Monograph On Antifungals A guide for postgraduate students in developing countries The Ebers Papyrus – Most Famous Plant Medicine ‘Encyclopedia’ Of Ancient Egypt By Mohamed K. Refai , Wael M. Tawakkol and Hanan M. Refai Cairo, 2017 1 Refai et al. (2017) Monograph on Antifungals A guide for postgraduate students in developing countries. https://www.academia.edu/manuals http://scholar.cu.edu.eg/?q=hanem/book/ https://www.researchgate.net/publication Prof. Dr. Mohamed Kamal Refai Department of Microbiology, Faculty of Veterinary Medicine, Cairo University, Giza Prof. Dr. Wael Mostafa Tawakkol Vice-Dean, Head, Department of Microbiology, College of Pharmaceutical Sciences and Drug Manufacturing Misr University for Science and Technology (MUST), 6 October City, Giza Egypt Prof Dr. Hanan Mohamed Refai Head, Department of Pharmaceutics and Industrial Pharmacy, College of Pharmaceutical Sciences and Drug Manufacturing, Misr University for Science and Technology (MUST), 6 October City, Giza Egypt 2 Dedication This monograph is dedicated to the eminent professors who initiated my interest in antifungals and encouraged me as a co-author in some of their publications in this field. Prof. Dr. Hans Rieth Prof. Dr. Abdel-Haleem Gobba Prof. Dr. Abdel-Aziz Sharaf Prof. Dr. Hanifa Moursi P Prof. Dr. Mohamed Kamal Refai Cairo, November 2017 3 Prof. Dr. Mostafa Tawakkol Prof. Dr. Gamal El-Bahy Contents 1. 2. 3. 4. 5. 6. 7. Introduction 5 Classification of antifungals 10 Targets of Antifungal Agents 26 Treatment of fungal infections 34 Antifungal Agents in Development 50 Antifungal resistance 58 Description of antifungals 72 7.1. Polyene antifungals 72 7.2. Echinocardins 125 7.3. Azoles 155 7.4. Allylamine Derivatives 475 7.5. Fluoropyrimidines 489 7.6. Morpholine Derivatives 494 7.7. Thiocarbamates 501 7.8. Antifungal organic acids 505 7.9. Antifungal fatty acids 531 7.10. Antifungal Essential Oils 536 7.11. Phytoalexins 641 7.12. Antiungal Peptides 646 7.13. Boric Acid 668 7.14. Ciclopirox 675 7.15. Antifungal Metals 679 7.16. Miscellaneous antifungal chemicals 729 4 1. Introduction 1. Ancient Egyptian Pharmacopeia    Until the 19th century, the main sources of information about ancient Egyptian medicine were writings from later in antiquity. Homer c. 800 BC remarked in the Odyssey: "In Egypt, the men are more skilled in medicine than any of human kind" and "the Egyptians were skilled in medicine more than any other art". The Greek historian Herodotus visited Egypt around 440 BC and wrote extensively of his observations of their medicinal practices. Pliny the Elder also wrote favorably of them in historical review. Hippocrates (the "father of medicine"), Herophilos, Erasistratus and later Galen studied at the temple of Amenhotep, and acknowledged the contribution of ancient Egyptian medicine to Greek medicine. In 1822, the translation of the Rosetta stone finally allowed the translation of ancient Egyptian hieroglyphic inscriptions and papyri, including many related to medical matters (Egyptian medical papyri). The resultant interest in Egyptology in the 19th century led to the discovery of several sets of extensive ancient medical documents, including the Ebers papyrus, the Edwin Smith Papyrus, the Hearst Papyrus, the London Medical Papyrus and others dating back as far as 3000 BC. the London Medical Papyrus  The Edwin Smith Papyrus is a textbook on surgery and details anatomical observations and the "examination, diagnosis, treatment, and prognosis" of numerous ailments It was 5 probably written around 1600 BC, but is regarded as a copy of several earlier texts. Medical information in it dates from as early as 3000 BC. Imhotep in the 3rd dynasty is credited as the original author of the papyrus text, and founder of ancient Egyptian medicine. The earliest known surgery was performed in Egypt around 2750 BC The Edwin Smith Papyrus   . Hearst Papyrus The Ebers Papyrus c. 1550 BC is full of incantations and foul applications meant to turn away disease-causing demons, and also includes 877 prescriptions. It may also contain the earliest documented awareness of tumors, if the poorly understood ancient medical terminology has been correctly interpreted. Other information comes from the images that often adorn the walls of Egyptian tombs and the translation of the accompanying inscriptions. Advances in modern medical technology also contributed to the understanding of ancient Egyptian medicine. Paleopathologists were able to use X-Rays and later CAT Scans to view the bones and organs of mummies. Electron microscopes, mass spectrometry and various forensic techniques allowed scientists unique glimpses of the state of health in Egypt 4000 years ago. Spices such as Cumin, Fenugreek and Corriander were used as medicine in Ancient Egypt. 6 2. Herbal remedies in Ancient Egypt                The Ancient Egyptians used thymol and carvacrol in the form of a preparation from the thyme plant (a member of the mint family) to preserve mummies. Thymol and carvacrol are now known to kill bacteria and fungi, making thyme well suited for such purposes. Herbs played a major part in Egyptian medicine. The plant medicines mentioned in the Ebers Papyrus for instance include opium, cannabis, myrrh, frankincense, fennel, cassia, senna, thyme, henna, juniper, aloe, linseed and castor oil. Cloves of garlic have been found in Egyptian burial sites, including the tomb of Tutankhamen and in the sacred underground temple of the bulls at Saqqara. Many herbs were steeped in wine, which was then drunk as an oral medicine. Egyptians thought garlic and onions aided endurance, and consumed large quantities of them. Raw garlic was routinely given to asthmatics and to those suffering with bronchialpulmonary complaints. Onions helped against problems of the digestive system. Garlic was an important healing agent then just as it still is to the modern Egyptian and to most of the peoples in the Mediterranean area: Fresh cloves are peeled, mashed and macerated in a mixture of vinegar and water. This can be used to gargle and rinse the mouth, or taken internally to treat sore throats and toothache, bronchial and lung complaints Coriander, C. Sativum was considered to have cooling, stimulant, carminative and digestive properties. Both the seeds and the plant were used as a spice in cooking to prevent and eliminate flatulence; they were also taken as a tea for stomach and all kinds of urinary complaints including cystitis. Cumin, Cumin cyminum is an umbelliferous herb indigenous to Egypt. The seeds were considered to be a stimulant and effective against flatulence. They were often used together with coriander for flavouring. Cumin powder mixed with some wheat flour as a binder and a little water was applied to relieve the pain of any aching or arthritic joints. Powdered cumin mixed with grease or lard was inserted as an anal suppository to disperse heat from the anus and stop itching (Zucconi, 2007). Leaves from many plants, such as willow, sycamore, acacia or the ym-tree, were used in poultices and the like. Tannic Acid derived from acacia seeds commonly helped for cooling the vessels and heal burns. Castor oil, figs and dates, were used as laxatives. Tape worms, were dealt with by an infusion of pomegranate root in water, which was strained and drunk. The alkaloids contained in it paralyzed the worms' nervous system, and they relin quished their hold. Ulcers were treated with yeast, as were stomach ailments (Majno, 1975). 7         Some of the medicines were made from plant materials imported from abroad. Mandrake, introduced from Canaan and grown locally since the New Kingdom, was thought to be an aphrodisiac and, mixed with alcohol, induced unconsciousness. Cedar oil, an antiseptic, originated in the Levant. The Persian henna was grown in Egypt since the Middle Kingdom, and was used against hair loss. They treated catarrh with aloe which came from eastern Africa. Lead-based chemicals like carbonates and acetates were popular for their therapeutic properties. Malachite used as an eye-liner also had therapeutic value. In a country where eye infections were endemic, the effects of its germicidal qualities were appreciated. It is interesting to note that ancient Egyptian chemists invented some other drugs, commonly known as household drugs (pesticides), meant to eliminate domestic pests. A popular recipe for pest control was to spray the house with nitron water and firewood coal, mixed with ground ―pipit " plant. 3. History of recent antifungal therapy    Benzimidazole, was already described in 1944 The first antifungal antibiotic, Nystatin was discovered in 1949 Amphotericin B deoxycholate, was introduced in 1958. It offers potent, broad-spectrum antifungal activity but is associated with significant renal toxicity and infusion reactions.  In the late 1960s, three new topical compounds were introduced: Clotrimazole, developed by Bayer Ag (Germany), and Miconazole and econazole, both developed by Janssen Pharmaceutica (Belgium) Flucytosine, a pyrimidine analogue introduced in 1973, is active against Candida and Cryptococcus. Its use is limited by emergence of drug resistance and toxicity.         Miconazole, was synthesised in 1969, was the first azole available for parenteral administration (not before 1978). Miconazole has been withdrawn from the market. In 1978, Fluconazole was introduced In 1981, the Food and Drug Administration (FDA) approved the systemic use of Ketoconazole, an imidazole derivative synthesised and developed by Janssen Pharmaceutica Terconazole, the first triazole marketed for human use, was active in the topical treatment of vaginal candidiasis and dermatomycoses. Fluconazole , a broad-spectrum triazole antifungal developed by Pfizer and approved for use in early 1990, The first-generation azole drugs, including Fluconazole and Itraconazole, became available in the 1990s. These agents offer the advantage of oral administration and have good activity against yeast pathogens. Due to CYP450 interactions, there are many drug– drug interactions. Lipid-based amphotericin B formulations were introduced in the 8   1990s and maintain the potent, broad-spectrum activity of the deoxycholate formulation with less toxicity. The echinocandin drugs became available in the 2000s and offer excellent activity against Candida with few drug–drug interactions; however, they are available in parenteral form only. The second-generation of azole drugs, including Voriconazole, Posaconazole, and Isavuconazole, were brought to market beginning in the 2000s. The major advantage of these agents is the extended spectrum of activity against filamentous fungi. References: 1. Arthur RR1, Drew RH, Perfect JR. Novel modes of antifungal drug administration. Expert Opin Investig Drugs. 2004 Aug;13(8):903-32. 2. Josef Jampilek (2016) Potential of agricultural fungicides for antifungal drug discovery, Expert Opinion on Drug Discovery, 11:1, 1-9, DOI: 10.1517/17460441.2016.111014 3. Neveen Helmy Abou El-Soud. Herbal medicine in ancient Egypt. Journal of Medicinal Plants Research Vol. 4(2), pp. 082-086, 18 January, 2010 Antifungal books 9 11 2. Classification of antifungals 2.1. Classification in nonspecific and site-targeted antifungals  Nonspecific antifungals Nonspecific antifungals can be considered as disinfectants-antiseptics especially for superficial/local treatment of skin or mucosa. They can be divided into o aldehydes (e.g., polynoxylin); o acids (e.g., benzoic acid, salicylic acid, 5-bromo-salicylic acid, undecylic acid); o phenols/halogenated phenols (e.g., chlorocresol, 2-chloro-4-nitrophenol, chlorophene, chlorophetanol, chloroxylenol, haloprogin, hexachlorophene, parabens, tetrabromo-o-cresol); o quinolinols (e.g., chloroxine); o amides/amidines (e.g., dimazole, ticlatone); o quaternary ammonium/phosphonium salts (e.g., dequalinium dichloride, dodecyltriphenylphosphonium bromide); o dyes (e.g., methylrosanilinium chloride). o Other potential antifungal agents under basic research, for example, (benz)azoles, benz(thia/oxa)zoles, pyrroles, (mono/di-aza)naphthalenes, naphthoquinones, morpholines, phenothiazines, etc.  Clinically used site-specific antifungal drugs o Fungal cell membrane  Polyene antifungal agents  Azole antifungal agents  Allylamine, thiocarbamate and morpholine antifungal agents o Fungal cell wall  Inhibitors of glucan synthesis. (aculeacins, echinocandins, and papulacandins)  Inhibitors of chitin biosynthesis (polyoxins and nikkomycins )  Inhibitors of mannoprotein biosynthesis(benanomicins, pradimicins, and benzonaphthacene quinones) o Fungal nucleic acid and protein biosynthesis  Interference with normal metabolic processes (flucytosine or s5fluorocytosine (5-fc)  Inhibitors of topoisomerase (eupolauridine)  Inhibitors of elongation factors (sordarins )  Inhibitors of protein farnesyltransferase (fpt inhibitor iii)  nhibitors of n-myristoyltransferase (analog of myristic acid )  Inhibitors of amino acids biosynthesis(cispentacin) o Other cellular functions  Inhibitors of microtubule aggregation (griseofulvin)  Inhibitors of calcineurin-dependent signaling (csa and fk-506) 11 2.2. Classification in human and agricultural antifungals 1. Approved human antifungals 12 2. Agricultral antifungals, Josef Jampilek, 2016 13 14 2.3. Classification of antifungals according to their generations Perfect, 2017 2.4. Classification of antifungal based on their chemical structure o Polyenes: o Amphotericin B, Nystatin, Hamycin, Natamycin (Pimaricin), Rimocidin, Hitachimycin, Filipin o Azoles o Imidazoles:  Bifonazole, Butoconazole,Clotrimazole,Croconazole, Eberconazole, Econazole,Enilconazole Fenticonazole, Flutrimazole, Isoconazole, Ketoconazole, Lanoconazole,Luliconazole, Miconazole, Omoconazole, Oxiconazole, Miconazole, Omoconazole, OxiconazolemSerticonazole, Sulconazole 15 o Triazoles:  Albaconazole, Cyproconazole, Difenoconazole, Efinaconazole, Epoxiconazole, Fluconazole,Flusilazole, Flutriafol, Fosfluconazole, Hexaconazole, Isavuconazole, Itraconazole, Metconazole, Myclobutanil, Posaconazole, Propiconazole, Prothioconazole, Ravuconazole,, Tebuconazole, Terconazole, Voriconazole o Thiazoles:  Abfangin, Thiabendazole o Allylamine: o Naftifine, Terbinafine, Butenafine o Thiocarbamate: o Tolnaftate, Tolciclate o Fluoropyrimidines: o Flucytosine o Morpholine Derivatives: o Amorolfine, Fenpropimorph: o Peptides/proteins: o Cispentacin o Acids: o Organic acids:  Acetic acid, Benzoic acid, Caprylic acid, Citric acid, Formic acid, Lactic acid, Propionic acid, Salicylic acid, Sorbic acid, Undecylenic acid o Fatty acids:  Butenoic acid, Hexenoic acid, Heptenoic acid, Octenoic acid, Nonenoic acid etc. o Inorganic acids: Boric acid o Essential oils o Anise essential oil, Arborvitae oil, Basil essential oil, Caraway essential oil, Ajowain (Carum copticum ) essential oil., Cinnamomum cassia oil, Citronella oil, Clove essential oil (Eugenol), Coriander essential oils, Cuminum cyminum essential oil, ,Eucalyptus essential oil, Garlic essential oils ( Allicin), Fennel essential oil, The galanga essential oil, Geraniol essential oil, Geranium essential oil, Ginger essential oil, Lavender essential oil , Laurus nobilis essential oils, linalool, Lemongrass essential oil (Citral), Oregano essential oil. Black pepper essential oil, Chili peppers essential oil, Piper bettle essential oil, Peppermint essential oil, Rosemary essential oils, Tea Tree essential oil, Thapsia villosa essential oil, Thyme essential oil 16 2.5. Classification of Antifungals according to drug administration A. Systemic Antifungal Drugs 1. Polyene antibiotics :Amphotericin B 2. Azole derivatives a) Imidazole: Ketoconazole, Miconazole b) Triazole: Fluconazole, Itraconazole, Voriconazole, Posaconazole, Ravuconazole 3. Echinocandin: Capsofungin, Anidulafungin, Micafungin 4. Antimetabolite: Flucytosine (5-FC) 5. Peptidyl nucleoside antibiotics: Nikkomycin B B. Topical Antifungal drugs 1. Polyene antibiotics: Nystatin, Hamycin, Natamycin (Pimaricin), Rimocidin, Hitachimycin, Filipin 2. Azoles–Imidazole: Clotrimazole, Ketoconazole, Miconazole, Econazole, Butaconazole, Oxiconazole, Sulconazole, Fenticonazole, Isoconazole, Bifonazole, Tiaconazol, Terconazole 3. Others: Tolnaftate, Undecyclinic acid, Povidone iodine, Triacetin, Gentian violet, Sodium thiosulphate, Cicloporox olamine, Benzoic acid, Quinidochlor C. Systemic antifungal drugs for superficial infections 1. Heterocyclic benzofurans: Corticofunvin, Griseofulvin 2. Allylamine: Terbinafine, Butenafine, Naftifine. 2.6. Classification of antifungals according to formulations 1. Antifungal creams, liquids or sprays (topical antifungals)  These are used to treat fungal infections of the skin, scalp and nails.  Theyinclude clotrimazole, econazole, ketoconazole, miconazole, tioconazole, terbinafine, amorolfine. o Sometimes an antifungal cream is combined with other creams when two actions are required. For example,  an antifungal cream is often combined with a mild steroid cream, such as hydrocortisone, to treat certain rashes.  antifungal cream clears the infection, and  mild steroid cream reduces the inflammation caused by the infection. 2. Antifungal shampoo  A shampoo which contains ketoconazole is sometimes used to help treat scalp fungal infections and certain skin conditions. 17 3. Antifungal pessaries  Some antifungal medicines are used as pessaries to treat vaginal thrush, particularly clotrimazole, econazole, miconazole, fenticonazole 4. Antifungal gel, liquid or tablets  Miconazole is available as an oral gel,  Nystatin is available as a liquid. o They are applied to the mouth. and throat.  Terbinafine, itraconazole, fluconazole, posaconazole, voriconazole are available as tablets, o The one chosen depends on what type of infection you have. For example:  Terbinafine is commonly used to treat nail infections which are usually caused by a tinea type of fungus.  Fluconazole is commonly used to treat vaginal thrush, as an alternative to using antifungal cream. It is also used to treat and prevent certain fungal infections within the body. 5. Antifungal injections  These may be used in serious systemic fungal infections  amphotericin, flucytosine, itraconazole, voriconazole, anidulafungin, caspofungin, micafungin 18 19 http://www.empr.com/clinical-charts/antifungal-formulations/article/642424/ 21 2.7. Classification according to the source 1. Fungi-derived Antifungals  Griseofulvin  Echinocardines 2. Bacteria-derived Antifungals  Hamycin,  Natamycin (Pimaricin),  Rimocidin,  Hitachimycin,  Filipin 3. Plant-derived Antifungals  Polyphenols, flavonoids, desmethyl isoencecalin, 5-hydroxy-6-acetyl-2hydroxymethyl- , 2-methyl chromene, flavanones , diterpenes, terpenes, pinelloside Phenylpropanoids, neolignans, sesquiterpene – tayunin, triterpenoids , sterols, cyclitols , essential oil, unsaturated fatty acids 4. Synthetic Antifungals  Azoles (mainly imidazoles, triazoles, and thiazole ketoconazole, miconazole, clotrimazole, tioconazole, econazole, fenticonazole, sulconazole, sertaconazole, oxiconazole, tinidazole, enilconazole (Imazalil), parconazole, eberconazole, lanoconazole, bifonazole, lombazole, voriconazole, itraconazole, butoconazole, fluconazole, terconazole, posaconazole, abafungin  Allylamine Naftifine, terbinafine, butenafine  Thiocarbamate Tolnaftate, tolciclate  Fluoropyrimidines Flucytosine  Morpholine Derivatives Amorolfine and fenpropimorph  Carabrol Ester Derivatives   Carboline Derivatives Miscellaneous o 5-Amino-6-arylamino-1H-pyrazolo[3,4-d]pyrimidin-4(5H)-one Derivatives o β-Trifluoroalkyl Aminovinyl Ketone Derivatives o Dithiocarbamate and Rhodanine Derivatives 21 Fungi-derived antifungals Natural products inhibitors of glucan synthesis, Vicente et al., 2003 Compound Producing species Reference Aspergillus nidulans Nyfeler and Keller 1974 [10] Lipopeptides Echinocandin B A. rugulosus Aculeacin Aspergillus aculeatus Mizuno et al. 1977 [107] Mulundocandin Aspergillus sydowii Roy et al. 1987 [25] Sporiofungins Penicillium arenicola Tscherter and Dreyfuss 1982 [108] Cryptosporiopsis sp. Pneumocandins Glarea lozoyensis Schwartz et al. 1992 [12] Pezicula sp. Bills et al. 1999 [13] Cryptosporiopsis sp. Noble et al. 1991 [109] Cryptocandin Cryptosporiopsis quercina Strobel et al. 1999 [110] WF11899 and related sulfate-derivatives Coleophoma empetri Hori 1999 [111] Coleophoma crateriformis Tolypocladium parasiticum Chalara sp. FR901469 Unidentified fungus Fujie et al. 2000 [27] Arborcandins Unidentified fungus Ohyama et al. 2000 [26] Clavariopsins Clavariopsis aquatica Kaida et al. 2001 [28] Glycolipids Papulacandins Papularia sphaerosperma Traxler et al. 1977 [29] Corynecandin Coryneum modonium Gunawardana et al. 1997 [112] Mer-WF3010 Phialophora cyclaminis Kaneto et al. 1993 [113] Fusacandin Fusarium sambucinum Yeung et al. 1996 [31] BU-4794F Gilmaniella sp. Aoki et al. 1993 [114] L-687781 Dictyochaeta simplex VanMiddlesworth et al. 1991 [115] Efumafungin Hormonema sp. Peláez et al. 2000 [34] Arundifungin Arthrinium arundinis Cabello et al. 2001 [33] Acidic terpenoids A. phaeospermum Leotiales anamorphs 22 Compound Producing species Reference Coelomycete undetermined Ascoteroside Ascotricha amphitricha Onishi et al. 2000 [32] Mycoleptodiscus atromaculans Ergokonin A Trichoderma longibrachiatum Vicente et al. 2001 [35] T. koningii T. viride Lipopeptides Echinocandin B Nyfeler and Keller 1974 [10] Aspergillus nidulans A. rugulosus Aculeacin Aspergillus aculeatus Mizuno et al. 1977 [107] Mulundocandin Aspergillus sydowii Roy et al. 1987 [25] Sporiofungins Penicillium arenicola Tscherter and Dreyfuss 1982 [108] Cryptosporiopsis sp. Pneumocandins Glarea lozoyensis Schwartz et al. 1992 [12] Pezicula sp. Bills et al. 1999 [13] Cryptosporiopsis sp. Noble et al. 1991 [109] Cryptocandin Cryptosporiopsis quercina Strobel et al. 1999 [110] WF11899 and related sulfate-derivatives Coleophoma empetri Hori 1999 [111] Coleophoma crateriformis Tolypocladium parasiticum Chalara sp. FR901469 Unidentified fungus Fujie et al. 2000 [27] Arborcandins Unidentified fungus Ohyama et al. 2000 [26] Clavariopsins Clavariopsis aquatica Kaida et al. 2001 [28] Glycolipids Papulacandins Papularia sphaerosperma Traxler et al. 1977 [29] Corynecandin Coryneum modonium Gunawardana et al. 1997 [112] Mer-WF3010 Phialophora cyclaminis Kaneto et al. 1993 [113] Fusacandin Fusarium sambucinum Yeung et al. 1996 [31] BU-4794F Gilmaniella sp. Aoki et al. 1993 [114] L-687781 Dictyochaeta simplex VanMiddlesworth et al. 1991 [115] 23 Acidic terpenoids Efumafungin Hormonema sp. Peláez et al. 2000 [34] Arundifungin Arthrinium arundinis Cabello et al. 2001 [33] A. phaeospermum Leotiales anamorphs Coelomycete undetermined Ascoteroside Ascotricha amphitricha Onishi et al. 2000 [32] Mycoleptodiscus atromaculans Ergokonin A Trichoderma longibrachiatum Vicente et al. 2001 [35] T. koningii T. viride Natural products inhibitors of shingolipid biosynthesis and protein synthesis, Vicente et al. 2001 Compound Producing species Reference Sphingolipid biosynthesis Sphingofungins Aspergillus fumigatus Zweerink et al. 1992 [51] Paecilomyces variotii Horn et al. 1992 [56] Lipoxamycin Streptomyces sp. Mandala et al. 1994 [57] Viridiofungins Trichoderma viride Mandala et al. 1997 [58] Myriocin Isaria sinclairii Miyake et al. 1995 [67] Fumonisin B1 Fusarioum moniliforme Wang et al. 1991 [59] Australifungin Sporormiella australis Mandala et al. 1995 [52] Aureobasidin A Aureobasidium pullulans Nagiec et al. 1997 [60] Khafrefungin Unidentified sterile fungus Mandala et al. 1997 [61] Rustmicin Micromonospora chalcea Takatsu et al. 1985 [69] Micromonospora sp. Mandala et al. 1998 [62] Galbonolide B Micromonospora sp. Harris et al. 1998 [71] Minimoidin Sporomiella minimoides Mandala et al. 2001 [63] Sordarin Sordaria araneosa Sigg et al. 1969 [79] Zofimarin Zopfiella marina Ogita et al. 1987 [83] BE31405 Penicillium minioluteum Okada et al. 1998 [85] SCH57404 Unidentified sterile fungus Coval et al. 1995 [86] Xylarin Xylaria sp. Schneider et al. 1995 [87] Protein synthesis 24 Compound Producing species Reference Hypoxysordarin Hypoxylon croceum Daferner et al. 1999 [88] GR135402 Graphium putredinis Kinsman et al. 1998 [92] Plant-derived antifungals, Trakranrungsie, 2011 25 26 3. Targets of Antifungal Agents 3.1. Fungal cell membrane as a drug development target 1.1. Inhibition of ergosterol function   Ergosterol, the principal sterol in the fungal cytoplasmic membrane, is the target site of action of polyene and the azole antifungals, Complexing with ergosterol in the plasma membrane causes membrane disruption, increased permeability, leakage of cytoplasmic contents and ultimately cell death  The polyene antifungals have a higher affinity for ergosterol than its mammalian counterpart, cholesterol, and are thus, relatively less toxic to mammalian cells.  