Nos últimos anos tem ocorrido um aumento de infecções fúngicas, devido à elevação do número de pacientes imunossuprimidos, principalmente pelo surgimento da epidemia da AIDS (Acquired Immunodeficiency Syndrome). O uso aumentado de antifúngicos tem levado ao surgimento de cepas resistentes a estes agentes, já verificado com o azólico fluconazol, o agente antifúngico mais utilizado na terapia de manutenção de pacientes com AIDS, que desenvolvem criptococose. Neste trabalho, foram determinadas as Concentrações Inibitórias Mínimas (CIMs) de fluconazol para isolados clínicos de Cryptococcus neoformans e Cryptococcus gattii, utilizando-se o teste de microdiluição em caldo padronizado pelo National Commitee for Clinical Laboratory Standards (NCCLS), o método padrão para testar susceptibilidade antifúngica de leveduras. Foram testados 173 isolados clínicos de C. neoformans e C. gattii, sendo que as CIMs para fluconazol variaram de 0,125 a 16 μg/mL, com uma CIM50% de 2 e uma CIM90% de 4 μg/mL. Todos os isolados foram considerados sensíveis a fluconazol. Também foi realizado um teste de indução de resistência a fluconazol, por exposição de um isolado sensível, a concentrações crescentes da droga, para verificar se apenas a exposição, levaria ao desenvolvimento de resistência. No entanto, verificou-se apenas uma resistência transitória, em uma das subpopulações, sendo que o fenótipo de sensibilidade foi restaurado. Os dados obtidos neste trabalho estão em concordância com estudos nacionais e internacionais, que também utilizaram o teste padrão de microdiluição em caldo. A resistência entre isolados clínicos de C. neoformans e C. gattii ainda tem se mostrado rara em termos mundiais comparada a resistência adquirida por outras leveduras. No entanto, devido aos relatos de desenvolvimento de resistência durante a terapia de manutenção da criptococose, é importante alertar quanto à possibilidade do surgimento e da propagação de cepas resistentes. / In the last years have occurred an increase of fungal infections due to rise of number of immunocompromised patients, particularly by appearance of the Acquired Immunodeficiency Syndrome (AIDS). The incresing use of antifungal agents has determined the appearance of resistants strains to this agents, already verified with the fluconazole azole, the antifungal agent more used in the maintenance therapy of AIDS patients that developing criptococosis. In this work were determined the Minimuns Inibitories Concentrations (MICs) of fluconazole to Cryptococcus neoformans and Cryptococcus gattii clinical isolates, using the National Commitee for Clinical Laboratory Standards (NCCLS) broth microdilution method. This is the test standard to test antifungal susceptibility to yeasts. Were tested 173 clinical isolates of C. neoformans and C. gattii. The MICs to fluconazole ranged of 0.125 to 16 μg/mL and the MIC50% was 2 and MIC90% was 4μg/mL. All isolates were considered susceptibles to fluconazole. A test of fluconazole resistance inducing was carry out by exposure to drug incresing concentrations of one susceptible isolate, to verify if only the exposure can to result in the resistance development. However occurred only a temporary resistance in one of the subpopulations, since the susceptibility profile was restored. The data obtained in this work are in agreement with national and international studies that also used the standard broth microdilution method. The resistance between C. neoformans and C. gattii clinical isolates has been rare in the world when compared with others yeasts. Nonetheless due to references to resistance development during the maintenance therapy of cryptococosis, it’s important to remain alert as for possibility of appearance and spread of resistants strains.

Ilex paraguariensis é uma importante planta nativa da América do Sul, popularmente conhecida como mate, cujas folhas são tradicionalmente consumidas na forma de infusão. Muitos benefícios à saúde são mencionados para a utilização de seus constituintes, entre eles as saponinas. Várias propriedades farmacológicas são atribuídas as saponinas. No mate, o maior teor delas ocorre nos frutos imaturos. Os fungos promovem sérias micoses invasivas em indivíduos com a saúde comprometida. Sendo assim, este trabalho objetiva avaliar o potencial antimicótico do extrato aquoso e de uma fração purificada de saponinas, ambos obtidos de frutos verdes do mate, frente aos principais fungos causadores de micoses. Visa também o estudo da associação entre a fração de saponinas e o fluconazol. Inicialmente foram avaliadas quanto à susceptibilidade 16 espécies, entre fungos leveduriformes e filamentosos. Nove Candida spp. foram selecionadas para os estudos de CIM, de associação por Checkerboard e pela metodologia de superfície de resposta, e por fim para pesquisa do mecanismo de ação. As espécies de Candida foram mais sensíveis a associação da fração de saponinas com fluconazol, que aos mesmos isoladamente. A associação foi capaz de reverter à resistência ao fluconazol em alguns isolados. Os testes de mecanismo de ação revelaram variações entre os isolados, não sendo possível afirmar apenas um mecanismo geral de ação da combinação. Ensaios microscópicos revelaram um predomínio do brotamento e a presença de um material viscoso em torno das leveduras, enquanto que o ergosterol exógeno revelou a possibilidade de interação com as saponinas, interferindo na atividade antifúngica. / Ilex paraguariensis is an important native plant from South America, generally known as Yerba Mate, which is traditionally consumed as an infusion made from the leaves. Many health benefits have been mentioned for the use of its constituents, including the saponins. Several pharmacological properties are atributed to the saponins, where it´s highest content can be found in mate green fruits. The fungi promote serious invasive mycoses in individuals with compromised health. Thus, this study aims to evaluate the antifungal potential of the crude extract and the purified saponins fraction, both obtained from unripe mate fruits, in the treatment of mycoses causing fungi. It also aims evaluate the antifungal association of saponins fraction and fluconazole. At first were evaluated the susceptibilities of 16 species, including yeasts and filamentous fungi. Nine Candida spp. were selected for the studies of minimal inhibitory concentration, association assay, checkerboard, response surface methodology, and finally to investigate the antifungal action mechanism. Candida species were more susceptible to the fraction of saponins more fluconazole, than the neat substances. Their association was able to reverse fluconazole resistance in some isolates. The mechanism of action assays revealed variations between the isolates, then, it was not possible to explain a general mechanism of action for this antifungal activity. Microscopic studies demonstrated a predominance of buds and a viscous liquid around the cells. Furthermore, exogenous ergosterol showed the possibility of interaction with saponins, interfering antifungal activity.

