertencem aos gêneros Trichophyton, Microsporum ou Epidermophyton e, de acordo com seu habitat natural, são classificados em espécies geofílicas, zoofílicas ou antropofílicas. A maior incidência de dermatofitoses é causada pelo gênero Trichophyton, sendo T. rubrum a espécie mais prevalente em infecções de pele e unhas em humanos. Devido à severidade e longevidade destas infecções, e à resistência ao tratamento, o estudo de fatores envolvidos na interação patógeno-hospedeiro, na resistência dos dermatófitos a agentes antifúngicos e na manutenção do processo infeccioso são de grande relevância. Por análises morfológicas, fisiológicas e de expressão gênica, comparamos cinco dermatófitos cujos genomas foram sequenciados por iniciativa do Broad Institute, Microsporum canis, Trichophyton equinum, Trichophyton interdigitale, Trichophyton rubrum e Trichophyton tonsurans. Cultivos em queratina, mimetizando o processo infeccioso, foram utilizados para analisar o envolvimento dos dermatófitos na interação patógeno-hospedeiro e manutenção do processo infeccioso. Também expusemos as espécies a concentrações subinibitórias de agentes terapêuticos, de modo a verificar a resposta destes fungos a diferentes drogas. Observamos que o acúmulo de transcritos dos genes relacionados à virulência em dermatófitos avaliados durante o crescimento em queratina sugere que a maquinaria metabólica com atividade de formação da parede celular do fungo, metabolização do substrato e adesão ao hospedeiro ativa nos períodos iniciais de infecção. Contudo, um padrão de expressão correlacionado à similaridade das sequências genômicas não foi observado nas condições testadas. Também não se observa correlação direta entre o nicho preferencial dos dermatófitos e os níveis transcricionais em resposta à queratina de origem animal. Analisamos três genes envolvidos na resistência a múltiplas drogas (MDR) durante crescimento na presença de drogas com atividade antifúngica. Nossos dados sugerem que os genes MDR atuam sinergicamente em dermatófitos, e podem atuar de forma compensatória quando em presença de drogas antifúngicas, o que pode ser uma importante causa de falhas no tratamento. Nossos resultados fornecem evidências de que a expressão dos genes analisados não se correlaciona com as relações filogenéticas entre estes dermatófitos, visto que apesar da íntima relação entre o conteúdo genético e organização do genoma, os níveis transcricionais destes genes são diferentes entre as espécies. Assim, diferenças na adaptação a nichos específicos e a progressão da doença entre os dermatófitos podem ser explicadas por diferentes perfis de transcrição do gene. / Dermatophytes are a group of closely related fungi, which have the ability to invade keratinized tissues, such as skin, hair, and nails of both human and animal hosts causing dermatophytosis. The agents involved in these infections belong to the genera Trichophyton, Microsporum or Epidermophyton and, according to their natural habitat, are classified as geophilic, zoophilic or anthropophilic species. The higher incidence of dermatophytosis is caused by the genera Trichophyton, being the specie T. rubrum the most prevalent causative of human skin and nail infections. Because of the severity and longevity of these infections and their resistance to treatment, the study of the factors involved in host-pathogen interaction, in resistance of dermatophytes to antifungal agents, and in maintenance of the infection is relevant. Through morphological, physiological and gene expression analysis we compared five dermatophytes, whose genomes were sequenced by initiative of the Broad Institute: Microsporum canis, Trichophyton equinum, Trichophyton interdigitale, T. rubrum and Trichophyton tonsurans. Growth in keratin, which mimetize the infectious process, was used to analyze the involvement of dermatophytes in host-pathogen interaction and maintenance of the infectious process. We also exposed the species to subinibitory concentrations of therapeutic agents to verify the response of these fungi to different drugs. We observed that the accumulation of transcripts of genes related to virulence in dermatophytes evaluated during growth in keratin, suggest that the metabolic machinery with activity on fungal cell wall formation, substrate metabolization, and host adhesion is activated in early stages of infection. However, an expression pattern correlating to genomic sequence similarity was not observed in the conditions tested. We also did not observe a direct correlation between the preferential niche of these dermatophytes and the transcriptional levels in response to the keratin from animal origin. We analyze three genes involved in multidrug resistance (MDR) during growth in the presence of drugs with antifungal activity. Our data suggest that MDR genes act synergistically in dermatophytes, and they may compensate for one another when challenged with antifungal drugs, which can be an important cause of therapeutic failure. We provide evidence that the expression of the analyzed genes does not correlate with the phylogeny of these dermatophytes since, in spite of the different species being highly related in gene content and genome organization, the transcription level of these genes is different among these species. Thus, differences in adaptation to a specific niche and disease progression among dermatophytes would be explained by different gene transcription profiles.