In liposomal formulation, polyene antifungals upon binding to the cell wall, the liposome is disrupted, and the drug is released and binds to ergosterol after being transferred through the cell wall. By this mechanism of action, the integrity of the liposome in mammalian cells is maintained, and thus, resulting in minimal toxicity to the host.  Azole antifungal agents form, through their azole ring, a stoichiometric complex with the heme iron of P-450 demethylase (DM). o The resulting ergosterol depletion and the accumulation of lanosterol and other 14-methylated sterols interfere with the ―bulk‖ functions of ergosterol as a membrane component. o The resulting disruption of the structure of the plasma membrane makes it more vulnerable to further damage, including the alteration of the activity of several membrane bound enzymes, such as those associated with nutrient transport and chitin synthesis, growth, and proliferation.  Allylamines and thiocarbamates mechanism of action is a reversible, noncompetitive inhibition of squalene epoxidase enzyme, which together with (2,3)-oxidosqualene cyclase, is responsible for the cyclization of squalene to lanosterol. o The resulting ergosterol depletion and squalene accumulation affect membrane structure and functions, such as nutrient uptake. o The benzylamine, butenafine, has a mechanism of action similar to that of allylamines and, in addition, causes direct membrane effects in ergosteroldepleted cells.  Morpholines act on the ergosterol pathway by inhibiting two enzymes, Δ14 reductase and Δ7–Δ8 isomerase. o The morpholine fenpropimorph also inhibits cholesterol biosynthesis in mammalian cells, although it appears to affect the demethylation of lanosterol rather than sterol reductases or isomerases. 1.2. Inhibition of sphingolipid biosynthesis  Sphingolipids are essential membrane components of both mammalian and fungal cells and they are localized primarily on the outer leaflet of the fungal cytoplasmic membrane 27 o All early steps of sphingolipid biosynthesis have mammalian counterparts and thus, are less attractive for the development of antifungal agents. 1.3. Inhibition of proton ATPases  Proton ATPases are involved in electrochemical proton gradient maintenance and intracellular pH regulation. Plasma membrane H1 ATPase is an abundant and essential enzyme and given that there are significant differences between the fungal and mammalian enzymes, plasma membrane H1 ATPase offers a great opportunity for exploitation as a rational drug design target. 1.4. Chelation of polyvalent metal cations, such as Fe3+ and Al3+.  Metal cations are cofactors of many enzymes, including cytochromes and their inhibition may lead to the disruption of the biosynthesis of ergosterol, e.g. Ciclopirox 3.2. Fungal cell wall as a drug development target    Fungal cells, like several other microorganisms are enclosed in a cell wall that provides structural support and protection to the cell. Mammalian cells lack a cell wall, making the fungal cell wall a desirable target for the development of antifungal agents. β-glucan, chitin and mannoproteins are components of the cell wall and disruption of their synthesis can lead to an ineffective cell wall unable to fully protect the cell. 1. Glucan Biosynthesis as a Target   Inhibition of glucan synthesis results in a loss of the enzymatic activity of 1,3-β-glucan synthase and this in turn compromises the structure and osmolarity of the cell wall. Echinocandin antifungal agents have been shown to target the fungal cell wall by inhibiting the synthesis of β-1,3-D-glucan, the key and critical cell wall component of many pathogenic fungi including Candida spp. 2. Chitin Biosynthesis as a Target    Chitin and chitosan are hallmark polysaccharides that are present in all known fungal pathogens and not in humans. Inhibition of chitin synthesis is an attractive target for antifungals Inhibitors of chitin biosynthesis results in inhibition of septation, osmotic lysis and death 3. Mannoprotein Biosynthesis as a Target  Mannoproteins are interstitial components of fungal cell walls. Structurally, these are complex chains of mannose units linked to proteins through N-acetylglucosamine and 28  asparagine residues. Mannoproteins may be involved in cell-cell recognition and reproductive processes. The mechanism of antifungal action involves initial calcium-dependent complexing of their free carboxyl group with the saccharide portion of cell surface. They then act primarily on the membrane, causing leakage of intracellular potassium. Antifungal targets. Numerous molecules can be attacked by antifungals, including fungus-specific components of the cell wall or cell membrane, or processes such as metabolism, DNA synthesis, mitochondrial function or the stress response. Investigational antifungal agents targeting these components are indicated in light blue boxes, and approved antifungal classes are indicated in dark blue boxes. Some antifungals exert their specificity by being taken up by fungus-specific transporters. Acs1, acetyl-CoA synthetase 1; BHBM, Nʹ-(3-bromo-4-hydroxybenzylidene)- 2-methylbenzohydrazide; Dhodh, dihydroorotate dehydrogenase; HOG, high-osmolarity glycerol; Hsp90, heat shock protein 90; Icl, isocitrate lyase; Pdk1, 3-phosphoinositide-dependent protein kinase 1; PMN, polymorphonuclear; UDP, uridine diphosphate Perfect, 2017 29 3.3. Fungal nucleic acid and protein biosynthesis as a drug development target 1. Interference with Normal Metabolic Processes   Targeting normal metabolic processes can be a viable strategy for drug development against fungal pathogens. Flucytosine is an antimetabolite antifungal agent, transported inside susceptible fungal cells by a cytosine permease, cytosine deaminase converts 5-FC into 5-fluorouracil (5FU). o Subsequent phosphorylation and incorporation into RNA, leads to miscoding and disruption of protein synthesis. o Additionally, phosphorylated 5-FU is converted to its deoxynucleoside and is believed to block DNA synthesis by inhibiting thymidilate synthase leading to the disruption of DNA replication. 2. Inhibition of Topoisomerase   Topoisomerases (TOP) I and II are involved in the replication, transcription, repair, and chromosomal segregation in cells. Fungal topoisomerase inhibitors apparently form complexes with the enzyme and ultimately derail the oncoming replication fork leading to inhibition of the fungal growth. 3. Inhibition of Elongation Factors     Elongation factor 1 (EF-1) and elongation factor 2 (EF-2) are required for the polypeptide chain elongation reactions in the synthesis of proteins in both fungal and mammalian cells. Elongation factor 3 (EF-3) required by fungi but not by mammalian cells is present in most fungi including C. albicans and P. carinii and is essential for cell viability. Elongation factor has ATPase activity and is specifically required by the yeast 40S ribosomal subunit. Elongation factor inhibition affects the protein synthesis machinery in fungi , but not in mammals. 4. Inhibitors of Protein Farnesyltransferase (PFT)    Many small G proteins require post-translational modification to allow functional association to the cell membrane. The enzymes that catalyze these reactions include protein farnesyltransferase and protein geranylgeranyltransferases. Inhibition of farnesyltransferase has been shown to result in dose-dependent cytostasis of C. neoformans, as well as prevention of hyphal differentiation in andida albicans. 31 5. Inhibitors of N-myristoyltransferase (NMT)   Fungal protein-N-myristoyltransferase (NMT) may serve as desirable targets for drug design against pathogenic microorganisms that require N-myristoylation. Inhibitors of NMT have demonstrated in vitro activity against yeasts including S. cerevisiae, C. albicans and C. neoformans and filamentous fungi such as A. niger. 6. Inhibitors of Nucleic Acid Biosynthesis  Several natural products have been reported to have antifungal activity by interfering with fungal cell nucleic acid biosynthesis 7. Inhibitors of Amino Acids Biosynthesis   Antifungal agents with in vivo activity against multiple targets, interferes with amino acid synthesis. The suggested mechanism of action involves interference with amino acid transport and cellular regulation of amino acid metabolism. 8. Inhibitors of Polyamine Biosynthesis  Ornithine decarboxylase, an enzyme involved in the biosynthesis of polyamine is a potential antifungal target. 9. Inhibitors of Folic Acid Biosynthesis  The diaminoquinazoline structures are reported to inhibit the dihydrofolate reductase enzyme, which catalyzes the reduction of dihydrofolic acid to tetrahydrofolic acid, and thus interferes with DNA biosynthesis. 3.4. Other cellular functions as drug development targets 1. Inhibitors of Microtubule Aggregation    Microtubules are polymers of α- and β-tubulin dimers. Microtubule aggregation-disaggregation plays a key role in cell morphology and growth. Griseofulvin inhibits microtubule aggregation by interacting with β-tubulin, a protein highly conserved in eukaryotes. 2. Inhibitors of Signal Transduction Pathways  The signal transduction cascades in fungi have become very attractive targets since their components are now emerging as potential targets for the development of new antifungal agents. 31 3. Inhibitors of Calcineurin-dependent Signaling   Calcineurin has been shown to be essential for the virulence composite of the major fungal pathogens (Aspergillus fumigatus, Candida albicans and Cryptococcus neoformans) and thus for fungal survival and fitness in the host. The potential to make calcineurin a viable target for antifungal drug discovery has been contingent on finding specific inhibitors that have the differential ability to block fungal over mammalian calcineurin. 4. Inhibitors of Target of Rapamycin (TORs) Dependent Signaling    TOR inhibitors are a class of drugs that inhibit the mechanistic target of rapamycin (mTOR), which is a serine/threonine-specific protein kinase that belongs to the family of phosphatidylinositol-3 kinase (PI3K) related kinases (PIKKs). mTOR regulates cellular metabolism, growth, and proliferation by forming and signaling through two protein complexes, mTORC1 and mTORC2.. Rapamycin (sirolimus) has been shown to bind to the FKBP receptor to yield a rapamycin-FKBP complex that binds to the TOR protein, and blocks signal transduction. 5. Inhibitors of Phosphoinositide 3-Kinases (PI-3-kinases)-dependent Signaling  Wortmannin is a hydrophobic steroid-related product of the fungus Talaromyces wortmanni that inhibits signal-transduction pathways. 6. Inhibitors of HSP90 and HSP90-dependent Signaling   Geldanamycin and two other structurally related analogues (herbimycin and macbecin) bind to and inhibit the 90 kDa heat-shock protein HSP90. HSP90, HSP70 and many of the associated chaperones are highly conserved between yeast and humans and involves the inhibition of HSP90-dependent signaling cascades that are required for cell function. 7. The trehalose pathway   The trehalose pathway possess attractive features of antifungal agents. The trehalose pathway is present in fungi, bacteria, plants and invertebrates, but is not found in the mammalian biochemical machinery.  The trehalose pathway contains two primary synthesizing enzymes (trehalose6-phosphate synthase (Tps1) and trehalose-6-phosphate phosphatase (Tps2)), which are essential to tolerating stress in all of the major fungal pathogens. 32 3. 5. Targets for miscellaneous antifungal agents      Organic acids such as caprylic acid, salicylic acid, undecylenic acid, propionic acid, and benzoic acid exhibit antifungal activity by interacting with non-specific components in the cell membrane. Allicin, the main parent antifungal compound in garlic, appears to have a mode of action related to its ability to cross the cell membrane and combine with sulfur-containing groups in amino acids and proteins and interfering with cell metabolism. Tea tree oil, citronella oil, lemon grass, orange oil, palmarosa oil, patchouli, lemon myrtle, neem seed oil and coconut oil all exhibit antifungal activity, might act by altering membrane properties and compromising membrane-associated functions. Olive leaf acts by interfering with the pathogen's amino acid properties and prevents the pathogen from reproducing and creating more microbes in the body and directly stimulating their phagocytosis. Zinc pyrithione is believed to act through the disruption of membrane transport by blocking the proton pump that energizes the transport mechanism. Fungi are capable of inactivating pyrithione in low concentrations. 3.6. Future approaches for identification of novel drug targets        Ideal targets require two major features. First they need to be essential to cell viability, and second, they need to be unique to the fungal organism. Annotated genome databases can serve as the main sources of information to identify genes with the potential to be therapeutic targets. Saccharomyces Genome Database (SGD), as of June 29, 2015, indicates that budding yeast contain 6,604 Open Reading Frames or ORFs (gene sequences which are predicted to encode for a protein) and 78% have been verified. Of these, 1,284 genes are essential indicating that their inactivation leads to cellular inviability. o Further analysis can indicate which of these essential genes are unique to the organism and absent in humans. Candida Genome Database o C. albicans has 6,218 ORFs but only 1,548 ORFs (24.9%) have been verified. As sequences become available and the ORF function including viability of the null alleles is determined, potential therapeutic targets can be identified. Aspergillus Genome Database o A genome snapshot of A. nidulans indicates it has 10,678 ORFs, of which only 1,198 (11.2%) have been verified so far. An alternative approach to increasing the effectiveness of current anti-fungal drugs involves the identification of genes which when inactivated render the organism hypersensitive to the agent. These genes are potential targets of therapeutic value since their inactivation results in hypersensitivity to the anti-fungal agent tested. 33 References: 1. Mazu TK, Bricker BA, Flores-Rozas H, Ablordeppey SY. The Mechanistic Targets of Antifungal Agents: An Overview. Mini reviews in medicinal chemistry. 2016;16(7):555578. 2. NAFSIKA H. GEORGOPAPADAKOU1* AND THOMAS J. WALSH2 Antifungal Agents: Chemotherapeutic Targets and Immunologic Strategies. ANTIMICROBIAL AGENTS AND CHEMOTHERAPY, Feb. 1996, p. 279–291\ 3. John R. Perfect. The antifungal pipeline: a reality check. NATURE REVIEWS | DRUG DISCOVERY VOLUME 16 | SEPTEMBER 2017 | 603 4. Treatment of fungal infections 4.1. Topical treatment        Topical treatment of fungal infections has proved to be quite advantageous due to various factors like targeting the site of infection, minimizing systemic side effects, enhanced efficacy of treatment, and improved patient compliance. Topical treatment has restricted drug delivery across the skin resulting in insufficient therapeutic index and may exert local as well as systemic side effects. Topical treatment accomplishment of drug delivery needs to pacify two anomalous aspects, o the barrier nature of stratum corneum, o deposition of drug within the skin should be ideally achieved with limited percutaneous absorption. to facilitate the delivery of antifungal drugs and improve the treatment aspects, various novel delivery carriers have been developed. Topical agents that are conventionally used for the treatment of skin fungal infections are usually formulated as creams, lotions or gels. Topical agents either exhibit fungicidal or fungistatic actions depending on the agent being delivered. Since the side effects of fungal agents applied topically are less than their oral counterparts, they are the preferred agents. Topical agents avoid drug-drug interactions, which are more common in case of oral administration. 34 Specific characteristics of a topical preparation, Bseiso et al., 2016   lipophilic nature of the drug o when such a drug is applied on the skin, a depot is formed in the lipidic stratum corneum which releases the drug slowly to the underlying skin layers, that is, epidermis and dermis. o in order to achieve a topical effect for an antifungal drug, the release rate of this lipophilic drug should be controlled by the formulation in order to achieve high local therapeutic concentration and to provide prolonged pharmacological effect. Molecular weight of the drug o this is especially important for antifungal drugs known to exceed 500 Da such as amphotericin B and ketoconazole. o these considerations have led to the development of several carriers which were found to improve topical drug delivery by either finding a way into a shunt such as hair follicle, accumulating between corneocytes, and intermingling with skin lipids, or by disintegrating and merging with lipidic layers. Novel Carriers for Treatment of Skin Fungal Infections, Bseiso et al., 2016   Micelles o Micelles are defined as a group of surfactant molecules dispersed in a liquid. o Micelles were reported to be promising carriers for delivering an antifungal drug topically. o Bachhav et al.(2011) developed new aqueous micellar solutions of clotrimazole, econazole nitrate, and fluconazole for the treatment of superficial fungal infections.  The micelles were prepared from novel amphiphilic methoxy poly(ethylene glycol)-hexyl substituted polylactide block copolymers.  These micelles, which were in the nanometer range, showed superior entrapment for econazole nitrate.  Upon topical application of the econazole micellar formula compared to the marketed Pevaryl ®cream on porcine skin, the deposition of econazole was found to be 13-fold higher in the former.  This was attributed to the ability of the micellar solution to utilize the follicular penetration pathway. These findings suggest the promising role of micelles in improving the cutaneous bioavailability of the antifungal drug. Solid lipid nanoparticles and nanostructured lipid carriers o Solid lipid nanoparticles are carriers in which the drug is entrapped within a solid lipid core matrix, e.g.triglycerides, diglycerides, monoglycerides, fatty acids, steroids, and waxes. o Nanostructured lipid carriers are the second generation of lipid nanoparticles in which the matrix is composed of a mixture of solid and liquid lipids. 35 o Both solid lipid nanoparticles and nanostructured lipid carriers have been recommended as good carriers for the treatment of topical skin infections, especially for antifungal drugs which are known to be lipophilic, and hence, can be successfully entrapped within the lipidic core of solid lipid nanoparticles or nanostructured lipid carriers. o Souto et al. (2004, 2005) prepared solid lipid nanoparticles and nanostructured lipid carriers for the topical delivery of clotrimazole. \  Both carriers were able to sustain its release for a period of 10 h, with solid lipid nanoparticles displaying occlusive property, which is desirable for topical application in general.  When solid lipid nanoparticles and nanostructured lipid carriers were used as topical carriers for ketoconazole, the latter was found to protect the drug against light degradation, conferring more stability to it and had comparable antifungal activity to the marketed product against Candida albicans. o Bhalekar ET AL. (2009) prepared and evaluated miconazole nitrate-loaded solid lipid nanoparticles for topical delivery  Solid lipid nanoparticles of miconazole incorporated in gel form were able to enhance its skin accumulation and uptake as compared to the marketed gel. o Jain et al. (2010) found that Miconazole loaded in solid lipid nanoparticles form more efficient in the treatment of candidiasis.  Microemulsions o Microemulsions are defined as thermodynamically stable mixtures of oil and water stabilized by surfactants and co-surfactants, with size in the nanometer range. o Owing to their ability to solubilize many poorly soluble drugs, microemulsions have been found very promising in the delivery of antifungal drugs which are characterized by their lipophilicity.  A microemulsion gel developed for topical delivery of fluconazole for the treatment of invasive fungal infections was developed and found very effective in enhancing percutaneous absorption of the drug. El Laithy and El-Shaboury (2002)  Several researchers further confirmed the ability of microemulsions to increase percutaneous permeability of fluconazole.Shah et al., 2009, Salemo et al., 2010)  Microemulsion based hydrogel of clotrimazole exhibited higher skin retention and higher in vitro activity against C. albicans when compared to the conventional cream. Furthermore, it demonstrated clinical efficacy when tested in patients suffering from tinea corporis, tinea circinata and tinea pedis with skin involvement of <10% of the total body surface area. Hashem et al. (2011)  Amphotericin B was also incorporated in microemulsion form for treatment of invasive fungal infections in which a 2-fold increase in skin retention was obtained with the microemulsion formulation compared to 36    the plain drug solution, with better in vitro antifungal activity against Trichophytonrubrum.Sahoo et al. (2014) Vesicular delivery systems o Vesicles are defined as highly ordered assemblies of one or several concentric lipid bilayers. They are formed when certain amphiphilic molecules such as phospholipids or surfactants are placed in water. o As a topical drug carrier, vesicular systems act as penetration enhancers owing to the penetration of their lipidic components into the stratum corneum leading to alteration in the intercellular lipid matrix. o They also serve as depots for localizing and sustaining the release of topically applied compounds o They were reported to reduce the systemic absorption of drugs owing to their high substantivity with the biological membranes. o Several vesicular systems have been prepared and successfully utilized in the treatment of skin fungal infections, among which are liposomes, niosomes, transferosomes, ethosomes, and penetration enhancer vesicles. Liposomes o Liposomes are vesicles which consist of one or more concentric lipid bilayers separated by water or aqueous buffer compartments, ranging in size from 10 nanometers to 20 micrometers. o Liposomes were reported to interact with the skin via several mechanisms. They are either adsorbed onto the skin surface leading to the release of drugs, or penetrate via the lipid-rich channels either intact, or after losing some lipid lamellae; alternatively, they form occlusive films which increase skin hydration and drug penetration into the stratum corneum.  