The Antifungal Pipeline: Fosmanogepix, Ibrexafungerp, Olorofim, Opelconazole, and Rezafungin

A bibliometric and visual analysis of the research status and hotspots of Pulmonary Aspergillosis based on web of science

BACKGROUND

Pulmonary Aspergillosis (PA) is a common fungal lung infection. Despite recent advancements, bibliometric studies on PA are scarce. This study uses bibliometric methods to analyze current research trends and key topics, offering insights into future directions in the field.

METHODS

PA-related literature was retrieved from the Web of Science Core Collection (WOSCC) database, and detailed analysis was conducted using CiteSpace, VOSviewer, and Excel 2019 software. This analysis aimed to identify trends and hot topics in the field of PA.

RESULTS

A total of 1,715 articles were analyzed from 1900 to 2024. The number of publications has shown steady growth, with a gradual increase from 1990 to 2019, followed by a sharp rise after 2019. The United States leads in this field. The main research hotspots and frontiers in PA include: the close association between PA and immunocompromised conditions, COVID-19 as a new risk factor for PA, and current clinical research focusing on antifungal treatments and enhancing host immunity.

CONCLUSION

This study reveals trends in PA research, notably the sharp increase in publications post-2019. Novel findings include the identification of COVID-19 as a new risk factor for PA and the growing emphasis on antifungal treatments and host immunity enhancement. These insights provide a clearer direction for future clinical and research priorities in PA.

Exploring the intricacies of antimicrobial resistance: Understanding mechanisms, overcoming challenges, and pioneering innovative solutions

Antimicrobial resistance (AMR) poses a growing global threat. This review examines AMR from diverse angles, tracing the story of antibiotic resistance from its origins to today's crisis. It explores the rise of AMR, from its historical roots to the urgent need to counter this escalating menace. The review explores antibiotic classes, mechanisms, resistance profiles, and genetics. It details bacterial resistance mechanisms with illustrative examples. Multidrug-resistant bacteria spotlight AMR's resilience. Modern AMR control offers hope through precision medicine, stewardship, combination therapy, surveillance, and international cooperation. Converging traditional and innovative treatments presents an exciting frontier as novel compounds seek to enhance antibiotic efficacy. This review calls for global unity and proactive engagement to address AMR collectively, emphasizing the quest for innovative solutions and responsible antibiotic use. It underscores the interconnectedness of science, responsibility, and action in combatting AMR. Humanity faces a choice between antibiotic efficacy and obsolescence. The call is clear: unite, innovate, and prevail against AMR.

Fungal cell wall biogenesis: structural complexity, regulation and inhibition

The cell wall is the defining organelle of filamentous and yeast-like fungi. It is responsible for morphology, biotic and abiotic interactions and its components confer its unique and variable signature, making it a natural target for antifungal drugs, but a moving target for immune recognition. The wall is however more than the sum of its many parts. The polysaccharides and proteins of the cell wall must be made at the right time and the right place, but also linked together and remodelled throughout the cell cycle and in response to environmental challenges, nutrient availability, damage after predation and to be complaint to the need to establish mutualistic and parasitic associations. This review summarises recent advances in our understanding of the complex and vital process of fungal cell wall biogenesis using the human pathogens Candida albicans and Aspergillus fumigatus as the principal model fungi.

Fungal biofilms in human health and disease

Increased use of implanted medical devices, use of immunosuppressants and an ageing population have driven the rising frequency of fungal biofilm-related diseases. Fungi are now recognized by the World Health Organization (WHO) as an emergent threat to human health, with most medically important species defined as critical or high-priority organisms capable of forming biofilms. Although we strive for a better understanding of diagnostic and therapeutic approaches to detect and treat these fungal diseases more generally, the issue of hard-to-treat biofilms is an ever-increasing problem. These are communities of interspersed cells that are attached to one another on a surface, such as a catheter, or trapped into a cavity such as a paranasal sinus. Biofilms are difficult to detect, difficult to remove and intrinsically tolerant to most antifungal agents. These factors can lead to devastating consequences for the patient, including unnecessary morbidity and mortality, need for reoperations and prolonged hospital stay. This Review describes the breadth and growing impact fungal biofilms have on patient management and explains the mechanisms promoting biofilm formation, focusing on how targeting these can improve therapeutic options.

New treatment options for critically important WHO fungal priority pathogens

BACKGROUND

Yet often overlooked in public health discourse, fungal infections pose a crucial global disease burden associated with annual mortality rates approximately equal to tuberculosis and HIV. In response, the WHO published its first global priority list of fungal pathogens in 2022 assigning Aspergillus fumigatus, Candida albicans, Candida auris, and Cryptococcus neoformans to the critical group.

OBJECTIVES

This review provides succinct insights into novel antifungals in development, aiming to contribute valuable information and perspectives with a focus on recent clinical findings and new treatment approaches for critical members of the WHO fungal pathogen priority list.

SOURCES

PubMed literature search using 'Aspergillus fumigatus', 'Cryptococcus neoformans', 'Candida auris', and 'Candida albicans', along with the names of novel antifungal substances, including 'fosmanogepix', 'ibrexafungerp', 'opelconazole', 'oteseconazole', 'MAT2203', 'olorofim', and 'rezafungin' was conducted.

CONTENT

For each critical pathogen, current issues and global clinical data from recent trials are covered. The remarkable development of three new antifungal therapeutics recently receiving Food and Drug Administration approval (ibrexafungerp-June 2021, oteseconazole -April 2022, and rezafungin-March 2023) is outlined, with two more exciting new antifungal substances, namely, olorofim and fosmanogepix expecting approval within the next years. Ibrexafungerp, fosmanogepix, and rezafungin have additionally been granted orphan drug status by the European Medicines Agency in Europe (ibrexafungerp-November 2021, fosmanogepix-July 2022, and rezafungin-January 2024).

IMPLICATIONS

Although the limited number of targets and the emergence of resistance have posed challenges to antifungal treatment, new drugs such as ibrexafungerp, rezafungin, fosmanogepix, or olorofim have shown promising clinical efficacy. These drugs not only provide alternative options for invasive fungal infections but also alleviate treatment in outpatient settings. More clinical data, implementation of stewardship programmes, and surveillance, including utilization of drugs in agriculture, are necessary to prevent resistance development and to ensure the safety and efficacy of these new agents.

In vitro activity of novel antifungals, natamycin, and terbinafine against Fusarium

The genus Fusarium includes several trans-kingdom pathogens, infecting plants, animals, and humans, with widespread occurrence. Invasive Fusarium infections are often destructive due to their prevalence in critically ill patients. Furthermore, severe superficial infections, like keratitis or endophthalmitis with potential loss of vision, are rising in incidence globally. Infections are difficult to treat due to the intrinsic resistance of Fusarium against echinocandins and often high minimal inhibitory concentrations (MICs) for azoles. In this article, we assessed the in vitro activity of the novel antifungals olorofim, manogepix, rezafungin, and ibrexafungerp, as well as the established but nonstandard drugs, natamycin and terbinafine, against a large set of molecularly identified clinical Fusarium isolates via EUCAST microdilution. The tested isolates represent the clinically most relevant species of the F. solani (FSSC), F. oxysporum (FOSC), F. fujikuroi (FFSC), F. incarnatum-equiseti (FIESC), F. dimerum (FDSC), and F. redolens (FRSC) species complexes. While rezafungin and ibrexafungerp showed no effect on the Fusarium spp. tested, a general antifungal susceptibility of Fusarium against natamycin and manogepix was found. Specific profiles were detailed for terbinafine and olorofim. While species from the FDSC, FSSC, and FIESC show high MICs for olorofim, specific susceptibility rates were found for species of the FFSC and FOSC. Furthermore, we report specific susceptibilities for terbinafine against FDSC, FFSC, and FOSC species. These findings of complex- and species-specific olorofim and terbinafine in vitro susceptibilities highlight the need for diagnostics below genus level.

