Therapeutic Switching of Rafoxanide: a New Approach To Fighting Drug-Resistant Bacteria and Fungi.

Control and management of life-threatening bacterial and fungal infections are a global health challenge. Despite advances in antimicrobial therapies, treatment failures for resistant bacterial and fungal infections continue to increase. We aimed to repurpose the anthelmintic drug rafoxanide for use with existing therapeutic drugs to increase the possibility of better managing infection and decrease treatment failures. For this purpose, we evaluated the antibacterial and antifungal potential of rafoxanide. Notably, 70% (70/100) of bacterial isolates showed multidrug resistance (MDR) patterns, with higher prevalence among human isolates (73.5% [50/68]) than animal ones (62.5% [20/32]). Moreover, 22 fungal isolates (88%) were MDR and were more prevalent among animal (88.9%) than human (87.5%) sources. We observed alarming MDR patterns among bacterial isolates, i.e., Klebsiella pneumoniae (75% [30/40; 8 animal and 22 human]) and Escherichia coli (66% [40/60; 12 animal and 28 human]), and fungal isolates, i.e., Candida albicans (86.7% [13/15; 4 animal and 9 human]) and Aspergillus fumigatus (90% [9/10; 4 animal and 5 human]), that were resistant to at least one agent in three or more different antimicrobial classes. Rafoxanide had antibacterial and antifungal activities, with minimal inhibitory concentration (MICs) ranging from 2 to 128 µg/mL. Rafoxanide at sub-MICs downregulated the mRNA expression of resistance genes, including E. coli and K. pneumoniae blaCTX-M-1, blaTEM-1, blaSHV, MOX, and DHA, C. albicans ERG11, and A. fumigatus cyp51A. We noted the improvement in the activity of ß-lactam and antifungal drugs upon combination with rafoxanide. This was apparent in the reduction in the MICs of cefotaxime and fluconazole when these drugs were combined with sub-MIC levels of rafoxanide. There was obvious synergism between rafoxanide and cefotaxime against all E. coli and K. pneumoniae isolates (fractional inhibitory concentration index [FICI] values ≤ 0.5). Accordingly, there was a shift in the patterns of resistance of 16.7% of E. coli and 22.5% of K. pneumoniae isolates to cefotaxime and those of 63.2% of C. albicans and A. fumigatus isolates to fluconazole when the isolates were treated with sub-MICs of rafoxanide. These results were confirmed by in silico and mouse protection assays. Based on the in silico study, one possible explanation for how rafoxanide reduced bacterial resistance is through its inhibitory effects on bacterial and fungal histidine kinase enzymes. In short, rafoxanide exhibited promising results in overcoming bacterial and fungal drug resistance. IMPORTANCE The drug repurposing strategy is an alternative approach to reducing drug development timelines with low cost, especially during outbreaks of disease caused by drug-resistant pathogens. Rafoxanide can disrupt the abilities of bacterial and fungal cells to adapt to stress conditions. The coadministration of antibiotics with rafoxanide can prevent the failure of treatment of both resistant bacteria and fungi, as the resistant pathogens could be made sensitive upon treatment with rafoxanide. From our findings, we anticipate that pharmaceutical companies will be able to utilize new combinations against resistant pathogens.

Comparison of the therapeutic efficacy of five anthelmintics against natural Fasciola hepatica infections in dairy cattle from the Mantaro Valley, Peru.