a liposomal gel of ketoconazole allowed more drug retention in the skin compared to the gel and cream formulations. Patel et al. (2009)  They were also reported to increase both the deposition and skin permeation of fluconazole when compared to controls, and enhance its therapeutic effectiveness against cutaneous candidiasis. Gupta et al. (2010)  Liposomes were also able to effectively decrease fungal colonies when encapsulating ciclopirox olamine. Verma et al. (2010)  Prolongation of the action of terbinafine was also suggested by other authors upon encapsulating into liposomal gels.Sudhakar et al. (2014)  Liposomes of croconazole too showed excellent activity against different fungal species when compared to miconazole cream as a control. ElBadry et al. (2014) Niosomes o Niosomes are similar to liposomes, they only differ in the replacement of phospholipids with non-ionic surfactants. o Upon topical application, they interact with the stratum corneum leading to a reduction of transepidermal water loss. o Similar to liposomes, they are either adsorbed on the surface of the skin leading to high thermodynamic activity gradient of the drug at the interface which facilitates 37 drug permeation, or they penetrate into the stratum corneum themselves and act as drug reservoirs.  Griseofulvin niosomes incorporated in gel showed high mycological cure rates of about 80% in patients suffering from tinea corporis.Kassem et al. (2006)  Terbinafine hydrochloride niosomes showed efficacy against Aspergillus niger. Sathali et al. (2010)  ketoconazole action was prolonged by its encapsulating into niosomes.Shirsand et al. (2012)  Itraconazole and miconazole niosomes were also found to be effective, proving themselves to be effective carrier systems for antifungal drugs. Firthouse et al. (2011)   Transferosomes o Transferosomes, also termed as ultradeformable or flexible liposomes, have been used as carriers.  Transferosomes are formed of phospholipids and an edge activator;  edge activator is a surfactant having a high radius of curvature that destabilizes the phospholipid lipid bilayers and increases the deformability of vesicles.  Transferosomes additionally have the ability to pass to deeper skin layers intact, owing to their deformability, driven by their ability to avoid dry surroundings.  Griseofulvin Transferosomes were found better than liposomes in the treatment of dermatophytosis, displaying complete mycological cure in 10 days. Aggarwal and Goindi (2012)  Griseofulvin Transferosomes proved themselves as effective carriers for itraconazole as well. Alomrani et al.(2014)  Amphotericin B Transferosomes was reported to be superior in its skin permeation and its antifungal activity against Trichophyton rubrum. Devi et al. (2011)  Miconazole Transferosomes showed a higher rate of permeation of the drug into the deeper skin layers. Pandt et al. (2014) Ethosomes o Ethosomes contain ethanol instead of edge activator in transferosomes as the penetration enhancer. Ethanol fluidizes the intercellular lipids of the stratum corneum upon topical application and allow the easy penetration of vesicles into deeper skin layers.Touitou etal. (2000)  Ethosomes were found superior as carriers of clotrimazole and econazole. Maheshwari et al. (2012)  Ethosomes also reported to be clinically more effective than liposomes and the marketed econazole product against Candida. Bhalaria et al. (2009) 38  Penetration enhancer vesicles o Penetration enhancer vesicles containing vesicles are prepared by penetration enhancers with or without soybean lecithin.  Penetration enhancer vesicles differ in their chemical structure and properties, the commonly used ones being oleic acid, Transcutol ® and Labrasol ® .  Penetration enhancer vesicles mechanism of action penetrate intact down to the epidermis, followed by further penetration to deeper layers owing to the enhancement of bilayers fluidity caused by the penetration enhancer.  the free penetration enhancer exerts a synergistic effect through interaction with skin lipids, which leads to the perturbation of the intercellular skin lipid pathway improving the accumulation of drugs in deeper skin layers. [83]  Fluconazole Oleic acid vesicles were shown to enhance the epidermal accumulation of the drug suggesting their potential for the treatment of deep localized skin fungal infections.Zakir et al. (2010) Antifungal drugs for topical treatment, Trakranrungsie, 2011 39 Topical and systemic treatment of tinea corporis / cruris, Dias et al., 2013 DRUG TERBINAFINE TINEA CORPORIS/ CRURIS A *Cream : applied 1 or 2 times a day for 1-4 weeks ITRACONAZOLEE FLUCONAZOLE KETOCONAZOLE *Oral: 200mg/day for 1 week *Oral: 150-300mg once a week for 24 weeks *1% solutionA: applied 1or 2 times a day for 1week *2% creamA: applied once a day for 2 weeks *OralA: 200400mg/day for 4 weeks *Oral: 250mg/day for 24 weeks DRUG GRISEOFULVIN GRISEOFULVIN TINEA *Micronized CORPORIS/CRURIS 500mg/dayA *Micronized 500mg/dayA OTHER TOPICAL DRUGS OTHER TOPICAL DRUGS *Ciclopirox 0.77%A cream and gel twice a day for 4 weeks *Ciclopirox 0.77%A cream and gel twice a day for 4 weeks *Ultramicronized *Ultramicronized 330-375mg/day 330- 375mg/day for for 2-4 weeks 2-4 weeks A: Approved by the FDA (Food and Drug Administration) Topical and systemic treatment of tinea pedis /manuum, , Dias et al., 2013 TERBINAFINE TINEA PEDIS/ MANUUMA A *Cream : applied 1 or 2 times a day for 1-4 weeks ITRACONAZOLE FLUCONAZOLE KETOCONAZOLE *Oral: 200mg 2 times a day for 1 week *Oral: 150mg once a week for 2-4 weeks *2% creamA: applied once a day for 6 weeks *1% solutionA: applied 1 or 2 times a day for 1 week *OralA: 200 400mg/day for > 4 weeks *Oral: 250mg/day for 2 weeks DRUG TINEA PEDIS/ MANUUMA GRISEOFULVIN *Micronized lg/day TOPICAL DRUGS A *Ciclopirox 0.77%A cream and gel twice a day for 4 weeks *Ultramicronized 660 or 750mg/day for 4-8 weeks *Antifungal powder for prevention 41 4.2. Oral treatment   Oral antifungal drugs currently in use include griseofulvin, nystatin, itraconazole, fluconazole, ketoconazole and terbinafine. Oral antifungal drugs are reserved for extensive or severe infection for which topical antifungal agents are inappropriate or ineffective, because of high cost, potential side effects and drug interactions. . 1. Griseofulvin          Griseofulvin has traditionally been the gold standard for the treatment of tinea capitis. Griseofulvin is an antifungal antibiotic produced by an unusual strain of Penicillium Griseofulvin is used orally to treat superficial fungal infections, primarily fingernail and toenail infections, but it does not penetrate skin or nails if used topically. Griseofulvin has very poor oral bioavailability. Griseofulvin is highly lipophilic with low water solubility. Griseofulvin is a fungi-static drug that interacts with mitotic spindle and inhibit cell division. Griseofulvin is absorbed best when it is taken with a high fat meal, such as a cheeseburger, whole milk, or ice cream. Griseofulvin is best taken with or after meals, especially fatty ones (e.g., whole milk or ice cream). Dosage Forms & Strengths o oral suspension, microsize 125mg/5mL o tablet, microsize 500mg (Grifulvin V) o tablet, ultramicrosize 125mg (Gris-PEG) 250mg (Gris-PEG) o Tinea Infection Infections affecting skin, body, hair/beard, or nails Microsize  Tinea corporis, cruris, or capitis: 500 mg/day PO  Tinea pedis or unguium: 1000 mg/day PO as single daily dose or divided q12hr Ultramicrosize  Tinea corporis, cruris, or capitis: 375 mg/day PO  Tinea pedis or unguium: 250 mg PO q8hr Treatment duration  Tinea corporis: 2-4 weeks  Tinea capitis: 4-6 weeks; may be up to 8-12 weeks\  Tinea pedis: 4-8 weeks  Tinea unguium: 4-6 months 41 2. Nystatin      Nystatin is both fungistatic and fungicidal in vitro against a wide variety of yeasts and yeast-like fungi. Nystatin acts by binding to sterols in the cell membrane of susceptible Candida species with a resultant change in membrane permeability allowing leakage of intracellular components Nystatin is well tolerated even with prolonged therapy. Nystatin Oral Suspension, for oral administration, contains 100,000 USP Nystatin Units per mL. Inactive ingredients: alcohol (≤ 1% v/v), methylparaben, NF; dibasic sodium phosphate, USP; monobasic sodium phosphate, USP; saccharin sodium, USP; sucrose (50% w/v), NF; glycerin, USP; carboxy-methylcellulose sodium, USP; propylparaben, NF; artificial wild cherry flavor # 14783 and purified water, USP Nystatin Oral Suspension dosage o INFANTS: 2 mL (200,000 units) four times daily (in infants and young children, use dropper to place one-half of dose in each side of mouth and avoid feeding for 5 to 10 minutes). o CHILDREN AND ADULTS: 4-6 mL (400,000 to 600,000 units) four times daily (one-half of dose in each side of mouth). 3. Itraconazole o Oral itraconazole (Sporanox™) is a useful broad spectrum antifungal drug. o Oral itraconazole should be taken after a fatty meal, preferably with an acidic drink such as orange juice.\ o Oral itraconazole dosing regimes depend on the skin condition, its duration and severity, and need for prophylaxis. For example:  Skin infections: 200 mg daily for one to four weeks  Vulvovaginal candidiasis: 200 mg twice daily for one day OR 200 mg daily for 3 days, repeated if necessary or regularly once-weekly to oncemonthly  Oral candidiasis: 100 mg daily for two weeks  Onychomycosis: 200 mg/day for 6-8 weeks (fingernails) or 3-4 months (toenails), OR 200 mg twice daily for 7 days, repeated monthly for 2 months (fingernails) or 3-4 months (toenails) o Oral itraconazole side effects  Nausea is the most common side effect.  Abnormal liver function tests affect 5% of those on long term therapy but are rarely severe (monitoring is recommended for prolonged courses).  The main concern with azoles is serious interactions with other medications.  As itraconazole needs acid for its absorption, antacids, H2 antagonists and omeprazole should not be taken for 2 hours after itraconazole.  Drugs should not be taken by those on itraconazole:  Cisapride 42   HMG Co-A reductase inhibitors (atorvastatin, lovastatin, simvastatin) – the interaction may cause heart failure; fluvastatin and pravastatin are acceptable alternatives.  Midazolam, triazolam  The antihistamines astemizole and terfenadine (withdrawn from New Zealand market) Dose of these drugs should be reduced:  Warfarin. Digoxin.Methyl prednisolone,Ciclosporin, Tacrolimus, Vinca alkaloids 4. Fluconazole o Oral Fluconazole (Diflucan™) is a triazole used for candidiasis and cutaneous dermatophyte infections. o Oral Fluconazole is not registered for nail infections. The dose and duration depends on the nature and severity of infection. Typically:  Oropharyngeal candidiasis: 50mg daily for 7-14 days  Vaginal candidiasis: 150 mg single dose  Dermatomycoses: 150 mg once weekly for 2 to 6 weeks  Oral Fluconazole main contraindication:  It is concomitant administration with cisapride.  It should be avoided in pregnancy / lactationand in the presence of electrolyte abnormalities, heart disease and renal impairment.  Oral Fluconazole Side effects include:  GI disturbance  Rashes including urticaria, exfoliative dermatitis  Arrhythmias  Hepatotoxicity  Drug interactions are similar to those for itraconazole. 5. Ketoconazole o Oral Ketoconazole (Nizoral™) is used to treat fungal infections where other treatments have failed or are contraindicated. o Oral Ketoconazole is effective for yeasts and dermatophytes o Oral Ketoconazole is usually prescribed in a daily dose of 200mg after food. o Oral Ketoconazole main concern is hepatic – liver function should be monitored. o Oral Ketoconazole has similar interactions with other drugs. 6. Terbinafine o Oral Terbinafine can be taken with or without food. o Oral Terbinafine side effects include:  GI upset 43        Rashes including urticaria, toxic epidermal necrolysis Arthralgia and myalgia Taste disturbance Hepatobiliary dysfunction Leukopenia Drug interactions are not as frequent or as serious as with itraconazole. Drug interactions are reported with tricyclic antidepressants, beta-blockers, SSRIa, MAOIs, hepatic enzyme inhibitors (cimetidine) or inducers (rifampicin) and possibly with oral contraceptives. Oral Antifungal Drugs in the Treatment of Dermatomycosis      Oral antifungal drugs are used primarily to treat tinea unguium; however, they are also useful for other types of tinea. For example, a combination of topical and oral antifungal drugs is effective in hyperkeratotic tinea pedis that is unresponsive to topical monotherapy. In cases of tinea facialis adjacent to the eyes, ears, or mouth, or widespread tinea corporis, or tinea cruris involving the complex skin folds of the external genitalia, it is difficult to apply topical drugs to all the lesions; therefore, oral antifungal drugs are necessary. Oral antifungal drugs are also useful not only for tinea but for widespread pityriasis versicolor and Malassezia folliculitis, candidal onychomycosis, and candidal paronychia and onychia. In tinea capitis, for example, irritation by topical drugs is likely to enhance inflammation; therefore, oral antifungal drug monotherapy is preferable. In interdigital tinea pedis with erosion or contact dermatitis, topical drugs are difficult to use because they tend to cause irritant dermatitis, resulting in exacerbation of the condition. 4.3. Systemic treatment   Currently, there are four major classes of antifungal drugs that are indicated for the treatment of invasive fungal infections. When used as indicated, these drugs can be highly effective at treating invasive fungal infections with significant beneficial effects on patient mortality. 1. Amphotericin B and Its derivatives   Amphotericin B and its newer lipid formulations are polyene antifungals that target the fungal plasma membrane. Amphotericin B acts as ―sponges‖ that bind to and remove ergosterol from the plasma membrane, reducing membrane integrity. 44       Amphotericin B is broad spectrum and indicated for the treatment of severe infections caused by Candida species, Cryptococcus species, Zygomycetes and as an alternative therapy for aspergillosis. Amphotericin B is also used to treat many life-threatening invasive fungal diseases due to other filamentous molds, as well as the thermally-dimorphic fungi, such as Histoplasma, Coccidioides and Blastomyces. Amphotericin B is cytocidal for most fungi. Amphotericin B is not highly bioavailable when administered orally, only intravenous (IV) formulations are used clinically. Amphotericin B can have severe side effects, such as nephrotoxicity due to off-target binding of host membranes, limiting its usage to patients with life-threatening infections Amphotericin B newer formulations, such as the lipid-associated and liposomal formulations, demonstrate more selective fungal targeting and less host toxicity. 2. Azoles and Triazoles           Antifungal agents in the azole class target the fungal plasma membrane through inhibition of the biosynthesis of ergosterol, a fungal plasma membrane component that is similar to cholesterol foundin mammalian cell membranes. This occurs through the inhibition of the sterol 14_-demethylase (cytochrome P450 51 or CYP51), which catalyzes the final step in ergosterol biosynthesis. The inhibition of this enzyme leads to defects in fungal plasma membrane integrity and cellular integrity. The most commonly-used azoles for treating invasive fungal diseases can be functionally divided between agents with primary activity against yeast-like fungi (yeast-active azoles), and those with expanded activity against fungi that often grow as molds (moldactive azoles). Fluconazole is the most widely-used yeast-active azole, Fluconazole is often very effective for treating infections caused by Cryptococcus and Candida species. Fluconazole resistance can present a significant clinical issue in systemic candidiasis: o some Candida species, such as C. krusei, are intrinsically resistant to this drug, and o other Candida isolates are often susceptible to this drug at high concentrations. o Therefore, precise species identification and targeted antifungal susceptibility testing for clinically- invasive fungal diseases relevant isolates are very important components of the care of patients with Candida. Itraconazole was the first available azole with significant activity against molds, such as Aspergillus fumigatus. Itraconazole bioavailability and toxicity limit its current use for invasive fungal diseases. Voriconazole has become the first-line antifungal drug for treatment of invasive aspergillosis due to Aspergillus fumigatus. Voriconazole is superior to many other antifungal agents for invasive aspergillosis due to Aspergillus fumigatus. 45        Posaconazole is indicated for the prevention of invasive fungal diseases, especially in the setting of prolonged neutropenia after high dosecancer chemotherapy. Voriconazole and Posaconazole have the potential to interact with other medications due to their inhibition of hepatic cytochrome P-450-dependent metabolism. Isavuconazole (Cresemba®, Astellas Pharmaceuticals, Tokyo, Japan) is the most recently approved triazole antifungal drug. It differs from other approved azoles in several clinically-relevant ways. Isavuconazole has expanded in vitro activity that includes the Mucorales molds (Zygomycetes), such as Rhizopus, Mucor and Cunninghamella species, Isavuconazole be an effective component of the complex, medical-surgical treatment of mucormycosis. Isavuconazole intravenous (IV) formulation lacks cyclodextrin, a solubilizing agent used with other triazoles that is associated with nephrotoxicity in patients with renal insufficiency. Isavuconazole does not appear to exacerbate QT prolongation, and it may actually shorten the QT interval in some patients. 3. Echinocandins         Echinocandins represent the newest class of antifungals. Echinocandins currently approved for clinical usage are: caspofungin, micafungin and anidulafungin Echinocandins affect cell wall biosynthesis through the noncompetitive inhibition of _1,3-glucan synthase. o This enzyme is involved in the biosynthesis of one of the most abundant fungal cell wall components. o Treatment with echinocandins leads to defects in fungal cell integrity. Echinocandins are primarily used for the treatment of invasive candidiasis and as an alternative therapy for treatment of aspergillosis. Echinocandins have low host toxicity and few drug interactions. Echinocandins have no activity against Cryptococcus species Echinocandins are not orally bioavailable, likely due to their large molecular size Echinocandins are only available in IV formulations. 4. 5-Fluorocytosine     5-fluorocytosine (flucytosine) is a fluoridated pyrimidine analog 5-fluorocytosine inhibits DNA and RNA synthesis by incorporating into the growing nucleic acid chain, preventing further extension. o This nucleic acid damage eventually leads to cellular defects in protein biosynthesis and cell division. 5-fluorocytosine has been attributed with cytostatic effects and high rates of resistance developing during monotherapy. 5-fluorocytosine is rarely used as a single agent for the treatment of fungal infections. 46    5-fluorocytosine has been shown in multiple clinical trials to be highly effective in combination with amphotericin B for the treatment of cryptococcal meningitis. 5-fluorocytosine can also be used in combination with other antifungals to treat Candida infections, though this is a less common practice. 5-fluorocytosine flucytosine adverse effects include bone marrow toxicity, especially in the presence of renal impairment. . 47 Some Drugs for Systemic Fungal Infections http://www.merckmanuals.com/professional/infectious-diseases/fungi/antifungal-drugs Drug Uses Amphotericin B Most fungal infections Conventional (deoxycholate) (Not formulation: 0.5–1.0 mg/kg IV for Pseudallescheria sp) once/day Various lipid formulations: 3–5 mg/kg IV once/day Candidiasis, including 200 mg IV on day 1, then 100 mg candidemia IV once/day For esophageal candidiasis, half of this dose Aspergillosis 70 mg IV on day 1, then 50 mg Candidiasis, including IV once/day candidemia Mucosal and systemic 100–800 mg po or IV once/day candidiasis (loading dose may be given) Cryptococcal Children: 3–12 mg/kg po or IV meningitis once/day Coccidioidal meningitis Candidiasis (systemic) 12.5–37.5 mg/kg po qid Cryptococcosis Anidulafungin Caspofungin Fluconazole Flucytosine Isavuconazole Aspergillosis Mucormycosis Itraconazole Dermatomycosis Histoplasmosis, blastomycosis, coccidioidomycosis, sporotrichosis Candidiasis, including candidemia Prophylaxis for invasive aspergillosis and candidiasis Oral candidiasis Micafungin Posaconazole Oral candidiasis refractory to itraconazole Voriconazole Invasive aspergillosis Fusariosis Scedosporiosis Dose Some Adverse Effects Conventional formulation: Acute infusion reactions, neuropathy, GI upset, renal failure, anemia, thrombophlebitis, Lipid formulations: Infusion reactions*, renal failure* Hepatitis, diarrhea, hypokalemia, infusion reactions Phlebitis, headache, GI upset, rash, GI upset, hepatitis, QT prolongation Pancytopenia due to bone marrow toxicity, neuropathy, nausea, vomiting, hepatic and renal injury, colitis Nausea, vomiting, hepatitis 372 mg po or IV q 8 h (6 doses) initially, then 372 mg po or IV once/day for maintenance 100 mg po once/day to 200 mg po Hepatitis, GI upset, rash, headache, bid dizziness, hypokalemia, hypertension, edema, QT prolongation 100 mg IV once/day (dose 150 mg for esophageal candidiasis) 200 mg po tid Phlebitis, hepatitis, rash, headache, nausea Hepatitis, GI upset, rash, QT prolongation 100 mg po bid on day 1, then 100 mg once/day for 13 days 400 mg po bid 6 mg/kg IV for 2 loading doses, then 200 mg po q 12 h or 3 to 6 mg/kg IV q 12 h GI upset, transient visual disturbances, peripheral edema, rash, hepatitis, QT prolongation *This adverse effect is less common with lipid formulations than with the conventional formulation. 48 Approved antifungal drugs for the treatment of invasive fungal infections. Pianalto and Alspaugh, 2016 Systemic treatment of tinea capitis, Dias et al., 2013 DRUG DOSE 21, 35 DURATION COMPLETE CURE RATEA *1- Micronized: 20-25 mg/kg/day 6-12 weeks *1 - 80-95% *2 - 88100% 7mg/kg/day 6 weeks 96% 5mg/kg/day 6 weeks 82-100% 8mg/kg/week 8 weeks 98-100% GRISEOFULVIN Pill 500mg or Suspension 125mg/5ml *2-Ultramicronized: 10-15 mg/kg/day B TERBINAFINE Pill 250mg B ITRACONAZOLE Pill 100mg or Suspension 10mg/ml FLUCONAZOLEC Pill 200mg or Suspension 200mg/5ml A: Cure with negative culture or microscopy B: Not approved by the FDA (Food and Drug Administration) for children.C: Not approved by the FDA to treat tinea capitis in children. Systemic treatment - hand nails DRUG DOSE DURATION ITRACONAZOLE CONTINUOUS 200mg/day 6-12 weeks ITRACONAZOLE PULSE 400mg day/7d/ month 2-3 pulses TERBINAFINE CONTINUOUS 250mg/day 6-12 weeks TERBINAFINE PULSE 500 mg day/7 d/ month 2-3 pulses FLUCONAZOLE 150mg/week Until clinically cured GRISEOFULVIN 500-1000mg Until clinically cured Systemic treatment - foot nails DRUG DOSE DURATION ITRACONAZOLE CONTINUOUS 200mg/day 12-24 weeks ITRACONAZOLE PULSE 400mg day/7d/month 3-6 pulses TERBINAFINE CONTINUOUS 250mg/day TERBINAFINE PULSE 500mg day/7d/month 3-6 pulses FLUCONAZOLE 150-300mg/week Until clinically cured GRISEOFULVIN 500-1000mg Until clinically cured 12-24 weeks Systemic treatment of oral/vulvovaginal/balano-preputial candidiasis DRUG ITRACONAZOLE FLUCONAZOLE KETOCONAZOLE CANDIDIASIS ORAL/VULVOVAGINAL BALANO-PREPUTIAL *Oral: 200mg/day for 5 days *Oral: 150mg single dose *Oral: 200mg/day for 5-10 days 49 5. Antifungal Agents in Development Novel compounds are in various stages of clinical development for the treatment of invasive fungal infections. These new agents have been identified in large-scale, unbiased screens for antifungal activity, as well as in targeted investigations based on detailed studies of fungalspecific cellular processes.  