The mechanism of action of the new antimycotic ketoconazole

Enhancing Solubility and Dissolution Rate of Antifungal Drug Ketoconazole through Crystal Engineering

To improve the solubility and dissolution rate of the BCS class II drug ketoconazole, five novel solid forms in 1:1 stoichiometry were obtained upon liquid-assisted grinding, slurry, and slow evaporation methods in the presence of coformers, namely, glutaric, vanillic, 2,6-dihydroxybenzoic, protocatechuic, and 3,5-dinitrobenzoic acids. Single-crystal X-ray diffraction analysis revealed that the hydroxyl/carboxylic acid. . .N-imidazole motif acts as the dominant supramolecular interaction in the obtained solid forms. The solubility of ketoconazole in distilled water significantly increased from 1.2 to 2165.6, 321.6, 139.1, 386.3, and 191.7 μg mL-1 in the synthesized multi-component forms with glutaric, vanillic, 2,6-dihydroxybenzoic, protocatechuic, and 3,5-dinitrobenzoic acid, respectively. In particular, the cocrystal form with glutaric acid showed an 1800-fold solubility increase in water concerning ketoconazole. Our study provides an alternative approach to improve the solubility and modify the release profile of poorly water-soluble drugs such as ketoconazole.

Repurposing antifungal drugs for cancer therapy

BACKGROUND

Repurposing antifungal drugs in cancer therapy has attracted unprecedented attention in both preclinical and clinical research due to specific advantages, such as safety, high-cost effectiveness and time savings compared with cancer drug discovery. The surprising and encouraging efficacy of antifungal drugs in cancer therapy, mechanistically, is attributed to the overlapping targets or molecular pathways between fungal and cancer pathogenesis. Advancements in omics, informatics and analytical technology have led to the discovery of increasing "off-site" targets from antifungal drugs involved in cancerogenesis, such as smoothened (D477G) inhibition from itraconazole in basal cell carcinoma.

AIM OF REVIEW

This review illustrates several antifungal drugs repurposed for cancer therapy and reveals the underlying mechanism based on their original target and "off-site" target. Furthermore, the challenges and perspectives for the future development and clinical applications of antifungal drugs for cancer therapy are also discussed, providing a refresh understanding of drug repurposing.

KEY SCIENTIFIC CONCEPTS OF REVIEW

This review may provide a basic understanding of repurposed antifungal drugs for clinical cancer management, thereby helping antifungal drugs broaden new indications and promote clinical translation.

RETRACTED ARTICLE: Mutagenesis combined with fermentation optimization to enhance gibberellic acid GA3 yield in Fusarium fujikuroi

Gibberellic acid (GA3) is a plant growth hormone that plays an important role in the production of crops, fruits, and vegetables with a wide market share. Due to intrinsic advantages, liquid fermentation of Fusarium fujikuroi has become the sole method for industrial GA3 production, but the broader application of GA3 is hindered by low titer. In this study, we combined atmospheric and room-temperature plasma (ARTP) with ketoconazole-based screening to obtain the mutant strain 3-6-1 with high yield of GA3. Subsequently, the medium composition and fermentation parameters were systematically optimized to increase the titer of GA3, resulting in a 2.5-fold increase compared with the titer obtained under the initial conditions. Finally, considering that the strain is prone to substrate inhibition and glucose repression, a new strategy of fed-batch fermentation was adopted to increase the titer of GA3 to 575.13 mg/L, which was 13.86% higher than the control. The strategy of random mutagenesis combined with selection and fermentation optimization developed in this study provides a basis for subsequent research on the industrial production of GA3.

Deletion of the Stress Response Gene DDR48 from Histoplasma capsulatum Increases Sensitivity to Oxidative Stress, Increases Susceptibility to Antifungals, and Decreases Fitness in Macrophages