The intensive use of anthelmintic drugs to control Fasciola hepatica infections in dairy cattle has resulted in the emergence of anthelmintic resistance. Cases of resistance to triclabendazole (TCBZ) have been reported worldwide. The main goal of this research was to evaluate the main five fasciolicides to control fasciolosis in dairy cattle in the Mantaro Valley, Peru. Two fecal egg count reduction tests were performed. In a first study, 24 naturally F. hepatica infected cattle were randomly grouped into three experimental groups (n = 8). Groups were treated with either TCBZ, nitroxynil (NTX) or closantel (CLOS). In a second experiment, 55 naturally infected cows were grouped into three experimental groups and treated with either TCBZ (n = 18), rafoxanide (RFX) + albendazole (ABZ) (n = 19) or clorsulon (CLN) + ivermectin (IVM) (n = 18). Therapeutic efficacy was determined following the WAAVP guidelines by measuring reduction in fluke egg output at days 15 and 30 post-treatment. Bootstrapping method was used to obtain the 95% confidence intervals. The efficacy of TCBZ was inadequate in both studies (≤80.8%). Closantel showed high efficacy (≥ 90%) at both days, while NTX showed 92.9% (83-100) and 82.1% (53.6-100), efficacy, at days 15 and 30, respectively. Efficacy for RFX were 92.1% (79.6-98.9) and 97.4% (94.1-99.4); and for CLN, 98.8% (97.6-100) and 80.1% (44.7-99.4), at days 15 and 30, respectively. The outcome of this study indicates reduced therapeutic efficacy of TCBZ against F. hepatica in an important dairy area of the Peruvian central highlands but also demonstrates the validity of four alternatives.

Discovery of rafoxanide as a novel agent for the treatment of non-small cell lung cancer.

Non-small cell lung cancer (NSCLC), which accounts for approximately 85% of all lung cancer cases, is associated with a poor outcome. Rafoxanide is an anthelmintic drug that inhibits tumor growth in certain malignancies. However, its impact on NSCLC remains unknown. In this study, we examined the effect of rafoxanide on NSCLC and dissected the underlying mechanism. The results showed that rafoxanide significantly inhibited the growth, invasion, and migration of NSCLC cells. Besides, rafoxanide can induce NSCLC cell apoptosis and cell cycle arrest in a dose-dependent manner. RNA-seq analysis revealed that genes associated with endoplasmic reticulum stress (ER) stress responses were activated. Mechanistically, we found Rafoxanide can induce ER stress and activate the unfolded protein response (UPR). Apoptosis was activated by excessive ER stress, and autophagy was activated to partially alleviate ER stress. In vivo, we found that rafoxanide inhibited the growth of A549 and H1299 xenograft mouse models without severe side effects. Collectively, the present study indicates that rafoxanide may be a candidate drug for the treatment of NSCLC.

Antitumor effects of rafoxanide in diffuse large B cell lymphoma via the PTEN/PI3K/Akt and JNK/c-Jun pathways.

AIMS: Diffuse large B-cell lymphoma (DLBCL) is one of the most aggressive lymphoid malignancies, which remains incurable, thus warranting the development of new therapies. Our previous study determined that rafoxanide is very effective in treating multiple myeloma (MM). In the present study, we tried to evaluate the effects of rafoxanide on DLBCL, as well as the potential underlying molecular mechanisms. MAIN METHODS: We used CCK-8 assay and flow cytometry to assess cell viability and apoptosis. The proteins and pathways associated with apoptosis and proliferation were evaluated through western blot, and xenograft mice were used as the experimental animal model. We also used the TUNEL assay and immunofluorescence for further analyses. KEY FINDINGS: Treatment with different doses of rafoxanide significantly inhibited cell viability and apoptosis. Additionally, the compound induced cell cycle arrest, reduced mitochondrial membrane potential (Δψm), and stimulated reactive oxygen species (ROS) generation without the influence of normal peripheral blood monocytes (PBMCs). As expected, rafoxanide played a role in regulating these proteins and the PTEN/PI3K/AKT and JNK/c-Jun pathways. Furthermore, immunofluorescence and western blot results showed that rafoxanide upregulated H2AX phosphorylation and then inhibited DNA repair in DLBCL. In the xenograft mouse model, tumor volumes were reduced after intraperitoneal injection with rafoxanide. We also observed that TUNEL positive cells were remarkably increased in rafoxanide-treated tumor tissues. SIGNIFICANCE: These results collectively provide a novel choice to regular treatment for DLBCL patients with poor prognosis.

Rafoxanide promotes apoptosis and autophagy of gastric cancer cells by suppressing PI3K /Akt/mTOR pathway.

