In Vitro Antifungal Combination of Terbinafine with Itraconazole against Isolates of Trichophyton Species.

Terbinafine is used as the first-line therapy for dermatophytosis, but the incidence of terbinafine resistance is increasing. A combination of terbinafine with itraconazole was tested using the checkerboard method based on the EUCAST methodology for antifungal susceptibility testing against 9 terbinafine-susceptible and 7 terbinafine-resistant clinical isolates of Trichophyton spp. from India. Synergistic interactions were observed for 4/9 of the susceptible isolates, with fractional inhibitory concentration index (FICI) values of 0.3125 to 0.5, and for 4/7 of the resistant isolates, with FICI values of 0.032 to 0.3125.

Evaluation of the Gradient Concentration Strip Method for Antifungal Susceptibility Testing of Isavuconazole and Comparators for Mucorales Species.

MIC values for amphotericin B and three azoles determined by the EUCAST reference technique and by gradient concentration strips were compared for 30 Mucorales isolates belonging to clinically important species. Essential agreement (EA) within ±2 dilution steps at 24 hours between the techniques was 83.3% for isavuconazole. EAs for itraconazole, amphotericin B, and posaconazole were 86.7%, 73.3%, and 56.7%, respectively. A good agreement was obtained between visual and spectrophotometric readings for EUCAST.

In vitro interactions between isavuconazole and tacrolimus, cyclosporin A or sirolimus against Mucorales.

OBJECTIVES: To evaluate the in vitro interactions of isavuconazole with immune suppressors (tacrolimus, cyclosporin A or sirolimus) against 30 Mucorales isolates belonging to the most common species responsible for mucormycosis in humans (Rhizopus arrhizus, Rhizopus delemar, Rhizopus microsporus, Lichtheimia corymbifera, Lichtheimia ramosa, Mucor circinelloides and Rhizomucor pusillus). METHODS: In vitro interaction was evaluated by a microdilution chequerboard technique. RESULTS: Combination of isavuconazole with tacrolimus, cyclosporin A or sirolimus, was synergistic for 50%, 46% and 7% of the isolates, respectively. Antagonistic interaction was observed for 4% of the isolates for the combination with cyclosporin A (one R. arrhizus isolate) and for 32% of the isolates for the combination with sirolimus (six R. arrhizus isolates and three R. pusillus isolates). CONCLUSIONS: These in vitro data show that calcineurin inhibitors are more likely than inhibitors of the mTOR pathway to enhance the activity of isavuconazole against Mucorales. These in vitro results warrant further animal experiments.

Antifungal combinations in Mucorales: A microbiological perspective.

Mucormycosis mostly affects immunocompromised patients and is associated with a high morbidity and mortality despite currently available treatments. In that context, combination therapy might be the key to a better outcome for these patients. Purpose of this review is to summarise and to discuss the current combination data obtained in vitro, in vivo in animal models of mucormycosis, and in patients. In vitro combination studies showed that most of the interactions between antifungal drugs were indifferent, even though that some synergistic interactions were achieved for the combination of echinocandins with either azoles or amphotericin B. Importantly, antagonism was never observed. Animal models of mucormycosis focused on infections caused by Rhizopus arrhizus, neglecting most other species responsible for human disease. In these experimental animal models, no strong interactions have been demonstrated, although a certain degree of synergism has been reported in some instances. Combinations of antifungals with non-antifungal drugs have also been largely explored in vitro and in animal models and yielded interesting results. In patients with ketoacidosis and rhino-orbito-cerebral infection, combination of polyene with caspofungin was effective. In contrast, despite promising experimental data, adjunctive therapy with the iron chelator deferasirox was unfavourable and was associated with a higher mortality than monotherapy with liposomal amphotericin B. More combinations have to be tested in vitro and a much larger panel of Mucorales species has to be tested in vivo to give a valuable statement if antifungal combination therapy could be an effective treatment strategy in patients with mucormycosis.

Molecular identification of fungi found on decomposed human bodies in forensic autopsy cases.