The stress response gene DDR48 has been characterized in Saccharomyces cerevisiae and Candida albicans to be involved in combating various cellular stressors, from oxidative agents to antifungal compounds. Surprisingly, the biological function of DDR48 has yet to be identified, though it is likely an important part of the stress response. To gain insight into its function, we characterized DDR48 in the dimorphic fungal pathogen Histoplasma capsulatum. Transcriptional analyses showed preferential expression of DDR48 in the mycelial phase. Induction of DDR48 in Histoplasma yeasts developed after treatment with various cellular stress compounds. We generated a ddr48∆ deletion mutant to further characterize DDR48 function. Loss of DDR48 alters the transcriptional profile of the oxidative stress response and membrane synthesis pathways. Treatment with ROS or antifungal compounds reduced survival of ddr48∆ yeasts compared to controls, consistent with an aberrant cellular stress response. In addition, we infected RAW 264.7 macrophages with DDR48-expressing and ddr48∆ yeasts and observed a 50% decrease in recovery of ddr48∆ yeasts compared to wild-type yeasts. Loss of DDR48 function results in numerous negative effects in Histoplasma yeasts, highlighting its role as a key player in the global sensing and response to cellular stress by fungi.

Transcriptome sequencing revealed the inhibitory mechanism of ketoconazole on clinical Microsporum canis

Background

Microsporum canis is a zoonotic disease that can cause dermatophytosis in animals and humans.

Objectives

In clinical practice, ketoconazole (KTZ) and other imidazole drugs are commonly used to treat M. canis infection, but its molecular mechanism is not completely understood. The antifungal mechanism of KTZ needs to be studied in detail.

Methods

In this study, one strain of fungi was isolated from a canine suffering with clinical dermatosis and confirmed as M. canis by morphological observation and sequencing analysis. The clinically isolated M. canis was treated with KTZ and transcriptome sequencing was performed to identify differentially expressed genes in M. canis exposed to KTZ compared with those unexposed thereto.

Results

At half-inhibitory concentration (½MIC), compared with the control group, 453 genes were significantly up-regulated and 326 genes were significantly down-regulated (p < 0.05). Quantitative reverse transcription polymerase chain reaction analysis verified the transcriptome results of RNA sequencing. Gene ontology enrichment analysis and Kyoto Encyclopedia of Genes and Genomes enrichment analysis revealed that the 3 pathways of RNA polymerase, steroid biosynthesis, and ribosome biogenesis in eukaryotes are closely related to the antifungal mechanism of KTZ.

Conclusions

The results indicated that KTZ may change cell membrane permeability, destroy the cell wall, and inhibit mitosis and transcriptional regulation through CYP51, SQL, ERG6, ATM, ABCB1, SC, KER33, RPA1, and RNP genes in the 3 pathways. This study provides a new theoretical basis for the effective control of M. canis infection and the effect of KTZ on fungi.

Repurposing of Antimicrobial Agents for Cancer Therapy: What Do We Know?

The substantial costs of clinical trials, the lengthy timelines of new drug discovery and development, along the high attrition rates underscore the need for alternative strategies for finding quickly suitable therapeutics agents. Given that most approved drugs possess more than one target tightly linked to other diseases, it encourages promptly testing these drugs in patients. Over the past decades, this has led to considerable attention for drug repurposing, which relies on identifying new uses for approved or investigational drugs outside the scope of the original medical indication. The known safety of approved drugs minimizes the possibility of failure for adverse toxicology, making them attractive de-risked compounds for new applications with potentially lower overall development costs and shorter development timelines. This latter case is an exciting opportunity, specifically in oncology, due to increased resistance towards the current therapies. Indeed, a large body of evidence shows that a wealth of non-cancer drugs has beneficial effects against cancer. Interestingly, 335 drugs are currently being evaluated in different clinical trials for their potential activities against various cancers (Redo database). This review aims to provide an extensive discussion about the anti-cancer activities exerted by antimicrobial agents and presents information about their mechanism(s) of action and stage of development/evaluation.

Topical ketoconazole for the treatment of androgenetic alopecia: A systematic review

Androgenetic alopecia (AGA) is common and associated with significant psychosocial distress. Treatment options are needed for patients that do not adequately respond to first line treatments of finasteride or minoxidil. Topical ketoconazole has been proposed as a promising treatment. The goal of this systematic review was to evaluate the efficacy of topical ketoconazole in the treatment of AGA. A systematic literature search was conducted within the MEDLINE database using the key terms "ketoconazole" and "alopecia." Forty-seven papers were screened for inclusion, of which nine were assessed for eligibility. Seven articles were included in the qualitative synthesis, including two animal studies (total of 40 participants) and five human studies (total of 318 participants). Murine studies demonstrated a significant increase in mean ratio of hair regrowth to denuded area in the ketoconazole treatment groups compared to controls. Human studies reported increased hair shaft diameter following ketoconazole use. One study reported a significant increase in pilary index (percent anagen phase × diameter) following treatment. Studies also demonstrated clinical improvement of AGA based on photographic assessment and subjective evaluation. Topical ketoconazole is a promising adjunctive or alternative therapy in the treatment of AGA. Randomized controlled trials are needed.