Candida spp. is the most common etiologic agent of opportunistic fungal infections and Candida albicans species still remains the most frequently isolated species in candidiasis. However, the rate of Candida non-albicans isolates has increased in hospitals, where the use of azole antifungals for prophylaxis or therapy is frequent. The prolonged and indiscriminate use of antifungals has favored the development of resistant yeasts. In this context, other species have emerged as clinically important pathogens. Candida dubliniensis species is one that has become important because the easy way that acquires resistance to fluconazole, and may become a relatively more resistant pathogen and therefore more difficult to treat. This framework requires that measures of surveillance the susceptibility or investigations about the magnitude of the resistance are taken. This study aimed to evaluate and interpret the results of in vitro susceptibility of Candida dubliniensis sensitive and resistant to fluconazol and Candida albicans to echinocandins, voriconazole, itraconazole and posaconazole in the light of official documents and also by using proposed points of epidemiological cuts. Where evalued thre groups of isolates: a group of isolates of C. albicans against fluconazole sensitive (Group I), the other two isolates of C. dubliniensis, a compound of isolates sensitive to fluconazole (Group II) and other derived from the first fluconazole resistant (Group III). Groups I and II tests with fluconazole were shown to be susceptible to this antifungal and group III after exposure to increasing concentrations of fluconazole was classified as resistant based on document M27-S3 (2008) and in epidemiological cutoffs. The group I was considered 100% sensitive to antifungal agents based on documents M27-S4 (2012) and M27-S3 (2008). Group II was regarded as 100% sensitive to echinocandins, voriconazole, itraconazole, based on M27-S3 and 100% sensitive to posaconazole based on epidemiological cutoff. However, when interpreting the epidemiological cutoffs MICs, was observed 9.09% for non-sensitive isolates to micafungin. Finally, the group III was 100% sensitive to echinocandins, voriconazole, 100% itraconazole resistant to based on the M27-S3. Based on the epidemiological cutoffs, 4.54% were resistant to anidulafungin, 31.8% resistant to micafungin, 22.7% resistant or susceptible to voriconazole and 100% posaconazole sensitive. Evaluation of antifungal susceptibility is a complex issue and, at the time re-definitions of MICs defining susceptibility or resistance are under intense review, note difficulties in the interpretation of such tests. / Candida spp. é o agente etiológico mais frequentemente causador de infecções fúngicas oportunistas e a espécie Candida albicans ainda permanece como a espécie mais frequentemente isolada nas candidíases. No entanto, a taxa de isolamentos de espécies de Candida não-albicans tem aumentado nas unidades hospitalares, onde o uso de antifúngicos azólicos de forma profilática ou terapêutica é frequente. O uso prolongado e indiscriminado dos antifúngicos tem favorecido o desenvolvimento de leveduras resistentes. Neste contexto, outras espécies emergiram como patógenos de importância clínica. Candida dubliniensis é uma das espécies que tornou-se relevante, por causa da facilidade com que adquire resistência ao fluconazol, podendo tornar-se um agente patogênico relativamente mais resistente e, consequentemente, mais difícil de tratar. Este quadro impõe que medidas de vigilância da suscetibilidade ou de investigações sobre a magnitude da resistência sejam tomadas. Este estudo objetivou avaliar e interpretar os resultados da suscetibilidade in vitro de Candida dubliniensis sensível e resistente ao fluconazol e Candida albicans às equinocandinas, voriconazol, itraconazol e posaconazol à luz dos documentos oficiais e também pelas propostas utilizando pontos de corte epidemiológicos. Foram avaliados três grupos de isolados: um grupo de isolados de C. albicans sensíveis ao fluconazol (Grupo I), os outros dois de isolados de C. dubliniensis, um composto por isolados sensíveis ao fluconazol (Grupo II) e outro derivado do primeiro resistente ao fluconazol (Grupo III). Os grupos I e II nos testes com o fluconazol foram evidenciados como sensíveis a este antifúngico e o grupo III após exposições a concentrações crescentes de fluconazol foi classificado como resistente, com base no documento M27-S3 (2008) e nos cutoffs epidemiológicos. O grupo I foi considerado 100% sensível aos antifúngicos com base nos documentos M27-S4 (2012) e M27-S3 (2008). O grupo II foi considerado 100% sensível às equinocandinas, voriconazol, itraconazol, com base no M27-S3 e 100% sensível ao posaconazol com base no cutoff epidemiológico. No entanto, ao interpretar as CIMs pelos cutoffs epidemiológicos, foi evidenciada 9,09% de isolados não sensíveis a micafungina. E, por fim, o grupo III que foi 100% sensível às equinocandinas, voriconazol, 100% resistente ao itraconazol com base no M27-S3. Com base nos cutoffs epidemiológicos, 4,54% foram considerados resistentes a anidulafungina, 31,8% resistente a micafungina, 22,7% resistente ou não sensíveis ao voriconazol e 100% sensível ao posaconazol. A avaliação da suscetibilidade aos antifúngicos é um tema complexo e, no momento em que redefinições das CIMs definidoras de sensibilidade ou resistência estão sofrendo intensas revisões, nota-se dificuldades nas interpretações de tais testes.