To investigate which fungi can be found during forensic autopsies, a PubMed literature review was done in regard to fungal growth on decomposed human bodies. Unfortunately, the existing data is limited and not all fungi were identified to the species level. We, therefore, collected skin samples with macroscopically visible fungal growth from 23 autopsy cases in Germany and identified the fungi to the species level by molecular methods. The identified species included Aspergillus fumigatus and Candida albicans, which pose an allergenic risk, especially to persons with underlying lung diseases. Because safety standards are lacking, we recommend the use of respiratory protection during exhumations and forensic autopsies, when fungal growth is noted. With regard to the future, a database was set up which could possibly be used as a forensic tool to determine the time of death.

Experience with an alternative form of samples for external quality assessment of urinary sediment (visual sample EQA).

BACKGROUND: Urinary sediment components are mainly unstable, especially in their original forms. This makes the use of such material in routine external quality assessment surveys (EQAS) almost impossible. The development of an alternative EQAS for urinary sediment using photomicrographs (visual-sample EQAS) is described here, together with results, improvements and future plans. METHODS: The original survey allowed a free-text interpretation, which proved to be time consuming and impractical. The next phase included a multiple choice answer (one from five alternatives). The current version challenges the participant with a list of over 50 alternatives, together with a "not-in-the-list" possibility. RESULTS: Certain elements are always interpreted more correctly (examples: erythrocytes, squamous cells, renal epithelial cells, bacteria--above 90%) than others (examples: leukocytes, fat droplets, certain crystals--below 55%). Pictures are included which are atypical (for example: decoy cells, which must be interpreted correctly, other artefacts). Occasionally interesting structures are included, but which are not evaluated. CONCLUSIONS: The two-dimensional pictures often limited the interpretation possibilities, so that in such cases more than one answer was allowed. The possibility of "online microscopy" using staple pictures is at present in evaluation. The acceptance of this type of EQAS is seen by the number of participants, at present over 500 per survey, four surveys per year.

An educational web-based external quality assessment outcome and evaluation: first experiences with urinary sediment and hemostaseology.

External quality assessment is a standard procedure for many medical laboratories, especially those accredited according to ISO 15189. INSTAND has developed web-based quality control surveys (WQ) with integrated case-based learning in collaboration with the Institute for Teaching and Educational Research in Health Sciences (IDBG), University of Witten/Herdecke. The WQs were presented via a weblink using the learning management system CASUS. Laboratories registered with INSTAND for conventional EQAs covering the same topic were invited to participate in the WQs. Statistics were calculated with the INSTAND EQA-evaluation program and with the "Statistical Program for Social Sciences" (SPSS Version 20). While the two pilot surveys (hemostaseology) were designed for laboratory technicians, WQ III (urine sediment) addressed the whole laboratory team. From the invited laboratories more than 80% participated successfully and the evaluations showed that, in general, more than half the participants solved the tasks as a team. The web-based EQAs were well accepted by the users, with some technical problems in WQ III and moderate criticism on the images and relevance for daily practice in the evaluation sheets. Well above 80% would like to participate in further WQs and would recommend them to other laboratories. Thus web-based quality control surveys can emerge as an important supplement to conventional EQAs.

Antifungal susceptibility and phylogeny of opportunistic members of the order mucorales.