Antibiofilm activity of manogepix, ibrexafungerp, amphotericin B, rezafungin, and caspofungin against Candida spp. biofilms of reference and clinical strains

This study comprehensively assessed the activity of manogepix (MNGX), ibrexafungerp (IBF), amphotericin B (AMB), rezafungin (RZF), and caspofungin (CAS) against planktonic cells and mature biofilms of Candida spp.-reference and clinical strains using the Calgary biofilm device. Mature-phase biofilms of C. albicans, C. auris (clades I, II, III, IV), and C. parapsilosis were exposed to a range of drug concentrations (0.12-128 µg/mL). Minimum Inhibitory Concentration (MIC) values for planktonic cells were ≤2 µg/mL for all strains; however, biofilm-associated MICs, minimum biocidal concentration (MBC), minimum biofilm eradication (MBEC), and minimum biofilm damaging concentration (MBDC) were significantly higher (2-4,119 times). Geometric mean (GM) of MBEC values indicated that MNGX had the highest antifungal activity within Candida species, with a GM-MBEC of 5.9 µg/mL. Despite its overall potency, MNGX was less effective against C. auris biofilms from clade IV strains, where IBF showed superior activity. While not the most potent agent overall, AMB induced the smallest fold-change increases (2- to 32-fold) in biofilm-associated states data compared to planktonic MICs. Conversely, CAS exhibited the lowest activity against Candida spp. biofilms. The eradication of C. auris and C. parapsilosis biofilms required substantially higher concentrations than C. albicans, with some agents, such as RZF and CAS, necessitating up to 42-fold increases in dosage. In conclusion, our in vitro model highlights the antibiofilm activity of novel antifungals against major Candida species, revealing significant differences in efficacy among species. MNGX demonstrated the highest activity, underscoring its potential as a promising candidate for the treatment of biofilm-related infections.

Recent Advances in the Development of Antifungal Agents: Beyond Azoles, Polyenes, and Echinocandins

The escalating incidence of antimicrobial resistance to antifungal agents, alongside the emergence of drug-resistant fungal strains, constitutes a significant threat to a potential global fungal pandemic. In response, researchers are intensifying efforts to identify novel antifungal compounds through diverse methodologies. Emerging strategies focus on innovative therapeutic targets that may reduce the risk of resistance development while offering broad-spectrum efficacy against fungal infections. Additionally, these approaches present potential cost-effectiveness and accelerated development timelines. This review systematically categorizes a range of novel antifungal compounds, including antifungal peptides, cationic amphiphiles, small molecules, polymers, and repurposed drugs, based on their efficacy in inhibiting fungal growth and associated virulence factors. These compounds exhibit notable antimicrobial activity across in silico, in vitro, and in vivo systems against various pathogenic fungal strains, with several showing substantial promise for clinical application. Furthermore, the review highlights the limitations of standard antifungals and elucidates the mechanisms by which fungal strains develop resistance. This work aims to engage researchers in the distinctive field of fungal biology and foster the exploration of new antifungal strategies.

A novel pan-fungal screening platform for antifungal drug discovery: proof of principle study

Broad-spectrum activity is a desirable property of novel antifungal drugs, but relevant in vitro testing is complicated by differential nutritional requirements and growth dynamics of fungal pathogens. Many screens for novel drugs are initiated against individual species or genera, with hit compounds later tested for "pan-fungal" activity. Hypothesizing that an optimized pan-fungal methodology would enhance the efficiency of early-stage drug discovery, a standardized assay was developed for a selection of World Health Organization-defined critical and high-priority fungal pathogens. Instead of using the standard susceptibility testing broth RPMI, an enriched media "fungal RPMI" (fRPMI), including multiple additional fungal growth-enhancing nutrients, was utilized. To assess utility for pan-fungal growth assessments, growth in fRPMI was compared to RPMI medium for 12 fungal pathogens. Growth was significantly improved in 7/12 species in fRPMI after 24 and/or 48 hours. For our proof-of-principle study, 500 chemical fragments from the Maybridge Ro3 Fragment library were screened at concentrations of 0.1 or 1 mM against five fungal pathogens: Aspergillus fumigatus, Candida albicans, Candida auris, Cryptococcus neoformans, and Nakaseomyces glabratus. Assay quality was assessed using z-factor analysis, and hits were normalized using a standard z-score to identify outliers. All assays achieved a high-quality z-factor (≥0.5) with readings at ≤24 hours, allowing the identification of 23 compounds with antifungal activity against at least one fungal species. From these, five compounds were identified as having pan-assay interference or broadly toxic properties. In conclusion, hits identified from pan-fungal phenotypic growth-based assays demonstrate reproducibility in all fungal species tested with carefully optimized conditions and precise timing.

Recent Advances in the Catalytic Synthesis of α-Ketoamides

α-Ketoamides are privileged chemical entities featuring a carbonyl group bonded to an amide. Bearing two pronucleophilic and two proelectrophilic sites, this structural scaffold exhibits distinct chemical properties and unparalleled biological activity. Owing to its wide application in medicinal, agricultural, and synthetic chemistry, methods for assembling this distinct moiety are ever-growing in demand. With the increasing focus on green synthesis, traditional routes to α-ketoamides have faded in recent years giving rise to the development of photocatalytic, electrosynthetic, and microwave-assisted catalytic protocols. We hereby provide a comprehensive and critical summary of all the catalytic advancements witnessed in this field from 2016 to the present.

Intratumor fungi specific mechanisms to influence cell death pathways and trigger tumor cell apoptosis

Cancer, uncontrolled cell growth due to the loss of cell cycle regulation, is often found to be associated with viral infections and, as recent studies show, with bacterial infections as well. Emerging reports also suggest a strong link between fungi and cancer. The crucial virulence trait of fungi, the switch from yeast (Y) to hyphal (H) form, is found to be associated with carcinogenesis. The physicochemical properties and signal transduction pathways involved in the switch to the hyphal form overlap with those of tumor cell formation. Inhibiting differentiation causes apoptosis in fungi, whereas preventing apoptosis leads to cancer in multicellular organisms. Literature on the fungi-cancer linkage, though limited, is increasing rapidly. This review examines cancer-specific fungal communities, the impact of fungal microbiome on cancer cell progression, similarities between fungal differentiation and cells turning cancerous at biochemical and molecular levels, including the overlaps in signal transduction pathways between fungi and cancer. Based on the available evidence, we suggest that molecules inhibiting the yeast-hyphal transition in fungi can be combined with those targeting tumor cell apoptosis for effective cancer treatment. The review points out fertile research areas where mycologists and cancer researchers can collaborate to unravel common molecular mechanisms. Moreover, antibodies targeting fungal-specific chitin and glucan can be used for the selective neutralization of tumor cells. These new combinations of potential therapies are expected to facilitate the development of target-specific, less harmful and commercially feasible anticancer therapies. We bring together available evidence to argue that fungal infections could either trigger cancer or have a significant role in the development and progression of cancer. Hence, cancer-associated fungal populations could be utilized as a target for a combination therapy involving the integration of anticancer and antifungal drugs as well as inhibitors of fungal morphogenesis to develop more effective anticancer therapies.