Memoria para optar al título de Químico Farmacéutico / La creciente resistencia a los fármacos antifúngicos es un problema de salud pública mundial. Según estadísticas de la Organización Mundial de la Salud (OMS), las infecciones por estos patógenos han aumentado por diversas causas entre las que se encuentran el aumento de pacientes inmunocomprometidos y el uso masivo de antibióticos de amplio espectro. Lo más alarmante es la alta tasa de morbilidad que exhibe este tipo de infecciones, las que se asocian con una alta tasa de resistencia a los fármacos actualmente ocupados. Uno de los mecanismos de resistencia más relevantes es la formación de biofilms, que se definen como comunidades microbianas rodeadas por una matriz de sustancias poliméricas extracelulares, la cual les otorgaría una protección mecánica frente a la acción de antimicrobianos. Una de las patologías donde la formación de biofilms está directamente asociada con el fracaso terapéutico es la estomatitis protésica, una inflamación crónica de la mucosa oral en contacto con una prótesis removible y que tiene una directa asociación con la presencia de biofilms de levaduras del género Candida. Por estas razones es de gran interés investigar novedosas estrategias farmacológicas para reducir o revertir los biofilms. Debido al escaso desarrollo de nuevas moléculas antifúngicas, es que se ha buscado potenciar el efecto de los antifúngicos convencionales con fármacos “no antimicrobianos”. En este sentido, se ha descrito que los antiinflamatorios no esteroidales (AINES), que inhiben la formación de prostaglandinas, poseen efecto antibiofilm. Esto estaría relacionado con el rol de la Prostaglandina E2 en los procesos claves involucrados en la formación de biofilms; entre ellos, la morfogénesis de Candida y la adhesión a superficies abióticas. Entre los AINES destaca la aspirina que es la que ha presentado mejor efecto antibiofilm. Otra molécula de interés como agente antimicrobiano, es el óxido nítrico (NO), cuya acción se ha ensayado con compuestos dadores de NO como el nitroprusiato de sodio o el isosorbide mononitrato. Estos han presentado efectos antibiofilm presumiblemente por los efectos antimicrobianos que presentan el NO y por su capacidad como inmunomodulador. Por estas razones en esta investigación se evaluó el efecto antibiofilm de la aspirina liberadora de óxido nítrico, cuya estructura aparece en la Figura 1; en este caso el efecto sobre los biofilms sería dual. En este trabajo se determinó la susceptibilidad a fluconazol de los aislados clínicos de C. albicans y se cuantificó el efecto antibiofilm de la aspirina liberadora de óxido nítrico. Para este efecto, se evaluaron los siguientes parámetros: adhesión, morfogénesis, morfología de los biofilms y viabilidad de los biofilms en presencia de fluconazol y aspirina liberadora de óxido nítrico. Este último fármaco fue eficaz sobre los biofilms, pero su efecto no fue sinérgico en presencia de fluconazol, confirmando que fluconazol no presenta efecto antifúngico frente a los biofilms. Estos resultados son prometedores y nuevos estudios están en progreso para confirmar su posible uso en este tipo de patologías / The growing resistance to antifungal drugs is a global public health problem. According to statistics from the World Health Organization (WHO), infections with these pathogens have increased for various reasons, among which are the increase of immunocompromised patients and the widespread use of broadspectrum antibiotics. Most alarming is the high rate of morbidity exhibiting these infections, which are associated with a high rate of resistance to drugs currently occupied. One of the most important mechanisms of resistance is the formation of biofilms, which are defined as microbial communities surrounded by a matrix of extracellular polymeric substances, which would provide them with mechanical protection against the action of antimicrobials. One of the conditions where the formation of biofilms is directly associated with treatment failure is denture stomatitis, a chronic inflammation of the oral mucosa in contact with a removable prosthesis and has a direct association with the presence of biofilms of Candida yeasts. For these reasons it is of great interest to investigate novel pharmacological strategies to reduce or reverse the biofilms. Due to the limited development of new antifungal molecules it is that they have sought to enhance the effect of conventional antifungals with "no antimicrobial" drugs. In this regard, it described those nonsteroidal anti-inflammatory drugs (NSAIDs) which inhibit the formation of prostaglandins, have antibiofilm effect. This would be related to the role of Prostaglandin E2 in the key processes involved in the formation of biofilms; including Candida morphogenesis and adherence to abiotic surfaces. Among the highlights NSAIDs aspirin presents the antibiofilm best effect. Another molecule of interest as an antimicrobial agent is nitric oxide (NO), whose action has been tested with NO donor compounds such as sodium nitroprusside or isosorbide mononitrate. These have presented antibiofilm effects presumably by antimicrobial effects of NO and its ability as an immunomodulatory agent. For these reasons in this investigation antibiofilm effect of aspirin releasing nitric oxide, was evaluated; in this case the effect on biofilms would be dual. Therefore, we evaluated fluconazole susceptibility of C. albicans clinical isolates and quantified the antibiofilm effect of aspirin releasing nitric oxide. For this purpose, adhesion, morphogenesis, morphology and viability of biofilms in the presence of fluconazole biofilms and aspirin releasing nitric oxide were evaluated. The latter drug was effective against biofilms, but its effect was not synergistic with those of fluconazole. This confirmed that fluconazole have no effect against biofilms. These results are promising and further studies are in progress to confirm their possible use in this type of pathology