CD101 (Biafungin) (Cidara Therapeutics) o CD101, or biafungin, is a novel echinocandin formulated for both intravenous and topical use. o CD101, or biafungin is similarly effective when compared to anidulafungin and caspofungin against Aspergillus and Candida species in vitro o CD101, or biafungin can be administered with once-weekly intravenous doses, rather than daily doses  SCY-078 (Scynexis) o SCY-078 is a novel _-1,3-glucan synthase inhibitor that is structurally distinct from the currently available echinocandin glucan synthase inhibitors. o SCY-078 is a first-in-class, orally-available _-1,3-glucan synthase inhibitor that has received QIDP designation. o SCY-078 intravenous formulation is also in development. o SCY-078 shows in vitro activity against isolates of Candida and Aspergillus species at MIC or MEC (Minimum Effective Concentration) levels below 0.5 _g/mL  Nikkomycin Z (University of Arizona) o Nikkomycin Z is a competitive inhibitor of chitin synthases, acting to decrease cell wall stability. o Nikkomycin has received Orphan Drug Status for its development as a treatment for coccidioidomycosis. o Nikkomycin clinical development of this drug was terminated due to difficulties in production o Nikkomycin was re-licensed to the University of Arizona, allowing for the reinstitution of clinical development.  T-2307 (Toyama Chemicals, Tokyo, Japan) o T-2307 is a novel arylamidine compound that inhibits fungal growth by interfering with fungal metabolism. o T-2307 specifically collapses fungal mitochondrial membrane potential, which prevents fungi from performing cellular respiration, thus compromising energy production for essential cellular processes o T-2307 has potent in vitro activity against Candida species, Cryptococcus neoformans, Aspergillus species and Fusarium solani, including echinocandinresistant Candida isolates o T-2307 performed as well as micafungin or amphotericin B, but at lower concentrations of compound 51  . Ilicicolin H o Ilicicolin H acts on the mitochondria by specifically inhibiting the activity of the cytochrome bc1 complex. This inhibition of enzymatic activity decreases fungal mitochondrial respiration, preventing the biosynthesis of ATP.  VL-2397 (Vical, San Diego, CA, USA) o VL-2397 represents a new class of antifungal compound that has received QIDP designation for development for treatment of aspergillosis. o VL-2397 exhibits significant in vitro activity against Aspergillus species, Cryptococcus neoformans, Candida glabrata, Candida kefyr and Trichosporon asahii, as well as modest activity against Fusarium solani o VL-2397 is currently in phase 1 clinical trials for the treatment of invasive aspergillosis.  AR-12 (Arno Therapeutics, Flemington, NJ, USA) o AR-12 was initially developed as an anticancer agent in 2006. o AR-12 is a potent inhibitor of the phosphoinositide-dependent kinase PDK1 in humans and induces cell-death promoting endoplasmic reticulum stress, inhibiting proliferative cell growth o AR-12 been granted the European Orphan Drug Designation for the treatment of cryptococcosis.  F901318 (F2G Ltd., Manchester, UK) o F901318 is a member of the novel orotomide class of antifungal drug that is formulated for both intravenous and oral delivery. o F901318 inhibits pyrimidine biosynthesis by blocking dihydroorotate dehydrogenase activity, preventing nucleotide biosynthesis. o F901318 inhibits the growth of Aspergillus species in vitro, with MEC levels below 0.5 g/mL. o F901318 is even effective against azole- and amphotericin B-resistant Aspergillus strains  E1210/1211 o E1210 and E1211 represent the active compound and its pro-drug, respectively, o E1210/1211 are inhibitors of fungal, but not human, glycophosphatidylinositol (GPI) anchor biosynthesis. This cellular process is required for the anchoring of proteins to both the fungal cell wall and cell membrane. The anti-GPI activity of E1210 is achieved through inhibition of the fungal Gwt1 protein, which catalyzes an early step in the creation of the GPI anchor, o E1210/1211 inhibit germ tube formation, as well asbiofilm formation and adherence to plastics in C. albicans, o E1210/1211 increased survival in mouse models of disseminated candidiasis and pulmonary aspergillosis, 51  Sampangine o Sampangine is a copyrine alkaloid natural product which inhibits heme biosynthesis in vivo that leads to defects in all heme-requiring pathways, including cellular respiration and ergosterol biosynthesis o Sampangine has very low MIC values for Cryptococcus neoformans (0.05 _g/mL), and it demonstrates inhibitory activity at concentrations of 3–6 _g/mL for Candida and Aspergillus species New antifungal agents in development. Pianalto and Alspaugh, 2016 Antifungal Compound Indication(s) 1 Activity (MIC) Cryptococcus neoformans 4 µg/mL Candida albicans 4 µg/mL Cryptococcus neoformans 0.25–8 µg/mL Cryptococcus gattii 0.5–2 µg/mL Candida glabrata 0.125– µg/mL Blastomyces dermatitidis 0.5–1 µg/mL Histoplasma capsulatum 0.125–1 µg/mL Pneumocystis jirovecii 0.072–0.912 µg/mL 2 Candidemia 3, * ≤0.008–2 µg/mL 4 Aspergillus species 5 ≤0.008–0.03 µg/mL 4 Aspergillus species 5 ≤0.008–0.25 µg/mL Candida species 6 ≤0.002–0.25 µg/mL Scedosporium species 0.03–0.25 µg/mL Fusarium species 0.015–0.25 µg/mL Aspergillus species 5 <0.03 µg/mL Candida species 7 0.01–5 µg/mL Aspergillus fumigatus 0.08 µg/mL Cryptococcus neoformans 0.2–1.56 µg/mL Coccidioidomycosis * 0.125 µg/mL Cryptococcus neoformans <0.05 µg/mL Candida albicans 3.1 µg/mL AR-12 >32 BHBM CD101 E1210/1211 F901318 Ilicicolin H Nikkomycin Z Sampangine 52 Antifungal Compound SCY-078 Sertraline Indication(s) 1 Activity (MIC) Candida glabrata 3.1 µg/mL Candida krusei 6.2 µg/mL Aspergillus fumigatus 6.2 µg/mL Invasive candidiasis * 0.03–2 µg/mL 8 Aspergillus species 5 0.03–0.25 µg/mL 4 Cryptococcus species * 2–6 µg/mL 4 Candida species 9 0.00025–0.0078 µg/mL Cryptococcus neoformans 0.0039–0.0625 µg/mL Aspergillus species 5,10 0.0156–2 µg/mL 4 Fusarium solani 0.125 µg/mL Mucor racemosus 2 µg/mL Cryptococcus neoformans 64 µg/mL Candida albicans 32 µg/mL Candida glabrata 8 µg/mL Invasive aspergillosis * 1–4 µg/mL 4,9 Candida glabrata ≤2 µg/mL Candida kefyr ≤2 µg/mL Cryptococcus neoformans ≤2 µg/mL Cryptococcal meningitis * <0.0001–0.25 µg/mL 4 Candida species 11 <0.0001–1 µg/mL Coccidioidomycosis NA 12 T-2307 Tamoxifen VL-2397 VT-1129 VT-1598 Antifungal Compound Indication(s) 1 Activity (MIC) AR-12 Cryptococcus neoformans 4 µg/mL Candida albicans BHBM 4 µg/mL Cryptococcus neoformans 0.25–8 µg/mL Cryptococcus gattii 0.5–2 µg/mL Candida glabrata 0.125– µg/mL Blastomyces dermatitidis 0.5–1 µg/mL 53 >32 Antifungal Compound Indication(s) 1 Activity (MIC) Histoplasma capsulatum 0.125–1 µg/mL Pneumocystis jirovecii 0.072–0.912 µg/mL 2 CD101 ≤0.008–2 µg/mL 4 Candidemia 3, * ≤0.008–0.03 µg/mL 4 Aspergillus species 5 E1210/1211 ≤0.008–0.25 µg/mL Aspergillus species 5 Candida species 6 ≤0.002–0.25 µg/mL Scedosporium species 0.03–0.25 µg/mL Fusarium species 0.015–0.25 µg/mL F901318 Aspergillus species 5 <0.03 µg/mL Ilicicolin H Candida species 7 0.01–5 µg/mL Aspergillus fumigatus 0.08 µg/mL Cryptococcus neoformans 0.2–1.56 µg/mL Nikkomycin Z Coccidioidomycosis * 0.125 µg/mL Sampangine Cryptococcus neoformans <0.05 µg/mL Candida albicans 3.1 µg/mL Candida glabrata 3.1 µg/mL Candida krusei 6.2 µg/mL Aspergillus fumigatus 6.2 µg/mL SCY-078 0.03–2 µg/mL 8 Invasive candidiasis * 0.03–0.25 µg/mL 4 Aspergillus species 5 Sertraline Cryptococcus species * 2–6 µg/mL 4 T-2307 Candida species 9 0.00025–0.0078 µg/mL Cryptococcus neoformans 0.0039–0.0625 µg/mL Aspergillus species 5,10 0.0156–2 µg/mL 4 Fusarium solani 0.125 µg/mL Mucor racemosus 2 µg/mL 54 Antifungal Compound Tamoxifen Indication(s) 1 Cryptococcus neoformans Activity (MIC) 64 µg/mL Candida albicans 32 µg/mL Candida glabrata 8 µg/mL VL-2397 1–4 µg/mL 4,9 Invasive aspergillosis * Candida glabrata ≤2 µg/mL Candida kefyr ≤2 µg/mL Cryptococcus neoformans ≤2 µg/mL VT-1129 <0.0001–0.25 µg/mL 4 Cryptococcal meningitis * <0.0001–1 µg/mL Candida species 11 VT-1598 NA 12 Coccidioidomycosis References: 1. 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Comparative topical delivery of antifungal drug croconazole using liposome and micro-emulsion-based gel formulations. Drug Deliv 2014;21:34-43. 12. El Laithy HM, El-Shaboury KM. The development of cutina lipogels and gel microemulsion for topical administration of fluconazole. AAPS PharmSciTech 2002;3:E35. 13. Gupta M, Goyal AK, Paliwal SR, Paliwal R, Mishra N, Vaidya B, et al. Development and characterization of effective topical liposomal system for localized treatment of cutaneous candidiasis. J Liposome Res 2010;20:341-50. 14. Hashem FM, Shaker DS, Ghorab MK, Nasr M, Ismail A. Formulation, characterization, and clinical evaluation of microemulsion containing clotrimazole for topical delivery. AAPS PharmSciTech 2011;12:879-86. 15. Jain S, Jain S, Khare P, Gulbake A, Bansal D, Jain SK. Design and development of solid lipid nanoparticles for topical delivery of an anti-fungal agent. Drug Deliv 2010;17:44351 16. Kassem MA, Esmat S, Bendas ER, El-Komy MH. 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Miconazole nitrate bearing ultraflexible liposomes for the treatment of fungal infection. J Liposome Res 2014;24:163-9. 23. Patel MR, Patel BR, Parikh RJ, Bhatt KK, Solanki BA. Investigating the effect of vehicle on in-vitro skin permeation of ketoconazole applied in O/W micro emulsions. Acta Pharm Sci 2010;52:65-87. 24. Pianalto, Kaila M., and J. Andrew Alspaugh. New Horizons in Antifungal Therapy. J. Fungi 2016, 2, 26; doi:10.3390/jof2040026 25. Sahoo S, Pani NR, Sahoo SK. Microemulsion based topical hydrogel of sertaconazole: Formulation, characterization and evaluation. Colloids Surf B Biointerfaces 2014;120:193-9. 56 26. Patel PR, Patel HH, Baria HA. Formulation and evaluation of carbopol gel containing liposomes of ketoconazole. Int J Drug Deliv Technol 2009;1:42-5. 27. Salerno C, Carlucci AM, Bregni C. Study of in vitro drug release and percutaneous absorption of fluconazole from topical dosage forms. AAPS PharmSciTech 2010;11:98693. 28. Sathali AA, Rajalakhmi G. 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Ethosomes - Novel vesicular carriers for enhanced delivery: Characterization and skin penetration properties. J Control Release 2000;65:403-18. 35. Tsunemi Y1. Oral Antifungal Drugs in the Treatment of Dermatomycosis. Med Mycol J. 2016;57(2):J71-5. 36. Verma ML, Palani S. Development and in-vitro evaluation of liposomal gel of ciclopirox olamine. Int J Pharma Bio Sci 2010;1:1-6. 37. Firthouse PU, Halith SM, Wahab SU, Sirajudin M, Mohideen SK. Formulation and evaluation of miconazole niosomes. Int J PharmTech Res 2011;3:1019-22. 38. Verma P, Pathak K. Nanosized ethanolic vesicles loaded with econazole nitrate for the treatment of deep fungal infections through topical gel formulation. Nanomedicine 2012;8:489-96. 39. Zakir F, Vaidya B, Goyal AK, Malik B, Vyas SP. Development and characterization of oleic acid vesicles for the topical delivery of fluconazole. Drug Deliv 2010;17:238-48 57 6. Antifungal resistance 6.1. Definition, Kanafani et al.. 2008   Microbiological resistance refers to non-susceptibility of a fungus to an antifungal in the laboratory testing Microbiological resistance can be primary (intrinsic) or secondary (acquired). o Primary resistance is found naturally among certain fungi without prior exposure to the drug and emphasizes the importance of identification of fungal species from clinical specimens. Examples include  resistance of Candida krusei to fluconazole  resistance of C. lusitaniae and amphotericin B  resistance of Cryptococcus neoformans to echinocandins.  resistance to all clinically available antifungals e.g., Lomentospora prolificans and Fusarium solani.  resistance to multiple class of available agents (e.g., Candida auris). o Secondary resistance develops among previously susceptible strains after exposure to the antifungal agent and is usually dependent on altered gene expression.  Clinical resistance is defined as the failure to eradicate a fungal infection despite the administration of an antifungal agent with in vitro activity against the organism. Such failures can be attributed to a combination of factors related to the host, the antifungal agent, or the pathogen.  Recent trends in acquired antifungal resistance include: o increased azole resistance among non-Candida albicans isolates, o azoles resistance in Aspergillus fumigatus, o echinocandin resistance in C. glabrata. 6.2. Mechanisms of antifungal resistance Mechanisms of antifungal resistance have been resolved at the molecular level for most antifungal agents and fungal pathogens. In principle, these mechanisms fall into distinct categories, including  decrease of effective drug concentration  drug target alterations  metabolic bypasses. 58 The three basic resistance mechanisms to antifungal drugs. They include (as listed in the text) (1) decrease of effective drug concentration with specific mechanisms including increased drug efflux, increased number of targets, drug sequestration of extracellular and intracellular origins, and poor pro-drug conversion; (2) drug target alterations; and (3) metabolic bypasses. Genome mutations are generally responsible for these three basic principles. Drug sequestration can be mediated by the formation of matrix polymers in biofilms, a state of cells that is not dependent on the occurrence of genome mutations. Wild type proteins are represented by blue circles catalyzing cellular functions; blue-shaded circles represent proteins blocked by drugs in which cellular functions are blocked causing decreased growth or death. Mutant proteins are represented by red circles. Drugs are represented with different symbols. Symbols: WT, wild type; M, mutant . Sanglard, 2016 59 61 6.3. Resistance to various antifungals 1. Polyene resistance        Polyene resistance is rarely acquired; Polyene resistance is mostly primary and thus observed in fungal species that have ergosterol membranes that are not susceptible to or only mildly affected by polyenes. Intrinsic polyene resistance is frequently noted in Candida lusitaniae and Trichosporon beigelii Polyenes can lose their fungicidal activity during prolonged exposure of the fungus to the drug, which leads to reduced efficacy or clinical resistance. Polyene resistance is increasingly encountered in Aspergillus species, such as Aspergillus flavus and even A. fumigatus, which traditionally exhibits the highest susceptibility to amphotericin B Amphotericin B resistance was recently reported among C. krusei and C. glabrata isolates. Polyene resistance mechanisms o Defects in the ERG3 gene involved in erogosterol biosynthesis lead to accumulation of other sterols in the fungal membrance. o Consequently, polyene-resistant Candida and Cryptococcus isolates have relatively low ergosterol content, compared with that of polyene-susceptible isolates. o Resistance to amphotericin B may also be mediated by increased catalase activity, with decreasing susceptibility to oxidative damage. 2. Azoles resistance Candida species Four major mechanisms of resistance to azoles have been described in Candida species: i. Decreased drug concentration.    The development of active efflux pumps results in decreased drug concentrations at the site of action. Efflux pumps are encoded in Candida species by 2 gene families of transporters: o the CDR genes of the ATP-binding cassette super family, o the MDR genes of the major facilitators class. o Up regulation of CDR1, CDR2, and MDR1 has been demonstrated in azole-resistant C. albicans. o CDR gene up-regulation confers resistance to almost all azoles, o MDR-encoded efflux pumps have a narrower spectrum specific for fluconazole. Other transporter genes have been detected in other Candida species, such as CgCDR1 and PDH1 in C. glabrata and CdCDR1 and CdMDR1in Candida dubliniensis. 61 ii. Target site alteration.   Mutations in ERG11, the gene encoding for the target enzyme lanosterol C14αdemethylase, prevents binding of azoles to the enzymatic site Decreased affinity of ERG11p to fluconazole has been reported in intrinsic resistance in C. krusei isolates to the drug iii. Up-regulation of target enzyme.  Target enzyme up-regulation can be achieved through gene amplification, increased transcription rate, or decreased degradation of the gene product. However, this mechanism is thought to contribute little to the overall resistance burden in Candida species, because only modest increases in enzyme levels have been described. iv. Development of bypass pathways    Exposure to azole compounds results in depletion of ergosterol from the fungal membrane and accumulation of the toxic product 14α-methyl-3,6-diol, leading to growth arrest. Mutation of the ERG3 gene prevents the formation of 14α-methyl-3,6-diol from 14αmethylfecosterol. Replacement of ergosterol with the latter product leads to functional membranes and negates the action of azoles on the ergosterol biosynthetic pathway. Aspergillus species       The first mechanism of azole resistance described in Aspergillus species is through reduced intracellular concentration of itraconazole caused by expression of efflux pumps. The second and more prevalent mechanism of azole resistance relies on modification of the 14α-sterol demethylase enzyme, which is encoded by the cyp51A and cyp51B genes. o amino acid substitutions at the M220 position are associated with a resistance phenotype with elevated MICs to all azoles, o amino acid substitutions at G54 result in cross-resistance to itraconazole and posaconazole. The third mechanism of azole resistance in Aspergillus fumigatus is mutations in the promoter region of cyp51A,which lead to overexpression of the protein product. Fluconazole resistance is indeed more common in non-C. albicans species (e.g. C. glabrata, C. parapsilosis, and C. tropicalis). Fluconazole resistance may also mean resistance to other azoles Fluconazole resistance is also highly variable between countries and institutions, with some reporting no azole resistance while others have reported that fluconazolesusceptible, dose-dependent plus resistant isolates may be as high as 50% in intensive care units 62 o In the USA, C. glabrata is the second most common cause of invasive candidiasis, and fluconazole resistance has been reported as high as 12%–18% in some institutions. Beyda et al. (2014) o In India, C. tropicalis is the predominant species, and rates of fluconazole resistance may vary significantly. Chakrabarti et al. (2015) o In China, C. parapsilosis prevalence of approaches that of C. albicans in patients with invasive infections. Guo et al. (2013) . Fluconazole resistance overall and in non-Candida albicans isolates, WHO, 2014 3. Echinocandins resistance  Echinocandin resistance can develop with exposure to the members of this class via point mutations within highly conserved regions (i.e., hot spots 1 and 2) of the FKS1 and FKS2 genes, which encode subunits of the glucan synthase enzyme. o These hot spot regions are conserved across different Candida species, and their detection has been reported in multiple species collected from patients who have experience both microbiologic and clinical failure. o In one study, the clinical failure rate approached 90% in patients who had prior echinocandin exposure and from whom a resistant C. glabrata isolate was isolated. Shieldset al. (2013) o In those whose infections were caused by echinocandin-susceptible isolates but with prior echinocandin exposure, clinical responses were still only ~50%. In addition to a patient‘s history of echinocandin exposure, the type of FKS mutation may also play an important role in response to therapy and the likelihood of failing treatment with an echinocandin. o In vitro studies have demonstrated that point mutations resulting in amino acid changes of serine to proline at codon 629 within Fks1p or codon 663 in Fks2p, as well as phenylalanine to serine at codon 659 in Fks2p in C. glabrata lead to reduced activity of the glucan synthase enzyme,32 which have translated into reduced in vivo efficacy of echinocandin therapy in an animal model of invasive candidiasis. Arendrup et al. (2012) 63 A 10-year profile for antifungal resistance of Candida glabrata isolates to azole and echinocandin drugs. Adapted from Re Alexander BD, et al. Increasing echinocandin resistance in Candida glabrata: clinical failure correlates with presence of FKS mutations and elevated minimum inhibitory concentrations.Perlin, 2015. Clin Infect Dis. 2013;56:1724–1732. 4 (A) Spectrum of Fks amino acid changes conferring clinical resistance. Amino acid sequences of Fks hot-spot sequences for major Candida species and positions associated with prominent resistance (red), weaker resistance (purple) and naturally occurring reduced susceptibility (blue). (B) Topology model for glucan synthase and predicted positions of amino acid substitutions conferring echinocandin resistance. Adapted by Perlin, 2015 from Johnson ME, Edlind TD. Topological and mutational analysis of Saccharomyces cerevisiae Fks1. Eukaryotic Cell. 2012;11:952–960. 64 4. 5-flucytosine resistance       Flucytosine is a base pyrimidine analog that inhibits cellular DNA and RNA synthesis. Flucytosine intrinsic resistance was reported in some yeast strains because of impaired cellular uptake secondary to a mutation in cytosine permease. Flucytosine iacquired resistance results from defects in flucytosine metabolism through mutations in cytosine deaminase or uracil phosphoribosyl transferase. Flucytosine primary resistance prevalence remains low (1%–2% among Candida isolates and <2% among C. neoformans isolates). Acquired resistance results from defects in flucytosine metabolism through mutations in cytosine deaminase or uracil phosphoribosyl transferase. the speed at which these yeasts can develop resistance to flucytosine has prompted clinicians to use flucytosine only in combination with other antifungal agents, mainly amphotericin B. 6.4. Antifungal Resistance from Environmental Origin     Azole antifungal agents are not only widely used in medicine but they also largely contribute to crop protection in agriculture and are used to preserve materials from fungal decay. o A. fumigatus, as a ubiquitous fungus, is likely to come into contact in the environment with the same substance class that is used in medicine. / o A first report on azole resistance from environmental isolates was published in 2007 from the Netherlands (Snelders et al., 2008).  In this study, the authors were able to identify a mutation in the azole target Cyp51A (a L98H substitution), which was associated with a 34-bp tandem repeat (TR34) in the gene promoter.  