Challenges in the diagnosis and treatment of chronic pulmonary aspergillosis in Japan

Chronic pulmonary aspergillosis (CPA) is a refractory infectious disease that occurs in patients with mildly compromised immunity or an underlying pulmonary disease. The mortality rate associated with pulmonary aspergillosis has also increased. In the diagnosis and management of CPA, numerous challenges persist. The Aspergillus IgG antibody test is a highly accurate adjunctive diagnostic method for CPA that has been approved in Japan since 2024. However, the diagnostic accuracy for non-fumigatus species is not as high as that for Aspergillus fumigatus. The development of an auxiliary diagnostic method for non-fumigatus CPA is a pressing concern. Azole-resistant strains, related species, and challenges in long-term therapy are significant issues. Currently, most azole-resistant strains in Japan are patient-route strains that harbor CYP51A mutations. Although the prevalence of azole-resistant strains transmitted via environmental routes remains limited, ongoing surveillance and monitoring are essential. Furthermore, the lack of health insurance coverage for drug susceptibility testing is another critical issue. The recommended treatment duration for CPA is a minimum of 6-12 months; however, maintaining long-term therapy is challenging because of the higher incidence of adverse events associated with antifungal agents than with other antimicrobial medications. Additionally, CPA co-infection in patients with non-tuberculosis mycobacteria has recently become a concern owing to poor prognosis and drug-drug interactions between antifungal and antimycobacterial agents. Therefore, the development of treatment agents with improved safety profiles and fewer drug-drug interactions is highly desirable.

Posaconazole versus fluconazole as primary antifungal prophylaxis for patients at high risk of invasive fungal infections receiving allogeneic hematopoietic stem cell transplantation

With the aim to reduce the incidence of invasive fungal infections (IFI) after allogeneic hematopoietic stem cell transplantation (allo-HSCT), the ECIL group recommends the use of drugs active against molds such as posaconazole instead of fluconazole in high-risk (HR) IFI patients. But data to support this recommendation are poor. The aim of this monocentric study was to compare retrospectively the use of fluconazole (n = 96) vs. posaconazole (n = 63), as primary antifungal prophylaxis within the first 90 days (D) post-transplant in a cohort of patients at HR-IFI (n = 159). HR-IFI was defined by the use of an alternative donor, post-transplant cyclophosphamide and/or sequential conditioning regimen, and/or an active disease at transplant or a previous allo-HSCT. Incidences of D90, 6-month, 1-year and 2-year CI of IFI as well as D90 primary prophylaxis failure (IFI resulting in the initiation of a curative antifungal therapy or a permanent discontinuation of the prophylaxis for toxicity) were similar between both groups. However, the number of probable/proven IFI that occurred between D0 and D90 was the double in the fluco group (9 vs. 4). Also, no proven IFI (vs. 4) or mucormycoses (vs. 1) or IFI related death (vs. 4) occurred in the posa group in the first 90 days. Posaconazole thus appears to be a good option to prevent IFI after allo-HSCT in patients at HR-IFI.

Primary antifungal prophylaxis in hematological malignancies. Updated clinical practice guidelines by the European Conference on Infections in Leukemia (ECIL)

At the 10th European Conference on Infections in Leukaemia (ECIL), the guidelines for antifungal prophylaxis in pediatric and adult patients with hematological malignancies (HM) were updated and some changes introduced. Regarding acute myeloid leukemia (AML) and myelodysplastic syndromes (MDS) patients undergoing remission induction chemotherapy, a B-II grading has been assigned to isavuconazole, micafungin, and caspofungin, based on non-randomized studies that have shown efficacy in preventing invasive fungal diseases (IFD). Regarding high-risk MDS patients treated with azacytidine, prophylaxis with posaconazole during the first four cycles of treatment is supported in the literature. Prophylaxis is not indicated in patients treated for myeloproliferative neoplasms (NPM), acute lymphoid leukemia (ALL), and Hodgkin lymphoma (HL). For patients with chronic lymphocytic leukemia (CLL) and non-Hodgkin lymphoma (NHL), prophylaxis is not generally indicated. For patients with multiple myeloma (MM), prophylaxis is not indicated and the limited epidemiological data available do not support the use of prophylaxis in subjects treated with bispecific antibodies. For patients undergoing allogeneic hematopoietic stem cell transplantation (HSCT), no substantial changes were made, apart from the addition of isavuconazole with grading B-II in the post-engraftment period. In patients undergoing auto-HSCT, antifungal prophylaxis is not indicated. Previous ECIL guidelines did not include CAR-T cells. The expert panel proposes to endorse the use of anti-mold prophylaxis in high-risk patients during pre-infusion and post-infusion, while in low-risk patients, anti-yeast prophylaxis can be recommended (B-II). For pediatric hematology patients, based on newly published data, caspofungin received a B-I grading as mold-active prophylaxis. Moreover, patients with ALL with insufficient treatment response during induction therapy, and children older than 12 y.o are now considered at high risk for IFD and are recommended to receive antifungal prophylaxis.

Induction Treatment for HIV-Associated Cryptococcal Meningitis: Where Have We Been and Where Are We Going?

Cryptococcal meningitis remains a leading cause of morbidity and mortality among individuals with HIV/AIDS, particularly in resource-limited settings. Treatment begins with induction therapy followed by consolidation and maintenance. Evidence related to induction therapy has evolved significantly over the past decade. Current treatment relies primarily on three antifungal agents: amphotericin B, flucytosine, and fluconazole, each with distinct mechanisms of action and limitations. The World Health Organization's 2022 guidelines for induction therapy recommend a single high dose of liposomal amphotericin B combined with 14 days of flucytosine and fluconazole. The 2010 IDSA guidelines for induction therapy recommend amphotericin B deoxycholate and flucytosine for two weeks. The U.S. CDC/NIH/IDSA/HIVMA joint guidelines and the ECCM/ISHAM/ASM joint guidelines list both options, but the recommendation varies by setting resources (e.g., resource-limited vs. other). The newer treatment approaches (single high-dose liposomal amphotericin B) that are supported by trials such as AMBITION-cryptococcal meningitis have limited adoption in high-resource settings, with recent studies showing that only 14% of North American infectious disease providers have utilized the regimen. Adjunctive medications, such as dexamethasone, tamoxifen, and sertraline, have proven ineffective or harmful in clinical trials. This review underscores the ongoing challenges in cryptococcal meningitis treatment and the need for continued research to improve patient outcomes, tracing the evolution from past monotherapy approaches to current combination strategies while exploring future directions.

Organoselenium compounds as an enriched source for the discovery of new antimicrobial agents

The urgent need for novel antifungal drugs is underscored by the limited number of antifungal agents in clinical development and the global spread of fungal resistance. This study highlights the potential of organoselenium compounds as a new source of scaffolds with promising antifungal activity against a variety of fungal strains. Analysis of over 300 000 compounds screened by the Community for Open Antimicrobial Drug Discovery (CO-ADD) for antibacterial and antifungal activity identified 233 organoselenium derivatives. A remarkable 33% (77) of these exhibited antifungal activity against two representative strains of Candida and Cryptococcus, in contrast to only 2% of the non-selenium-containing organic compounds tested by CO-ADD. Of these compounds that displayed antifungal activity (MIC < 16 μg mL-1), 87% did not exhibit cytotoxicity against mammalian cell lines or haemolytic properties at similar concentrations, compared to only 35% of the organic 'hits'. A subset of these 69 compounds was further evaluated against three clinically relevant fungal strains that often exhibit resistance to current antifungals (Candida auris, MDR Candida auris, and Cryptococcus deuterogattii), and generally retained good activity. Lastly, we compared a handful of matched sulfur and selenium compounds which further highlighted the beneficial impact of this bioisosteric conversion on antifungal activity.