Infections with the opportunistic yeast Candida albicans are frequently treated with the first-line drug fluconazole, which inhibits ergosterol biosynthesis. An alarming problem in clinics is the development of resistances against this azole, especially during long-term treatment of patients. Well-known resistance mechanisms include mutations in the zinc cluster transcription factors (ZnTFs) Mrr1 and Tac1, which cause an overexpression of efflux pump genes, and Upc2, which results in an overexpression of the drug target. C. albicans strains with such gain-of-function mutations (GOF) have an increased drug resistance conferring a selective advantage in the presence of the drug. It was previously shown that this advantage comes with a fitness defect in the absence of the drug. This was observed in different conditions and is presumably caused by a deregulated gene expression. One aim of the present study was to examine whether C. albicans can overcome the costs of drug resistance by further evolution. Therefore, the relative fitness of clinical isolates with one or a combination of different resistance mutations in Mrr1, Tac1 and/or Upc2 was analyzed in competition with the matched fluconazole-susceptible partner. Most fluconazole-resistant isolates had a decreased fitness in competition with their susceptible partner in vitro in rich medium. In contrast, three fluconazole-resistant strains with Mrr1 resistance mutations did not show a fitness defect in competition with their susceptible partner. In addition, the fitness of four selected clinical isolate pairs was examined in vivo in mouse models of gastrointestinal colonization (GI) and disseminated infection (IV). In the GI model all four fluconazole-resistant strains were outcompeted by their respective susceptible partner. In contrast, in the IV model only one out of four fluconazole-resistant isolates did show a slight fitness defect in competition with its susceptible partner during infection of the kidneys. It can be stated, that in the present work the in vitro fitness did not reflect the in vivo fitness and that the overall fitness was dependent on the tested conditions. In conclusion, C. albicans cannot easily overcome the costs of drug resistance caused by a deregulated gene expression. In addition to GOFs in Mrr1, Tac1 and Upc2, resistance mutations in the drug target Erg11 are a further key fluconazole resistance mechanism of C. albicans. Clinical isolates often harbor several resistance mechanisms, as the fluconazole resistance level is further increased in strains with a combination of different resistance mutations. In this regard, the question arises of how strains with multiple resistance mechanisms evolve. One possibility is that strains acquire mutations successively. In the present study it was examined whether highly drug-resistant C. albicans strains with multiple resistance mechanisms can evolve by parasexual recombination as another possibility. In a clonal population, cells with individually acquired resistance mutations could combine these advantageous traits by mating. Thereupon selection could act on the mating progeny resulting in even better adapted derivatives. Therefore, strains heterozygous for a resistance mutation and the mating type locus (MTL) were grown in the presence of fluconazole. Derivatives were isolated, which had become homozygous for the resistance mutation and at the same time for the MTL. This loss of heterozygosity was accompanied by increased drug resistance. In general, strains which are homozygous for one of both MTL configurations (MTLa and MTLα) can switch to the opaque phenotype, which is the mating-competent form of the yeast, and mate with cells of the opposite MTL. In the following, MTLa and MTLα homozygous strains in the opaque phenotype were mated in all possible combinations. The resulting mating products with combined genetic material from both parents did not show an increased drug resistance. Selected products of each mating cross were passaged with stepwise increasing concentrations of fluconazole. The isolated progeny showed high levels of drug resistance and loss of wild-type alleles of resistance-associated genes. In conclusion, selective pressure caused by fluconazole exposure selects for resistance mutations and at the same time induces genomic rearrangements, resulting in mating competence. Therefore, in a clonal population, cells with individually acquired resistance mutations can mate with each other and generate mating products with combined genetic backgrounds. Selection can act on these mating products and highly drug-resistant und thus highly adapted derivatives can evolve as a result. In summary, the present study contributes to the current understanding of the evolution of antifungal drug resistance by elucidating the effect of resistance mutations on the fitness of the strains in the absence of the drug selection pressure and investigates how highly drug-resistant strains could evolve within a