The in vitro susceptibilities of 66 molecularly identified strains of the Mucorales to eight antifungals (amphotericin B, terbinafine, itraconazole, posaconazole, voriconazole, caspofungin, micafungin, and 5-fluorocytosine) were tested. Molecular phylogeny was reconstructed based on the nuclear ribosomal large subunit to reveal taxon-specific susceptibility profiles. The impressive phylogenetic diversity of the Mucorales was reflected in susceptibilities differing at family, genus, and species levels. Amphotericin B was the most active drug, though somewhat less against Rhizopus and Cunninghamella species. Posaconazole was the second most effective antifungal agent but showed reduced activity in Mucor and Cunninghamella strains, while voriconazole lacked in vitro activity for most strains. Genera attributed to the Mucoraceae exhibited a wide range of MICs for posaconazole, itraconazole, and terbinafine and included resistant strains. Cunninghamella also comprised strains resistant to all azoles tested but was fully susceptible to terbinafine. In contrast, the Lichtheimiaceae completely lacked strains with reduced susceptibility for these antifungals. Syncephalastrum species exhibited susceptibility profiles similar to those of the Lichtheimiaceae. Mucor species were more resistant to azoles than Rhizopus species. Species-specific responses were obtained for terbinafine where only Rhizopus arrhizus and Mucor circinelloides were resistant. Complete or vast resistance was observed for 5-fluorocytosine, caspofungin, and micafungin. Intraspecific variability of in vitro susceptibility was found in all genera tested but was especially high in Mucor and Rhizopus for azoles and terbinafine. Accurate molecular identification of etiologic agents is compulsory to predict therapy outcome. For species of critical genera such as Mucor and Rhizopus, exhibiting high intraspecific variation, susceptibility testing before the onset of therapy is recommended.

Carbodiimide-fueled catalytic reaction cycles to regulate supramolecular processes.

Using molecular self-assembly, supramolecular chemists can create Gigadalton-structures with angstrom precision held together by non-covalent interactions. However, despite relying on the same molecular toolbox for self-assembly, these synthetic structures lack the complexity and sophistication of biological assemblies. Those assemblies are non-equilibrium structures that rely on the constant consumption of energy transduced from the hydrolysis of chemical fuels like ATP and GTP, which endows them with dynamic properties, e.g., temporal and spatial control and self-healing ability. Thus, to synthesize life-like materials, we have to find a reaction cycle that converts chemical energy to regulate self-assembly. We and others recently found that this can be done by a reaction cycle that hydrates carbodiimides. This feature article aims to provide an overview of how the energy transduced from carbodiimide hydration can alter the function of molecules and regulate molecular assemblies. The goal is to offer the reader design considerations for carbodiimide-driven reaction cycles to create a desired morphology or function of the assembly and ultimately to push chemically fueled self-assembly further towards the bottom-up synthesis of life.

In Vitro Activity of Amphotericin B in Combination with Colistin against Fungi Responsible for Invasive Infections.

The in vitro interaction of amphotericin B in combination with colistin was evaluated against a total of 86 strains comprising of 47 Candida species (10 Candida albicans, 15 Candida auris, five Candida glabrata, three Candida kefyr, five Candida krusei, four Candida parapsilosis and five Candida tropicalis), 29 Aspergillus species (five Aspergillus flavus, 10 Aspergillus fumigatus, four Aspergillus nidulans, five Aspergillus niger, and five Aspergillus terreus), and 10 Rhizopus species (seven Rhizopus arrhizus, one Rhizopus delemar and two Rhizopus microsporus) strains. For the determination of the interaction, a microdilution checkerboard technique based on the European Committee on Antimicrobial Susceptibility Testing (EUCAST) reference method for antifungal susceptibility testing was used. Results of the checkerboard technique were evaluated by the fractional inhibitory concentration index (FICI) based on the Loewe additivity model for all isolates. Different inhibition endpoints were used to capture both the interaction at MIC and sub-MIC levels. Additionally, checkerboard technique results for Candida species were evaluated by response surface analysis based on the Bliss independence model. Against common Candida species, the combination was synergistic for 75% of the strains by FICI and for 66% of the strains by response surface analysis. For C. tropicalis, the interaction was antagonistic for three isolates by FICI, but antagonism was not confirmed by response surface analysis. Interestingly, synergistic and antagonistic FICIs were simultaneously present on checkboard microplates of all three strains. Against C. auris the combination was synergistic for 73% of the strains by response surface analysis and for 33% of the strains by FICI. This discrepancy could be related to the insensitivity of the FICI to detect weak interactions. Interaction for all other strains was indifferent. For Aspergillus and Rhizopus species combination exhibited only indifferent interactions against all tested strains.