Promising Role of Fruitless Wolfberry Bud Tea in Combating Nakaseomyces glabratus Resistance

The rising antifungal resistance in Nakaseomyces glabratus, especially to azole drugs like fluconazole, itraconazole, and voriconazole, presents a significant clinical challenge. Plant-derived compounds with synergistic antifungal effects offer a promising solution. Fruitless wolfberry bud tea, rich in flavonoids from a Lycium barbarum L. hybrid, shows potential but is underexplored in antifungal therapies. This study assessed FWE's antifungal efficacy alone and with azoles against resistant N. glabratus isolates, exploring mechanisms like efflux pump inhibition and gene expression changes. A total of 52 clinical isolates were tested. Fruitless wolfberry bud tea was methanol-extracted (FWE) and lyophilized. Antifungal susceptibility was evaluated using broth microdilution, and synergistic effects were analyzed with checkerboard assays. Growth inhibition, rhodamine 6G efflux, and qRT-PCR for resistance-related genes were conducted. FWE demonstrated inhibitory activity with MICs ranging from 16 to 32 μg/mL. When combined with ITR or VRC, synergistic or additive effects were observed, reducing MICs by 2-8-fold. FWE + VRC exhibited synergy (FICI ≤ 0.5) in 50% of isolates, while FWE + ITR showed synergy in 37.5%. Efflux pump activity, measured by rhodamine 6G, significantly decreased in combination groups (11.4-14.6%) compared to monotherapy (17.3-17.5%). qRT-PCR indicated downregulation of CgCDR1, CgERG11, and CgPDR1 in FWE-treated Cg 1 isolate, with greater suppression in combination groups. FWE might boost the bacteriostatic impact of azole antifungal drugs by blocking efflux pumps and altering the expression of resistance genes. This study identifies FWE as a potent adjuvant to overcome cross-resistance, supporting its inclusion in antifungal strategies. Further research to identify bioactive compounds in FWE and in vivo validation is necessary for clinical application.

In vitro activities of lipopeptides against fluconazole-resistant Candida auris

Candida auris has increasingly become a global threat due to its wide range of antifungal resistances as well as its ability to sustain outbreaks in clinical settings. Two lipopeptides, C14-NleRR-NH2 (Nel) and C14-WRR-NH2 (WR), were evaluated against six fluconazole-resistant C. auris isolates. Both molecules showed good antimicrobial activity as demonstrated by MIC determination, time-kill, and microscopy experiments. The peptides were able to inhibit fungal growth, while sub-MIC concentrations of the molecules delayed the growth. Moreover, the combinations of the two peptides with fluconazole demonstrated a reciprocal potentiation by checkerboard and time-kill experiments. Our results showed that antimicrobial peptides could be a promising option for the treatment of antifungal-resistant C. auris.IMPORTANCEAs well as antibiotics, also in fungal infections, antimicrobial resistance increased over the years. Moreover, in the last years, a new species emerged, Candida auris, as a nosocomial pathogen. C. auris possesses intrinsic resistance to common antifungals, such as azoles, that complicate therapeutic options. The combination of these two elements poses a risk for the treatment of fungal infections in the next years. The search for novel compounds with antimicrobial properties is crucial for the treatment of infections to overcome the increasing resistance of these etiological agents.

Profiling Drug Susceptibility and Species Identification of Aspergillus Isolates From Patients With Superficial Infection

BACKGROUND

Aspergillus infections pose significant challenges in clinical management due to rising resistance rates and limited diagnostic accuracy. Superficial infections, particularly in immunocompetent individuals, are often understudied, despite their prevalence in specific populations.

OBJECTIVES

This study aimed to characterise the distribution and antifungal susceptibility patterns of Aspergillus isolates from a tertiary hospital in Shandong, China, and evaluate the performance of matrix-assisted laser desorption time-of-flight (MALDI-TOF) mass spectrometry versus multi-gene sequencing for species identification.

PATIENTS/METHODS

A total of 120 Aspergillus isolates were collected from patients with localised aspergillosis (nails, external auditory canal, cornea, sub-throat secretions) between 2020 and 2021. Species identification was performed using MALDI-TOF and multi-gene sequencing (ITS, BenA, CaM, RPB2). Antifungal susceptibility testing was conducted for micafungin, azoles (itraconazole, voriconazole, posaconazole, fluconazole), and amphotericin B following standard protocols.

RESULTS

Species Identification: MALDI-TOF identified 52.5% of isolates to the species level, whereas multi-gene sequencing achieved 100% accuracy. Aspergillus terreus was the most prevalent species (38.3%). Antifungal Susceptibility: Micafungin showed the highest resistance rate (40%), followed by amphotericin B (reduced susceptibility in 31.7%). Azoles demonstrated low resistance (3.3%-6.7%) except for fluconazole (21.7%). Clinical Correlates: Superficial infections were most common in middle-aged/elderly patients (68.3%), frequently linked to external trauma (41.7%) or environmental exposure (35.8%).

CONCLUSIONS

Multi-gene sequencing outperformed MALDI-TOF for Aspergillus identification. A. terreus dominance and micafungin resistance highlight regional epidemiological trends. Natamycin and nystatin remain cost-effective first-line topical options. Enhanced surveillance in trauma-prone and environmentally exposed populations is warranted.

Clinical and Hospital Environmental Fusarium in Taiwan: Molecular Identification, Antifungal Susceptibilities, and Phylogenetic Analyses

BACKGROUND

Fusarium species are emerging pathogens known to cause both superficial and disseminated human infections. Aerosolized Fusarium species in healthcare settings have been associated with nosocomial fusariosis, particularly in patients with severe immunosuppression.

OBJECTIVES

To analyse the phylogenetic relationships of clinical and hospital environmental Fusarium isolates and assess their susceptibility to available antifungal agents.

METHODS

Clinical Fusarium isolates were procured from four hospitals in Taiwan, with environmental air and water sampling collected at Kaohsiung Chang Gung Memorial Hospital (KCGMH). All clinical and hospital environmental Fusarium isolates were identified through gene sequencing of translation elongation factor 1-α and internal transcribed spacer regions of ribosomal DNA. Antifungal susceptibility testing followed the CLSI M38-A3 broth microdilution method.

RESULTS

A total of 41 clinical and 4 hospital environmental Fusarium isolates were identified, belonging to five species complexes (SC): F. solani SC (FSSC) (62.8%), F. fujikuroi SC (FFSC) (14.0%), F. incarnatum-equiseti SC (11.6%), F. dimerum SC (7.0%), and F. oxysporum SC (4.7%). Phylogenetic analysis revealed that clinical Fusarium isolates from KCGMH were closely related to environmental Fusarium isolates from air samples at the same hospital. Amphotericin B exhibited high activity against most Fusarium species. With the exception of FFSC, other Fusarium SC demonstrated significantly elevated MIC values to itraconazole, voriconazole, posaconazole, and isavuconazole.