mammalian host. / Infektionen mit dem opportunistischen Hefepilz Candida albicans werden häufig mit dem First-Line-Medikament Fluconazol behandelt, welches die Ergosterol-Biosynthese hemmt. Ein besorgniserregendes Problem in der Klinik, insbesondere bei der Langzeitbehandlung von Patienten, ist die Entwicklung von Resistenzen gegen dieses Azol. Zu den bekannten Resistenzmechanismen gehören Resistenzmutationen in den Zink-Cluster-Transkriptionsfaktoren (ZnTFs) Mrr1 und Tac1, die eine Überexpression von Effluxpumpen-Genen bewirken und Resistenzmutationen in Upc2, die zu einer Überexpression des Wirkstofftargets führen. C. albicans Stämme mit solchen Gain-of-Function-Mutationen (GOF) weisen eine erhöhte Medikamentenresistenz auf, was einen selektiven Vorteil in Gegenwart des Medikaments bedeutet. Es wurde zuvor gezeigt, dass dieser Vorteil mit einem Fitnessdefekt in Abwesenheit des Medikaments einhergeht. Dies wurde in verschiedenen Bedingungen nachgewiesen und wird vermutlich durch eine deregulierte Genexpression verursacht. Ein Ziel der vorliegenden Studie war es zu untersuchen, ob C. albicans die Kosten der Medikamentenresistenz durch Evolution kompensieren kann. Daher wurde die relative Fitness von klinischen Isolaten mit einer oder einer Kombination verschiedener Resistenzmutationen in Mrr1, Tac1 und/oder Upc2 im Wettbewerb mit dem zugehörigen Fluconazol-sensitiven Partner analysiert. Die meisten Fluconazol-resistenten Isolate hatten eine verminderte Fitness im Wettbewerb mit ihrem sensitiven Partner in vitro in vollwertigem Medium. Dennoch zeigten drei Fluconazol-resistente Stämme mit Mrr1-Resistenzmutationen keinen Fitnessdefekt im Wettbewerb mit ihrem jeweiligen Partner. Zusätzlich wurde die Fitness von vier ausgewählten klinischen Isolat-Paaren in vivo in Mausmodellen für gastrointestinale Kolonisation (GI) und disseminierte Infektion (IV) untersucht. Im GI-Modell wurden alle vier Fluconazol-resistenten Stämme von ihren sensitiven Partnern überwachsen. Im Gegensatz dazu zeigte im IV-Modell nur einer der vier Fluconazol-resistenten Isolate einen leichten Fitnessdefekt im Wettbewerb mit dem jeweiligen Fluconazol-sensitiven Partner während der Infektion der Nieren. Es kann festgestellt werden, dass in der vorliegenden Arbeit die in vitro-Fitness nicht die in vivo-Fitness widerspiegelt und dass die Gesamtfitness von den getesteten Bedingungen abhängig ist. Zusammenfassend lässt sich sagen, dass C. albicans die Kosten der Medikamentenresistenz, die durch eine deregulierte Genexpression verursacht werden, nur schwer überwinden kann. Neben GOFs in Mrr1, Tac1 und Upc2 sind Resistenzmutationen im Wirkstofftarget Erg11 ein wichtiger Resistenzmechanismus von C. albicans. Klinische Isolate weißen oft mehrere Resistenzmechanismen auf, da die Kombination verschiedener Resistenzmutationen die Fluconazol-Resistenz potenziert. In diesem Zusammenhang stellt sich die Frage, wie sich Stämme mit mehreren Resistenzmechanismen entwickeln. Eine Möglichkeit ist, dass Stämme Mutationen sequenziell erwerben. In der vorliegenden Studie wurde untersucht, ob als weitere Möglichkeit hochresistente C. albicans Stämme mit multiplen Resistenzmechanismen durch parasexuelle Rekombination evolvieren können. In einer klonalen Population könnten Zellen mit individuell erworbenen Resistenzmutationen diese vorteilhaften Eigenschaften durch Paarung kombinieren. Daraufhin könnte Selektionsdruck auf die Matingprodukte wirken und so die Entstehung von besser angepassten Derivaten begünstigen. Daher wurden Resistenzmutation und Mating Type Locus (MTL) heterozygote Stämme in Gegenwart von Fluconazol kultiviert. So konnten Derivate isoliert werden, die homozygot für die Resistenzmutation und gleichzeitig für den MTL geworden waren. Dieser Verlust der Heterozygotie ging mit einer erhöhten Medikamentenresistenz einher. Generell können Stämme, die homozygot für eine der beiden MTL-Konfigurationen (MTLa und MTLα) sind, in den opaque Phänotyp wechseln, der die paarungskompetente Form der Hefe darstellt, und sich mit Zellen des gegensätzlichen MTL paaren. Im Folgenden wurden MTLa und MTLα homozygote Stämme im opaque Phänotyp in allen möglichen Kombinationen verpaart. Die resultierenden Matingprodukte mit kombiniertem genetischem Material beider Elternteile wiesen keine erhöhte Medikamentenresistenz auf. Ausgewählte Paarungsprodukte jeder Kreuzung wurden mit stufenweise ansteigenden Konzentrationen von Fluconazol passagiert. Die isolierten Nachkommen zeigten ein hohes Maß an Medikamentenresistenz und den Verlust von Wildtyp-Allelen der resistenzassoziierten Gene. Zusammenfassend lässt sich sagen, dass der selektive Druck, der durch die Fluconazol-Exposition verursacht wird, für Resistenzmutationen selektiert und gleichzeitig genomische Umlagerungen induziert, die eine Paarung ermöglichen. Daher können sich in einer klonalen Population Zellen mit individuell erworbenen Resistenzmutationen miteinander paaren und Matingprodukte mit kombiniertem genetischem Hintergrund generieren. Auf diese Matingprodukte kann die Selektion wirken, woraufhin sich hochresistente und damit stark an ihre Umwelt angepasste Derivate entwickeln können. Zusammenfassend trägt die vorliegende Studie zum aktuellen Verständnis der Evolution der Antimykotika-Resistenz bei, indem sie den Effekt von Resistenzmutationen auf die Fitness der Stämme in Abwesenheit des Medikamenten-Selektionsdrucks untersucht und aufklärt, wie sich hochgradig resistente Stämme in einem Säugetierwirt entwickeln könnten.