Rafoxanide is commonly used as anti-helminthic medicine in veterinary medicine, a main compound of salicylanilide. Previous studies have reported that rafoxanide, as an inhibitor of BRAF V600E mutant protein, inhibits the growth of colorectal cancer, multiple myeloma, and skin cancer. However, its therapeutic effect on gastric cancer (GC) and the potential mechanism has not been investigated. Here, we have found that rafoxanide inhibited the proliferation of GC cells in vitro, arrested the cell cycle in the G0/G1 phase, and promoted apoptosis and autophagy in GC cells. Treatment with specific autophagy inhibitor 3-methyladenine drastically inhibited the apoptotic cell death effect by suppressing the switch from autophagy to apoptosis. Mechanistically, we found that rafoxanide inhibited the growth of GC cells in vitro by inhibiting the activity of the PI3K/Akt/mTOR signaling pathway. This process induced autophagy, which essentially resulted in the apoptosis of GC cells. Results from subcutaneous implanted tumor models in nude mice also indicated that rafoxanide inhibited the growth of GC cells in vivo. Taken together, our findings revealed that rafoxanide inhibited the growth of GC cells both in vitro and vivo, indicating a potential drug candidate for the treatment of GC.

Comparative efficacy of different anthelmintics against fenbendazole-resistant nematodes of pashmina goats.

A trial using albendazole, albendazole plus rafoxanide combination, ivermectin and doramectin was conducted in Pashmina goats having history of fenbendazole resistance to Haemonchus spp. and maintained at high altitude (>2350 m above sea level). Day 0 infection level was variable in different groups of animals and their larval cultures indicated Haemonchus, Trichostrongylus, Ostertagia and Oesophagostomum spp. infection, in addition to Nematodirus spp. as observed in egg counts. Efficacy of drugs was calculated on day 14 post treatment by faecal egg count reduction test (FECRT). Albendazole was least effective (14%) followed by its combination with rafoxanide (54%). However, ivermectin and doramectin were 96% and 94% effective against gastrointestinal nematodes of Pashmina goats. It was concluded that use of albendazole and its combination with rafoxanide are ineffective in controlling the nematodes of goats at this farm; hence, future use must be avoided. However, regular monitoring of the efficacy of ivermectin and doramectin is needed.

A dual anthelmintic treatment strategic scheme for the control of fasciolosis in dairy sheep farms.

A clinical longitudinal field trial was conducted on a dairy sheep farm in southern Italy to assess the effectiveness of a novel anthelmintic treatment strategic scheme against Fasciola hepatica. The scheme utilizes a dual anthelmintic treatment (DAT), i.e., the use of either one of two different anthelmintics on the flock, albendazole sulphoxide (SO) at 1-month intervals and rafoxanide at 2-month intervals, administered to the lactating and non-lactating animals, respectively. The DAT strategic scheme lasted 3 years. In Year 1 and Year 2, shotgun monthly DATs for 5 consecutive months (July, August, September, October, and November) were performed on the flock. In Year 3 there was only one monthly DAT, in July. Overall, the DAT scheme reduced the prevalence of F. hepatica infection by 94.4% (from an average prevalence of 71.1% during the pre-DAT period to an average prevalence of 4.0% during Year 3), and the eggs/gram of faeces (EPG) from 29.3 to 1.3. In conclusion, the DAT strategic scheme reported in the present study successfully reduced both the prevalence and EPGs of F. hepatica to a level at which there were no longer any clinical symptoms of the disease. This scheme did not influence the albendazole SO efficacy against GI nematodes and might be used for the treatment of fasciolosis in dairy sheep farms.

Field trial on comparative efficacy of four fasciolicides against natural liver fluke infection in cattle.