CONCLUSIONS

FSSC was the most prevalent SC in Taiwan, exhibiting higher MIC values for azoles than FFSC isolates. The clinical Fusarium isolates were observed to form clusters with the corresponding environmental isolates. The potential of airborne nosocomial infections in the healthcare environment cannot be overlooked.

Towards a holistic approach to pulmonary infections. Insights from the Sixth Annual Meeting of Spanish Experts 2024

Pneumonia is the leading cause of death from infection in the developed world. In recent years, researchers and healthcare professionals have worked extensively to reduce this burden. Prevention is better than cure, and significant advances have been made in areas such as vaccination and the prevention of nosocomial pneumonia in intensive care units. Comprehensive surveillance programmes and new diagnostic methods have been developed to assess trends in this disease and to identify the infectious agents involved. Clinical presentation can be challenging in elderly patients or those with certain comorbidities, prompting new studies in these populations to address these issues. Correct and early management of severe community-acquired pneumonia represents a major opportunity to reduce its associated mortality. Although fungal pathogens are an uncommon cause of lung infection, they are associated with high morbidity and mortality, highlighting the need for new approaches. Finally, new drugs are available for the treatment of pneumonia, and a thorough understanding of them is key to ensuring their correct use, particularly to combat multi-resistance. To provide an update on these points, a multidisciplinary team of Spanish experts convened at the Sixth Annual Meeting of Pneumonia Day, under the scientific sponsorship of GEIPC-SEIMC. This paper reflects the information shared at this meeting, offering the latest insights on these topics and supporting a holistic approach to pneumonia management.

Enhanced antifungal activity of siRNA-loaded anionic liposomes against the human pathogenic fungus Aspergillus fumigatus

We developed siRNA-loaded anionic liposomes, co-encapsulating low-dose amphotericin B, to enhance siRNA penetration through the fungal cell wall of Aspergillus fumigatus. Targeting mRNAs of three key genes, these liposomes visibly inhibited fungal growth, demonstrating for the first time the antifungal potential of siRNA against human fungal pathogens.

Emerging Treatments in Neonatal Fungal Infections: Progress and Prospects

Fungal infections in neonates are potentially life threatening. The differential diagnosis for neonatal rashes is extensive, with common culprits including both bacteria and fungi. Candida albicans is the predominant fungal pathogen, causing infections that range from superficial disease to severe systemic conditions, including sepsis and meningitis. Neonates, especially those who are preterm, are particularly susceptible because of developmentally immature immune systems and the use of invasive procedures and devices in neonatal intensive care units. Congenital cutaneous candidiasis, acquired in utero or during delivery, can lead to disseminated infection with high mortality rates. Early diagnosis and prompt antifungal treatment are crucial but challenging because of subtle clinical presentations, making accurate identification of the offending organism essential for selecting the appropriate treatment. Candida species account for the majority of neonatal fungal infections, with different species necessitating distinct treatments because of varying susceptibility profiles. Aspergillus, another significant pathogen, poses high mortality risks and can present either cutaneously or systemically. Malassezia, though less common, primarily affects preterm infants with catheter-related fungemia. Other fungal species, including Zygomycetes, Trichosporon, and Cryptococcus, rarely produce neonatal infections but are noteworthy for consideration. Treatment of fungal infection is critical despite the relative paucity of information regarding the clinical pharmacology of many antifungal drugs in neonates. We review the major antifungal agents (e.g., amphotericin B, the echinocandins, the azoles) and provide pharmacologic and dosing information. Finally, preventive strategies, including the use of stringent aseptic techniques and careful clinical monitoring, are essential to mitigate both the incidence and severity of these infections in neonates and infants in the first months of life.

The GPCR antagonist PPTN synergizes with caspofungin providing increased fungicidal activity against Aspergillus fumigatus

Fungal pathogens pose a serious threat to human health, with Candida and Aspergillus spp. representing some of the most significant opportunistic invaders. Aspergillus fumigatus causes aspergillosis, one of the most prevalent fungal diseases of humans. There is a limited number of drugs available to combat these infections, and antifungal drug resistance is on the rise. In this manuscript, we show 4-[4-(4-Piperidinyl) phenyl]-7-[4-(-(trifluoromethyl) phenyl]-2-naphthalenecarboxylic acid (PPTN), a highly specific antagonist of the human P2Y14 receptor, is a promising antifungal adjuvant against diverse fungal pathogens. PPTN interacts with caspofungin (CAS), ibrexafungerp, voriconazole (VOR), and amphotericin against A. fumigatus CAS- and VOR-resistant clinical isolates, and also CAS against Candida spp and Cryptococcus neoformans. The combination of PPTN and CAS increases cell death in A. fumigatus. In the model yeast Saccharomyces cerevisiae, heterozygous deletion of genes involved in chromatin remodeling results in PPTN hypersensitivity, and in A. fumigatus, PPTN can have increased fungicidal activity when combined with the histone deacetylase inhibitor trichostatin A and the DNA methyltransferase inhibitor 5-azacytidine. Finally, PPTN has reduced toxicity to human immortalized cell lineages and partially clears A. fumigatus conidia infection in A549 pulmonary epithelial cells. Our results indicate that PPTN is a novel adjuvant antifungal drug against fungal diseases caused by A. fumigatus and Candida spp.

IMPORTANCE

Invasive fungal infections have a high mortality rate, causing more deaths annually than tuberculosis or malaria. Aspergillus fumigatus is the main etiological agent of aspergillosis, one of the most prevalent and deadly fungal diseases. There are few therapeutic options for treating this disease, and treatment commonly fails due to host complications or the emergence of antifungal resistance. Drug repurposing, where existing drugs are deployed for other clinical indications, has increasingly been used in the process of drug discovery. Here, we show that 4-[4-(4-Piperidinyl) phenyl]-7-[4-(-(trifluoromethyl) phenyl]-2-naphthalenecarboxylic acid (PPTN), a highly specific antagonist of the human P2Y14 receptor, when combined with caspofungin (CAS), ibrexafungerp, voriconazole (VOR), and amphotericin can increase the fungicidal activity against not only A. fumigatus CAS- and VOR-resistant clinical isolates but also CAS against Candida spp.

Redefining Antifungal Treatment: The Innovation of Metal-Based Compounds

Fungal infections are a significant contributor to global morbidity and mortality, particularly among immunocompromised patients. With the increasing prevalence of drug-resistant strains, it has become imperative to identify alternative approaches. Metal ion coordination enhances drug efficacy through novel modes of action and may hinder resistance mechanisms. This article aims to identify gaps in the current metal-based antifungal therapy to guide research directions and facilitate drug development. Relevant metal complexes, together with their ligands, have been categorized according to their metal coordination and their activities highlighted. Most examples reported were found to be more effective against drug-resistant strains than non-coordinated ligands, thus establishing the importance of metal ion and co-ligand(s) nature, the influence of electron-withdrawing substituents on structure-activity relationships, and the unique structural features of Schiff bases. Although still at the preclinical phase, the in vitro efficacy of these examples suggests that metal-based drugs may represent a promising approach to overcoming antifungal resistance.