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.

No description available.

El presente estudio ha tenido como interés evaluar, en pacientes ambulatorios con onicomicosis del pie atendidos en Consultorios Externos de Dermatología del Hospital Militar Central, el aspecto de seguridad a nivel hepático de los antimicóticos (fluconazol y terbinafina vía oral). Para ello, se realizó la monitorización y evaluación del perfil bioquímico hepático de los pacientes. El diseño del trabajo fue de tipo descriptivo, longitudinal y prospectivo. Se selecciono, de una población de 143 pacientes, a 24, de los cuales 11 presentaron alteración en el perfil hepático, control final, durante el tratamiento con fluconazol o terbinafina, detectándose hepatotoxicidad grado uno, en tres pacientes: dos de ellos tomaban fluconazol y uno terbinafina; el resto de pacientes no presentaron hepatotoxicidad. La prevalencia de hepatotoxicidad grado uno fue 12,5% del total de 24 pacientes, y la alteración del perfil hepático, 45,8% del total. Al análisis estadístico, se encontró que no existe diferencia significativa (p > 0,05) entre el tratamiento con fluconazol o terbinafina vía oral, edad, género, resultados basales de transaminasas glutámico oxalacética y glutámico pirúvica, colesterol, triglicéridos y los resultados del perfil hepático control final de los pacientes durante el tratamiento antimicótico. Los 11 pacientes con alteración del perfil hepático, control final, presentaron factores de riesgo para hepatotoxicidad como hábito nocivo (ingesta de bebidas alcohólicas); enfermedades de antecedente, al basal o al control (trastorno del metabolismo de las lipoproteínas y otras lipidemias, hepatomegalia, patología biliar, diabetes mellitus, esteatosis hepática, sospecha de esteatosis hepática o de esteatohepatitis no alcohólica con dos o tres factores de riesgo); condición fisiológica a la captación (adulto mayor, sobrepeso u obesidad), y toma de medicamentos concomitantes. En conclusión, la mayor influencia en la alteración del perfil hepático control final habría sido la sospecha de esteatosis hepática o de esteatohepatitis no alcohólica con dos factores de riesgo (cuatro casos), seguida por la atorvastatina como tratamiento concomitante (dos casos). De los 11 pacientes con alteración del perfil hepático, siete tomaron fluconazol, se sospechó que éste tuvo causalidad condicional para tres de los siete, y para los restantes cuatro pacientes de tratamiento con terbinafina, que ésta tuvo causalidad posible para dos de los cuatro, como predominantes, por aplicación del Algoritmo de Decisión para la Evaluación de Causalidad de una RAM. Incluido en los casos citados, estuvieron los tres casos de hepatotoxicidad, y por aplicación del Algoritmo referido, se hallo que fluconazol ha tenido causalidad improbable para un caso y para el otro, condicional; para el caso de terbinafina, tuvo causalidad posible. Palabras clave: transaminasas, gamma-glutamiltransferasa, bilirrubina, agentes antifúngicos, onicomicosis, hepatotoxicidad. / This study has been to assess interest in ambulatory patients with onychomycosis of the foot seen at the Dermatology Outpatient Hospital Central Militar, the security aspect in the liver of antifungals (fluconazole and terbinafine orally). To do this, we performed the monitoring and assessment of hepatic biochemical profile of patients. The research design was descriptive, longitudinal and prospective. Was selected from a population of 143 patients, 24 of which 11 patients showed abnormal liver profile, final inspection, during treatment with fluconazole or terbinafine, a grade hepatotoxicity detected in three patients: two of them taking fluconazole and a terbinafine, and the remaining patients showed no hepatotoxicity. The prevalence of hepatotoxicity was 12.5% level a total of 24 patients, and abnormal liver profile, 45.8% of the total. The statistical analysis, they found no significant difference (p> 0,05) between treatment with fluconazole or oral terbinafine, age, gender, baseline results glutamic oxaloacetic transaminase and glutamic pyruvic transaminase, cholesterol, triglycerides and liver profile monitoring results end of patients during antifungal therapy. The 11 patients with abnormal liver profile, final inspection, had risk factors for hepatotoxicity as harmful habit (alcohol intake), diseases of background, the baseline or control (disorder of lipoprotein metabolism and other lipidemias, hepatomegaly, biliary disease, diabetes mellitus, hepatic steatosis, suspicion of hepatic steatosis or of nonalcoholic steatohepatitis with two or three risk factors); physiological condition to uptake (elderly, overweight or obese), and taking concomitant medications. In conclusion, the greatest influence on the abnormal liver profile final check would have been the suspicion of hepatic steatosis or of nonalcoholic steatohepatitis with two risk factors (four cases), followed by concomitant atorvastatin (two cases). Of the 11 patients with abnormal liver profile, seven took fluconazole, was suspected that this was conditional causality for three of the seven, and for the remaining four patients treated with terbinafine, it was possible causality for two of the four, as predominant, by application of Decision Algorithm for the Evaluation of Causality of ADR. Included in the cases cited, were the three cases of hepatotoxicity, and by applying the algorithm mentioned, it was found that fluconazole causality unlikely to have had a case and for the other conditional, in the case of terbinafine, causality was possible. Keywords: transaminase, gamma-glutamyltransferase, bilirubin, antifungal agents, onychomycosis, hepatotoxicity.

