Antifungal stewardship: the Latin American experience.

Antifungal stewardship is a critical component of healthcare management that focuses on optimizing the use of antifungal medications to improve patient outcomes, minimize resistance, and reduce healthcare costs.  In resource-limited settings, the prevalence of fungal infections remains a significant health concern, often exacerbated by factors such as compromised immune systems, inadequate diagnostic capabilities, and limited access to antifungal agents. This paper reviews the current state of antifungal stewardship practices in developing countries, addressing the unique socioeconomic and healthcare landscape.

COVID-19 patients display changes in lymphocyte subsets with a higher frequency of dysfunctional CD8lo T cells associated with disease severity.

This work examines cellular immunity against SARS-CoV-2 in patients from Córdoba, Argentina, during two major waves characterized by different circulating viral variants and different social behavior. Using flow cytometry, we evaluated the main lymphocyte populations of peripheral blood from hospitalized patients with moderate and severe COVID-19 disease. Our results show disturbances in the cellular immune compartment, as previously reported in different cohorts worldwide. We observed an increased frequency of B cells and a significant decrease in the frequency of CD3+ T cells in COVID-19 patients compared to healthy donors (HD). We also found a reduction in Tregs, which was more pronounced in severe patients. During the first wave, the frequency of GZMB, CD107a, CD39, and PD-1-expressing conventional CD4+ T (T conv) cells was significantly higher in moderate and severe patients than in HD. During the second wave, only the GZMB+ T conv cells of moderate and severe patients increased significantly. In addition, these patients showed a decreased frequency in IL-2-producing T conv cells. Interestingly, we identified two subsets of circulating CD8+ T cells with low and high CD8 surface expression in both HD and COVID-19 patients. While the percentages of CD8hi and CD8lo T cells within the CD8+ population in HD are similar, a significant increase was observed in CD8lo T cell frequency in COVID-19 patients. CD8lo T cell populations from HD as well as from SARS-CoV-2 infected patients exhibited lower frequencies of the effector cytokine-producing cells, TNF, IL-2, and IFN-γ, than CD8hi T cells. Interestingly, the frequency of CD8lo T cells increased with disease severity, suggesting that this parameter could be a potential marker for disease progression. Indeed, the CD8hi/CD8lo index helped to significantly improve the patient's clinical stratification and disease outcome prediction. Our data support the addition of, at least, a CD8hi/CD8lo index into the panel of biomarkers commonly used in clinical labs, since its determination may be a useful tool with impact on the therapeutic management of the patients.

Different cytokine and chemokine profiles in hospitalized patients with COVID-19 during the first and second outbreaks from Argentina show no association with clinical comorbidities.

Background: COVID-19 severity has been linked to an increased production of inflammatory mediators called "cytokine storm". Available data is mainly restricted to the first international outbreak and reports highly variable results. This study compares demographic and clinical features of patients with COVID-19 from Córdoba, Argentina, during the first two waves of the pandemic and analyzes association between comorbidities and disease outcome with the "cytokine storm", offering added value to the field. Methods: We investigated serum concentration of thirteen soluble mediators, including cytokines and chemokines, in hospitalized patients with moderate and severe COVID-19, without previous rheumatic and autoimmune diseases, from the central region of Argentina during the first and second infection waves. Samples from healthy controls were also assayed. Clinical and biochemical parameters were collected. Results: Comparison between the two first COVID-19 waves in Argentina highlighted that patients recruited during the second wave were younger and showed less concurrent comorbidities than those from the first outbreak. We also recognized particularities in the signatures of systemic cytokines and chemokines in patients from both infection waves. We determined that concurrent pre-existing comorbidities did not have contribution to serum concentration of systemic cytokines and chemokines in COVID-19 patients. We also identified immunological and biochemical parameters associated to inflammation which can be used as prognostic markers. Thus, IL-6 concentration, C reactive protein level and platelet count allowed to discriminate between death and discharge in patients hospitalized with severe COVID-19 only during the first but not the second wave. Conclusions: Our data provide information that deepens our understanding of COVID-19 pathogenesis linking demographic features of a COVID-19 cohort with cytokines and chemokines systemic concentration, presence of comorbidities and different disease outcomes. Altogether, our findings provide information not only at local level by delineating inflammatory/anti-inflammatory response of patients but also at international level addressing the impact of comorbidities and the infection wave in the variability of cytokine and chemokine production upon SARS-CoV-2 infection.