A controlled trial was conducted to evaluate the current efficacy of albendazole (ABZ), rafoxanide (RFX), triclabendazole (TRC) or clorsulon (CLS) against Fasciola hepatica in naturally infected cattle. This trial was conducted in Turkey during the spring, the time of year when liver fluke infection is endemic. Fifty crossbred cattle were selected for inclusion in the trial based on finding eggs of F. hepatica in the feces. The cattle were weighed and randomly allotted into five groups of 10 cattle and treatments were as follows: Group 1 served as non-treated control (CONT), Group 2 was treated orally with ABZ at 12 mg/kg, Group 3 was treated orally with RFX at 10 mg/kg, Group 4 received TRC orally at 12 mg/kg and Group 5 received CLS administered subcutaneously (s.c.) at 2 mg/kg. On day 0 (inclusion day), individual fecal samples were collected on days 0 (inclusion day), 7, 14, 28 and 56, after treatment. The drug efficacy was assessed as a percentage of the egg or fluke reduction and body weight gain relative to the untreated control. The results in the study showed a mean reduction of egg counts by 66.7%, 68.2%, 78% and 84.2% in Groups 2-5, respectively. In conclusion, our results indicate that CLS is a highly effective compound for the treatment of F. hepatica in cattle under these field conditions.

The Hymenolepis diminuta-golden hamster (Mesocricetus auratus) model for the evaluation of gastrointestinal anticestode activity.

A novel laboratory anticestode assay was developed using Hymenolepis diminuta in the hamster. The commercial anticestode compounds, praziquantel, bunamidine, and niclosamide were active against patent infections of Hymenolepis diminuta in golden hamsters (Mesocricetus auratus) when given orally at 3.125, 100, and 200 mg/kg, respectively. The gastrointestinal nematode anthelmintics, cambendazole and mebendazole, were active at 50 mg/kg. Rafoxanide (fasciolicide) was active at 25 mg/kg, the lowest level tested. The coccidiostat, nicarbazin, was active at experimental levels (800 mg/kg and up). The anthelmintic-ectoparasiticide (endectocide), ivermectin, was inactive against the tapeworm at 0.5 mg/kg, as expected.

Anthelmintic resistance of nematodes in communally grazed goats in a semi-arid area of South Africa.

A survey was conducted on the occurrence of anthelmintic resistance of nematodes in communally grazed goats in a semi-arid area in South Africa. In herds belonging to 10 small-holder goat farmers, the efficacies of fenbendazole, levamisole and rafoxanide were tested by faecal egg count reduction (FECR) tests. Efficacies of 80% were considered a threshold for anthelmintic resistance. The FECR tests showed that all drugs tested more than 80% effective in most instances, but there were notable exceptions. In 1 case, rafoxanide was only 31% effective and in another case fenbendazole was only 47% effective. The occurrence of anthelmintic resistance in this farming sector is of concern. Steps should be taken to prevent its further spread and to avoid the development of a situation as on numerous commercial sheep farms in South Africa where resistance is very common.

Anthelmintic resistance on an organized sheep farm in India.

Monitoring anthelmintic resistance in strongyle nematodes by the faecal egg count reduction test and a commercial larval development assay on an organized sheep farm in the semi-arid area of Rajasthan revealed the emergence of resistance to benzimidazoles and rafoxanide and a potential risk of the development of levamisole/tetramisole resistance. A benzimidazole/levamisole combination, avermectins and closantel were each found to be efficacious.

Anthelmintic resistance in South Africa: surveys indicate an extremely serious situation in sheep and goat farming.