A ceratite fúngica é uma doença grave que pode levar à perda da visão. O tratamento consiste na aplicação de antifúngicos, no entanto a administração tópica não tem se mostrado efetiva devido aos mecanismos de defesa do olho que levam à baixa retenção da formulação no local de aplicação e à baixa permeação do fármaco através da córnea. Sendo assim, formulações mais adequadas e sistemas de liberação vêm sendo estudados na tentativa de melhorar a biodisponibilidade local de antifúngicos. No presente trabalho foram obtidos e caracterizados dois sistemas para a liberação ocular do fluconazol (FLU), um antifúngico de atividade reconhecida: um gel termorreversível in situ e micropartículas poliméricas. A permeação passiva e iontoforética do fármaco através da córnea foi estudada in vitro a partir dos sistemas desenvolvidos. O gel termorreversível in situ contendo 16% de poloxamer e 1,0% de quitosana apresentou temperatura de geleificação adequada, propriedades mucoadesivas, melhores parâmetros mecânicos (dureza, compressibilidade e adesividade) que ambos os polímeros separadamente e mostrou-se superior que micropartículas poliméricas, com fluxo de permeação passiva cerca de duas vezes maior. A maior quantidade de fármaco retido na córnea foi obtida após aplicação da iontoforese em solução aquosa do fármaco. Ainda assim, o fluxo iontoforético do FLU não foi significativamente diferente do fluxo passivo a partir do gel termorreversível. O desempenho in vivo desta formulação foi então avaliado em modelo animal. Estudos de permeação, utilizando a técnica de microdiálise para amostragem da câmara anterior, confirmaram a maior biodisponibilidade do fármaco. Por fim, exames de cintilografia em humanos confirmaram maior tempo de retenção na superfície ocular. Portanto, o gel termorreversível in situ obtido e caracterizado no presente trabalho e a iontoforese, representam sistemas promissores para a liberação ocular tópica do FLU. O primeiro possui características promotoras de permeação, prolongado tempo de retenção e facilidade de obtenção e administração, e o segundo é capaz de promover maior retenção do fármaco na córnea. / Fungal keratitis is a serious disease that can lead to loss of sight. The treatment consists in antifungal application; however topical administration has not shown to be effective due to defense mechanisms of the eye, which leads to low retention at the application site and low permeation of the drug trough the cornea. In this way, more suitable formulations and delivery systems have been studied in an attempt to increase local availability of antifungal agents. At the present work it was obtained and characterized two systems for the passive and iontophoretic ocular delivery of fluconazole (FLU), a well known antifungal agent: an in situ forming gel and polymeric microparticles. Passive and iontophoretic drug permeation across the cornea was studied in vitro from the developed systems. The in situ forming gel containing 16% of poloxamer and 1.0% of chitosan presented more adequate gelation temperature, mucoadhesive properties, improved mechanical parameters (strength, compressibility and adhesiveness) than both polymers separately and showed to be superior to the polymeric microparticles, with passive permeation flux almost twice higher. The greatest amount of drug retained in the cornea was achieved after iontophoresis application using an aqueous solution of the drug. Even though, the iontophoretic drug flux was not significantly different from the passive drug flux using the in situ forming gel. The in vivo performance of this formulation was then evaluated in an animal model. Permeation studies, using the microdialysis technique for the anterior chamber sampling, confirmed the increased drug availability. At the end, scintigraphy exams in humans confirmed the greater retention time at the ocular surface. Therefore, the in situ forming gel obtained and characterized at the present work and iontophoresis, represent promising systems for the topical ocular delivery of FLU. The first possess permeation enhancement properties, prolonged retention time and facility of obtention and administration, and the second is capable of promoting higher drug retention in the cornea.