Invasive Candidiasis: Update and Current Challenges in the Management of This Mycosis in South America.

Invasive candidiasis encompassing Candida bloodstream infections and deep-seated candidiasis can become a persistent health problem. These infections are caused by Candida species and have high morbidity and mortality rates. Species distribution, access to diagnosis, treatment and mortality are different around the world. The mortality rate is high in South America (30-70%), and Candida albicans is the most prevalent species in this region. However, a global epidemiological shift to non-albicans species has been observed. In this group, C. parapsilosis is the species most frequently detected, followed by C. tropicalis, and at a slower rate, C. glabrata, which has also increased, in addition to the emerging C. auris, resistance to several drugs. This article summarizes relevant aspects of candidemia pathogenesis, such as the mechanisms of fungal invasion, immune response, and the impact of genetic defects that increase host susceptibility to developing the infection. We also discuss relevant aspects of treatment and future challenges in South America.

Candidiasis invasora: un enfoque a la infección en el sistema nervioso central

Resumen La candidemia es la micosis invasora más frecuente en los pacientes internados en hospitales de alta complejidad en el mundo. La infección fúngica en el sistema nervioso central constituye una complicación potencialmente mortal que agrava el pronóstico de los pacientes. El presente artículo aborda aspectos relevantes sobre las características clínicas de esta enfermedad, los mecanismos de invasión del hongo, la respuesta inmunitaria local frente a Candida albicans y el impacto de los defectos genéticos en receptores de la inmunidad innata, que aumentan la susceptibilidad a la neurocandidiasis.

[Invasive candidiasis: A view to central nervous system infection]. / Candidiasis invasora: un enfoque a la infección en el sistema nervioso central.

Candidemia is the most frequent invasive mycosis in hospitalized patients worldwide. Fungal infection in central nervous system is a life-threatening complication which aggravates patients' prognosis. This article summarizes relevant aspects on the clinical characteristics of this pathology, mechanisms of fungus invasion, local immune response to Candida albicans and the impact of genetic defects on innate immune receptors that increase susceptibility to the acquisition of this form of mycosis.

Candida lipases: a review on biochemical, molecular and pathogenic aspects. / [Lipasas de especies Candida: una revisión sobre aspectos bioquímicos, moleculares y patogénicos.]

In the last half century there was a significant increase in the incidence of fungal infections being likely to become a global health priority. The sophisticated degree of host-Candida interaction is the product of different virulence strategies used by the fungus to invade the tissues and the various defense mechanisms that it develops to control it. There is a significant amount of literature that indicates that this opportunistic commensal fungus has components that can be considered virulence factors related to the stage of the infectious process. Among the virulence factors of this fungus can be mentioned the adherence to cell surfaces, the formation of biofilms and the production of hydrolytic enzymes. The most studied hydrolases secreted by C. albicans are aspartyl proteinases, phospholipases and esterases, while lipases have been the least studied. These enzymes would have the function to facilitate active penetration into the cells, participating in the digestion and synthesis of lipid esters for their nutrition and contributing to the invasion of the tissue by hydrolyzing the lipid components of the host cell membranes. There is also bibliographic evidence that these enzymes are capable to damage cells and molecules of the immune system to avoid the antimicrobial activity.Taking into account the foregoing, this review provides an updated description of biochemical and molecular characteristics of the lipases secreted by Candida, its role as a virulence factor and its potential for the development of new antifungal drugs.