Surveys to determine the prevalence and degree of resistance of Haemonchus spp. of sheep and goats to the available anthelmintics in South Africa indicate that small ruminant production is entering a crisis situation. Three surveys employing the faecal egg count reduction (FECR) test to determine resistance were conducted in some of the main sheep-producing areas in the summer rainfall region of South Africa, where H. contortus is the principal worm species in sheep. After analyzing the data recorded in the surveys by six different methods, including the RESO test at two different levels of confidence, the results obtained in the least stringent one (geometric mean reduction of the worm egg counts of drenched, vs untreated group of sheep) are reported in this paper, so that if any bias was obtained it would be in the favour of the anthelmintic. In Mpumalanga and KwaZulu-Natal there was anthelmintic resistance in Haemonchus spp. on all the 52 farms surveyed. Sixteen percent of the strains of H. contortus were < 60% susceptible to three of the four anthelmintics tested, and 8% of the strains were < 40% susceptible to all four of the anthelmintics. FECR tests of sheep in six localities in the Lebowa district of Northern Province indicated that even in previously disadvantaged communities where anthelmintic treatment is less intensive, anthelmintic resistance is developing, and is possibly at the level at which the situation on commercial sheep and goat farms in South Africa was 25 years ago. From the data it appears that the level of anthelmintic resistance of H. contortus in South Africa is possibly the highest that has so far been recorded in the world and that strains of it are emerging that may soon not be controllable by treatment with any of the existing anthelmintics. Farmers in the summer rainfall region, if not the whole country, must be alerted to the immediate need for testing the parasite burdens of their sheep for susceptibility to preparations in all four groups of anthelmintic compounds currently available. Alternative methods of integrated worm control, including biological, must be sought and implemented with urgency, to reduce further selection for resistance and to induce reversion of the resistance that has already developed.

Multiple anthelmintic resistance on a goat farm in Kenya.

The anthelmintic efficacy of benzimidazoles, levamisole, rafoxanide and ivermectin was evaluated on an institutional farm in Kenya using faecal egg count reduction test, larval cultures and a controlled slaughter trial. The results of this study indicated simultaneous resistance of Haemonchus contortus against benzimidazoles, levamisole and rafoxanide and Trichostrongylus columbriformis and Oesophagostomum sp. against levamisole on the same farm. Injectable and orally administered ivermectin was effective against the benzimidazole and levamisole resistant H. contortus.

Quality control in generic anthelmintics: is it adequate?

We became increasingly concerned about indications of possible substandard efficacy of some generic anthelmintics, particularly after P.C. van Schalkwyk (personal communication, 1990) had found some batches of imported generic products obtained from international brokers to be poorly active, despite apparently normal physical characteristics. Therefore, considering the serious consequences this would have for sheep farming, it was decided to test the efficacy of some of the generic rafoxanide products available on the South African market. One of the three commercial formulations (of highly reputable companies) tested against a known susceptible strain of Haemonchus contortus in sheep was markedly substandard, with an arithmetic mean efficacy of 66.2% (Class B, Reinecke, 1973), compared to Class A efficacy of the other two, which also differed significantly from one another (Mann-Whitney; P = 0.01). Larger differences were found between the three products against a natural infection with a partially resistant strain of H. contortus than against the susceptible strain, with corresponding arithmetic mean efficacies of 28.7% (Class X, or ineffective), 71.3% (Class B) and 87.7% (also Class B). It is concluded that the most likely reason for the observed differences is that international brokers do not disclose the sources of supply of different batches of active ingredient (with the result that the companies buying anthelmintics from them have no way of telling when a source of supply is changed); that the efficacy of such batches differs; and that efficacy testing of individual batches in some cases is inadequate. It is suggested that registering authorities should consider simplified efficacy testing of each new batch of active ingredient before it may be marketed.

Anthelmintic resistance of trichostrongylids in sheep in the highveld of Zimbabwe.

A survey was conducted on the occurrence of anthelmintic resistance of trichostrongylids on commercial sheep farms in the highveld of Zimbabwe. On ten farms the efficacy of fenbendazole, levamisole and rafoxanide was tested by a faecal egg count reduction test. Benzimidazole resistance was additionally examined using an egg hatch assay with thiabendazole. Results of the faecal egg count reduction tests and larval differentiations showed fenbendazole resistance of Haemonchus sp. on all investigated farms. Resistance of Haemonchus sp. against rafoxanide was demonstrated on all farms with reliable egg counts. Levamisole resistance of Haemonchus sp. was found on most farms but 2 farms showed an efficacy of 100%.

Effects of the anthelmintics clorsulon, rafoxanide, mebendazole and arprinocid on Echinostoma caproni in ICR mice.