As infecções fúngicas se tornaram um grande problema de saúde pública, especialmente em ambientes hospitalares. Candida spp. são os principais patógenos em infecções fúngicas invasivas. A produção de aspartato proteases secretadas (Sapp) por Candida spp. pode estar relacionado com o aumento do número de infecções e resistência aos medicamentos. A produção de proteases é codificada por uma família de 10 genes SAP1-10, sendo SAP2 o gene mais comumente expresso em Candida albicans. A expressão de SAP4 está associada à produção de enzimas Sap4p e formação de hifas que podem contribuir para a invasão dos tecidos hospedeiros e destruição de macrófagos em processos infecciosos. Este trabalho avaliou a expressão dos genes SAP2 e SAP4 em C. albicans ATCC 10231 cultivadas na presença ou ausência de macrófagos e expostas a concentrações subinibitórias de fluconazol e anfotericina B. Candida albicans foi cultivada em ágar Sabouraud Dextrose a 37ºC por 24 h, e posteriormente em caldo carbono levedura base enriquecido com soro-albumina bovina (YCB-BSA), e na ausência ou presença de concentrações subinibitórias de fluconazol e anfotericina B. A linhagem celular monocítica humana de origem leucemia (THP-1) foi cultivada em meio RPMI-1640 suplementado com 10% de soro fetal bovino, penicilina (100 U/ml) e estreptomicina (100 μg/ml) a 37ºC, sob atmosfera de 5% de CO2 durante 10 dias. Para a indução da diferenciação das células, 106 monócitos foram cultivados em meio RPMI-1640 suplementado e forbol-12-miristato-13-acetato (PMA) 100 nM durante 48 h. Foram utilizadas amostras de 5x106 C. albicans cultivadas na presença ou ausência de 106 macrófagos e expostas ou não a concentrações subinibitórias de antifúngicos. A amostras foram cultivadas em placas de cultura celular com 6 poços por 1 h a 37 °C, sob atmosfera de 5% de CO2. O RNA total foi extraído das amostras utilizando o reagente TRIzol®, após a purificação do RNA com DNase I, este foi convertido em cDNA, e, em seguida, a quantificação do gene SAP4 foi realizada por Reação em Cadeia de Polimerase quantitativa (qPCR) utilizando ACT1 como gene normalizador. Candida albicans cultivada na presença de macrófagos apresentou regulação positiva na expressão de SAP2 e SAP4 (p < 0,01), respectivamente, na ordem de 4,83 e 10,34 vezes maior se comparada com amostras da levedura cultivada sem contato com macrófagos. E ainda, a exposição de C. albicans a concentrações subinibitórias de fluconazol aumentou a expressão de SAP2 e diminuiu a expressão de SAP4, já a exposição da levedura a concentrações subinibitórias de anfotericina B diminuiu a expressão de SAP2 e SAP4. Os genes SAP2 e SAP4 são relacionados como fatores de virulência de C. albicans e sua expressão pode ser regulada pelo contato com fagócitos ou exposição a antifúngicos. Portanto, compreender a expressão desses genes na patogênese fúngica pode ajudar na pesquisa e desenvolvimento de novos medicamentos para o tratamento da candidíase, contribuindo assim para a redução da incidência de morbidade e mortalidade associada a infecções fúngicas. / Fungal infections have become a major public health problem especially in hospital settings. Candida spp. are considered the main pathogen in invasive fungal infections. The production of secreted aspartic proteinases (Sapp) by Candida spp. can be related to the increase in the number of infections and drug resistance. The production of proteinases is encoded by a family of 10 genes known as SAP1-10, of which, SAP2 is the most commonly expressed gene in Candida albicans. The expression of SAP4-6 is associated to the production of Sap4-6p enzymes and hyphae formation which can contribute to the invasion of host tissues and destruction of macrophages during infectious processes. This study evaluates SAP2 and SAP4 gene expression in C. albicans ATCC 10231 grown in the presence or absence of macrophages and exposed to subinibitory concentrations of fluconazole and amphotericin B. C. albicans was grown in Sabouraud Dextrose Agar for 24 h at 37ºC and after in yeast carbon base more 0.2% bovine serum albumin (YCB-BSA) in the absence or presence of subinibitory concentrations of Fluconazole and Amphotericin B. The human monocytic leukemia cell line (THP-1) was grown in RPMI-1640 Medium supplemented with 10% fetal bovine serum, penicillin (100U/ml) and streptomycin (100μg/ml) at 37 °C and atmosphere of 5% CO2 during 10 days. For the induction of cell differentiation, 106 cells were seeded in RPMI-1640 medium supplemented and phorbol 12-myristate 13-acetate (PMA) 100 nM for 48 h. The samples of 5x106 C. albicans were cultured in the presence or absence of 106 macrophages and these was exposed or not to subinibitory concentrations of antifungals. All samples were incubated in culture test plates with 6 flat-botton wells for 1 h at 37 °C and atmosphere of 5% CO2. Total RNA was extracted from the samples using TRIzol® reagent, after RNA purification with DNaseI it was converted to cDNA, and then, the relative quantification of the SAP4 gene was performed by Real-Time Polymerase Chain Reaction (qPCR) using ACT1 gene as normalizing endogenous gene. Candida albicans grown in the presence of macrophages showed upregulation in the expression