En el último medio siglo se produjo un aumento significativo en la incidencia de infecciones fúngicas siendo probable que se conviertan en una prioridad de salud global. El sofisticado grado de interacción hospedador-Candida es producto de diferentes estrategias de virulencia que utiliza el hongo para invadir los tejidos y de los diversos mecanismos de defensa que este último desarrolla para controlarlo. Existe bibliografía que indica que este hongo comensal oportunista posee componentes que pueden ser considerados factores de virulencia asociados a la etapa del proceso infeccioso. Dentro de los factores de virulencia de este hongo pueden mencionarse la adherencia a las superficies celulares, la formación de biofilms y la producción de enzimas hidrolíticas. Las hidrolasas secretadas por C. albicans más estudiadas son las aspartil proteinasas, las fosfolipasas y las esterasas, mientras que las lipasas han sido las menos exploradas. Estas enzimas tendrían como función facilitar la penetración activa en las células, participar en la digestión y síntesis de ésteres de lípidos para su nutrición y contribuir a la invasión del tejido al hidrolizar los componentes lipídicos de las membranas celulares del hospedador. También hay evidencia bibliográfica que indica que estas enzimas son capaces de dañar células y moléculas del sistema inmune para evitar la actividad antimicrobiana. Teniendo en cuenta lo precedente, esta revisión, proporciona una actualizada descripción de las características bioquímicas y moleculares de las lipasas secretadas por el hongo Candida, su rol como factor de virulencia y su potencial para el desarrollo de nuevos fármacos antifúngicos.

Curcumin-Loaded Liquid Crystalline Systems for Controlled Drug Release and Improved Treatment of Vulvovaginal Candidiasis.

Vulvovaginal candidiasis (VVC) is the most common infection caused by Candida albicans and greatly reduces the quality of life of women affected by it. Due to the ineffectiveness of conventional treatments, there is growing interest in research involving compounds of natural origin. One such compound is curcumin (CUR), which has been proven to be effective against this microorganism. However, some of CUR's physicochemical properties, especially its low aqueous solubility, make the therapeutic application of this compound difficult. Thus, the incorporation of CUR in mucoadhesive liquid crystalline systems (MLCSs) for vaginal administration may be an efficient strategy for the treatment of VVC. MLCSs are capable of potentiating the compound's action, releasing it in a controlled manner, and can enable longer exposure at the site of infection. In this study, MLCSs consisting of oleic acid and ergosterol 5:1 (w/w) as the oily phase, PPG-5-CETETH-20 as the surfactant, and a polymer dispersion of 1% chitosan as the aqueous phase, were developed for the application of CUR (MLCS-CUR) in VVC treatment. The formulations were characterized by polarized light microscopy (PLM), small-angle X-ray scattering (SAXS), oscillatory rheometry, continuous shear rheometry, texture profile analysis, and in vitro mucoadhesion. In addition, the antimicrobial activity was evaluated in vitro, and the effects on local fungal burden and cytokine profiles were investigated in a murine model of VVC. PLM and SAXS showed that the developed formulations presented a characteristic of a microemulsion. However, after the addition of artificial vaginal mucus (AVM), PLM showed that the formulations had structures similar to the "Maltese cross" characteristic of lamellar MLCS. Mucoadhesive test results showed an increase in the mucoadhesive strength of these formulations. Rheology analyses suggested long-lasting action of the formulation at the infected site. The in vitro antimicrobial activity assays suggested that CUR possesses antifungal activity against Candida albicans, determined after its incorporation into the MLCS. Further, MLCS-CUR was also more effective in vivo in the control of vaginal infection than treatment with fluconazole. Immunological assays showed that the ratio of pro-inflammatory (IL-1ß) to anti-inflammatory (TGF-ß) cytokines has decreased and that there is a reduction in the number of polymorphonuclear neutrophils recruited to the vaginal lumen, showing that treatment with MLCS-CUR was effective in modulating the inflammatory reaction associated with the infection. The results suggest that MLCSs could potentially be used in the treatment of VVC with CUR.

Study of virulence factor of Candida species in oral lesions and its association with potentially malignant and malignant lesions.