Dermatófitos são um grupo de fungos intimamente relacionados, que tem a capacidade de invadir tecidos queratinizados como pele, cabelos e unhas de homens e outros animais causando dermatofitoses. Os agentes envolvidos nessas infecções pertencem aos gêneros Trichophyton, Microsporum ou Epidermophyton e, de acordo com seu habitat natural, são classificados em espécies geofílicas, zoofílicas ou antropofílicas. A maior incidência de dermatofitoses é causada pelo gênero Trichophyton, sendo T. rubrum a espécie mais prevalente em infecções de pele e unhas em humanos. Devido à severidade e longevidade destas infecções, e à resistência ao tratamento, o estudo de fatores envolvidos na interação patógeno-hospedeiro, na resistência dos dermatófitos a agentes antifúngicos e na manutenção do processo infeccioso são de grande relevância. Por análises morfológicas, fisiológicas e de expressão gênica, comparamos cinco dermatófitos cujos genomas foram sequenciados por iniciativa do Broad Institute, Microsporum canis, Trichophyton equinum, Trichophyton interdigitale, Trichophyton rubrum e Trichophyton tonsurans. Cultivos em queratina, mimetizando o processo infeccioso, foram utilizados para analisar o envolvimento dos dermatófitos na interação patógeno-hospedeiro e manutenção do processo infeccioso. Também expusemos as espécies a concentrações subinibitórias de agentes terapêuticos, de modo a verificar a resposta destes fungos a diferentes drogas. Observamos que o acúmulo de transcritos dos genes relacionados à virulência em dermatófitos avaliados durante o crescimento em queratina sugere que a maquinaria metabólica com atividade de formação da parede celular do fungo, metabolização do substrato e adesão ao hospedeiro ativa nos períodos iniciais de infecção. Contudo, um padrão de expressão correlacionado à similaridade das sequências genômicas não foi observado nas condições testadas. Também não se observa correlação direta entre o nicho preferencial dos dermatófitos e os níveis transcricionais em resposta à queratina de origem animal. Analisamos três genes envolvidos na resistência a múltiplas drogas (MDR) durante crescimento na presença de drogas com atividade antifúngica. Nossos dados sugerem que os genes MDR atuam sinergicamente em dermatófitos, e podem atuar de forma compensatória quando em presença de drogas antifúngicas, o que pode ser uma importante causa de falhas no tratamento. Nossos resultados fornecem evidências de que a expressão dos genes analisados não se correlaciona com as relações filogenéticas entre estes dermatófitos, visto que apesar da íntima relação entre o conteúdo genético e organização do genoma, os níveis transcricionais destes genes são diferentes entre as espécies. Assim, diferenças na adaptação a nichos específicos e a progressão da doença entre os dermatófitos podem ser explicadas por diferentes perfis de transcrição do gene. / Dermatophytes are a group of closely related fungi, which have the ability to invade keratinized tissues, such as skin, hair, and nails of both human and animal hosts causing dermatophytosis. The agents involved in these infections belong to the genera Trichophyton, Microsporum or Epidermophyton and, according to their natural habitat, are classified as geophilic, zoophilic or anthropophilic species. The higher incidence of dermatophytosis is caused by the genera Trichophyton, being the specie T. rubrum the most prevalent causative of human skin and nail infections. Because of the severity and longevity of these infections and their resistance to treatment, the study of the factors involved in host-pathogen interaction, in resistance of dermatophytes to antifungal agents, and in maintenance of the infection is relevant. Through morphological, physiological and gene expression analysis we compared five dermatophytes, whose genomes were sequenced by initiative of the Broad Institute: Microsporum canis, Trichophyton equinum, Trichophyton interdigitale, T. rubrum and Trichophyton tonsurans. Growth in keratin, which mimetize the infectious process, was used to analyze the involvement of dermatophytes in host-pathogen interaction and maintenance of the infectious process. We also exposed the species to subinibitory concentrations of therapeutic agents