of SAP2 and SAP4 (p < 0.01), respectively, in the order of 4.83 and 10.34 fold higher as compared to yeast samples grown without contact with macrophages. Concerning exposure to antifungal agents, C. albicans exposed to subinhibitory concentrations of amphotericin B showed downregulation in expression of SAP2 and SAP4. However, the yeast's exposure to subinhibitory concentrations of fluconazole caused upregulation in SAP2 expression and downregulation in SAP4 expression. SAP2 and SAP4 genes are related to virulence factors of C. albicans and its expression can be regulated by contact with phagocytes or exposure to antifungals. Therefore, understanding the expression of these genes in fungal pathogenesis may aid in research and development of new drugs for treating candidiasis, thus contributing to reducing the incidence of morbidity and mortality associated with fungal infections. / Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - CAPES

A participação das espécies reativas de oxigênio (ERO) no mecanismo de ação dos antifúngicos azólicos, bem como a relação entre resistência aos antifúngicos e resposta ao estresse oxidativo, têm sido sugeridos. Entretanto, os dados ainda são inconclusivos e diferem entre os micro-organismos. Neste estudo estão apresentados os resultados da geração de ERO pelo fluconazol em isolados de C. glabrata sensíveis e resistentes a esse antifúngico e a resposta antioxidante da levedura. Nesses isolados, tratados e não tratados com fluconazol em concentração subinibitória, de acordo com sua concentração inibitória mínima (CIM), até fase de crescimento estacionário, foi avaliado se o fluconazol geraria ERO. Subsequentemente, foram analisadas as defesas antioxidantes glutationa peroxidase (GPx), superóxido dismutase (SOD), glutationa-S-transferase (GST), consumo de peróxido de hidrogênio e glutationa total, bem como possível dano oxidativo causado pelo fluconazol em lipídeos, proteínas e ácidos nucleicos e os níveis de nitritos e nitratos. Os resultados mostram que nos isolados de C. glabrata sensíveis e resistentes ao fluconazol, na presença do antifúngico, houve um aumento da geração ERO e maior atividade enzimática da GPx e SOD comparada a dos isolados não tratados com fluconazol, não havendo diferença estatística entre isolados sensíveis e resistentes nesses três parâmetros citados. Em relação à enzima GST, os isolados sensíveis mostraram maior atividade enzimática comparada aos resistentes, e quando as células sensíveis foram tratadas com fluconazol, a atividade da GST diminuiu. O fluconazol não induziu dano oxidativo em proteínas e em lipídeos, entretanto foi observado dano oxidativo ao DNA. Diante disso, sugere-se que o fluconazol gera ERO como parte do seu mecanismo antifúngico em C. glabrata em fase de crescimento estacionário, induzindo dano oxidativo no DNA. Como resposta, observa-se aumento na atividade enzimática da SOD e da GPx na levedura. O entendimento da resposta antioxidante de leveduras patogênicas tem importante interesse clínico, uma vez que o desenvolvimento racional de novas drogas antifúngicas requer conhecimento do metabolismo fúngico. / The participation of reactive oxygen species (ROS) in azoles antifungal mechanism of action has been suggested, as well as the relation between antifungal resistance and oxidative stress response. However, data are still inconclusive and differ between microorganisms. This study presents the results of ROS generation by fluconazole in fluconazole-susceptible and resistant C. glabrata strains and their antioxidant response. It was evaluated whether fluconazole generates ROS in those isolates treated and untreated with fluconazole at sub-inhibitory concentration according to their minimal inhibitory concentration (MIC). This treatment was conducted until stationary growth phase was reached. Subsequently, the antioxidant defenses glutathione peroxidase (GPx), superoxide dismutase (SOD), glutathione-S-transferase (GST), consumption of hydrogen peroxide and total glutathione, the possible oxidative damage in lipids, proteins and nucleic acids and the levels of nitrites and nitrates were analyzed. Results showed increased ROS generation in fluconazole-susceptible and resistant C. glabrata strains treated with fluconazole, and also higher GPx and SOD enzymatic activity, compared to untreated cells. No statistical difference of those three parameters was observed between susceptible and resistant strains. In relation to GST, susceptible strains demonstrated higher activity compared to the resistant ones, and when susceptible cells were treated with fluconazole the GST activity decreased compared to untreated. Fluconazole did not induce oxidative damage in proteins and in lipids, however oxidative DNA damage was observed. Therefore, it is suggested that fluconazole generates ROS as part of its antifungal mechanism in C. glabrata at stationary growth phase, inducing oxidative DNA damage. In response, there was increase in the enzymatic activity of SOD and GPx in yeast. The understanding of the pathogenic yeast antioxidant response has important clinical interest, since the rational development of new antifungal drugs requires knowledge about the fungal metabolism.