Drug design strategies for Cushing's syndrome

INTRODUCTION

Cushing's syndrome (CS) is a metabolic disorder caused by chronic hypercortisolism. CS is associated with cardiovascular, metabolic, skeletal and psychological dysfunctions and can be fatal if left untreated. The first-line treatment for all forms of CS is a surgery. However, medical therapy has to be chosen if surgical resection is not an option or is deemed ineffective. Currently available therapeutics are either not selective and have side effects or are only available as an injection (pasireotide). Areas covered: The authors discuss the recent drug developments for the medical treatment of CS through two validated molecular targets. Specifically, the authors look at selective inhibitors of CYP11B1 that reduce cortisol production by inhibiting steroid 11beta-hydroxylase and glucocorticoid receptor (GR) antagonists that interrupt cortisol-mediating transcriptional regulation of related genes. Expert opinion: Patients with CS have limited treatment options; indeed, there is an unmet need for new compounds that target CYP11B1 selectively versus several steroidogenic enzymes and/or GR-signaling pathways. The complexity of steroid biosynthesis and signaling requires the application of structure-based drug discovery techniques that use molecular targets and highly similar off-targets. Significant differences in steroidogenesis between humans and other species necessitates caution over the choice of in vivo model for the preclinical evaluation of future potential compounds.

Ketoconazole-induced estrogen deficiency causes transient decrease in placental blood flow associated with hypoxia and later placental weight gain in rats

This study investigated the relationship among estrogen, placental blood flow and placental weight gain in rats treated with ketoconazole. Oral administration of ketoconazole (25mg/kg/day) on Days 12-14 of pregnancy induced reduction of plasma estradiol-17β (E2) concentration, transient decrease in placental blood flow and increased intensity of a hypoxia-related marker in the placenta on Day 14 of pregnancy. On Day 20 of pregnancy, placental weights of ketoconazole-treated rats increased when compared to controls. Histologically, maternal sinusoidal area of the placenta decreased on Day 14 of pregnancy and the total area of maternal and fetal sinusoids increased on Day 20. All the changes disappeared by concomitant subcutaneous infusion of E2. These results indicate that ketoconazole-induced E2 deficiency causes transient decrease in placental blood flow associated with hypoxia and later placental weight gain in rats.

Drug safety assessment of oral formulations of ketoconazole

INTRODUCTION

Ketoconazole was the first broad-spectrum oral antifungal approved by the FDA in 1981. Post-marketing reports of drug-related hepatotoxicity, endocrine dysregulation and drug interactions resulted in market withdrawal of the drug in some countries and strict product relabeling in others.

AREAS COVERED

This drug safety review summarizes reports of oral ketoconazole-related adverse events retrieved from a search of the PubMed database using the search strategy 'ketoconazole OR Nizoral AND hepat*', references from relevant publications, and data from the FDA Adverse Event Reporting System.

EXPERT OPINION

Although oral ketoconazole is effective in treating fungal infections, the potential for drug interactions, endocrine dysregulation, and hepatotoxicity may outweigh its benefits. Newer oral antifungals have similar or greater efficacy in treating dermatologic conditions and are associated with less risk. Likewise, newer agents with specific targets and fewer drug interactions have been developed to treat systemic fungal infections. Therefore, by the time ketoconazole prescribing guidelines were amended, its use had already largely been replaced with newer antifungals. Being that ketoconazole was the first broad-spectrum oral antifungal, experience with the drug made patient safety, and especially hepatic safety, an important consideration in future antifungal development.