Female ICR mice, 5 to 6 weeks old, were exposed by stomach tube to 25 metacercarial cysts of Echinostoma caproni per mouse. At 14 days post-exposure, mice were fed by stomach tube clorsulon (1000 mg/kg, 500 mg/kg and 100 mg/ kg) or rafoxanide (50 mg/kg, 25 mg/kg and 5 mg/kg) dissolved in dimethylsulphoxide (DMSO) carrier and mebendazole (1000 mg/kg and 500 mg/ kg) or arprinocid (100 mg/kg and 50 mg/kg) suspended in a 2:1 polyethylene glycol (PEG)/DMSO carrier. All drugs were obtained from Merck Inc. (Rahway, New Jersey, USA) and only single dose regimes were used. Experimentally infected mice that served as controls received either DMSO or 2:1 PEG/DMSO carriers or were not given the carrier. Mice were necropsied 15, 16, 18 and 20 days postexposure to worms. Doses of 100 mg/kg of clorsulon and 50 mg/kg of rafoxanide were 100% effective in eliminating the echinostomes on day 1 post-administration of the anthelmintics. Mebendazole and arprinocid were ineffective in eliminating worms at 1 or 2 days post drug administration.

Effects of the anthelmintics clorsulon, rafoxanide, mebendazole and arprinocid on Echinostoma caproni in ICR mice [corrected and reapublished in J Helminthol 1996 Mar;70(1):95-6].

Female ICR mice, 5 to 6 weeks old, were exposed by stomach tube to 25 metacercarial cysts of Echinostoma caproni per mouse. At 14 days post-exposure, mice were fed by stomach tube clorsulon (1000 mg/kg, 500 mg/kg and 100 mg/kg) or rafoxanide (50 mg/kg, 25 mg/kg and 5 mg/kg) dissolved in dimethylsulphoxide (DMSO) carrier and mebendazole (1000 mg/kg and 500 mg/kg) or arprinocid (100 mg/kg and 50 mg/kg) suspended in a 2:1 polyethylene glycol (PEG)/DMSO carrier. All drugs were obtained from Merck Inc. (Rahway, New Jersey, USA) and only single dose regimes were used. Experimentally infected mice that served as controls received either DMSO or 2:1 PEG/DMSO carriers or were not given the carrier. Mice were necropsied 15v, 16, 18 and 20 days postexposure to worms. Doses of 100 mg/kg of clorsulon and 50 mg/kg of rafoxanide were 100% effective in eliminating the echinostomes on day 1 post-administration of the anthelmintics. Mebendazole and arprinocid were ineffective in eliminating worms at 1 or 2 days post drug administration.

Experiments on anthelmintic control of Fasciola hepatica in Brazil.

Two separate field trials involving naturally infected cattle were carried out on two farms known to have a history of Fasciola hepatica infection. On the first farm, 15 animals per group were allocated as follows: G1, triclabendazole (TCBZ) four times a year; G2, TCBZ twice a year (May and September); G3, untreated control. All groups grazed together and after 3.5 years the animals were slaughtered and their livers examined by federal meat inspectors who condemned 100% of livers in G3 and 8.3% in G2 owing to the presence of lesions of fasciolosis. In G1 no livers were condemned. Significant differences in weight gains were not detected and fluke counts remained at low levels in the treated groups. Also, in the control group, egg counts started to decrease when animals were 2 years old. On the second farm, groups of 20 animals were treated as follows: G1, TCBZ three times a year (May, September and December); G2, TCBZ twice a year (May and September); G3, nitroxynil twice a year (May and September); G4, rafoxanide twice a year (May and September); G5, untreated controls. All animals were weighed and faecal samples examined at approximately 28-day intervals. During the period of the study, larger weight gains were detected in the TCBZ treated groups than in the others. TCBZ treatment kept F. hepatica egg counts at a lower level for longer periods than the other drugs and significant differences in weight gains were only obtained between the group receiving TCBZ three times a year and the control group.