OBJECTIVE: The aim of this study was to explore the association between malignant and premalignant lesions and the virulence factor profile of Candida spp. recovered from different oral lesions. DESIGN: Candida spp. isolated from malignant lesions (squamous cell carcinoma, OC, n = 25), atypical lichen planus (AL, n = 11), chronic candidiasis (CC, n = 25), and asymptomatic carriers (WI, n = 15, control strains.) Isolates were identified in chromogenic medium, colony morphology and biochemical tests. The lipolytic and proteinase activity was determined on supplemented agar with olive oil and BSA, respectively. The biofilm formation with XTT reduction assay and cellular surface hydrophobicity (CSH) by water-hydrocarbon method were performed. RESULTS: All isolates recovered from oral lesions produced the four virulence factors studied with significantly higher levels than in WI isolates. Interestingly, lipolytic activity was absent in WI isolates. The proteolytic activity was similar in AL and OC isolates. OC isolates showed significantly higher CSH values than other clinical isolates. Non-albicans species showed higher biofilm formation than C.albicans (P = 0.03.) There were no significant differences in virulence factors among species. A strong positive correlation was found between proteinase and lipase activity (r = 0.90, P < 0.0001), and between hydrophobicity and biofilm (R = 0.81, P < 0.0001.) CONCLUSIONS: Our results indicate that OC Candida isolates exhibited a significant higher attributes of virulence than other lesions fungus isolates, providing evidence about the association between Candida pathogenicity and lesions severity.

Contribution of TLR2 pathway in the pathogenesis of vulvovaginal candidiasis.

Candida albicans is the prevalent etiological agent in acute vulvovaginal infection and the most severe chronic condition known as recurrent vulvovaginal candidiasis (VVC). A critical role of local innate immunity in defense and pathogenesis of vaginal infection by Candida is proposed. The fungal recognition by the innate immune receptor is an essential step for the induction of local responses including cytokines and antimicrobial peptides (AMPs) production for host protection. Using TLR2-deficient mice, we characterized the early innate immune response during VVC. Intravaginal challenge of TLR2-/- mice with C. albicans demonstrated that in response to the initial massive penetration, a strong local inflammatory reaction with recruitment of polymorphonuclear neutrophils was developed. Both interleukin 1ß (IL1ß)-regarded as the hallmark of VVC immunopathogenesis-and IL6 were increased in vaginal lavage. Murine beta defensin 1 (mBD1), a constitutive AMP with fungicidal and chemotactic activity, was significantly upregulated in wild type (WT) animals in response to infection. Interestingly, in the absence of TLR2 recognition, levels of mBD1 RNA more than twice higher than those in WT infected animals were observed. Interestingly, our results demonstrate that TLR2 signaling is important to control the fungal burden in the vaginal tract. These finding provide new evidence about the role of this innate receptor during VVC.

Candidiasis vulvovaginal: una antigua enfermedad con nuevos desafíos / Vulvovaginal candidiasis: an old disease with new challenges

La candidiasis vulvovaginal es una antigua enfermedad que aún en el mundo moderno continúa presentando una elevada incidencia. A pesar de los avances terapéuticos no existen siempre tratamientos efectivos y nuestro conocimiento sobre la patogenia de esta micosis es todavía incompleto. El presente artículo discute los avances más sobresalientes relacionados con los factores de virulencia del hongo, el papel de los mecanismos inmunológicos involucrados en la protección vaginal y los defectos genéticos responsables de la recurrencia de esta micosis. Los tratamientos actuales, el uso de nuevos agentes con actividad antifúngica y el desarrollo de estrategias como la vacunación son abordados en el contexto del complejo escenario que rigen las interacciones entre Candida y su hospedador (AU)

Vulvovaginal candidiasis is an old disease that, even in a modern world, continues to have a high incidence. Despite the therapeutic advances, treatments are not always effective, and our understanding of the pathogenesis of this fungal infection is still incomplete. A discussion is presented in this article on the most significant developments related to the fungal virulence factors, the role of the immunological mechanisms involved in the vaginal protection, and the genetic alterations that confer susceptibility to the recurrent form of this mycosis. Current treatments, the use of new agents with antifungal activity, as well as the development of strategies, such as vaccination, are approached in the context of the complex scenario that governs the interactions between Candida and its host (AU)

[Vulvovaginal candidiasis: An old disease with new challenges]. / Candidiasis vulvovaginal: una antigua enfermedad con nuevos desafíos.