Effects of an ergosterol synthesis inhibitor on gene transcription of terpenoid biosynthesis in Blakeslea trispora

Highly efficient induction of carotene biosynthesis of Blakeslea trispora by ketoconazole (KCZ), an inhibitor of ergosterol biosynthesis, was found previously. To get some insight into the regulatory mechanisms of KCZ controlling terpenoid (including carotene) biosynthesis, the transcript levels of gene hmgR, encoding HMGR, which initiates the biosynthesis of all terpenoids, and gene carRA, encoding lycopene cyclase and phytoene synthase in the carotene biosynthsis pathway, were investigated in B. trispora cells treated with KCZ. Upon KCZ treatment, up-regulation of hmgR and carRA genes, increased beta-carotene and ubiquinone contents, and decreased ergosterol content were all observed. The results suggest that the inhibition of ergosterol biosynthesis by KCZ triggered hmgR gene transcription, which might present a positive feedback regulation of gene hmgR in response to a depletion of ergosterol. Furthermore, KCZ could be used as a new agent to improve not only beta-carotene but also ubiquinone production, whose regulatory mechanisms controlling terpenoid biosynthesis differ from the agents reported previously.

Inhibitory Activity of 1-Farnesylpyridinium on the Spatial Control over the Assembly of Cell Wall Polysaccharides in Schizosaccharomyces pombe

The modes of actions of 1-farnesylpyridinium (FPy) on yeast cell growth were investigated on the basis of its effects on cell cycle progression, morphogenesis and the related events for construction of cell wall architecture in Schizosacchromyces pombe. FPy predominantly inhibited the growth of the yeast cells after various cycles of cell division so that cells were arrested at the phase of separation into daughter cells accompanying morphological changes to swollen spherical cells at 24 h of incubation. FPy-treated cells were osmotically stable but were susceptible to the lytic action of (1, 3) beta-D-glucanases, and characterized by serious damages to the cell wall architecture as represented by a rough and irregular surface outlook. The isolated cell wall fraction gave a similar hexose composition with or without FPy treatment, suggesting that FPy did not inhibit the synthesis of each cell wall polysaccharide. FPy was permissive for the extracellular accumulation of amorphous cell wall materials and septum development in protoplasts, but absolutely interfered with the following morphogenetic process for construction of the rod-shaped cell wall architecture. Our results suggest the inhibitory activity of FPy on the spatial control over the assembly of cell wall polysaccharides.

Current use of anti-infectives in dermatology

Dermatologic diseases encompass a broad category of pathologic situations. Infection remains a significant aspect of the pathology faced in patient encounters, and it is natural to expect that anti-infectives play a major element in the armamentarium utilized by dermatologists. Aside from the treatment of the classic bacterial and fungal infections, there are now new uses for antiviral agents to help suppress recurrent disease, such as herpes simplex. There is also the novel approach of using anti-infectives, or agents that have been thought to have antimicrobial activity, to treat inflammatory diseases. This review describes anti-infectives, beginning with common antibiotics used to treat bacterial infections. The discussion will then cover the current use of antivirals. Finally, the description of antifungals will be separated, starting with the oral agents and ending with the topical antimycotics. The use of anti-infectives in tropical dermatology has been purposefully left out, and perhaps should be the subject of a separate review. Cutaneous bacterial infections consist chiefly of those microorganisms that colonize the skin, such as species of staphylococcus and streptococcus. Propionibacterium acnes and certain other anaerobes can be involved in folliculitis, pyodermas and in chronic conditions such as hidradenitis suppurativa.

High-content profiling of drug-drug interactions: cellular targets involved in the modulation of microtubule drug action by the antifungal ketoconazole

Drug-drug interactions play an important role in the discovery and development of therapeutic agents. High-content profiling was developed to unravel the complexity of these interactions by providing multiparameter measurements of target activity at the cellular and subcellular levels. Two microtubule drugs, vinblastine and curacin A, were shown to modulate multiple cellular processes, including nuclear condensation, the activation of the extracellular signal-regulated kinase pathway as measured by RSK90 phosphorylation, and the regulation of the microtubule cytoskeleton as measured in detergent-extracted cells. The heterogeneity of the response, addressed through population analysis and multiparameter comparisons within single cells, was consistent with vinblastine and curacin A having similar effects on nuclear morphology and 90 kDa ribosomal s6 kinase (RSK90) phosphorylation despite having distinct effects on the microtubule cytoskeleton. Ketoconazole, originally developed as an antifungal agent, exhibited concentration-dependent inhibitory and potentiating effects on both drugs in HeLa and PC-3 cells at concentration ranges near the plasma levels of ketoconazole attained in human subjects. Thus, high-content profiling was used to dissect the cellular and molecular responses to interacting drugs and is therefore a potentially important tool in the selection, characterization, and optimization of lead therapeutic compounds.