to verify the response of these fungi to different drugs. We observed that the accumulation of transcripts of genes related to virulence in dermatophytes evaluated during growth in keratin, suggest that the metabolic machinery with activity on fungal cell wall formation, substrate metabolization, and host adhesion is activated in early stages of infection. However, an expression pattern correlating to genomic sequence similarity was not observed in the conditions tested. We also did not observe a direct correlation between the preferential niche of these dermatophytes and the transcriptional levels in response to the keratin from animal origin. We analyze three genes involved in multidrug resistance (MDR) during growth in the presence of drugs with antifungal activity. Our data suggest that MDR genes act synergistically in dermatophytes, and they may compensate for one another when challenged with antifungal drugs, which can be an important cause of therapeutic failure. We provide evidence that the expression of the analyzed genes does not correlate with the phylogeny of these dermatophytes since, in spite of the different species being highly related in gene content and genome organization, the transcription level of these genes is different among these species. Thus, differences in adaptation to a specific niche and disease progression among dermatophytes would be explained by different gene transcription profiles.

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior / Candida species are the most common etiologic agent of opportunistic fungal infections. Candida albicans is the most frequent species in candidiasis, however species of non-albicans species have emerged increasingly in hospitals in which the use of azoles as a prophylactic or therapeutic is common. C. glabrata is the species most relevant in this scenario, causing infections with high morbidity and mortality due to high rates of resistance to antifungal azoles, especially fluconazole, and reduced sensitivity to amphotericin B and echinocandins. The remarkable resistance of these species to antifungal agents requires the search for new therapeutic options. An alternative is the combination of drugs with different mechanisms of action. This study aimed to evaluate the in vitro susceptibility of Candida glabrata to conventional antifungal agents (amphotericin B, ketoconazole, itraconazole, fluconazole and voriconazole), and these associations with non-antifungal drugs (chlorpromazine, linezolid, minocycline, sulfamethoxazole, tacrolimus and diphenyl diselenide). Two groups of clinical isolates of C. glabrata were evaluated. The first group consists of fluconazole-sensitive clinical isolates (FS) (n = 30) and the second, derivative of the first, fluconazole-resistant clinical isolates (FR) (n = 30). Based on protocol M27-A3 (CLSI, 2008), the checkerboard method. In isolation, MICs (Minimum Inhibitory Concentration) for fluconazole ranged from 0.25 to ≥ 64.00 μg/mL (FS) and 64.00 to 256.00 μg/mL (FR); for amphotericin B ranged from 0.06 to 0.50 μg/mL (FS) and 0.03 to 0.50 μg/ mL (FR); for itraconazole 0.50 to 8.00 μg/ mL (FS) and 1.00 to 16.00 μg/mL (FR); for ketoconazole 0.13 to 2.00 μg/mL (FS) and 0.50 to 16.00 μg/mL (FR); for voriconazole 0.13 to 4.00 μg/mL (FS) and 1.00 to 16.00 μg/mL (FR). The combinations of tacrolimus with azoles showed significant synergism rates; for the group FS tacrolimus + ketoconazole (43%), tacrolimus + itraconazole (43%), tacrolimus + voriconazole (37%); for the group FR ketoconazole + tacrolimus (77% ) tacrolimus + itraconazole (73%), tacrolimus + voriconazole (63%). Linezolid combined with ketoconazole and voriconazole showed high rates of synergism against the FR group, 76.67% and 70%, respectively. Minocycline + amphotericin B obtained 46.67% (FS) and 36.67% (FR) of synergism; chlorpromazine + amphotericin B was synergistic for 40% of the FR. Chlorpromazine combined to azoles showed high rates of antagonism for resistant group, 76.67%, 70% and 80% for ketoconazole, itraconazole and voriconazole, respectively, for the sensitive group combinations had higher rates of indifference. Sulfamethoxazole evidenced a higher percentage of indifferent interactions associated with all tested