In Vitro Synergy of Isavuconazole Combined With Colistin Against Common Candida Species.

Interactions of isavuconazole and colistin were evaluated against 57 common Candida strains belonging to the species Candida albicans (n = 10), Candida glabrata (n = 10), Candida kefyr (n = 8), Candida krusei (n = 10), Candida parapsilosis (n = 9), and Candida tropicalis (n = 10) by a broth microdilution checkerboard technique based on the European Committee on Antimicrobial Susceptibility Testing (EUCAST) reference methodology for antifungal susceptibility testing. Results were analyzed with the fractional inhibitory concentration index and by the response surface analysis. Interpretation by the fractional inhibitory concentration index showed synergy for 50%, 80%, 90%, and 90% of the C. kefyr, C. krusei, C. glabrata, and C. tropicalis strains, respectively. Combination of isavuconazole with colistin against C. albicans and C. parapsilosis exhibited only indifference for 100% and 90% of the strains, respectively. The results were confirmed by response surface analysis for all species except for C. glabrata, for which an indifferent interaction was found for the majority of strains. Antagonistic interaction was never seen regardless of the interpretation model was used.

Synergistic In Vitro Interaction of Isavuconazole and Isoquercitrin against Candida glabrata.

In vitro interactions of broad-spectrum azole isavuconazole with flavonoid isoquercitrin were evaluated by a broth microdilution checkerboard technique based on the European Committee on Antimicrobial Susceptibility Testing (EUCAST) reference methodology for antifungal susceptibility testing against 60 Candida strains belonging to the species Candida albicans (n = 10), Candida glabrata (n = 30), Candida kefyr (n = 6), Candida krusei (n = 5), Candida parapsilosis (n = 4), and Candida tropicalis (n = 5). The results were analyzed with the fractional inhibitory concentration index and by response surface analysis based on the Bliss model. Synergy was found for all C. glabrata strains, when the results were interpreted by the fractional inhibitory concentration index, and for 60% of the strains when response surface analysis was used. Interaction for all other species was indifferent for all strains tested, whatever interpretation model used. Importantly, antagonistic interaction was never observed.

Suppression of realgar cage degradation during complexation: formation of hybrid coordination polymers with As4S4, PAs3S3, and Cu(I) halide building blocks.

Realgar, As(4)S(4), reacts with Cr(CO)(5)THF under cage degradation to give As(4)S(3)·Cr(CO)(5) (1). The reverse structural change is found if solutions of 1 in CH(2)Cl(2) react with equimolar amounts of PAs(3)S(3)·W(CO)(5) and CuX (X = Cl, Br, I) in CH(3)CN under biphasic diffusion conditions. The resulting coordination polymers 2-4 contain a reconstituted realgar molecule along with the PAs(3)S(3) cage. The crystal structures of (CuX)(As(4)S(4))(PAs(3)S(3)) (X = Cl: 2; Br: 3) are characterized by one-dimensional (1D) (CuX)(As(4)S(4)) strands, which are formed by alternating As(4)S(4) cages and CuX dumbbells. Terminal PAs(3)S(3) molecules are coordinated to copper by apical phosphorus and bridging realgar through sulfur. The As(3) triangles of the resulting (CuX)(As(4)S(4))(PAs(3)S(3)) strands interact with halides of neighbored strands to give a folded three-dimensional (3D) network. The structure of (CuI)(3)(As(4)S(4))(PAs(3)S(3)) (4) contains 1D (Cu(3)I(3))(n) strands as backbones, which are bridged by sulfur atoms of two η(1:2)-As(4)S(4) molecules while PAs(3)S(3) confines the resulting sheet. The As(3) triangles at the surface of the layers interact with iodide of the next layer to form a layered 3D network.

PAs3S3 cage as a new building block in copper halide coordination polymers.