Is a Fungal Apocalypse Inevitable or Just a Hallucination? An Overview of the Antifungal Armamentarium Used in the Fight against Pathogenic Fungi

The World Health Organization (WHO) fungal priority pathogens list (WHO FPPL) published in 2022 highlighted the inequity and research challenges faced by researchers who study pathogenic fungi that afflict humans. Antifungal drugs are the only weapon available to treat infections; however, these drugs are old, are not effective against multidrug-resistant (MDR) fungal strains, and are associated with substantial toxicity in clinical use. This Microperspective summarizes challenges pertaining to antifungal drug discovery in addition to highlighting recent advances and antifungal agents in clinical trials.

Candida auris: A Continuing Threat

Candida auris is a World Health Organization critical-priority fungal pathogen that has variable resistance to antifungal treatments. Multiple clades have been identified through genomic analysis and have appeared in different geographic locations simultaneously. Due to a combination of factors including antifungal resistance, ability to colonize and persist in the environment, and thermotolerance, it can thrive. Infected patients are associated with a high mortality rate, especially those with multiple health risk factors like those associated with other Candida species. This review highlights the current situation of this pathogen to help provide guidance for future work.

Cryptococcosis

Cryptococcosis is an invasive fungal infection caused by yeasts of the genus Cryptococcus that causes a significant global burden of disease in both immunocompromised and immunocompetent individuals. Over the past several decades, diagnosis and management of cryptococcal disease have moved to focus on rapid, reliable, and cost-effective care delivery, with the advent of new antigen detection assays and novel antifungal treatment strategies.

ERS Congress 2024: highlights from the Respiratory Infections Assembly

This highlights article shares key updates in the field of respiratory infections from the 2024 #ERSCongress, focusing on new research and the need for fair access to care to help tackle global challenges in respiratory infections and improve patient care https://bit.ly/40gDmrj.

Green synthesis of zinc oxide nanoparticles using Cnidium monnieri fruit extract: Prescription optimization, Characterization and antifungal activity

Currently, the drugs employed to treat superficial fungal infections are encountering challenges, particularly the rise of drug resistance. Numerous studies have suggested that zinc oxide nanoparticles (ZnO NPs) show promise in the realm of antifungal treatment. Green synthesis makes the preparation of ZnO NPs more environmentally friendly and economical. In order to prepare antifungal active nanoparticles with low economic cost and stable performance, zinc oxide nanoparticles (CM-ZnONPs) were synthesized for the first time in this study using zinc sulfate heptahydrate (ZnSO4·7H2O) with a Cnidium monnieri (L.) Cuss. (C. monnieri) fruit extract as a reducing agent. In this study, the Box-Behnken design method was used to optimize the manufacturing process of CM-ZnONP. Various techniques, including UV-vis, Fourier Transform Infrared Spectroscopy (FTIR) and X-ray Powder Diffraction (XRD) were employed to demonstrate the successful preparation of CM-ZnONPs. The Transmission Electron Microscopy (TEM) analysis indicated that the size of CM-ZnONPs was 53.30 ± 12.89 nm. The dynamic light scattering (DLS) analysis showed the size of 157.7 ± 15.57 nm for CM-ZnONPs, along with an average polydispersity index (PDI) of 0.1791 ± 0.1394. The zone of inhibition of CM-ZnONPs against Candida albicans (C. albicans) was demonstrated to be 17.0 ± 0.8 mm by paper diffusion experiments. The minimum inhibitory concentration (MIC) of CM-ZnONPs against C. albicans was established at 58.59 μg/mL through the microdilution method. In summary, CM-ZnONPs exhibit excellent performance and antifungal activity in various properties. It is expected to be widely produced and used as an effective treatment for superficial fungal infections.

Coccidioidomycosis

Coccidioidomycosis is the clinical disease caused by the dimorphic pathogenic fungi Coccidioides immitis and C posadasii. The number of clinically recognized coccidioidomycosis cases continues to increase yearly including in regions outside the traditional regions of endemicity. Following inhalation of Coccidioides spores, the course may range from asymptomatic exposure with resultant immunity, to a subacute pulmonary illness, to life-threatening disseminated infection. This review will summarize recent advances in our understanding of the infection and will include the ecology of Coccidioides, epidemiology and risk factors for infection, vaccine and novel antifungals in development, and management of immunosuppressed patients.

Dematiaceous Molds

Dematiaceous molds are darkly pigmented environmental molds found worldwide, especially prevalent in tropical and subtropical regions. Common genera include Bipolaris, Cladophialophora, Exophiala, and Alternaria. They cause disease in both immunocompetent and immunocompromised individuals, presenting as cutaneous infections, allergic sinusitis, pneumonia, and, rarely, disseminated infections. Contaminated medical products have also led to fungal meningitis outbreaks. Treatment typically involves itraconazole, voriconazole, or posaconazole, along with source control and reduction in immunosuppression, if possible. Newer antifungals may have a role in treatment. Mortality is high in disseminated disease, especially with Lomentospora prolificans in immunocompromised individuals, prompting global efforts to improve diagnostics and treatments.

Ibrexafungerp for the treatment of vulvovaginal candidiasis: A systematic review and meta-analysis of randomized placebo-controlled trials

INTRODUCTION

Vulvovaginal candidiasis (VVC) is a prevalent fungal infection affecting millions of women globally, primarily caused by Candida species, most notably Candida albicans. Ibrexafungerp emerges as a promising candidate in the treatment arsenal against VVC, presenting a novel approach to combating this prevalent fungal infection.

METHODS

A systematic literature search was conducted across major databases, including PubMed, EMBASE, and the Cochrane Library, to identify relevant randomized controlled trials (RCTs) evaluating the efficacy and safety of ibrexafungerp in the treatment of VVC. Following rigorous methodology, data extraction, risk of bias assessment using Cochrane's RoB 2 tool, and meta-analysis were conducted.

RESULTS

Four RCTs were included in the analyses. The ibrexafungerp regimen utilized across the studies were 300 mg administered twice daily for one day. Meta-analysis revealed that ibrexafungerp was associated with significantly higher clinical cure rates compared to placebo in patients with VVC (pooled odds ratio (OR) 2.32; 95 % confidence interval (CI) 1.80 to 2.98). Complete symptom resolution was achieved in a greater proportion of participants receiving ibrexafungerp (pooled OR 2.76; 95 % CI 1.62 to 4.71). Analysis of treatment-emergent adverse events revealed a significant higher incidence of at least one treatment-emergent adverse event with ibrexafungerp compared to placebo (pooled OR 2.83; 95 % CI 2.06 to 3.88).

CONCLUSION

This study provides robust support for the efficacy of ibrexafungerp in the treatment of VVC. While the safety profile of ibrexafungerp appears favorable with mostly mild adverse events reported, decision-making in the clinical context should be guided by individual patient factors.

Non-Candida mycosis in Gulf Cooperation Council (GCC) countries: perspective of a low-incidence region

BACKGROUND

Fungal pathogens are ubiquitous microorganisms that are implicated in a wide range of infections, affecting individuals with underlying health conditions and immune suppression therapy; however, immunocompetent individuals may also be at risk. Among these infections, many are caused by molds and yeasts other than Candida and are recognized in clinical practice, such as aspergillosis, mucormycosis, fusariosis, phaeohyphomycosis, and basidiobolomycosis, among others, each presents different clinical manifestations and requires clinical management specific to the site of involvement. Although pathogenic fungal contaminants and potential sources of mycosis in humans are plentiful in Gulf Cooperation Council (GCC) countries, epidemiological reports regarding mycosis in the region are scarce.