This mutation results in resistance to all medical azoles (pan-azole resistance). One argument that is crucial to support environmental acquisition of azole resistance is that between 64 and 71% of patients with IA due to an azole-resistant A. fumigatus isolate had never received azole treatment before (van der Linden et al., 2013). There are concerns that azole resistance could become a global public health threat, since fungal spores can disperse easily by circulating air flows across long distances. Currently, environmental resistance is documented in several other European and Asian countries and America. Other Cyp51A mutations than the L98H/TR34 are now also reported from environmental isolates, including TR46/Y121F/T289A, as well as others (G54A and M220I) that were until now exclusively recovered from clinical isolates. 65 The environmental and clinical routes of azole resistance development. (A) The exposure of A. fumigatus to azole compounds in agriculture may create mutations in conidia inducing a resistant phenotype. (B) Azole naive patient becomes ill upon inhalation of airborne resistant and sensitive A. fumigatus strains. (C) The azole naive patient is treated with medical triazoles creating a persistent pressure of azole leading to the selection of resistant strains. (D)Patients infected by inhaling sensitive A. fumigatus molds receive long-term azole therapy. (E) A small proportion of patient who received long-term azole therapy without developing resistant A. fumigatus strains (black arrow). (F) Patients with A. fumigatus resistant strains that have developed through long-term azole therapy (blue arrow) or by the use of azole in agriculture (green arrow). This induces a failure in the management of Aspergillus diseases. Adapted by Berger et al,m 2017 from Verweij et al. (2009). 6.5. Antifungal Resistance from clinical reservoirs, Perlin, 2015       The gastrointestinal tract is a normal commensal site for Candida species, and genotyping confirms that colonizing isolates are often the infecting strain for most patients with invasive disease. Candida colonization of the gastrointestinal tract is associated with a mixed bacterial and fungal biofilm. Drug penetration into the glucan matrix of the biofilm is irregular, and there are varying levels of drug exposure resulting in the emergence of drug-tolerant and fks resistant mutants. In the presence of drug, these resistant cells proliferate and are available to cause systemic infections. The biofilm acts as a reservoir that seeds resistant infections. Another important reservoir involves intra-abdominal candidiasis, which occurs in 40% of patients with repeated gastrointestinal surgery, perforation. or necrotizing pancreatitis. These high-burden infections, along with poor drug penetration, are a critical reservoir that promotes resistance. 66 6.6. Multidrug Resistance (MDR). Sanglard, 2016 Multidrug resistance is the simultaneous resistance to at least two different classes of antifungal agents  Multidrug resistance to several different agents of the same class of antifungals (Perlin et al., 2011). o Specific resistance mechanisms can result in cross-resistance to several drugs of the same class. o Expression of ABC transporters (i.e., CDR1 or CgCDR1) mediate cross-resistance to all azoles used in medicine. o Specific FKS1 mutations in C. albicans (F641S, S645Y) yield cross-resistance to all echinocandins  Multidrug resistance between 2 different classes of antifungals o Multidrug resistance between azoles and Amphotericin B  Multidrug resistance against azoles and Amphotericin B was mediated by different genomic mutations as reported in C. albicans (Vale-Silva et al., 2012) and C. dubliniensis (Pinjon et al., 2003).  Multidrug resistance against azoles and Amphotericin B occurred as a result of other ERG gene defects, such as the loss-of-function mutation in ERG2 observed in C. albicans (Vincent et al., 2013)  Multidrug resistance against azoles and Amphotericin B may result from simultaneous mutations in several genes as a cause of MDR. This was reported in:  C. tropicalis by ERG3/ERG11 loss-of-function mutations (Vincent et al., 2013)  C. albicans by ERG11/ERG5 mutations (Martel et al. 2010). o Multidrug resistance between azoles and echinocandins  A first report of MDR to caspofungin and azoles in C. glabrata isolated from blood cultures was made caspofungin therapy (Chapeland-Leclerc et al., 2010).  Other observations were made recently on MDR with both azoles and echinocandins in C. glabrata. (Farmakiotis et al.,2014)  Multidrug resistance beyond two antifungals classes o Combining resistance for more than two drug classes is not a frequent observation in clinical isolates. o Few cases have emerged recently and highlight the capacity of specific pathogens to adapt to strong antifungal selective pressure. 67 o A recent case illustrated the evolution of multidrug resistance in C. albicans sequential isolates taken from a patient at different sites (oropharynx, esophagus, feces, and colon) treated over time (Jensen et al., 2015).  The evolution of drug resistance followed the course of drug treatments. (Jensen et al., 2015). o Fluconazole treatment induced first a GOF mutation in TAC1 with corresponding azole resistance (MIC fluconazole >16 μg/ml). o Caspo- and anidulafungin treatment resulted in resistance (MIC caspofungin >32 μg/ml) with a corresponding FKS1 mutation (S645P). o Lastly, AmB treatment established AmB resistance (MIC > 32 μg/ml) with a lossof-function mutation in ERG2. All three mutations were conserved in the final multidrug resistant strain. o multidrug resistance evolution took place within a time lapse of 5 years.  The evolution of drug resistance in Camdida lusitaniae infection in a young immunocompromised patient with severe enterocolitis and visceral adenoviral disease (Asner et al., 2015). o C. lusitaniae isolates recovered from blood cultures and stools over a period of 3 months were fully susceptible to Caspofungin. o Caspofungin regimen resulted in detection of resistance (MIC = 4 μg/ml) with a corresponding FKS1 mutation in HS1 (S638Y). o This resistance coincided with AMB resistance, although not administered simultaneously. o The therapy was continued by fluconazole from which resistance rapidly emerged (MIC = 32 μg/ml).  Fluconazole resistance associated with upregulation of a MFS transporter (MFS7), accompanied by 5-FC resistance, without 5-FC being administered. (Asner et al., 2015) o Combination therapy with caspofungin and voriconazole was next attempted, and isolates with simultaneous resistance to caspofungin, fluconazole, and 5-FC were detected. o These isolates exhibited another FKS1 mutation (S631Y) and MFS7 upregulation. o This study highlighted a very dynamic property of C. lusitaniae, which responded quickly to antifungal exposure. In this specific type of abdominal disease, it is believed that a reservoir of fungal cells was present with mixed MDR genotypes, and, depending on the drug treatment regimen, dominant populations could emerge. Multidrug-resistant Candida isolates, Wiederhold, 2017  Resistance to multiple classes of drugs is also a concern in some non-C. albicans species. o In one publication from the SENTRY study, 11% of fluconazole-resistant bloodstream infections were also resistant to an echinocandin. Pfaller et al. (2012) 68 o In a large surveillance study conducted in four large metropolitan areas in the USA, which included over 1300 isolates, a third of the isolates that were nonsusceptible to an echinocandin were also resistant to fluconazole. Vallabhaneni et  al.(2014) Emerging pathogen Candida auris, isolated in 2009 from the external ear canal of a patient o In a recent retrospective review of the clinical history of 54 patients, most had multiple risk factors for invasive disease and candidemia was observed in 61% . o the mortality rate in this series of patients was 59%. Unfortunately, antifungal therapy may be limited, as up to 90% of the isolates may be resistant to fluconazole, and 50% have elevated voriconazole minimum inhibitory concentrations. Lockhart et al. (2017) Multidrug-resistant Aspergillus species   Recent attention has also begun to focus on azole-resistant Aspergillus species, with particular interest in resistant A. fumigatus isolates. Howard et al. (2009) o Resistance to the mould active triazoles, itraconazole, posaconazole, voriconazole, and isavuconazole can develop with prolonged clinical exposure. o This acquired resistance in A. fumigatus is caused by point mutations in the CYP51A gene, which encodes the Cyp51 enzyme responsible for the conversion of lanosterol to ergosterol. o Different mutations can differentially affect the azoles, with some causing resistance to voriconazole and isavuconazole, some causing resistance to posaconazole and itraconazole, and others causing pan-azole resistance. It is now known that environmental exposure to the azoles, which are used in a variety of means, including agriculture, can also lead to the development of azole resistance. o In these isolates, tandem base pair repeats (TR) have been found within the promoter region of this gene in azole-resistant A. fumigatus isolates collected from the environment, in addition to the point mutations within the CYP51A gene. o These include the TR34/L98H, which causes pan-azole resistance, and TR46/Y121F/T289A, which causes reduced posaconazole potency and high-level resistance to voriconazole and posaconazole. van der Linden (2013) o Both of these mutations have been documented in isolates collected from patients with invasive aspergillosis without a history of prior azole exposure and in the environment where azoles or similar demethylase inhibitors are used as fungicides. Verweij et al.(2016) o Isolates harboring these mutations have also been documented in numerous countries around the world. Verweij et al.(2016) o several species within Aspergillus section Fumigati (e.g., Aspergillus lentulus, Aspergillus felis, Aspergillus parafelis, Aspergillus pseudofelis, Aspergillus pseudoviridinutans, Aspergillus udagawae), as well as other Aspergillus species in different sections (e.g., Aspergillus calidoustus, Aspergillus flavus, Aspergillus sydowii, Aspergillus terreus, Aspergillus versicolor) may have reduced or variable susceptibility to the azoles as well as other antifungals. Sugui et al. (2014) 69 References: 1. Asner SA, Giulieri S, Diezi M, Marchetti O, Sanglard D. Acquired multidrug antifungal resistance in Candida lusitaniae during therapy. Antimicrob Agents Chemother (2015) 5910.1128/AAC.022042. Arendrup MC, Perlin DS, Jensen RH, Howard SJ, Goodwin J, Hope W. Differential in vivo activities of anidulafungin, caspofungin, and micafungin against Candida glabrata isolates with and without FKS resistance mutations. Antimicrob Agents Chemother. 2012;56(5):2435–2442. 3. Berger , Sarah †, Yassine El Chazli†, Ambrin F. Babu† and Alix T. Coste* Azole Resistance in Aspergillus fumigatus: A Consequence of Antifungal Use in Agriculture? Front. Microbiol., 07 June 2017 | https://doi.org/10.3389/fmicb.2017.01024 4. Beyda ND, John J, Kilic A, Alam MJ, Lasco TM, Garey KW. FKS mutant Candida glabrata: risk factors and outcomes in patients with candidemia. Clin Infect Dis. 2014;59(6):819–825. 5. Chakrabarti A, Sood P, Rudramurthy SM, et al. Incidence, characteristics and outcome of ICU-acquired candidemia in India. Intensive Care Med. 2015;41(2):285–295. 6. Chapeland-Leclerc F, Hennequin C, Papon N, Noël T, Girard A, Socié G, et al. Acquisition of flucytosine, azole, and caspofungin resistance in Candida glabrata bloodstream isolates serially obtained from a hematopoietic stem cell transplant recipient. Antimicrob Agents Chemother (2010) 54:1360–2.10.1128/AAC.01138-09 7. Farmakiotis D, Tarrand JJ, Kontoyiannis DP. 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Juliana Alves Parente-Rocha, Alexandre Melo Bailão, André Correa Amaral, et al., ―Antifungal Resistance, Metabolic Routes as Drug Targets, and New Antifungal Agents: An Overview about Endemic Dimorphic Fungi,‖ Mediators of Inflammation, vol. 2017, Article ID 9870679, 16 pages, 2017. doi:10.1155/2017/9870679 12. Kanafani, Zeina A., John R. Perfect; Resistance to Antifungal Agents: Mechanisms and Clinical Impact, Clinical Infectious Diseases, Volume 46, Issue 1, 1 January 2008, Pages 120–128, https://doi.org/10.1086/524071 13. LA, Coste AT, Ischer F, Parker JE, Kelly SL, Pinto E, et al. Azole resistance by loss of function of the sterol δ5,6-desaturase gene (ERG3) in Candida albicans does not necessarily decrease virulence. Antimicrob Agents Chem. (2012) 56:1960– 14. Lockhart SR, Etienne KA, Vallabhaneni S, et al. Simultaneous emergence of multidrugresistant Candida aurison 3 continents confirmed by whole-genome sequencing and epidemiological analyzes. Clin Infect Dis. 2017;64(2):134–140. 15. Martel CM, Parker JE, Bader O, Weig M, Gross U, Warrilow AGS, et al. A clinical isolate of Candida albicans with mutations in ERG11 (encoding sterol 14alpha71 demethylase) and ERG5 (encoding C22 desaturase) is cross resistant to azoles and amphotericin B. Antimicrob Agents Chemother (2010) 54:3578–83. 16. Pfaller MA, Castanheira M, Lockhart SR, Ahlquist AM, Messer SA, Jones RN. Frequency of decreased susceptibility and resistance to echinocandins among fluconazole-resistant bloodstream isolates of Candida glabrata. J Clin Microbiol. 2012;50(4):1199–1203 17. Perlin DS. Current perspectives on echinocandin class drugs. Future Microbiol (2011) 6:441–57.10.2217/fmb.11.19 18. Perlin DS. Mechanisms of echinocandin antifungal drug resistance. Ann N Y Acad Sci. 2015 September; 1354(1): 1–11 19. Perlin DS1, Rautemaa-Richardson R2, Alastruey-Izquierdo A. The global problem of antifungal resistance: prevalence, mechanisms, and management. Lancet Infect Dis. 2017 Jul 31. pii: S1473-3099(17)30316-X. 20. Pinjon E, Moran GP, Jackson CJ, Kelly SL, Sanglard D, Coleman DC, et al.Molecular mechanisms of itraconazole resistance in Candida dubliniensis. Antimicrob Agents Chemother (2003) 47:2424–37.10.1128/aac.47.8.2424-2437.2003 21. Sanglard D. Emerging Threats in Antifungal-Resistant Fungal Pathogens. Frontiers in Medicine. 2016;3:11. doi:10.3389/fmed.2016.00011. 22. Shields RK, Nguyen MH, Press EG, Updike CL, Clancy CJ. Anidulafungin and micafungin MIC breakpoints are superior to that of caspofungin for identifying FKS mutant Candida glabrata strains and Echinocandin resistance. Antimicrob Agents Chemother. 2013;57(12):6361–6365. 23. Snelders E, van der Lee HAL, Kuijpers J, Rijs AJMM, Varnga J, Samson RA, et al. Emergence of azole resistance in Aspergillus fumigatus and spread of a sigle resistance mechanism. PLoS Med (2008) 5:e219.10.1371/journal.pmed.0050219 24. Sugui JA, Peterson SW, Figat A, et al. Genetic relatedness versus biological compatibility between Aspergillusfumigatus and related species. J Clin Microbiol. 2014;52(10):3707–3721 25. Vallabhaneni S, Cleveland AA, Farley MM, et al. Epidemiology and risk factors for echinocandin nonsusceptible Candida glabrata bloodstream infections: data from a large multisite population-based candidemia surveillance program, 2008–2014. Open Forum Infect Dis. 2015;2(4):ofv163. 26. van der Linden JWM, Camps SMT, Kampinga GA, Arends JPA, Debets-Ossenkopp YJ, Haas PJA, et al. Aspergillosis due to voriconazole highly resistant Aspergillus fumigatus and recovery of genetically related resistant isolates from domiciles. Clin Infect Dis (2013) 57:513–20.10.1093/cid/cit320 27. Verweij PE, Chowdhary A, Melchers WJ, Meis JF. Azole resistance in Aspergillus fumigatus: can we retain the clinical use of mold-active antifungal azoles? Clin Infect Dis. 2016;62(3):362–368. 28. Vincent BM, Lancaster AK, Scherz-Shouval R, Whitesell L, Lindquist S. Fitness tradeoffs restrict the evolution of resistance to amphotericin B. PLoS Biol (2013) 11:e1001692.10.1371/journal.pbio.1001692. 29. Wiederhold NP. Antifungal resistance: current trends and future strategies to combat, Infection and Drug Resistance, August 2017, 10, 249-259 30. World Health Organization. Antimicrobial Resistance: Global Report on Surveillance. Available from: http://www.who.int/drugresistance/documents/surveillancereport/en/ 71 7. Description of antifungals 7.1. Polyene antifungals         Polyene antifungals, sometimes referred to as polyene antibiotics, are a class of antimicrobial polyene compounds that target fungi. Polyene antifungals are typically obtained from some species of Streptomyces bacteria. Polyene antifungals bind to ergosterol in the fungal cell membrane and thus weakens it, causing leakage of K+ and Na+ ions, which may contribute to fungal cell death. Polyene antifungals examples:Amphotericin B, nystatin, and natamycin Polyene antifungals are a subgroup of macrolides. The antifungal agents nystatin (1954), amphotericin B (1958), natamycin (1958), and mepartrican (1975) represent a fraction of the over 200 polyene macrolide antibiotics produced by the soil actinomycete Streptomyces. Polyene antifungals are characterised by a rigid non-polar cyclic ring with multiple conjugated bonds that are linked to a polar side chain comprising a large number of hydroxy groups and an amino sugar mycosamine. These structural characteristics are responsible for the amphipathic nature of polyene compounds and their chemical instability.  Polyenes primarily act by binding membrane ergosterol and forming pores in the plasma membrane which is similar to the proposed mode of action for antimicrobial peptides  Amphotericin B is the only polyene macrolide antifungal that has been successfully developed into a systemic antifungal agent for the treatment of invasive aspergillosis (IA). Structures   Polyene antifungals chemical structures feature a large ring of atoms (in essence, a cyclic ester ring) containing multiple conjugated carbon-carbon double bonds (hence polyene) on one side of the ring and multiple hydroxyl groups bonded to the other side of the ring. Polyene antifungals structures also often have a d-mycosamine (a type of aminoglycoside) group bonded to the molecule. 72 1. Griseofulvin   Griseofulvin is an antifungal antibiotyic produced by several Penicillium species, namely P. aethiopicum, P. coprophilum , P. dipodomyicola , P. griseofulvum, P. persicinum and P. sclerotigenum. Griseofulvin is fungistatic and acts only against dermatophytes. History of griseofulvin discovery          1939, Oxfordd, Raistrick and Simonart isolated a metabolic product of Penicillium griseofulvum. 1946, Brian Curtis and Hemming isolated an antibiotic from Penicillium janczewskii, which they called ―curling factor‖ 1947, Grove and McGowan showed the curling factor was identical with griseofulvin 1949, Brian showed griseofulvin to be fungistatic to most mycelial fungi 1951, Brian, Wright, Stubbs and Way demonstrated systemic antifungal activity in plants 1957-1958, Williams and Peterkin reported that griseofulvin failed when applied topically to ringworm lesions 1958, Tomich proved that griseofulvin showed a remarkable absence of acute toxicity, when administered orally to animals, even in very high dosage 1958, James C. Gentles showed in a prelilinary report that oral griseofulvin rapidly cleared artificially induced ringworm in guinea-pigs 1959, Gustav Riehl in Vienna treated the first human case of ringworm by griseofulvin orally 73 P.W. Brian James Clark Gentles Gustav Riehl Morphology of Griseofulvin-producing Penicillium species Spectrum of activity  Amphotericin B continues to exhibit very good in vitro activity against a broad spectrum of clinically relevant fungal isolates, including most strains 74    of Candida spp., Aspergillus spp., and most other filamentous fungi, such as the Mucorales. Antifungal resistance has been demonstrated very infrequently, Some species demonstrate intrinsic resistance to amphotericin B, including Aspergillus terreus, Fusarium spp. , Scedosporium spp., and Trichosporon asahii, Some species exhibit phenotypic switching to amphotericin-resistant isolates when exposed to drug pressure, as seen with Candida lusitaniae. Mechanism of Action, Russell E. Lewis. 2010       The initial steps of AMB activity involve the irreversible binding of the drug to ergosterol in the fungal cell plasma membrane. Binding to ergosterol results in the formation of a transmembrane pore comprised of 8– 10 AMB molecules that allow leakage of monovalent cations, membrane depolarisation and disorganisation, intracellular acidification, and precipitation of cytoplasmic components leading to cell death. The selectivity of AMB for the fungal cell membrane versus mammalian membrane can be explained, in part, by the greater affinity of ergosterol versus cholesterol for forming Van der Waals-type bonds with the rigid cyclic heptane backbone of polyenes. AMB does retain some affinity for cholesterol – a property that plays an important role in the cellular toxicity and nephrotoxicity if the molecule in mammalian hosts. AMB also inhibits exogenous and endogenous respiration in Aspergillus fumigatus by mechanisms independent of fungal cell membrane sterol interactions. There is also evidence to suggest that AMB-mediated killing may be due in part to its oxidative properties that result in the generation of reactive oxygen intermediates and peroxidation of lipids in fungal cell membrane.  In vitro, amphotericin B demonstrates concentration-dependent killing against a wide range of fungi. Consequently, fungicidal activity could potentially be maximized by administering large doses of the drug in an effort to optimize the Cmax/minimum inhibitory concentration (MIC) ratio; unfortunately, dose-related toxicities of amphotericin B make this strategy impractica Lipid-formulated amphotericin B preparations  The amphipathic characteristics of amphotericin B made it possible to formulate the drug into lipid carriers for intravenous infusion without the bile salt deoxycholate. Three such formulations are currently marketed: o amphotericin B lipid complex (AbelcetR , ABLC); o amphotericin B colloidal dispersion (AmphotecR , AmphocilR , ABCD), and a o amphotericin B liposomal (AmbisomeR ; L-AMB).  All three formulations have two important advantages over conventional d-AMB formulation: o the ability to administer higher daily dosages of drug; o reduced or delayed nephrotoxicity. 75  Consequently, the lipid formulations of AMB are the preferred formulations for the treatment of invasive aspergillosis. 1. Amphotericin B Lipid Complex  ABLC (Abelcet®; The Liposome Company, Princeton, NJ, USA) received initial approval in the UK in April 1995 and was the first lipid-based formulation approved by the FDA in the USA, in December 1995.  ABLC consists of amphotericin B complexed with two lipids—L-α-dimyristoyl phosphatidylcholine (DMPC) and L-α-dimyristoyl phosphatidylglycerol (DMPG); DMPC and DMPG are present in a 7:3 molar ratio with an approximate 1:1 drug to lipid ratio.  ABLC appears as a very large ribbon-like structure with a diameter in the 1.6–11 μm range.  ABLC-DMPG component predominately distributes into HDLs because of its interaction with the protein components, apolipoproteins A1 and AII, of the HDL particle.  ABLC is a relatively large compound, the largest of the lipid preparations, such that following infusion, it is recognized in blood by macrophages and is taken up rapidly in significant quantities and becomes sequestered in tissues of the mononuclear phagocyte system (e.g., liver and spleen).  Consequently, compared with amphotericin B, it has lower circulating amphotericin B serum concentrations, reflected in a marked increase in V d and clearance.  The very large Vd and correspondingly low AUC indicate rapid and extensive tissue distribution, predominately to the liver, spleen, lungs, and, to a much lesser extent, the heart, kidneys, and brain.  Lung levels are considerably higher than those achieved with other lipid-associated preparations.  The prolonged serum half-life is likely due to slow distribution from these tissues.  