Vulvovaginal candidiasis is an old disease that, even in a modern world, continues to have a high incidence. Despite the therapeutic advances, treatments are not always effective, and our understanding of the pathogenesis of this fungal infection is still incomplete. A discussion is presented in this article on the most significant developments related to the fungal virulence factors, the role of the immunological mechanisms involved in the vaginal protection, and the genetic alterations that confer susceptibility to the recurrent form of this mycosis. Current treatments, the use of new agents with antifungal activity, as well as the development of strategies, such as vaccination, are approached in the context of the complex scenario that governs the interactions between Candida and its host.

[Innate receptors and IL-17 in the immune response against human pathogenic fungi]. / Receptores Innatos e IL-17 en la respuesta inmune frente a hongos patógenos humanos.

In recent years, the rise of human fungal infections has been associated to lack of early diagnosis, uneffective antifungal therapies and vaccines. Disturbance in immune homeostasis, which can be caused by medical interventions and immunosuppression nduced by disease, are well known as risk factors for these pathologies. Cells of the innate immune system are equipped with surface and cytoplasmic receptors for recognition of microorganisms called pattern recognition receptors (PRRs). PRRs recognize specific pathogen-associated molecular patterns (PAMPs) that are crucial for the activation and killing of pathogenic fungi by immune system. This review will outline the PRRs and cells required for effective antifungal immunity, with a special focus on the major antifungal cytokine IL-17. Finally, naturally occurring human mutations involved in the increased susceptibility to fungal infections are also discussed.

Candida albicans up-regulates the Fas-L expression in liver Natural Killer and Natural Killer T cells.

After Candida albicans arrival to the liver, the local production of proinflammatory cytokines and the expanded intrahepatic lymphocytes (IHL) can be either beneficial or detrimental to the host. Herein we explored the balance between protective inflammatory reaction and liver damage, focusing our study on the contribution of TNF-α and Fas-Fas-L pathways in the hepatocellular apoptosis associated to C. albicans infection. A robust tissue reaction and a progressive increase of IL-1ß, IL-6 and TNF-α were observed in infected animals. Blocking the biological activity of TNF-α did not modify the number of apoptotic cells observed in C. albicans infected animals. Fas-L molecule was up regulated on purified hepatic mononuclear cells and its expression progressed with the infection. In the IHL compartment, the absolute number of Fas-L+ NK and NKT cells increased on days 1 and 3 of the infection. C. albicans was also able to up regulate Fas-L expression in normal liver NK and NKT cells after in vitro contact. The innate receptor TLR2 was involved in this phenomenon. In the interplay between host factors and evasion strategies exploited by pathogens, the mechanism supported here could represent an additional way that allows this fungus to circumvent protective immune responses in the liver.

Evaluation of Syngonanthus nitens (Bong.) Ruhl. extract as antifungal and in treatment of vulvovaginal candidiasis.

The purpose of this study was to evaluate the in vitro anticandidal activity of a methanolic extract of Syngonanthus nitens scapes against different Candida species and clinical isolates from patients with vulvovaginal candidiasis (VVC), and its effect in vivo in the treatment of vaginal infection. Chemical characterization of the extract was performed by HPLC-UV analyses and showed the presence of flavones derivatives. The extract was effective against several Candida strains from our collection and species recovered from VVC patients, and was able to inhibit the yeast-hyphal transition. No cytotoxic activity against human female reproductive tract epithelial cells and no hemolytic activity against human red blood cells were observed. In the in vivo model of VVC, we evaluated the efficacy of the intravaginal treatment with a cream containing the extract at doses of 0.5, 1.0 and 2.0%. The treatment eradicated the vaginal fungal burden in infected rats after 8 days of treatment. S. nitens extract could be considered as an effective and non-toxic natural antifungal agent in the treatment of vulvovaginal candidiasis.

Correlation among antioxidant, antimicrobial, hemolytic, and antiproliferative properties of Leiothrix spiralis leaves extract.