Malassezia pachydermatis with special reference to canine skin disease

A review of the diseases caused by Malassezia pachydermatis has led to the conclusion that the yeast is an opportunistic pathogen that depends on predisposing host factors and different immune suppressive mechanisms for clinical manifestation. Until recently, the role of M. pachydermatis in seborrhoeic dermatitis and otitis externa in dogs has been largely unrecognized. The clinical manifestation, aetiology, diagnosis and treatment of disease conditions in dogs caused by M. pachydermatis are reviewed. Human Malassezia furfur infections are briefly described.

In vivo pharmacokinetics and pharmacodynamics of topical ketoconazole and miconazole in human stratum corneum

A direct study evaluating whether differential drug uptake of topical 2% miconazole and 2% ketoconazole from cream formulations into human stratum corneum correlated with differential pharmacological activity against Candida albicans was investigated in healthy human subjects. A single 24-h topical dose of 2% ketoconazole cream or 2% miconazole cream was applied unoccluded, at the same dose (2.6 mg of formulation per cm2 of surface area), at four skin sites on both ventral forearms of six human subjects. At the end of the treatment, residual drug was removed with a tissue from all sites and the treated site was tape stripped 11 times, either 1, 4, 8, or 24 h later. The first tape disc was discarded. The remaining tape discs, 2 through 11, were combined and extracted for drug quantification by high-performance liquid chromatography and bioactivity against C. albicans growth in vitro. Topical 2% ketoconazole produced 14-, 10-, and 7-fold greater drug concentrations in stratum corneum than 2% miconazole at 1, 4, and 8 h after a single topical dose. Ketoconazole and miconazole concentrations in the stratum corneum were similar 24 h after drug removal. Tape disc extracts from 2% ketoconazole-treated skin sites demonstrated significantly greater bioactivity in the bioassay than 2% miconazole. The increased efficacy of 2% ketoconazole compared with that of 2% miconazole in vitro reflects their differential uptake into the stratum corneum and inherent pharmacological activity. Tape stripping the drug-treated site in conjunction with a bioassay is therefore a useful approach in the determination of bioavailability of topical antifungal agents.

A comparison between fluconazole tablets and clotrimazole troches for the treatment of thrush in HIV infection

Fluconazole, a newly available triazole, has been evaluated extensively as a treatment for thrush. It has been effective in the treatment of this condition in patients with HIV infection. Clotrimazole troches have been a common treatment for thrush in patients with HIV infection for several years. This study compared the efficacy and safety of fluconazole 100 mg tablets once per day versus clotrimazole 10 mg troches five times per day in the treatment of thrush in patients with HIV infection. Patients were evaluated at baseline, day 7, 14, 28, and 42. The following parameters were evaluated: clinical cure, colonization at the end of treatment, relapse at day 28, and relapse at day 42. Side effects including liver enzyme values were also monitored. Clinical cure was superior with fluconazole tablets than with clotrimazole troches. Also, rates of colonization at the end of therapy and relapse at days 28 and 42 were less with fluconazole tablets than with clotrimazole troches. However, these differences were not statistically significant. Patient compliance with fluconazole was superior to that of clotrimazole. This difference was statistically significant. Both fluconazole tablets and clotrimazole troches are effective in treating thrush in patients with HIV infection. The avoidance of multiple-per-day dosing would appear to favor fluconazole.

Fungal morphology after treatment with itraconazole as a single oral dose in experimental vaginal candidosis in rats

The therapeutic effect of a single, oral dose of itraconazole was studied in rats inoculated intravaginally with Candida albicans and in which an established vaginal infection was present. We used light microscopy, transmission and scanning electron microscopy to document the structural alterations in the 3 days after treatment. The most important observations include the speed (within 24 hours) with which itraconazole inhibits the further penetration of the fungus into the vaginal squamous epithelium, the ability of the drug to reach and structurally alter intracellularly located fungal elements, and the prolonged drug effect of a single dose leading to complete eradication of the fungus from the vagina within 3 days.

Ketoconazole in the treatment of pityriasis versicolor: international review of clinical trials

Multiple open and double-blind studies have confirmed the efficacy of ketoconazole in the treatment of pityriasis versicolor. Single-dose (400 mg) or short-course (200 mg/d for five days) therapy may be highly effective for selected patients with pityriasis versicolor. Toxicity seems to be minimal at this dosage.