antifungals, 70% (FS), 73.34% (FR) associated to ketoconazole, 60% (FS), 43.34% (FR) associated to itraconazole, 56.67% (FS), 66.67% (FR) ins association with voriconazole, 86.66% (FS), 80% (FR) associated to amphotericin B. Synergistic (76.66%) and indifferent (23.34%) interactions were observed for diphenyl diselenide + amphotericin B combination for the sensitive group. Diphenyl diselenide + fluconazole combination demonstrated indifferent (50%) and antagonistic (40%) interactions for sensitive group, whereas synergistic interactions were observed in 10% of the isolates. The most significant associations deserve in vivo evaluation in order to verify their potential in the treatment of infections caused by C. glabrata. / Candida spp é o mais frequente agente etiológico de infecções fúngicas oportunistas. Candida albicans é a espécie mais isolada nas candidíases, no entanto espécies de Candida não-albicans têm emergido de forma crescente nas unidades hospitalares em que o uso de azólicos de forma profilática ou terapêutica é frequente. C. glabrata é uma das espécies mais relevantes neste cenário, causando infecções com alta morbidade e mortalidade, devido às altas taxas de resistência frente aos antifúngicos azólicos, em especial ao fluconazol, e a reduzida sensibilidade a anfotericina B e equinocandinas. A marcante resistência desta espécie aos antifúngicos impõe a busca por novas possibilidades terapêuticas. Uma alternativa é a combinação entre fármacos com distintos mecanismos de ação. Este estudo objetivou avaliar a suscetibilidade in vitro de C. glabrata a antifúngicos convencionais (anfotericina B, fluconazol, cetoconazol, itraconazol e voriconazol) e associações destes, com fármacos e compostos não-antifúngicos (clorpromazina, linezolida, minociclina, sulfametoxazol, tacrolimus e disseleneto de difenila). Foram avaliados dois grupos de isolados clínicos de C. glabrata. O primeiro grupo composto de isolados sensíveis ao fluconazol (FS) (n=30) e o segundo, derivado do primeiro, isolados clínicos resistentes ao fluconazol (FR) (n=30). Com base no protocolo M27-A3 (CLSI, 2008), pelo método de checkerboard. Isoladamente, as CIMs (Concentrações Inibitórias Mínimas) para o fluconazol variaram de 0,25 - ≥64,00 μg/mL (FS) e 64,00 - 256,00 μg/mL (FR); para anfotericina B variaram de 0,06 - 0,50 μg/mL (FS) e 0,03 - 0,50 μg/mL (FR); para o itraconazol 0,50 - 8,00 μg/mL (FS) e 1,00 - 16,00 μg/mL (FR); para cetoconazol 0,13 - 2,00 μg/mL (FS) e 0,50 - 16,00 μg/mL (FR); para voriconazol 0,13 - 4,00 μg/mL (FS) e 1.00 - 16.00 μg/mL (FR). As combinações de tacrolimus com azólicos apresentaram consideráveis taxas de sinergismo; para o grupo FS tacrolimus + cetoconazol (43%), tacrolimus + itraconazol (43%), tacrolimus + voriconazol (37%). Para o grupo FR tacrolimus + cetoconazol (77%), tacrolimus + itraconazol (73%), tacrolimus + voriconazol (63%). Linezolida associada ao cetoconazol e ao voriconazol apresentou altas taxas de sinergismo frente ao grupo FR, 76,67% e 70%, respectivamente. Minociclina + anfotericina B obteve 46,67% (FS) e 36,67% (FR) de sinergismo; clorpromazina + anfotericina B foi sinérgica para 40% do grupo FR. Clorpromazina combinada aos azólicos apresentou altas taxas de antagonismo para o grupo resistente, 76,67%, 70% e 80% para cetoconazol, itraconazol e voriconazol, respectivamente; para o grupo sensível as combinações com clorpromazina tiveram maiores taxas de indiferença. Interações sinérgicas (76,66%) e indiferentes (23,34%) foram observadas na combinação de anfotericina B e disseleneto de difenila para o grupo sensível. A combinação de disseleneto de difenila com fluconazol apresentou indiferença (50%) e antagonismo (40%) para o grupo sensível, 10% dos isolados apresentaram sinergismo. Sulfametoxazol apresentou um maior porcentual de interações indiferentes, associado a todos os antifúngicos testados frente aos dois grupos, 70% (FS), 73,34% (FR) associado ao cetoconazol, 60% (FS), 43,34% (FR) associado ao itraconazol, 56,67% (FS), 66,67% (FR) na associação com voriconazol, 86,66% (FS), 80% (FR) associado à anfotericina B. As associações de maior relevância merecem avaliação in vivo, a fim de verificar o potencial das mesmas no tratamento de infecções por Candida glabrata.