The biological activities of a plant extract depend on a complex sum of individual properties including the antioxidant activity. Several biological activities protect against the harmful action of reactive oxygen species (ROS), and here we focused our attention on the relationship between the biological activities tested and the antioxidant properties. In this study, the total flavonoid content as well as the antioxidant, antimicrobial, hemolytic and cytotoxicity activities of the methanolic extract of Leitothrix spiralis leaves were evaluated. The extract showed a total flavonoid content of 19.26% and the chemical characterization by HPLC-PAD confirmed the presence of flavonoids as the major secondary metabolite compounds. Significant antioxidant activity (IC(50) = 1.743 µg/mL ± 0.063) was demonstrated and was effective against Gram-negative organisms and all Candida strains tested, and showed an ability to inhibit hyphal formation. Non-hemolytic and antiproliferative activity could be demonstrated.

Abrogation of spontaneous liver tolerance during immune response to Candida albicans: contribution of NKT and hepatic mononuclear cells.

Hepatic mononuclear cells (HMC) are a heterogeneous population with innate immune properties involved in the response to several pathogens. Herein, during the primary infection with Candida albicans, we observed dynamic changes in CD3+, NK+ and NKT+ intrahepatic lymphoid subsets and a significant increase in the absolute number of antigen-presenting cells (APC). The liver tolerogenic microenvironment sustained by higher levels of IL-10, transforming growth factor-ß and IL-4 was severely modified upon the robust IFN-γ production after the fungal colonization. NKT cells purified from infected animals released significant amounts of IFN-γ and the production of this cytokine was exacerbated after a second contact with the fungus. Interestingly, C. albicans per se was unable to activate tolerogenic NKT cells from naive animals. In vitro experiments performed with HMC cells depleted of the CD11b/c+ population revealed that in the absence of APC, NKT cells are unable to produce IFN-γ in response to C. albicans. Our findings constitute the first evidence that this innate lymphocyte population is involved in the pathogenesis of C. albicans infection.

Candida albicans-secreted lipase induces injury and steatosis in immune and parenchymal cells.

Virulence depends on opposing reactions between host and pathogen and is intrinsically linked to the host immune status. Virulence factors rely upon microbial attributes that mediate cell damage. While the activity of several Candida albicans hydrolytic enzymes is well characterized, the biological role of lipases is uncertain. In this report, we identified, isolated, and characterized a C. albicans 70 kDa lipase that exhibited maximal activity at physiological pH and temperature. We evaluated the ability of C. albicans lipase to interact with two types of mammalian host cells: macrophages, as crucial immune effector cells involved in fungal control, and hepatocytes, as examples of parenchymal cells compromised during fungal dissemination. Herein, we demonstrate for the first time that an extracellular lipase released by C. albicans directly induced cytotoxicity and promoted the deposition of lipid droplets in the cytoplasm of macrophages and hepatocytes.

High dissemination and hepatotoxicity in rats infected with Candida albicans after stress exposure: potential sensitization to liver damage.

The liver constitutes the first barrier in the control of hematogenous dissemination for Candida albicans of intestinal origin. The ability of this organ to limit the growth of the yeast and to mount an efficient inflammatory reaction is crucial in determining the outcome of the fungal infection. When rats infected with C. albicans are exposed to chronic varied stress, the cell recruitment is impaired at the site of the infection, the tissue reaction is highly disorganized in target organs and the infection evolution is more severe. At hepatic level, higher fungal burden is associated with hyphal form and the consistent presence of steatosis (fatty liver). Herein we aimed at characterizing the steatosis associated with C. albicans infection and to provide molecular evidence of the correlation among liver injury markers, stress products and the initiation of the inflammatory tissue reaction. After 3 days of stress and infection, we observed micro and macro steatosis in acinar zone 1 (specific lipid stain), higher lipid peroxidation and increased levels of serum alanine aminotransferase and gamma glutamil transferase. While infection triggered hepatic NO production and arginase activity, stress down-modulated both. Remarkably, defects in levels of TNF-alpha and NO were observed during the first step of the inflammatory response. Our results demonstrate that stress mediators down-regulate the acute inflammatory reaction in the hepatic scenario, promoting a major liver injury with particular immunopathological traits.