it is also postulated that the enhanced therapeutic index of ABLC relative to amphotericin B is due, in part, to the relative stability of the complexes in serum along with selective release of active amphotericin B at sites of phospholipases released from activated host cells such as phagocytic cells, vascular smooth muscle cells, or capillary endothelial cells or by the fungus itself.  This postulated mechanism suggests that amphotericin B is then free to complex with the ergosterol of the fungal cell membranes to damage the organism specifically at the site of infection, rather than being released by degradation of the complex in the bloodstream, where it is more capable of contributing to toxicity.  In vitro, unlike amphotericin B deoxycholate, ABLC fails to stimulate proinflammatory signaling molecules TLR-2 and CD14, and either down-regulates or has no effect on macrophage pro-inflammatory cytokine gene expression. Despite these in vitro findings, comparative clinical trials have not unequivocally demonstrated a decreased frequency of infusion-related reactions observed with this product. 76 2. Amphotericin B Colloidal Dispersion ( ABCD)  ABCD was previously marketed as both Amphocil ® and Amphotec® and was initially approved in the UK in 1994 and by the FDA in the USA in December 1996. Rights to the drug were recently acquired by Alkopharma Pharmaceuticals (Martigny, Switzerland).  ABCD consists of a 1:1 molar ratio of amphotericin B and cholesteryl sulfate, a naturally occurring metabolite of cholesterol, in a highly organized structure. Two molecules of amphotericin B bind to two molecules of cholesteryl sulfate, forming a tetramer that has both a hydrophilic and a hydrophobic portion. These tetramers aggregate into spiral arms that form a disk-type structure with a diameter of approximately 122 nm and a thickness of 4 nm.  ABCD complexes, after intravenous infusion, remain largely intact and are rapidly removed from the circulation by cells of the macrophage phagocyte system, predominately by Kupfer cells of the liver, and to a lesser extent in the spleen and bone marrow. As a result, less drug is available to bind to circulating LDLs and, consequently, less is delivered to the kidney.  On a milligram-to-milligram basis, the Cmax achieved is lower than that attained by conventional amphotericin B, although the larger doses of ABCD that are administered produce an absolute level that is similar to amphotericin B.  ABCD exhibits a general, similar trend of inflammatory gene up-regulation as that seen with conventional amphotericin B deoxycholate, resulting in increases in IL-1β, IL-1ra, MCP-1, MIP-1β, and TNFα.  These in vitro observations are reflected in clinical manifestations of a similar or higher frequency of infusion-related reactions with ABCD compared with amphotericin B deoxycholate. o In phase I and II studies, infusion-related phenomena were frequent with ABCD. o Patients receiving >4 mg/kg/day had more infusion-related reactions than those receiving ≤4 mg/kg/day.  In a dose-ranging, phase I study, an increase in the daily dose to 8 mg/kg/day led to an unacceptable level of cardiovascular toxicity with hypotension.  a dose of ABCD of 7.5 mg/kg/day is considered the maximum tolerated daily dose.  this high rate of infusion-related events led to premature discontinuation of a study comparing ABCD to fluconazole for prophylaxis of fungal infections in neutropenic patients. 77  Those subjects who received a dosage of 4 mg/kg/day experienced high fevers, hypotension, dyspnea, and tachypnea. 3. Amphotericin B Liposomal L-AmB (AmBisome®; Astellas Pharma USA, Inc. Deerfield, IL, USA) received initial approval in Ireland in 1989, but did not receive FDA approval in the USA until August 1997.               It is a small unilamellar vesicle formulation, the only true liposomal preparation, and is supplied as a lyophilized powder which must be reconstituted before intravenous infusion. The liposome consists of hydrogenated soy phosphatidylcholine:cholesterol:distearoyl phosphatidylglycerol (DSPG):amphotericin B in a 2:1:0.8:1 ratio. Amphotericin B is tightly bound to the liposome through charge pairing between the amino group of the amphotericin B and the phosphate group of DSPG, with further strengthening through the interaction of the stearyl residues of the DSPG and polyene portion of the macrolide ring of amphotericin B. The multimeric barrel-pore arrangement of amphotericin B in fungal membranes is thought to be replicated in the L-AmB formulation. Each group of eight amphotericin B molecules is complexed with DSPG and cholesterol of the liposome similar to the interaction with ergosterol of the fungi [35]. Addition of cholesterol to the liposome stabilizes it against HDL destruction; consequently, <5 % of amphotericin B dissociates from the liposome during a 72-h incubation with serum. Using sulphorhodamine-labeled liposomes, it has been demonstrated that L-AmB accumulates at sites of fungal infections in tissues. Gold-labeled liposomal lipid has been shown to bind to fungal membranes and penetrate into the fungal cytoplasm, suggesting that these liposomal complexes break down and release drug after contact with fungi. Because of its small size and negative charge, the vesicle avoids substantial recognition and uptake by the mononuclear phagocyte system. Therefore, a single dose of L-AmB results in a much higher C max than conventional amphotericin B deoxycholate and a much larger AUC. L-AmB demonstrates a similar triphasic plasma profile as amphotericin B with a very long terminal half-life of approximately 152 h. Unlike amphotericin B, less than 10 % of infused drug is excreted in the urine and feces after 1 week. Total recovery of L-AmB is only 24 % compared with 93.4 % of amphotericin B; it is suspected that the drug is sequestered in deep or protected tissue compartments such as macrophages. In a published dose-finding study, there was no demonstrable dose-limiting nephrotoxicity or infusion-related toxicity over a dosage range of 7.5–15.0 mg/kg/day. 78 o There was a distinctly non-linear profile of plasma pharmacokinetics over the range of 7.5–15.0 mg/kg/day. Cmax and AUC did not increase above doses of 10 mg/kg/day. o Tissue concentrations in patients receiving L-AmB tend to be highest in the liver and spleen and much lower in kidneys and lung.  In a rabbit model of hematogenous Candida albicans meningoencephalitis using standard dosages of amphotericin B deoxycholate and the various lipid amphotericin B preparations, o significantly higher brain tissue concentrations were attained with L-AmB compared with the other lipid formulations or amphotericin B deoxycholate. o these higher levels resulted in significantly decreased fungal burden in the brain, supporting the role of this preparation as a preferred agent for treatment of invasive CNS fungal infections.  The small size and negative charge of the liposomes in L-AmB divert the normal macrophage response from pro-inflammatory to an anti-inflammatory cytokine profile by shifting from a TLR-2 to a TLR-4 type response, resulting in a decrease in the upregulation of pro-inflammatory cytokines and attenuation of the infusion-related reactions. Clinical Pharmacology, https://www.accessdata.fda.gov/drugsatfda_docs/label/2014/062279s022lbl.pdf  Griseofulvin absorption from the gastrointestinal tract varies considerably among individuals mainly because of insolubility of the drug in aqueous media of the upper GI tract.  Griseofulvin absorption has been estimated to range between 27 and 72%.  Griseofulvin, after an oral dose, is primarily absorbed from the duodenum with some absorption occurring from the jejunum and ileum.  Griseofulvin peak serum level in fasting adults given 0.5 g occurs at about four hours and ranges between 0.5 to 2 mcg/mL.  Griseofulvin serum level may be increased by giving the drug with a meal with a high fat content. o In one study in pediatric patients 19 months to 11 years of age, 10 mg/kg of Griseofulvin microsize given with milk resulted in mean peak serum concentrations approximately four-fold greater than the same Griseofulvin dose given alone (1.29 mcg/mL versus 0.34 mcg/mL, respectively). o The area under the curve value was ten-fold larger when 10 mg/kg Griseofulvin and milk were administered simultaneously as compared to the same dosage given to fasting patients. o Griseofulvin administered with milk resulted in more consistently detected serum levels across subjects.  Following oral administration, Griseofulvin is deposited in the keratin precursor cells and has a greater affinity for diseased tissue.  Griseofulvin is tightly bound to the new keratin which becomes highly resistant to fungal invasions. 79    Griseofulvin concentrations in the skin decline less rapidly than those in plasma, when the drug is discontinued. Griseofulvin is metabolized by the liver to 6-desmethylGriseofulvin and its glucuronide conjugate. Griseofulvin has a variable elimination half-life in plasma (9 to 24 hours). o Approximately 30% of a single oral dose of Griseofulvin is excreted in the urine within 24 hours and about 50% of the dose is excreted in the urine within 5 days, mostly in the form of metabolites. o Unchanged Griseofulvin in the urine accounts for less than 1% of the administered dose. In addition, approximately one-third of a single dose of Griseofulvin is excreted in feces within 5 days. o Griseofulvin is also excreted in perspiration. Amphotericin B-Associated Toxicity  The major factor limiting the use of amphotericin B deoxycholate is toxicity, which is manifested as acute infusion-related reactions and dose-related nephrotoxicity.  In fact, the dose-related toxicity of amphotericin B usually limits the maximal tolerated dose to 0.7–1.0 mg/kg/day, a dosage that may be suboptimal for clinical success against invasive fungi in compromised hosts.  Infusion-related toxicities associated with amphotericin B include fever and chills, rigors, arthralgias, nausea, vomiting and headaches.  Because amphotericin B is a microbial product, it is recognized by Toll-like receptor (TLR) 2 and the transmembrane signaling protein CD14 on the surface of mononuclear cells. o Through intracellular signaling pathways that include the adapter protein MyD88 and nuclear factor κB, amphotericin B induces the expression of proinflammatory cytokine genes, including interleukin (IL)-1β, tumor necrosis factor (TNF)-α, IL-6, IL-1ra and the chemokines IL-8, monocyte chemotactic protein (MCP)-1, and macrophage inflammatory protein (MIP)-1β, which are thought to be the principal causes of the acute infusion-related toxicities associated with amphotericin B. o Amphotericin B deoxycholate-induced synthesis of IL-1β occurs between 2 and 6 h, similar to the clinically observed time interval noted in actual patients who are receiving the drug and experiencing infusion-related events.  A number of pre-treatment regimens, including non-steroidal anti-inflammatory agents, antihistamines, meperidine, and corticosteroids, have been administered in an attempt to ameliorate these reactions; however, the actual benefits of most of these maneuvers are uncertain.  Following infusion of amphotericin B, there is a rapid vasoconstrictive effect on the afferent renal arterioles, causing a decrease in renal blood flow and a decrease in the glomerular filtration rate.  Furthermore, although amphotericin B has a tenfold greater affinity for binding to the fungal ergosterol (Kd = 6.9 × 105) than to the cholesterol of the mammalian cell membranes (Kd = 5.2 × 104), non-selective disruption of mammalian cells does occur [. 81   It is likely that the basis for most of the renal toxicity regularly associated with amphotericin B results from a higher relative exposure of the drug to renal cells Renal tubular cell uptake of amphotericin B is thought to result from LDL receptormediated endocytosis of the serum LDL-amphotericin B complexes, due to a relative abundance of LDL receptors on renal tubular cells and paucity of HDL receptors Formulations/Preparations  Griseofulvin Oral Suspension USP is available as a pink to orange colored, tutti-frutti flavored, uniform suspension containing 125 mg/5 mL Griseofulvin, USP (microsize) in a 4 ounce (120 mL) bottle. Brand names 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. griseofulvin (+)-Griseofulvin 126-07-8 Amudane Fulvicin Grisactin Grisovin Griseofulvinum Grifulvin Grisefuline Spirofulvin Fulcin Lamoryl Likuden Poncyl Griseofulvina Griseofulvine Grisofulvin Grizeofulvin Grysio Curling factor Delmofulvina Griscofulvin Fulvinil Fulvistatin Fungivin Gresfeed Grifulin Griseomix Grisetin 31. 32. 33. 34. 35. 36. 37. 38. 41. 42. 43. 44. 45. 46. 47. 48. 51. 52. 53. 54. 55. 56. 57. 58. 59. Fulcine Fulvicin Pg Tab 330mg Fulvina Fulvicin Uf Tab 500mg Greosin Griseofulviin (microsize) Grisactin Ultra Grisovin Fp Tab 125mg Biogrisin-FP Grisovin Fp Tab 250mg Neo-Fulcin Grisovin Fp Tab 500mg Fulvican grisactin Grisovin-FP 125mg Tab Griseofulvin forte Grisovin-FP 250mg Tab Griseofulvin-forte Ultramicrosize Griseofulvin Fulvicin P/G Fulvicin U/f Tab 250mg Fulvicin-P/G Griseofulvin (JAN/USP/INN) Fulvicin-U/F GRISEOFULVIN, Grifulvin V ULTRAMICROSIZE Gris-PEG Xuanjing Gricin GRISEOFULVIN, MICROSIZE Griseo Griseostatin Griseofulvine [INN-French] Likunden Griseofulvina [INN-Spanish] Sporostatin xan GRISEOFULVIN, MICROCRYSTALLINE Grisovin FP Caswell No. 471B Spiro(benzofuran ULTRAGRIS-165 91. grisefulin ULTRAGRIS-330 92. Crivicin UNII-32HRV3E3D5 93. fulvicin UF FULVICIN P/G 165 94. S-Fulvin FULVICIN P/G 330 Grisactin V (TN) C17H17ClO6 Gris-peg (TN) CCRIS 320 Grison-250 GRISEOFULVIN, 39. Guservin ULTRAMICROCRYSTALLINE Murfulvin HSDB 1722 81 Recent reports: Anusha and Sangeetha (2016) carried out a study in production of griseofulvin from marine fungus Penicillium fellutanum using three different media (semisolid medium, potato dextrose agar medium and minimal medium) for maximum production of Griseofulvin. TLC and FT-IR techniques were carried out for determination of Griseofulvin from crude extracts. Among these media were tested semi solid media exhibited more biomass (2.36g/ 100ml) and ethanolic extract of griseofulvin (86 mg/ 100 ml) production when compared other two different media. Potato dextrose agar also produced satisfactory amount of biomass (1.88 g/100ml) but not in a griseofulvin (32 mg/100 ml) production. In case of minimal medium exhibited least biomass (1.52 g/100ml) but high rate of griseofulvin production (56mg/100ml). Marcos et al. (2016) evaluated the effects of αCD concentration (0-10%w/w) on the phase behavior of aqueous dispersions of Pluronic(®) P123 (14%w/w) mixed with HEC (2%w/w) at 4, 20 and 37°C. The cooperative effects of the inclusion complex formation between poly(ethylene oxide) (PEO) blocks and HEC with αCD prevented phase separation and led to supramolecular 82 networks that solubilize the antifungal drug. Rheological and bioadhesive properties of gels with and without griseofulvin could be easily tuned modulating the polymers proportions. Supramolecular gels underwent sol-gel transition at lower temperature than P123 solely dispersions and enabled drug sustained release for at least three weeks. All gels demonstrated good biocompatibility in the HET-CAM test. Furthermore, the drug-loaded gels showed activity against Trichophyton rubrum and Trichophyton mentagrophytes and thus may be useful for the treatment of tinea capitis and other cutaneous fungal infections. Marto et al. (2016) prepared a new GRF formulation for topical application using lipid-based nanosystems; to study its permeation and penetration, cell viability and to evaluate its therapeutic action. Ethosomal systems composed of soy bean phosphatidylcholine, ethanol and water were prepared for incorporating GRF. After the characterization of the vesicles in terms of size, charge and penetrability, permeation through newborn pig using Franz diffusion cells was conducted. Cell viability at different concentrations of the chosen formulation was determined. At last, skin adapted agar diffusion test was performed to assess the therapeutic efficacy of the formulation. GRF vesicles had mean size of 130nm. Permeation and penetration assays revealed that GRFloaded ethosomes have an adequate profile to be used in a topical formulation since drug retention in the stratum corneum was achieved. Cell viability tests proved this formulation presented no cytotoxicity to HaCaT cells for concentrations below 50μg/mL. The skin diffusion test evidenced the potential of developed formulation to target skin dermatophytes. Petersen et al. (2016) reported two types of modifications to the natural product griseofulvin as strategies to improve solubility and metabolic stability: the conversion of aryl methyl ethers into aryl difluoromethyl ethers at metabolic hotspots and the conversion of the C-ring ketone into polar oximes. The syntheses of the analogues are described together with their solubility, metabolic half-life in vitro and antiproliferative effect in two cancer cell lines. We conclude that on balance, the formation of polar oximes is the most promising strategy for improving the properties of the analogues. Rydberg et al. (2016) explored the use of the poly(ethylene glycol) (PEG) conjugated phospholipids DSPE-PEG2000 and DSPE-PEG5000 as stabilizers of felodipine and griseofulvin nanocrystals. Nanocrystal stability and physicochemical properties were examined and the interaction between the PEGylated lipids and the nanocrystal surface as well as a macroscopic model surface was investigated. Using quartz crystal microbalance with dissipation monitoring both mass adsorption and the thickness of the adsorbed layer were estimated. The results indicate that the PEGylated lipids are adsorbed as flat layers of around 1-3nm, and that DSPE-PEG5000 forms a thicker layer compared with DSPE-PEG2000. In addition, the mass adsorption to the drug crystals and the model surface are seemingly comparable. Furthermore, both DSPEPEG2000 and DSPE-PEG5000 rendered stable drug nanocrystals, with a somewhat higher surface binding and stability seen for DSPE-PEG2000. These results suggest DSPE-PEG2000 and DSPE-PEG5000 as efficient nanocrystal stabilizers, with DSPE-PEG2000 giving a somewhat higher surface coverage and superior colloidal stability, whereas DSPE-PEG5000 shows a more extended structure that may have advantages for prolongation of circulation time in vivo and facilitation for targeting modifications. Roine et al. (2015) encapsulated a poorly water-soluble model drug, griseofulvin, as disordered solid dispersions into Eudragit L 100-55 enteric polymer micromatrix particles, which were produced by electrospraying. Similar micromatrix particles were also produced with griseofulvin-loaded thermally oxidized mesoporous silicon (TOPSi) nanoparticles dispersed 83 to the polymer micromatrices. The in vitro drug dissolution at pH 1.2 and 6.8, and permeation at pH 7.4 across Caco-2/HT29 cell monolayers from the micromatrix particles, were investigated. The micromatrix particles were found to be gastro-resistant, while at pH 6.8 the griseofulvin was released very rapidly in a fast-dissolving form. Compared to free griseofulvin, the permeability of encapsulated griseofulvin across the intestinal cell monolayers was greatly improved, particularly for the TOPSi-doped micromatrix particles. The griseofulvin solid dispersions were stable during storage for 6 months at accelerated conditions. Shemer et al. (2015) evaluated the efficacy of griseofulvin and fluconazole in reducing the potential for person-to-person transmission of tinea capitis (TC) in children. Children with TC with positive fungal cultures were treated with griseofulvin 25 mg/kg/day (group A) or fluconazole 6 mg/kg/day (group B) for at least 21 days and up to 12 weeks until cure was achieved. Clinical and mycologic examinations occurred before treatment and on days 3, 7, 10, 14, and 21 of treatment. During each visit, mycologic examination was performed from scalp lesions of children and fingertips of medical staff and parents after a brief touch of the patient's scalp lesions. Ninety patients were enrolled: 48 treated with griseofulvin and 42 with fluconazole. The predominant species were Trichophyton violaceum (n = 44) and Microsporum canis (n = 41), followed by Trichophyton mentagrophytes (n = 3) and Trichophyton rubrum (n = 2). Ten days after treatment more than 75% of patients from both treatment groups were noncontagious. At day 21, all patients from group A were noncontagious and two (7%) with positive culture of M. canis from group B were still contagious. CONCLUSIONS: No statistically significant differences were found between treatment groups. Griseofulvin and fluconazole reduced the potential for disease transmission in children with TC, with griseofulvin being more effective for M. canis infections, although children with TC may be potentially contagious even after up to 3 weeks of treatment. Aggarwal et al. (2013) developed a microemulsion (ME) formulation of griseofulvin for the treatment of dermatophytosis (Indian Patent Application 208/DEL/2009). The oil phase was selected on the basis of drug solubility whereas the surfactant and cosurfactant were screened on the basis of their oil solubilizing capacity as well as their efficiency to form ME from pseudoternary phase diagrams. The influence of surfactant and cosurfactant mass ratio (Smix) on the ME formation and its permeation through male Laca mice skin was studied. The optimized formulation (ME V) consisting of 0.2% (w/w) griseofulvin, 5% (w/w) oleic acid, 40% (w/w) Smix (1:1, Tween 80 and ethanol) possessed globule size of 12.21 nm, polydispersity index of 0.109 and zeta potential value of -0.139 mV. ME V exhibited 7, 5 and almost 3-fold higher drug permeation as compared to aqueous suspension, oily solution and conventional cream respectively. Besides this the formulation was also evaluated for drug content, pH, stability, dermatopharmacokinetics and antifungal activity against Microsporum canis using guinea pig model for dermatophytosis. Treatment of guinea pigs with ME V resulted in a complete clinical and mycological cure in 7 days. The formulation was observed to be non-sensitizing, histopathologically safe, and stable at 5±3°C, 25±2°C and 40±2°C for a period of six months. Reitz et al. (2013) demonstrated the scale-up of the SCS technology to standard, lab-scale extrusion equipment--a change from previous investigations, which used small batch sizes. A twin-screw extruder was modified to account for the rapid crystallization of the carrier. The screw speed and the barrel temperature were identified as critical process parameters and were varied systematically in several experimental designs. Finally, parameters were identified that produced extrudates with rapid dissolution rates. After extrusion, the extrudates were milled to 84 granules and then tableted. These tablets were investigated with respect to their bioavailability in beagle dogs. It was found that drug particle size reduction in the hot melt extrusion led to 3.5fold higher bioavailability in these dogs than occurred with the physical mixture of the used substances. The solid crystal suspension formulation had a slightly higher bioavailability than the marked product. References: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. Aggarwal N1, Goindi S, Khurana R. Formulation, characterization and evaluation of an optimized microemulsion formulation of griseofulvin for topical application. Colloids Surf B Biointerfaces. 