AIM

The aim of this review is to shed some light on the epidemiology of clinically associated molds and yeasts other than Candida and to survey all related case reports and epidemiological studies conducted in the GCC over the past 10 years.

METHODS

A comprehensive search of the Medline (PubMed) and Scopus databases was conducted using the following keywords: Aspergillosis, Mycosis, Mucormycosis, Fusarium, Kuwait, Bahrain, Saudi Arabia, Qatar, Oman and the United Arab Emirates. A timeframe was set to include only articles that were published from 2014 to 2024.

RESULTS

One hundred thirty-five of the 1563 articles examined fulfilled the purpose of this review. Most studies were in Saudi Arabia (45%), Qatar (18%) and Kuwait (16%). Mucormycosis, aspergillosis, phaeohyphomycosis and basidiobolomycosis were among the most commonly reported fungal infections in the GCC, with corresponding mortality rates of 53%, 37%, 69% and 24%, respectively. The average estimations of non-Candida fungal infections indicate a low regional incidence in comparison with global estimations.

CONCLUSION

Awareness and a high index of suspicion are warranted in successfully managing non-Candida mycosis. More specific immunological and molecular markers are needed for differential diagnosis to rule out fungal infections. Additionally, incorporating non-Candida mycosis-related antifungal resistance surveys in GCC national surveillance efforts should be enforced, especially when considering the increase in global mycosis rates.

Prodrugging fungicidal amphotericin B significantly decreases its toxic effects

Amphotericin B (AmB) is one of the most effective antifungal drugs, with a strong, dose-dependent activity against most Candida and Aspergillus species responsible for life-threatening infections. However, AmB is severely toxic, which hinders its broad use. In this proof-of-concept study, we demonstrate that prodrugging AmB considerably decreases AmB toxicity without affecting its fungicidal activity. For this purpose, we modified the AmB structure by attaching a designer phosphate promoiety, thereby switching off its mode of action and preventing its toxic effects. The original fungicidal activity of AmB was then restored upon prodrug activation by host plasma enzymes. These AmB prodrugs showed a safer toxicity profile than commercial AmB deoxycholate in Candida and Aspergillus species and significantly prolonged larval survival of infected Galleria mellonella larvae. Based on these findings, prodrugging toxic antifungals may be a viable strategy for broadening the antifungal arsenal, opening up opportunities for targeted prodrug design.

An update on newer antifungals

INTRODUCTION

Fungal infections constitute a significant global health threat, with an estimated incidence of 6.5 million invasive fungal infections and 2.5 million associated deaths each year. New antifungal agents are being developed to address the challenges of fungal infections management, driven by the evolving fungal epidemiology, the emergence of antifungal resistance, and the limitations of existing treatments.

AREA COVERED

This review provides a thorough overview of the latest developments in novel antifungal agents, highlighting pivotal evidence obtained from clinical trials.

EXPERT OPINION

New antifungal agents hold promising future for difficult-to-treat fungal infections, providing for improved bioavailability, pharmacokinetic properties, adverse events and drug interactions, as well as, spectrum of activity. However, further data is needed before incorporating these agents in everyday clinical practice for the management of invasive fungal infections.

Diagnosis and Prevention of Invasive Fungal Infections in the Immunocompromised Host

TOPIC IMPORTANCE

The prevalence of invasive fungal infections (IFIs) has risen in the past 3 decades, attributed to advancements in immune-modulatory therapies used in transplantation, rheumatology, and oncology.

REVIEW FINDINGS

Organisms that cause IFI evade the host's natural defenses or at opportunities of immunologic weakness. Infections occur from inhalation of potentially pathogenic organisms, translocation of commensal organisms, or reactivation of latent infection. Organisms that cause IFI in immunocompromised populations include Candida species, Cryptococcus species, environmental molds, and endemic fungi. Diagnosis of these infections is challenging due to slow organism growth and fastidious culture requirements. Moreover, fungal biomarkers tend to be nonspecific and can be negatively impacted by prophylactic antifungals. Antibody-based tests are not sensitive in immunocompromised hosts making antigen-based testing necessary. Prevention of IFI is guided by pathogen avoidance, removal or minimization of immune-suppressing factors, and pharmacologic prophylaxis in select hosts.

SUMMARY

Understanding the complex interplay between the immune system and opportunistic fungal pathogens plays a key role in early diagnosis and prevention.

Fungal Metabolomics: A Comprehensive Approach to Understanding Pathogenesis in Humans and Identifying Potential Therapeutics

Metabolomics has emerged as a transformative tool in the study of microbes, including pathogenic fungi, facilitating the identification of unique metabolic profiles that elucidate their pathogenic mechanisms, host interactions, and treatment resistance. This review highlights key applications of metabolomics in understanding fungal metabolites essential for human virulence, such as mycotoxins produced by various fungal species, including Aspergillus fumigatus (gliotoxin, fumagillins) and Candida species (phenylethyl alcohol, TCA cycle metabolites), and secondary metabolites that contribute to pathogenicity. It also explores the metabolic adaptations of fungi in relation to drug resistance and biofilm formation, revealing alterations in key metabolic pathways during infection, as seen in C. albicans and C. auris. Furthermore, metabolomics aids in deciphering host-pathogen interactions, showcasing how fungi like Cryptococcus neoformans and Candida modify host metabolism to promote survival and evade immune responses. The study of antifungal resistance mechanisms has also benefited from metabolomic approaches, identifying specific metabolite patterns that signify resistance, such as in Candida albicans and Candidozyma (Candida) auris, and informing new therapeutic strategies. The integration of metabolomics with other omics technologies is paving the way for a comprehensive understanding of fungal biology and pathogenesis. Such multi-omics approaches are crucial for discovering new therapeutic targets and developing innovative antifungal treatments. Thus, the purpose of this review is to provide an overview of how metabolomics is revolutionizing our understanding of fungal pathogenesis, drug resistance, and host interactions, and to highlight its potential for identifying new therapeutic targets and improving antifungal strategies.

Invasive Aspergillosis in the Intensive Care Unit

Invasive aspergillosis (IA) is a fungal infection, which has traditionally been associated with neutropenia and immunosuppressive therapies. Our understanding of invasive aspergillosis has been evolving and, in the past few decades, IA among ICU patients has been recognized as a common infection and has become more widely recognized. The diagnosis and management of invasive aspergillosis in the ICU is particularly challenging, due to the unstable clinical condition of the patients, lack of diagnostic markers, increased risk of further clinical deterioration, multiple comorbidities, and a need for early assessment and treatment. In this article, we will discuss the challenges and pitfalls of the diagnosis and management of invasive aspergillosis in an ICU setting, along with a review of the current literature that is pertinent and specific to this population.

The evolution of antifungal therapy: Traditional agents, current challenges and future perspectives

Fungal infections kill more than 3 million people every year. This high number reflects the significant challenges that treating these diseases worldwide presents. The current arsenal of antifungal drugs is limited and often accompanied by high toxicity to patients, elevated treatment costs, increased frequency of resistance rates, and the emergence of naturally resistant species. These treatment challenges highlight the urgency of developing new antifungal therapies, which could positively impact millions of lives each year globally. Our review offers an overview of the antifungal drugs currently available for treatment, presents the status of new antifungal drugs under clinical study, and explores ahead to future candidates that aim to help address this important global health issue.