First examples of the coordination chemistry of the PAs(3)S(3) cage were obtained from solutions of PAs(3)S(3)·W(CO)(5) (1) in CH(2)Cl(2) or CH(2)Cl(2)/toluene and CuX (X = Cl, Br, I) in MeCN through interdiffusion techniques. Crystals of [Cu(PAs(3)S(3))(4)]X (2, X = Cl; 3, X = Br) and [(Cu(2)I)(PAs(3)S(3))(3)]I (4) were obtained and characterized by Raman spectroscopy (2) and single-crystal X-ray crystallography. The solid-state structures reveal an unexpected coordination versatility of the PAs(3)S(3) ligand: apical phosphorus and bridging sulfur atoms interact with copper, while As···X interactions determine the dimensionality of the frameworks. The structures of 2 and 3 contain tetrahedral [(PAs(3)S(3))(4)Cu](+) cations as secondary building units (SBUs), which are arranged by interactions with Cl(-) or Br(-) anions into two- and three-dimensional substructures. These interpenetrate into a (2D + 3D) polycatenane. Compound 4 is built up by a one-dimensional [(Cu(2)I)(PAs(3)S(3))(3)](n)(n+) ribbon with PAs(3)S(3) cages as P,S-linkers. The As atoms of the exo PAs(3)S(4) linkers interact with iodide counterions (3.35 < d(As-I) < 3.59 Å). The resulting two-dimensional layer is organized by weak As···I interactions (d(As-I = 3.87 Å) into a 3D network.

Techniques for the Assessment of In Vitro and In Vivo Antifungal Combinations.

Systemic fungal infections are associated with high mortality rates despite adequate treatment. Moreover, acquired resistance to antifungals is increasing, which further complicates the therapeutic management. One strategy to overcome antifungal resistance is to use antifungal combinations. In vitro, several techniques are used to assess drug interactions, such as the broth microdilution checkerboard, agar-diffusion methods, and time-kill curves. Currently, the most widely used technique is the checkerboard method. The aim of all these techniques is to determine if the interaction between antifungal agents is synergistic, indifferent, or antagonistic. However, the interpretation of the results remains difficult. Several methods of analysis can be used, based on different theories. The most commonly used method is the calculation of the fractional inhibitory concentration index. Determination of the usefulness of combination treatments in patients needs well-conducted clinical trials, which are difficult. It is therefore important to study antifungal combinations in vivo, in experimental animal models of fungal infections. Although mammalian models have mostly been used, new alternative animal models in invertebrates look promising. To evaluate the antifungal efficacy, the most commonly used criteria are the mortality rate and the fungal load in the target organs.

Parasitic behavior in competing chemically fueled reaction cycles.

Non-equilibrium, fuel-driven reaction cycles serve as model systems of the intricate reaction networks of life. Rich and dynamic behavior is observed when reaction cycles regulate assembly processes, such as phase separation. However, it remains unclear how the interplay between multiple reaction cycles affects the success of emergent assemblies. To tackle this question, we created a library of molecules that compete for a common fuel that transiently activates products. Often, the competition for fuel implies that a competitor decreases the lifetime of these products. However, in cases where the transient competitor product can phase-separate, such a competitor can increase the survival time of one product. Moreover, in the presence of oscillatory fueling, the same mechanism reduces variations in the product concentration while the concentration variations of the competitor product are enhanced. Like a parasite, the product benefits from the protection of the host against deactivation and increases its robustness against fuel variations at the expense of the robustness of the host. Such a parasitic behavior in multiple fuel-driven reaction cycles represents a lifelike trait, paving the way for the bottom-up design of synthetic life.

Chemically fueled materials with a self-immolative mechanism: transient materials with a fast on/off response.