2013 May 1;105:158-66. Anusha Mayavan and Sangeetha D. Production of griseofulvin from marine fungi Penicillium fellutanum International Journal of Applied Research 2016; 2(8): 701-704 Azanza JR1, Sádada B, Reis J. Liposomal formulations of amphotericin B: differences according to the scientific evidence. Rev Esp Quimioter. 2015 Dec;28(6):275-81. BRIAN, P. W. 1949. Studies on the biological activity of griseofulvin. Ann. Bot. London 13:59- 77. BRIAN, P. W. 1960. Griseofulvin. Trans. Brit. Mycol. Soc. 43:1-13. Brian, P. W., P. J. Curtis, and H. G. Hemming. 1946. A substance causing abnormal development of fungal hyphae produced by Penicillium janczewskii Zal. I. Biological assay, production and isolation of "curling factor." Trans. Brit. Mycol. Soc. 29:173-187. GENTLES, J. C. 1958. Experimental ringworm in guinea pigs: oral treatment with griseofulvin. Nature 182:476-477 George Serhan, Colin M Stack, Gabriel G Perrone and Charles Oliver Morton. The polyene antifungals, amphotericin B and nystatin, cause cell death in Saccharomyces cerevisiae by a distinct mechanism to amphibian-derived antimicrobial peptides .Ann. Clin.Microbiol.Antimicrobials 201413:18 Lewis R.E. (2009) Polyene Antifungal Agents. In: Comarú Pasqualotto A. (eds) Aspergillosis: From Diagnosis to Prevention. Springer, Dordrecht Marcos X1, Pérez-Casas S1, Llovo J2, Concheiro A3, Alvarez-Lorenzo C4. Poloxamer-hydroxyethyl cellulose-α-cyclodextrin supramolecular gels for sustained release of griseofulvin. Int J Pharm. 2016 Mar 16;500(1-2):11-9. Marto J1, Vitor C2, Guerreiro A3, Severino C4, Eleutério C5, Ascenso A6, Simões S7. Ethosomes for enhanced skin delivery of griseofulvin. Colloids Surf B Biointerfaces. 2016 Oct 1;146:616-23. OXFORD, A. E., H. RAISTRICK, AND P. SIMONART. 1939. Studies in the biochemistry of microorganisms. LX. Griseofulvin-a metabolic product of Penicillium griseofulvum Dierkx. Biochem. J. 33:240-248. Petersen AB1, Konotop G2, Hanafiah NHM2, Hammershøj P1, Raab MS2, Krämer A3, Clausen MH4. Strategies for improving the solubility and metabolic stability of griseofulvin analogues. Eur J Med Chem. 2016 Jun 30;116:210-215. Reitz E1, Vervaet C2, Neubert RH3, Thommes M4. Solid crystal suspensions containing griseofulvin-preparation and bioavailability testing. Eur J Pharm Biopharm. 2013 Feb;83(2):193-202. Roine J1, Kaasalainen M1, Peurla M2, Correia A3, Araújo F3,4,5, Santos HA3, Murtomaa M1, Salonen J1. Controlled Dissolution of Griseofulvin Solid Dispersions from Electrosprayed Enteric Polymer Micromatrix Particles: Physicochemical Characterization and in Vitro Evaluation. Mol Pharm. 2015 Jul 6;12(7):2254-64. Rydberg HA1, Yanez Arteta M1, Berg S1, Lindfors L1, Sigfridsson K2. Probing adsorption of DSPEPEG2000 and DSPE-PEG5000 to the surface of felodipine and griseofulvin nanocrystals. Int J Pharm. 2016 Aug 20;510(1):232-9. Shemer A1,2, Grunwald MH3, Gupta AK4,5, Lyakhovitsky A1, Daniel CR 3rd6,7, Amichai B2,8. Griseofulvin and Fluconazole Reduce Transmission of Tinea Capitis in Schoolchildren. Pediatr Dermatol. 2015 Sep-Oct;32(5):696-700. 85 2. Nystatin  Nystatin is a polyene antifungal drug to which many molds and yeasts are sensitive. It was also the first antifungal antibiotic to be safe and effective in treating human diseases. Not only did it cure many serious fungal infections of the skin, mouth, throat, and intestinal tract, but it could also be combined with antibacterial drugs to balance their side effects.  Nystatin is used to treat Candida infections of the skin including diaper rash, thrush, esophageal candidiasis, and vaginal yeast infections.  Nystatin is both fungistatic, which means it inhibits the growth of fungi, it is also an extremely effective fungicidal, which means it kills the actual Candida cells. History      Nystatin is of bacterial origin. It was isolated from Streptomyces noursei in 1950 by Elizabeth Lee Hazen and Rachel Fuller Brown, who were doing research for the Division of Laboratories and Research of the New York State Department of Health. Hazen found a promising micro-organism in the soil of a friend's dairy farm. She named it Streptomyces noursei, after Jessie Nourse, the wife of the farm's owner. Hazen and Brown named nystatin after the New York State Health Department in 1954. The two discoverers patented the drug, and then donated the $13 million in profits to a foundation to fund similar research. Elizabeth Lee Hazen (left) and Rachel Fuller Brown Streptomyces noursei Nystatin properties     Nystatin is a light yellow or brownish powder, hygroscopic, thermolabile, and sensitive to moisture, light, oxygen and extreme pH. Nystatin is almost insoluble in water and other common solvents, therefore, it must be suspended in preparations. Nystatin is resorbed by the skin or mucosa and its gastrointestinal resorption is very poor too. Thus, it is preferentially formulated for oral administration. Nystatin is produced by fermentation, therfore its relative potency is presented as international units per miligram (IU/mg). 86     Due to the poor absorption of nystatin in gastrointestinal tract there are no drug-drug interactions and systemic adverse effects. The structure of this active compound is characterized as a polyene macrolide with a deoxysugar D-mycosamine, an aminoglycoside The genomic sequence of nystatin reveals the presence of the polyketide loading module (nysA), six polyketide synthases modules (nysB, nysC, nysI, nysJ, and nysK) and two thioesterase modules (nysK and nysE). It is evident that the biosynthesis of the macrolide functionality follows the polyketide synthase I pathway. Mechanism of action       Like amphotericin B and natamycin, nystatin binds to ergosterol, a major component of the fungal cell membrane. When present in sufficient concentrations, it forms pores in the membrane that lead to K+ leakage, acidification, and death of the fungus. Ergosterol is a sterol unique to fungi, so the drug does not have such catastrophic effects on animals or plants. However, many of the systemic/toxic effects of nystatin in humans are attributable to its binding to mammalian sterols, namely cholesterol. This is the effect that accounts for the nephrotoxicity observed when high serum levels of nystatin are achieved. Pharmacokinetic data o Bioavailability: 0% on oral ingestion o Metabolism: None (not extensively absorbed)\ o Biological half-life: Dependent upon GI transit time o Excretion: Fecal (100%) Nystatin Products  The medication is available in a variety of forms, which include: o o o o o o o Liquid (Oral suspension) Powder (for external application) Capsules Tablets Lozenges (Pastilles) Creams and Ointments Vaginal Pessaries 87     An oral suspension form is used for the prophylaxis or treatment of oropharyngeal thrush, a superficial candidal infection of the mouth and pharynx. A tablet form is preferred for candidal infections in the intestines. Nystatin is available as a topical cream and can be used for superficial candidal infections of the skin. A liposomal formulation of nystatin was investigated in the 1980s and into the early 21st century. The liposomal form was intended to resolve problems arising from the poor solubility of the parent molecule and the associated systemic toxicity of the free drug.  Due to its toxicity profile when high levels in the serum are obtained, no injectable formulations of this drug are currently on the US market. However, injectable formulations have been investigated in the past. Nystatin uses    Nystatin has been used as a local antimycotic in mucosal and skin candidiasis. o Nystatin has an important action in treatment of the mouth cavity (oral candidiasis), pharynx (oropharyngeal candidiasis), esophagus (esophageal candidiasis) and alternatively in distal gastrointestinal tract (intestinal candidiasis). Nystatin is very important in prophylaxis and therapy of mucosal candidiasis in o full-term and premature newborns, infants, and in people with high risk of candidiasis (e.g., immunocompromised individuals). o candidate subjects for transplantation, especially in total denture wearers. The use is safe in children, including newborns and infants, as well as in patients after transplantation or other special populations. Dosage     The most commonly used activity in finished preparations is 100 000 IU/g. The recommended dosage in oromucosal candidiasis is 200 000 ñ 600 000 IU four times a day in children and adults, and 100 000 ñ 200 000 IU four times a day in newborns and infants. Dose of 100 000 IU four times a day is considered adequate for premature newborns and newborns with low birth weight. In intestinal candidiasis, the doses are usually 0.5 ñ 1.5 million IU three times a day, and 150 000 ñ 300 000 IU three times a day in infants. Nystatin should be administered after a meal and the usual treatment duration is 5 to 10 days. The treatment should continue at least 48 h after the symptoms disappear. Adverse effects   The oral suspension form produces a number of adverse effects including: 1. Diarrhea 2. Abdominal pain 3. Rarely, tachycardia, bronchospasm, facial swelling, muscle aches Both the oral suspension and the topical form can cause: 88 1. Hypersensitivity reactions, including Stevens-Johnson syndrome in some cases 2. Rash, itching, burning and acute generalized exanthematous pustulosis Other uses     The spot absent of growth had nystatin applied to it before the fungus covered the fruit. It is also used in cellular biology as an inhibitor of the lipid raft-caveolae endocytosis pathway on mammalian cells, at concentrations around 3 µg/ml. In certain cases, nystatin has been used to prevent the spread of mold on objects such as works of art. For example, it was applied to wood panel paintings damaged as a result of the Arno River Flood of 1966 in Florence, Italy. After the Florence Flood: Saving Vasari's 'Last Supper' Conservators positioning panels of the work to align. Credit Archives of the Opificio delle Pietre Dure, Firenze  Nystatin is also used as a tool by scientists performing "perforated" patchclamp electrophysiologic recordings of cells. When loaded in the recording pipette, it allows for measurement of electrical currents without washing out the intracellular contents, because it forms pores in the cell membrane that are permeable to only monovalent ions. Brand names The original brandname was Fungicidin    Penicillium-infected tangerine Nyamyc Pedi-Dri Pediaderm AF Complete 89                             Candistatin Nyaderm Bio-Statin PMS-Nystatin Nystan (oral tablets, topical ointment, and pessaries, formerly from Bristol-Myers Squibb) Infestat Nystalocal from Medinova AG Nystamont Nystop (topical powder, Paddock) Nystex Mykinac Nysert (vaginal suppositories, Procter & Gamble) Nystaform (topical cream, and ointment and cream combined with iodochlorhydroxyquine and hydrocortisone; formerly Bayer now Typharm Ltd) Nilstat (vaginal tablet, oral drops, Lederle) Korostatin (vaginal tablets, Holland Rantos) Mycostatin (vaginal tablets, topical powder, suspension Bristol-Myers Squibb) Mycolog-II (topical ointment, combined with triamcinolone; Apothecon) Mytrex (topical ointment, combined with triamcinolone) Mykacet (topical ointment, combined with triamcinolone) Myco-Triacet II (topical ointment, combined with triamcinolone) Flagystatin II (cream, combined with metronidazole) Timodine (cream, combined with hydrocortisone and dimethicone) Nistatina (oral tablets, Antibiotice Iaşi) Nidoflor (cream, combined with neomycin sulfate and triamcinolone acetonide) Stamicin (oral tablets, Antibiotice Iaşi) Lystin Animax (veterinary topical ointment or cream; combined with neomycin sulfate, thiostrepton and triamcinolone acetonide) Candio-Hermal 91 91 Recent reports Silva et al. (2017) described the development and stability studies of an innovative formulation of nystatin and lidocaine pastilles for the treatment of oral mucositis. Full pharmaceutical quality testing was carried out, including disintegration and dissolution testing, texture profile analysis, grittiness and an antifungal activity testing. A soft pastille formulation containing 0.25% lidocaine and 78,000 IU nystatin was obtained, presenting suitable pharmaceutical characteristics, as a disintegration time of 17 ± 2 min, dissolution rate and microbiological and physicochemical for 30 days when stored at 2-8 °C under light protection. Palatability was also evaluated, being well accepted by a panel of 38 healthy volunteers. This formulation allows an accurate drug dosing by the prescriber, while enabling the patients to control the retention time of the drugs in the oral cavity and consequently manage their pain treatment. Lyu et al. (2016) systematically reviewed and assessed the efficacy, different treatment protocols (formulation, dosage, and duration), and safety of nystatin for treating oral candidiasis. 92 Four electronic databases were searched for trials published in English till July 1, 2015. Randomized controlled trials comparing nystatin with other antifungal therapies or a placebo were included. Clinical and/or mycological cure was the outcome evaluation. A meta-analysis or descriptive study on the efficacy, treatment protocols, and safety of nystatin was conducted. The meta-analysis showed that nystatin pastille was significantly superior to placebo in treating denture stomatitis. Nystatinsuspension was not superior to fluconazole in treating oral candidiasis in infants, children, or HIV/AIDS patients. The descriptive investigations showed that administration of nystatin suspension and pastilles in combination for 2 weeks might achieve a higher clinical and mycological cure rate, and using the nystatin pastilles alone might have a higher mycological cure rate, when compared with using nystatinsuspensions alone. Nystatin pastilles at a dose of 400,000 IU resulted in a significantly higher mycological cure rate than that administrated at a dose of 200,000 IU. Furthermore, treatment with nystatin pastilles for 4 weeks seemed to have better clinical efficacy than treatment for 2 weeks. Descriptive safety assessment showed that poor taste and gastrointestinal adverse reaction are the most common adverse effects of nystatin. It was concluded that Nystatin pastille was significantly superior to placebo in treating denture stomatitis, while nystatin suspension was not superior to fluconazole in treating oral candidiasis in infants, children, or HIV/AIDS patients. Indirect evidence from a descriptive study demonstrated that administration of nystatin pastille alone or pastille and suspension in combination is more effective than that of suspension alone; prolonged treatment duration for up to 4 weeks can increase the efficacy of nystatin. More well designed and high quality randomized control studies are needed to confirm these findings. Sardi et al. (2016) tested the antifungal potential of caffeic acid and 8 of its derivative esters against Candida albicans ATCC 90028 and 9 clinical isolates and carried out a synergism assay with fluconazole and nystatin. Propyl caffeate (C3) showed the best antifungal activity against the tested strains. When in combination, C3 markedly reduced the MIC of fluconazole and nystatin with synergistic effect up to 64-fold. Finally, C3 showed a high IC50 value and selective index against oral keratinocytes, demonstrating low toxicity against this cell type and selectivity for yeast cells. Further research should confirm its antifungal potential for development of combined therapy to treat C. albicans infections. Pinto Reis et al. (2016) performed a study is to enhance the effectiveness of nystatinusing particulate system such as beads, micro- and nanoparticles of alginate incorporated into toothpaste. Those particulate systems of nystatin were prepared by extrusion/external gelation for beads and emulsification/internal gelation for micro- and nanoparticles and characterized. Small, anionic charged and monodispersed particles were successfully produced. The type of particulate system influenced all previous parameters, being microparticles the most suitable particulate system of nystatin showing the slowest release, the highest inhibitory effect of Candida albicans over a period of one year. Those results allowed the conclusion that alginate exhibits properties that enable the in vitro functionality of encapsulated nystatin and thus may provide the basis for new successful approaches for the treatment of oral antifungal infections such as oral candidiasis. Vega et al. (2016) reported the case of a 66-year-old woman who presented with concomitant sensitization to inhaled budesonide and oral nystatin presenting as allergic contact stomatitis and systemic allergic contact dermatitis. It is notable that one of the reactions was caused by oral nystatin, which generally is not considered to be allergenic due to its poor intestinal absorption. Diagnoses were confirmed on patch testing with histologic examination along with 93 oral challenge testing. They also used challenge testing to rule out cross-reactivity among nystatin and other macrolide drugs, both antifungals and antibiotics. Chulkov et al. (2015) investigated the effect of flavonoids and styryl dyes on the steady-state conductance induced by a cis-side addition of nystatin by using electrophysiological measurements on artificial membranes. The assessment of changes in membrane dipole potential by dipole modifiers was carried out by their influence on K(+)-nonactin (K(+)-valinomycin) current. The alterations of the phase segregation scenario induced by nystatin and flavonoids were observed via confocal fluorescence microscopy. The introduction of phloretin, phlorizin, biochanin A, myricetin, quercetin, taxifolin, genistin, genistein, and RH 421 leads to a significant increase in the nystatin-induced steady-state transmembrane current through membranes composed of a mixture of DOPC, cholesterol and sphingomyelin (57:33:10 mol%). Conversely, daidzein, catechin, trihydroxyacetophenone, and RH 237 do not affect the transmembrane current. Three possible mechanisms that explain the observed results are discussed: changes in the membrane dipole potential, alterations of the phase separation within the lipid bilayer, and influences of the dipole modifiers on the formation of the lipid mouth of the polyene pore. Most likely, changes in the monolayer curvature in the vicinity of trans-mouth of a nystatin singlelength channel prevail over alterations of dipole potential of membrane and the phase segregation scenarios induced by dipole modifiers. Maqsood et al. (2015) designed and developed Nystatin micro emulsion based gel for efficient delivery of drug to the skin by water titration method. The Pseudoternary phase diagrams 1:2, 1:1 and 2:1 were constructed by water titration method. Micro emulsion based gel was prepared by using oleic acid, Tween 20, propylene glycol as an oil phase, surfactant and cosurfactant respectively. Cabopol 940 was used as a gelling agent. In vitro evaluation of micro emulsion based gel was done for pH, Viscosity, spreadability and droplet size. Micro emulsion based gel showed greater antifungal activity against Candida albicansas compared to control formulations. In vitro drug release studies were conducted for micro emulsion based gel and control formulation using Franz diffusion cell. Drug penetration through synthetic skin followed Zero order model as the values for R2 higher in case of zero order equation. The optimized micro emulsion based gel was found to be stable and showed no physical changes when exposed to different temperatures for a period of 4 week. The results indicated that the micro emulsion based gel system studied would be a promising tool for enhancing the percutaneous delivery of Nystatin. Martín et al. (2015) successfully elaborated three types of microspheres, alginate (AM1), chitosan coated (CCM) and hydrogel (AM2) containing nystatin (Nys) by emulsification/internal gelation method to develop more effective antifungal mucoadhesive systems for the treatment of oral candidiasis,. Physicochemical properties of microspheres resulted in 85-135 μm mean sizes, spherical shaped with narrow distribution. Optimal encapsulation efficiency and negative zeta potentials were observed. AM2 showed a consistent decrease in viscosity with increasing shear rate (Herschel-Bulkley). Optimal mucoadhesive properties and swelling behaviour where evidenced. Nys release from AM1 and CCM followed a concentration gradient pattern, contrary AM2 followed a complex release mechanism. All systems exhibited a marked fungicidal activity against Candida albicans strains. In vivo studies demonstrated that Nys was not found in systemic circulation assuring the safety of the treatment. Nys amounts retained in the mucosa were more than enough to ensure an effective fungicidal action without tissue damage. Based on 94 the obtained results, AM2 could be proposed as the vehicle with the best properties for the buccal vehiculization of Nys Semis et al. (2015) evaluated the efficacy of combinations of nystatin-intralipid, found previously to be more active than nystatin, with antifungals of different mode of activity, against Aspergillus terreus. Antifungal activity of combinations of nystatin-intralipid with voriconazole, caspofungin, terbinafine or 5-fluorocytosine were evaluated by the checkerboard and disk diffusion methods. The results were compared to those obtained with nystatin. The combination of nystatin-intralipid with caspofungin exhibited better antifungal activity than each drug alone and resulted in a synergistic interaction in three out of six tested strains of A. terreus. No such effect was obtained with Nystatin and caspofungin. Nystatin-intralipid or nystatin with voriconazole yielded indifferent interactions. When nystatin-intralipid was combined with terbinafine, a strong antagonism was produced in all six A. terreus strains. This effect was observed both by checkerboard and disk diffusion methods. In contrast no interaction or only slight antagonism was observed in the combination of nystatin with terbinafine. Disk diffusion method revealed similar inhibition zones when disks impregnated with 5-fluorocytosine were placed on plain, nystatin-intralipid or nystatin containing agar plates. Among four tested combinations, only combination of nytatin-intralipid with caspofungin, a representative of the echinocandin class of antifungals, resulted in synergistic interaction. Antagonism obtained by combining nystatin-intralipid with terbinafine can be explained by existence of hydrophobic interaction between these two compounds interfering with their antifungal action. The fact that nystatin-intralipid and nystatin interact differently with other antifungals, may indicate differences in their mechanisms of activity. Hussein-Al-Ali et al. (2014) prepared a nystatin nanocomposite (Nyst-CS-MNP) by loading nystatin (Nyst) on chitosan (CS) coated magnetic nanoparticles (MNPs). The magnetic nanocomposites were characterized by X-ray powder diffraction (XRD), Fourier transform infrared spectroscopy (FT-IR), thermogravimetry analysis (TGA), vibrating sample magnetometer (VSM), and scanning electron microscopy (SEM). The XRD results showed that the MNPs and nanocomposite are pure magnetite. The FTIR analysis confirmed the binding of CS on the surface of the MNPs and also the loading of Nyst in the nanocomposite. The Nyst drug loading was estimated using UV-Vis instrumentation and showing a 14.9% loading in the nanocomposite. The TEM size image of the MNPs, CS-MNP, and Nyst-CS-MNP was 13, 11, and 8 nm, respectively. The release profile of the Nyst drug from the nanocomposite followed a pseudo-second-order kinetic model. The antimicrobial activity of the as-synthesized Nyst and Nyst-CS-MNP nanocomposite was evaluated using an agar diffusion method and showed enhanced antifungal activity against Candida albicans. In this manner, this study introduces a novel nanocomposite that can decrease fungus activity on-demand for numerous medical applications. Boros-Majewska et al. (2014) focused their investigation on novel derivatives of the antifungal antibiotic Nystatin A1, generated by modifications at the amino group of this molecule. The aims of this study were to evaluate the antifungal effectiveness and host cell toxicity of these new compounds using an in vitro model of oral candidosis based on a reconstituted human oral epithelium (RHOE). Initial studies employing broth microdilution, revealed that against planktonic C. albicans, Nystatin A1 had lower minimal inhibitory concentration than novel derivatives. However, Nystatin A1 was also markedly more toxic against human keratinocyte cells. Interestingly, using live/dead staining to assess C. albicans and tissue cell viability after 95 RHOE infection, Nystatin A1 derivatives were more active against Candida with lower toxicity to epithelial cells than the parent drug. Lactate dehydrogenase activity released by the RHOE indicated a fourfold reduction in tissue damage when certain Nystatin derivatives were used compared with Nystatin A1. Furthermore, compared with Nystatin A1, colonisation of the oral epithelium by C. albicans was notably reduced by the new polyenes. In the absence of antifungal agents, confocal laser scanning microscopy showed that C. albicans extensively invaded the RHOE. However, the presence of the novel derivatives greatly reduced or totally prevented this fungal invasion. References: Boros-Majewska J1, Salewska N, Borowski E, Milewski S, Malic S, Wei XQ, Hayes AJ, Wilson MJ, Williams DW. Novel Nystatin A₁ derivatives exhibiting low host cell toxicity and antifungal activity in an in vitro model of oral candidosis. Med Microbiol Immunol. 