Virtual screening assisted identification of a phytocompound as potent inhibitor against Candida lusitaniae; an in-silico study

Candida lusitaniae is one of the fungal species which causes serious health illnesses including peritonitis, vaginitis and fungemia, among others. Several antifungal drugs have been designed to tackle its infections but their efficacy is still questionable due to their associated side effects. Hence, there is a need to design those drugs which possess comparatively higher degree of therapeutic potential. Phytochemicals were selected in this regard because these compounds which satisfactorily follow this criteria as, their therapeutic index is comparatively larger than the synthetic drugs. Considering this fact, different phyto-compounds were opted in this research work to estimate their therapeutic efficiency against the secreted aspartyl proteinase (SAP) of C. lusitaniae since, it assists this pathogen in developing the infections. Initially, the structure of SAP was modelled for subsequent docking analysis. The results of molecular docking suggested that three compounds, opelconazole, daidzin 4'0-glucuronide and naringin exhibited better docking scores. Afterwards, ADME analysis of all these four compounds was performed to comprehend their drug-likeness attributes. The results of ADME analysis revealed that only the daidzin 4'0-glucuronide followed all the required parameters. Lastly, MD simulations were conducted in which top three compounds in context of docking scores along three approved anti-fungal drugs in complex with SAP were incorporated for the comparative analysis. The overall results of MD simulations suggested that daidzin 4'0-glucuronide exhibited comparatively better results. This outcome indicated that this particular compound not only showed better binding affinity with SAP during docking analysis and fulfilled all of the drug-likeness moieties among other compounds but also, displayed better simulation results, leading to a conclusion that daidzin 4'0-glucuronide could be a potential drug candidate against C. lusitaniae. However, its real-time efficacy could only be validated in clinical settings.

New pharmacotherapeutic strategies for drug-resistant Candida infections: a review

INTRODUCTION

Candida species produce a wide array of infections ranging from mucocutaneous to systemic infections. Candida albicans remains the most common species identified; however, the non-albicans Candida species have continued to increase as the diagnosis and therapeutic regimens have progressed.

AREAS COVERED

This review with discussion of the various Candida species, especially the non-albicans species, some of the important mechanisms of resistance, and newer in vitro and clinical studies describing the recent and novel antifungal options such as rezafungin, ibrexafungerp, and oteseconazole, along with a novel antifungal, fosmanogepix.

EXPERT OPINION

Initial antifungal therapy is frequently obsolete due to the expansion of antifungal resistance. This is especially true with C. glabrata, C. krusei, and most recently with C. auris. The newer and novel antifungals discussed here will add valuable tools to our antifungal armamentarium to be able to appropriately and adequately treat and manage these difficult infections. Each of the antifungals has unique and novel properties that will expand the arsenal useful to treat these fungal infections in the years to come.

Role of Posaconazole Drug in the Treatment of Invasive Fungal Disease: A Review

Posaconazole is an antifungal medication used primarily to treat invasive fungal infections caused by various organisms, such as Aspergillus, Candida, and certain molds. It belongs to the class of drugs known as triazole antifungals. Clinical studies have reported posaconazole to be effective in treating various invasive fungal infections, especially in patients who are immunocompromised, such as those with weakened immune systems due to conditions like HIV/AIDS, undergoing chemotherapy, or having received an organ transplant. It has effectively treated invasive candidiasis, aspergillosis, zygomycosis, and other serious fungal infections. The effectiveness of the drug varies based on factors, such as the type of infection, the patient's immune status, and the site of infection. This review describes the types of infection, the drug's safety profile, the development of resistance to posaconazole, and strategies to manage or prevent resistance.

Lactams Exhibit Potent Antifungal Activity Against Monospecies and Multispecies Interkingdom Biofilms on a Novel Hydrogel Skin Model

Infections of intact and damaged skin barriers and keratin are frequently associated with complex biofilm communities containing bacteria and fungi, yet there are limited options for successful management. This study intended to focus on the utility of some novel proprietary lactam molecules, quorum sensing (QS)-derived halogenated furanones, which act to block the QS pathway, against key fungal pathogens of the skin (Candida albicans, Malassezia furfur and Microsporum gypseum). Moreover, we aimed to assess how these actives performed against complex interkingdom biofilms in a clinically relevant model. Two lactam derivatives were tested against a panel of important fungal pathogens and then quantitatively assessed against simple and increasingly complex interkingdom biofilm models on polystyrene coverslips and a novel keratin hydrogel system. The lactams were shown to be effective against a wide range of fungal species in the planktonic and biofilm forms, with no ability to regrow. The fungal component of the multispecies biofilm models was significantly reduced with lactam treatment. Lactam treatment was also comparably effective compared to the non-prescription topical antifungal 'Lamisil' against C. albicans early and late biofilms. This study highlights the effectiveness of lactams as a novel antimicrobial for the management of the polymicrobial and interkingdom multispecies biofilms.

Efficacy of two novel antifungal lipopeptides, AF4 and AF5 of bacillomycin D family in murine models of invasive candidiasis, cryptococcosis, and aspergillosis

Invasive fungal diseases are an important public health concern due to an increase in the at-risk population and high mortality associated with these infections. Managing invasive fungal infections poses a significant challenge given the limited antifungal options and the emergence of resistance in key fungal pathogens. Through a comprehensive approach, we evaluated the in vitro antifungal activity and the in vivo efficacy of two novel lipopeptides, AF4 and AF5 in murine models of disseminated candidiasis, cryptococcosis, and aspergillosis. Flow cytometry analysis with propidium iodide showed a dose-dependent increase in the permeability and disruption of fungal cell membranes, underscoring the membrane perturbing effects of AF4 and AF5. These observations were further substantiated by SEM analyses that showed yeast cell and hyphal deformation and leakage of cellular contents. Our in vivo investigations utilizing two doses (5 and 10 mg/kg bodyweight) of each lipopeptide and its comparison with standard antifungal therapies showed lipopeptides significantly improved the odds of mice survival in invasive candidiasis and cryptococcosis models, with a reduction in organ fungal burden by 2 to 3-log10 order. Additionally, in the disseminated aspergillosis model, treatment with 10 mg/kg of AF4 significantly improved median survival from 4 to 10 days while achieving a notable 1-log10 order reduction in organ fungal burden. Overall, our study underscores the potent and broad-spectrum antifungal activity of lipopeptides in mouse infection models, hinting at their promising therapeutic potential in invasive fungal disease.

Fungerps: discovery of the glucan synthase inhibitor enfumafungin and development of a new class of antifungal triterpene glycosides

Covering: up to 2024Fungal pathogens are a major threat to public health, with emerging resistance to all three classes of antifungals that are currently available and increased incidence of invasive fungal infections among hospitalized patients. Ibrexafungerp is a semi-synthetic analog of enfumafungin and the first antifungal agent approved in more than 20 years since the launch of caspofungin, the first of echinocandins. This new drug approval was made possible after a long arduous journey lasting 25 years by dedicated and talented medicinal chemists from two companies that undertook tedious atom-by-atom chemical modification of the natural product enfumafungin, a glycosylated fernane-type triterpenoid isolated from the fungus Hormonema carpetanum. This highlight will cover the discovery of enfumafungin, its biosynthesis and the characterisation of its antifungal profile and mode of action that led to the development of ibrexafungerp. We will discuss the challenges encountered during this long preclinical program and the clinical trial validation of this first-in-class oral antifungal approved to treat vulvovaginal candidiasis with an enormous therapeutic potential to treat future major threatening drug-resistant fungal pathogens.