There is an increasing demand for transient materials with a predefined lifetime like self-erasing temporary electronic circuits or transient biomedical implants. Chemically fueled materials are an example of such materials; they emerge in response to chemical fuel, and autonomously decay as they deplete it. However, these materials suffer from a slow, typically first order decay profile. That means that over the course of the material's lifetime, its properties continuously change until it is fully decayed. Materials that have a sharp on-off response are self-immolative ones. These degrade rapidly after an external trigger through a self-amplifying decay mechanism. However, self-immolative materials are not autonomous; they require a trigger. We introduce here materials with the best of both, i.e., materials based on chemically fueled emulsions that are also self-immolative. The material has a lifetime that can be predefined, after which it autonomously and rapidly degrades. We showcase the new material class with self-expiring labels and drug-delivery platforms with a controllable burst-release.

Droplet Formation by Chemically Fueled Self-Assembly: The Role of Precursor Hydrophobicity.

We investigate active droplets that form at the expense of a chemical fuel in aqueous buffer and vanish autonomously. Dynamic light scattering reveals the scattered intensity, the hydrodynamic radius, and the width of the size distribution with high precision as well as high temporal and spatial resolutions. Comparing the resulting time-dependent behavior of the droplet characteristics with the time-dependent concentration of the anhydrides, the roles of the chemical reaction cycle and of colloidal growth processes are elucidated. The droplet sizes and lifetimes depend strongly on the hydrophobicity of the precursor, and the growth rate is found to correlate with the deactivation rate of the product.

Molecular detection and identification of zygomycetes species from paraffin-embedded tissues in a murine model of disseminated zygomycosis: a collaborative European Society of Clinical Microbiology and Infectious Diseases (ESCMID) Fungal Infection Study Group (EFISG) evaluation.

The present study was performed to assess the interlaboratory reproducibility of the molecular detection and identification of species of Zygomycetes from formalin-fixed paraffin-embedded kidney and brain tissues obtained from experimentally infected mice. Animals were infected with one of five species (Rhizopus oryzae, Rhizopus microsporus, Lichtheimia corymbifera, Rhizomucor pusillus, and Mucor circinelloides). Samples with 1, 10, or 30 slide cuts of the tissues were prepared from each paraffin block, the sample identities were blinded for analysis, and the samples were mailed to each of seven laboratories for the assessment of sensitivity. A protocol describing the extraction method and the PCR amplification procedure was provided. The internal transcribed spacer 1 (ITS1) region was amplified by PCR with the fungal universal primers ITS1 and ITS2 and sequenced. As negative results were obtained for 93% of the tissue specimens infected by M. circinelloides, the data for this species were excluded from the analysis. Positive PCR results were obtained for 93% (52/56), 89% (50/56), and 27% (15/56) of the samples with 30, 10, and 1 slide cuts, respectively. There were minor differences, depending on the organ tissue, fungal species, and laboratory. Correct species identification was possible for 100% (30 cuts), 98% (10 cuts), and 93% (1 cut) of the cases. With the protocol used in the present study, the interlaboratory reproducibility of ITS sequencing for the identification of major Zygomycetes species from formalin-fixed paraffin-embedded tissues can reach 100%, when enough material is available.

In Vitro Interaction between Isavuconazole and Tacrolimus, Cyclosporin A, or Sirolimus against Aspergillus Species.

The interaction of isavuconazole with immunosuppressors (tacrolimus, cyclosporin A, or sirolimus) against 30 Aspergillus isolates belonging to the most common species responsible for invasive aspergillosis in humans (Aspergillus flavus, Aspergillus fumigatus, Aspergillus nidulans, Aspergillus niger, and Aspergillus terreus) was evaluated in vitro by a microdilution checkerboard technique based on the EUCAST reference method for antifungal susceptibility testing. The interpretation of the results was performed based on the fractional inhibitory concentration index. The combination of isavuconazole with tacrolimus, cyclosporin A, or sirolimus, was synergistic for 56, 20, or 10% of the isolates, respectively. Interestingly synergy of the combination of isavuconazole with tacrolimus was also achieved for the majority of azole-resistant isolates of A. fumigatus, and for all A. niger isolates with isavuconazole minimal inhibitory concentrations ≥ 8 µg/mL. Antagonistic interactions were never observed for any combination tested.