Antifungal therapy in oropharyngeal mycotic infections

Oral and pharyngeal candidiasis is a significant infection, particularly in immunosuppressed persons. Candidiasis may be evident as red or white lesions and may produce symptoms. In immunosuppressed persons, oral candidiasis may lead to extensive regional involvement and to systemic infection and can result in death. Because of the significance and prevalence of candidiasis, the recognition and management of infection are important.

Antifungal agents in dermatology

Development of new antifungal agents has increased significantly over the past two decades, with recent advances reflecting interest in synthetic agents as opposed to antibiotics. We review the various antifungal medications in use or under development, beginning with a discussion of over-the-counter agents, antibiotics, and older azole compounds and ending with an evaluation of newer azoles and the new class of antifungals, the allylamines.

Antibiotic tetaine--a selective inhibitor of chitin and mannoprotein biosynthesis in Candida albicans

The antibiotic tetaine inhibits in Candida albicans the biosynthesis of two important cell wall constituents, chitin and mannoprotein. This effect is a consequence of inactivation of the enzyme glucosamine-6-phosphate synthetase. Due to the lack of glucosamine-6-phosphate the effective secretion of mannoprotein enzymes, acid phosphatase and invertase, by Candida albicans spheroplasts is inhibited. In the presence of tetaine, probably a modified mannoprotein, lacking a branched polymannan, is synthesized. The antibiotic action decreases the viability of Candida albicans cells, especially that of mycelial forms of this fungus.

Candidal costochondritis responsive to ketoconazole in an iv drug abuser

Infections caused by Candida albicans have been reported in many organ systems in intravenous drug users. Amphotericin B (Fungizone) has been shown to be effective in treatment. However, because of its numerous side effects and difficulty in maintaining intravenous access in this population, the agent is difficult to use. Ketoconazole (Nizoral), administered orally, is a more convenient and better tolerated agent and was efficacious in the case of candidal costochondritis described here. Further evaluation of ketoconazole is needed to better define its role in the treatment of disseminated candidiasis, particularly in cases associated with intravenous drug abuse.

Ketoconazole's inhibition of fungal antigen-induced thymidine uptake by lymphocytes from patients with psoriasis

Ketoconazole, an oral antifungal imidazole, has been effective in some refractory cases of psoriasis, particularly those with scalp involvement, perhaps because of suppression of Pityrosporum ovale. To assess an ancillary immunologically mediated role for ketoconazole, its effects were evaluated on psoriatic patients' lymphocyte function. Ketoconazole in vitro markedly inhibited Pityrosporum antigen-induced lymphocyte blastogenesis as indicated by impairment of cellular tritiated thymidine uptake. Ketoconazole likewise inhibited lymphocyte uptake of other pyrimidine nucleosides by both normal and psoriatic lymphocytes. Neither imidazole or an investigational triazole antifungal (Bay n7133) inhibited the uptake. Thus, ketoconazole potentially could affect psoriasis in seborrheic areas of skin by a direct antifungal action or indirectly by suppressing fungal antigen-induced lymphocyte-mediated immune responses affecting the skin.

Epidemic postsurgical Candida parapsilosis endophthalmitis. Clinical findings and management of 15 consecutive cases

Fifteen cases of postoperative Candida parapsilosis endophthalmitis occurring secondary to a contaminated lot of an irrigating solution were studied. All patients underwent a vitreous tap or diagnostic and therapeutic vitrectomy. Eleven of the 15 specimens were positive for the organism. Fourteen patients were treated with pars plana vitrectomy surgery. All patients were treated with intravitreal amphotericin B and systemic amphotericin B and 5-fluorocytosine. Two clinical recurrences were successfully treated with intravitreal amphotericin B, removal of the pseudophakos, and oral ketoconazole. The intraocular lens was retained in 11 of the 14 pseudophakic patients. Final visual acuities ranged from 20/25 to no light perception with eight of 15 patients having 20/60 or better visual acuities. Measurable levels of intraocular amphotericin B were found after systemic amphotericin B administration. Two patients with totals of 20 and 30 micrograms of intravitreal amphotericin B over 48 and 96 hours, respectively, had near normal ERGs one year later. Posterior capsulotomy and vitrectomy appear to decrease amphotericin B toxicity and allow sequential intraocular injection of this drug within a short time period.

Experimental chronic vaginal candidosis in rats

In the past, the rat model of experimental vaginal candidosis has been used to study the efficacy of antifungal agents in eradicating acute vaginitis. In the present study, chronic vaginal candidosis was induced to study the natural history of the infection. Results indicate that chronic infection is readily achieved and is strictly dependent on oophorectomy and hormonal maintenance of pseudoestrous. Histologic studies confirm that rats so infected and with long term vaginal carriage of Candida albicans have true chronic infection with extensive mycelial formation and superficial mucosal invasion.

Do the imidazoles have a role in the management of genitourinary fungal infections?

The imidazoles have demonstrated antifungal activity against a number of fungi that are pathogenic for man. Effective clinical use has been demonstrated in patients with cutaneous and systemic candidiasis, aspergillosis, blastomycosis, coccidioidomycosis, cryptococcus and systemic candidiasis, aspergillosis, blastomycosis, coccidioidomycosis, cryptococcus and histoplasmosis. We report our experience with the oral imidazole agent ketoconazole in the management of 8 patients with significant urinary candidiasis as judged by elevated urinary candidal counts (greater than 15,000/ml.). Only 4 of the 8 patients had resolution of candiduria with ketoconazole therapy. Intravenous miconazole, another imidazole, has been available for treatment of systemic and genitourinary fungal infections. Limited success (50 per cent) with intravenous miconazole has been noted in the treatment of systemic candidiasis with urinary involvement. Miconazole also has been used as a systemic and local irrigant in the treatment of bladder and renal candidiasis. Based on these observations and our own studies, we believe that the imidazoles have a limited role in the management of patients with significant fungal involvement of the urinary tract.

Itraconazole, a new triazole that is orally active in aspergillosis

Itraconazole is a new orally active triazole derivative with broad-spectrum antifungal activity. This drug is effective in experimental aspergillosis and possesses in vitro activity against various species and strains of Aspergillus. Morphological destruction of inoculated hyphae and complete inhibition of hyphal outgrowth in culture is obtained from 0.07 micrograms ml-1 (10(-7)M) onward. These properties make itraconazole a likely candidate for clinical evaluation in disseminated aspergillosis.

Ketoconazole: an orally effective antifungal agent. Mechanism of action, pharmacology, clinical efficacy and adverse effects

Ketoconazole is a new, orally effective, antifungal agent. It is an imidazole compound and like other antifungals of this group, has a wide spectrum of use. Effectiveness has been shown in a variety of deep fungal infections as well as in superficial infections such as candidiasis, dermatophytosis and tinea versicolor. Although it first appeared to be a remarkably safe agent associated with only minor side effects, with more use it has become apparent that symptomatic drug-induced hepatitis occurs in approximately 1 in 12,000 patients. This idiosyncratic side effect and potential effects on testosterone and cortisol synthesis may limit the use of ketoconazole to deep fungal infections and severe recalcitrant superficial infections of the skin.

The control of morphogenesis in Candida albicans

Morphogenesis (germ-tube formation) in Candida albicans was induced gratuitously by N-acetylhexosamine derivatives (N-acetyl-glucosamine covalently linked to agarose, N-acetylmannosamine, hyaluronic acid, colloidal chitin, and mucin). These compounds were not taken up by the yeast cells and did not support growth. 2-Deoxyglucose was a potent inhibitor of germ-tube formation (50 microM), but did not affect the yeast growth yield at a concentration of 2.5 mM. 2-Deoxyglucose covalently linked to agarose did not affect germ-tube formation, and the inhibition by free 2-deoxyglucose was overcome by the addition of glucose to the germ-tube-forming cells. Glucose competitively inhibited 2-deoxyglucose uptake (Ki = 0.14 mM), and these data indicate that 2-deoxyglucose acted intracellularly.

Ketoconazole in the prevention of experimental candidal vaginitis

The prophylactic and therapeutic activities of ketoconazole were evaluated in rats inoculated intravaginally with Candida albicans. Daily doses of 2.5 mg/kg initiated 48 h before challenge and continued for 48 h thereafter protected 80% of the rats against infection. A similar result in rats with established infection was attained with daily doses of 5.0 mg/kg.