2014 Oct;203(5):341-55. 2. Chulkov EG1, Schagina LV2, Ostroumova OS2. Membrane dipole modifiers modulate singlelength nystatin channels via reducing elastic stress in the vicinity of the lipid mouth of a pore. Biochim Biophys Acta. 2015 Jan;1848(1 Pt A):192-9. 3. Fan S1, Liu X, Wu C, Xu L, Li J. Vaginal nystatin versus oral fluconazole for the treatment for recurrent vulvovaginal candidiasis. Mycopathologia. 2015 Feb;179(1-2):95-101. 4. Hussein-Al-Ali SH1, El Zowalaty ME2, Kura AU3, Geilich B4, Fakurazi S5, Webster TJ6, Hussein MZ7. Antimicrobial and controlled release studies of a novel nystatin conjugated iron oxide nanocomposite. Biomed Res Int. 2014;2014:651831. 5. Lyu X1, Zhao C1, Yan ZM1, Hua H1. Efficacy of nystatin for the treatment of oral candidiasis: a systematic review and meta-analysis. Drug Des Devel Ther. 2016 Mar 16;10:1161-71. doi: 10.2147/DDDT.S100795. eCollection 2016. 6. Maqsood I1, Masood MI2, Bashir S3, Nawaz HM2, Anjum AA2, Shahzadi I2, Ahmad M4, Imran Masood IM4. Preparation and in vitro evaluation of Nystatin micro emulsion based gel. Pak J Pharm Sci. 2015 Sep;28(5):1587-93. 7. Martín MJ1, Calpena AC2, Fernández F2, Mallandrich M2, Gálvez P1, Clares B3. Development of alginate microspheres as nystatin carriers for oral mucosa drug delivery. Carbohydr Polym. 2015 Mar 6;117:140-9. 8. Pinto Reis C1, Vasques Roque L2, Baptista M1, Rijo P1. Innovative formulation of nystatin particulate systems in toothpaste for candidiasis treatment. Pharm Dev Technol. 2016;21(3):282-7 9. Sardi JC1, Gullo FP2, Freires IA3, Pitangui NS2, Segalla MP4, Fusco-Almeida AM2, Rosalen PL3, Regasini LO5, Mendes-Giannini MJ6. Synthesis, antifungal activity of caffeic acid derivative esters, and their synergism with fluconazole and nystatin against Candida spp. Diagn Microbiol Infect Dis. 2016 Dec;86(4):387-391. 10. Semis R1, Nahmias M2, Lev S2, Frenkel M2, Segal E3. Evaluation of antifungal combinations of nystatinintralipid against Aspergillus terreus using checkerboard and disk diffusion methods. J Mycol Med. 2015 Mar;25(1):63-70. doi: 10.1016/j.mycmed.2014.12.002. Epub 2015 Jan 29. 11. Silva FC1,2, Marto JM2, Salgado A2, Machado P3, Silva AN3, Almeida AJ2. Nystatin and lidocaine pastilles for the local treatment of oral mucositis. Pharm Dev Technol. 2017 Mar;22(2):266-274. 12. Vega F1, Ramos T2, Las Heras P2, Blanco C2. Concomitant sensitization to inhaled budesonide and oral nystatin presenting as allergic contact stomatitis and systemic allergic contact dermatitis. Cutis. 2016 Jan;97(1):24-7. 1. 96 3. Natamycin (Pimaricin) , Aparicio, Jesús F. et al., 2016           Natamycin is a natural product produced by given members of the genus Streptomyces Natamycin belongs to the polyene class of macrolide polyketides, Natamycin displays a strong and broad spectrum mould inhibition activity, Natamycin is safe and effective at very low concentrations. Natamycin molecular target is ergosterol, an essential constituent of fungal membranes, Natamycin has become one of the major mould inhibitors used in the food industry. Natamycin use was approved in 1967 as a cheese preservative, and since then, it has been extended to a wide variety of foods and beverages. Natamycin has been regarded as the most important agent in the management of fungal keratitis. Natamycin is also used as a crop protection agent to prevent mould contamination. Natamycin is also active against protozoa having ergosterol in their membranes. Discovery and structure    Natamycin is a small-sized polyene antibiotic. Natamycin name derives from the South African region of Natal (‗Christmas‘ in Portuguese, Vasco da Gama having landed on its shores on 25 December 1497), where the first producing strain, Streptomyces natalensis, was isolated. Natamycin is also produced by other strains like S. gilvosporeus, S. lydicus and S. chatanoogensis . S. chattanoogensis Chemical structure     Natamycin tetraene nature was unveiled shortly after its discovery. Natamycin correct covalent structure was not solved until 1966. Natamycin stereochemical structure was reported some 24 years later. Natamycin solution NMR structure has been described. 97  Natamycin molecule contains a mycosamine (3-amino-3,6-dideoxy-D-mannose) moiety linked to the macrolactone ring via a β-glycosidic bond at C15. o In the aglycone, the most characteristic features are the presence of an epoxide group at C4-C5, which originates from a double bond o an exocyclic carboxyl function at C12 that derives from a methyl group o an internal hemiketal ring resulting from spontaneous cyclisation between a keto group at C9 and a hydroxyl group at C13.  Natamycin shows characteristic physicochemical properties, including a strong UVvisible light absorption and photolability. o Natamycin UV-visible light absorption spectrum shows a characteristic shape due to its multipeak pattern . o Natamycin chromophore is located opposite to a number of hydroxyl functions, making Natamycin strongly amphipathic, the region where the chromophore lies has a planar and rigid lipophilic nature, whilst the hydroxylated region is typically flexible and hydrophilic.  This feature allows the molecule to interact with the sterol molecules present in fungal cell membranes (predominantly ergosterol), by means of hydrophobic interactions between the hydrophobic portion of the polyene and the sterol, which results in cell death.  Because of its amphiphilic nature, it is poorly soluble in water and almost insoluble in non-polar solvents. As a powder, it is stable in the dark, with no loss of activity, but it is light sensitive in aqueous suspensions. Bioactivity  Natamycin has a strong antifungal activity on most fungi (minimal inhibitory concentrations are in the micromolar range).  Natamycin blocks fungal growth by binding specifically to ergosterol but without permeabilising the membrane. o Van Leeuwen et al. (2009) have proven that Natamycin inhibits endocytosis in germinating conidia of Penicillium discolor without causing extensive cell damage (i.e. without membrane permeabilisation), 98    o te Welscher et al. (2010) mentioned that Natamycin impairs vacuole fusion via perturbation of ergosterol-dependent priming reactions that precede membrane fusion o te Welscher et al. 2012) proved that Natamycin inhibits growth of yeasts and fungi via the immediate inhibition of amino acid and glucose transport across the plasma membrane by an ergosterol-dependent inhibition of transport proteins. Natamycin is extremely unlikely to provoke microbial resistance, because its molecular target is ergosterol, a structural constituent of fungal membranes. Natamycin has been involved in the immune response activation by triggering interleukin-1β secretion through activation of the NLRP3 inflammasome. o The mechanism of activation relies on the induction of potassium efflux from the cells as well as on phagocytosis-dependent lysosome destabilisation. o This suggests that besides inhibiting fungal growth directly, it may also suppress fungal growth indirectly via activating innate host defence. Natamycin has also been found to be active ‗in vitro‘ against several protozoa such as Trypanosoma or Acanthamoeba. These organisms have ergosterol-derived compounds as components of their membranes, making Natamycin or its derivatives also potentially useful as antiparasitic agents. Applications Therapy  Natamycin has found clinical application as a topical agent in the treatment of various fungal infections, including oral, intestinal or vulvovaginal candidiasis.  Natamycin most important playground is in the treatment of ophthalmic mycoses.  Natamycin was the first antifungal agent approved by the Food and Drug Administration (FDA) of the United States (in 1978);  Natamycin can be used for the treatment of fungal blepharitis, conjunctivitis, scleritis and endophthalmitis.  Natamycin constitutes the first-line treatment in fungal keratitis.  Natamycin possesses activity against a great variety of yeast and filamentous fungal pathogens,including Alternaria, Candida, Cephalosporium, Colletotrichum, Curvularia, Lasiodiplodia, Scedosporium, Trichophyton and Penicillium spp.  Natamycin is currently considered the most effective medication against Fusarium and Aspergillus.  Natamycin is also effective for the treatment of keratitis produced by protozoa such as Acanthamoeba. Food Because of its broad spectrum of activity, its low likelihood of causing microbial resistance and especially its low toxicity to mammalian cells,   Natamycin has been widely used as a food preservative for more than 40 years. Natamycin is significantly more effective than sorbate, another commonly used antifungal preservative. 99             Natamycin does not affect food organoleptic properties (taste, texture and colour), and has prolonged antimicrobial activity, being safe for consumption because its oral absorption is negligible. Natamycin has been authorised by the European Food Safety Authority (EFSA) (additive E235), the World Health Organisation (WHO) and the FDA for protecting foods from yeast and mould contamination and possible inherent risks of mycotoxin poisoning. Natamycin is the only antifungal agent with a generally regarded as safe (GRAS) status. Natamycin is not active against bacteria, thus making it an ideal antimicrobial during bacterial ripening and fermentation processes for fermented foods. Thus, it has been traditionally used as a preservative in cheese and cured sausage production. Natamycin is used for the surface treatment of almost every type of cheese, either added as an emulsion for coating the cheese rind or applied by dipping or spraying. Under these conditions, Natamycin crystals remain on the surface of the product, and the soluble fraction hardly penetrates, thus not interfering with the internal microorganisms that confer their organoleptic properties to these products. Natamycin is used for sausages treatment by dipping or spraying to prevent fungal growth during ageing. Natamycin can also be used to prevent mould growth in yoghurt and other dairy products such as unripened cheese (e.g. cream cheese, cottage cheese and mozzarella) or whey protein cheese (e.g. ricotta), also in dried uncooked meats and in iberico and prosciutto hams. Natamycin can also be used to extend the shelf life of different fruit and vegetable preparations, salad mixes, baking products, sauces, fish, poultry, etc. Natamycin has been used to successfully inhibit the growth of fungi during natural black olive fermentation. Natamycin wasused to prevent carrot spoilage in refrigerated storage facilities. Natamycin has been successfully incorporated into different packaging films/coatings , including some that are edible, where it has proven to be gradually released over long periods of time, thus extending the shelf life of the product. Beverages  Natamycin has also been described to be very effective for controlling growth of Aspergillus carbonarius, the fungus responsible for contamination of wine, grapes and grape juice with ochratoxin A.  Natamycin is used to prevent fungal spoilage in other beverage products before their packaging, as it is effective at low concentrations,  Natamycin is stable if kept protected from light and it is not affected by a wide range of pH values.  Natamycin may be used in fruit juices, beer, wine, cider or iced tea. Pesticide  Natamycin is also used as a natural and safe product for crop protection.  Natamycin is used to control various fungal diseases but especially basal rots on ornamental bulbs such as daffodils that are caused by Fusarium oxysporum . 111     Natamycin efficacy to control tomato gray mould disease caused by Botrytis cinerea in greenhouse conditions has also been reported. Natamycin has been approved in 2012 as a biopesticide by the US Environmental Protection Agency for its use in enclosed mushroom production facilities to prevent dry bubble disease caused by Lecanicillium fungicola, a devastating pathogen in the mushroom industry. Natamycin efficacy controlling Aspergillus niger contamination in rice leaffolder larvae (Cnaphalocrocis medinalis, a Lepidoptera important for rice growth) mass-rearing facilities has been reported. Natamycin is also used in selective growth media to prevent growth of yeast and filamentous fungi, such as in the isolation of Brucella (Stack et al. 2002) or Legionella spp. Prospects  Amongst the major applications of Natamycin, its use as a natural food antimicrobial is generalised worldwide, being used in more than 150 countries.  Natamycin has been used for more than 40 years now and continues to constitute a gold standard in the preservation of foods and beverages against mould spoilage and the inherent risk of mycotoxin poisoning.  Natamycin broad spectrum of activity against almost every type of fungi but not bacteria, its lack of effect on the quality of food, its low likelihood of causing microbial resistance and especially its safeness for consumption have made this molecule an ideal biopreservative.  Natamycin use that was initially restricted to the surface treatment of some types of cheese has expanded exponentially to other foods, beverages, storage facilities and even some crops. Furthermore,  The increasing demand of healthy processed foods and beverages with natural antimicrobials as alternatives to physical- and chemical-based antimicrobial treatments ensures that Natamycin use will continue growing in the future.  Natamycin derivatives with improved properties have been developed, and many of the bottlenecks hampering Natamycin production at high titres have been overcome. Brands 111 Recent reports Aparicio et al. (2016) mentioned that biosynthesis of Natamycin antifungal agent with a GRAS status has been thoroughly studied, which has permitted the manipulation of producers to engineer the biosynthetic gene clusters in order to generate several analogues. Regulation of its production has been largely unveiled, constituting a model for other polyenes and setting the leads for optimizing the production of these valuable compounds. This review describes and discusses the molecular genetics, uses, mode of action, analogue generation, regulation and strategies for increasing pimaricin production yields. Bouaoud et al. (2016) developed and evaluate food-grade liposomal delivery systems for the antifungal compound natamycin. Liposomes made of various soybean lecithins are prepared by solvent injection, leading to small unilamellar vesicles (<130 nm) with controlled polydispersity, able to encapsulate natamycin without significant modification of their size characteristics. Presence of charged phospholipids and reduced content of phosphatidylcholine in the lecithin mixture are found to be beneficial for natamycin encapsulation, indicating electrostatic interactions of the preservative with the polar head of the phospholipids. The chemical instability of natamycin upon storage in these formulations is however significant and proves that uncontrolled leakage out of the liposomes occurs. Efficient prevention of natamycin degradation is obtained by incorporation of sterols (cholesterol, ergosterol) in the lipid mixture and is linked to higher entrapment levels and reduced permeability of the phospholipid membrane provided by the ordering effect of sterols. Comparable action of ergosterol is observed at concentrations 2.5fold lower than cholesterol and attributed to a preferential interaction of natamycin-ergosterol as well as a higher control of membrane permeability. Fine-tuning of sterol concentration allows preparation of liposomal suspensions presenting modulated in vitro release kinetics rates and enhanced antifungal activity against the model yeast Saccharomyces cerevisiae. 112 Sun et al. (2016) developed a new detection method of natamycin via HPLC-MS/MS that uses an Agilent 6460 HPLC-MS/MS instrument and an Agilent RP18 (2.1mm×50mm, 1.8μm); the LOD was 1μg/L, the LOQ was 3.34μg/L, the recovery was 70-94%, the RSD was approximately 2-4%, and the total run time was 5min. In the new detection method of natamycin via HPLCMS/MS, processing of the sample before detection is necessary, which can be performed using solid phase extraction. Surprisingly, natamycin was not detected in any the sampled retail commercial wines from the Chinese market. Natamycin is very unstable in wine because many process steps, including the malo-lactic fermentation, clarification and storage, could result in degradation of natamycin. Regarding the clarifying agents, bentonite exhibited the strongest effect on natamycin. During the storage period, natamycin is very sensitive to light. Streekstra et al. (2016) addressed the possible development of tolerance against the antifungal food preservative natamycin. A selection of 20 fungal species, originating from a medical as well as a food product context, was subjected to increasing concentrations of natamycinfor prolonged time, a procedure designated as "training". The range of Minimum Inhibitory Concentrations (M.I.C.) before (1.8-19.2μM) and after (1.8-19.8μM) training did not change significantly, but natamycin-exposure caused an increase of M.I.C. in 13 out of 20 tested strains. The average M.I.C. increased from 6.1 to 8.6μM and 4 strains showed a >2-fold increase of tolerance after training. One strain (of Aspergillus ochraceus) also showed increased tolerance to amphotericin B and nystatin. However, two Fusarium strains showed similar or even decreased tolerance for these other polyene antifungals. The work reported here shows that a continuous and prolonged increasing selection pressure induced natamycin tolerance in individual strains. This implies that such a selection pressure should be avoided in the technical application of natamycin to ensure its continued safe use as a food preservative. Wang et al. (2016) performed a study to confirm the positive effect of the gene pimE on natamycin biosynthesis. An additional copy of the gene pimE was inserted into the genome of Streptomyces gilvosporeus 712 under the control of the ermE* promoter (permE*) using intergeneric conjugation. Overexpression of the target protein engendered 72% and 81% increases in the natamycin production and cell productivity, respectively, compared with the control strain. Further improvement in the antibiotic production was achieved in a 1 L fermenter to 7.0 g/l, which was a 153% improvement after 120 h cultivation. Exconjugants highly expressing pimE and pimM were constructed to investigate the effects of both genes on the increase of natamycin production. However, the co-effect of pimE and pimM did not enhance the antibiotic production obviously, compared with the exconjugants highly expressing pimE only. These results suggest not only a new application of cholesterol oxidase but also a useful strategy to genetically engineer natamycin production Dalhoff et al. (2015) mentioned that Natamycin is a poorly soluble, polyene macrolide antifungal agent used in the food industry for the surface treatment of cheese and sausages. This use is not of safety concern. However, highly soluble natamycin-cyclodextrin inclusion complexes have been developed for the protection of beverages. This practice leads to high drug exposures exceeding the safety level. Apart from the definition of an acceptable daily dietary exposure to natamycin, its effect on the faecal flora as a reservoir for resistance has to be examined. Consumption of food to which natamycin has been added and mixed homogeneously, such as yoghurt, and in particular the addition of cyclodextrin inclusion complexes to beverages and wine generates high faecal natamycin concentrations resulting in high drug exposures of faecal Candida spp. Development of natamycin resistance has been observed in Candida spp. 113 colonising the intestinal tract of patients following natamycintreatment of fungal infections. Horizontal gene transfer among different Candida spp. and within Aspergillus fumigatus spreads resistance. Therefore, it cannot be denied that use of natamycin for preservation of yoghurt and beverages may foster development of resistance to polyenes in Candida spp. Jain et al. (2015) carried out a stoidy to enhance the penetration ability of the antifungal drug natamycin, known to possess poor penetration ability through the corneal epithelium, by complexing with cell penetrating peptides. The drug, natamycin was conjugated to a cell penetrating peptide, Tat-dimer (Tat2). The uptake ability of the conjugate in human corneal epithelial cells and its antifungal activity against filamentous fungi, F.solani has been elucidated. The cellular penetration ability of natamycin increased upon conjugation with Tat2. The conjugation between natamycin and Tat2 also lead to enhanced solubility of the drug in aqueous medium. The antifungal activity of the conjugate increased two- folds in comparison to unconjugated natamycin against clinical isolates of F.solani. It was concluded that the formation of CPP-natamycin complex is clinically significant as it may enhance the bioavailability of natamycin in corneal tissues and aid in efficient management of fungal keratitis. Liu et al. (2015) obtained four natamycin analogs with high titers, including two new compounds, by engineering of six post-polyketide synthase (PKS) tailoring enzyme encoding genes in a natamycin industrial producing strain, Streptomyces chattanoogensis L10. Precise analysis of S. chattanoogensis L10 culture identified natamycin and two natamycin analogs, 4,5deepoxy-natamycin and 4,5-deepoxy-natamycinolide. The scnD deletion mutant of S. chattanoogensis L10 did not produce natamycin but increased the titer of 4,5-deepoxynatamycin. Inactivation of each of scnK, scnC, and scnJ in S. chattanoogensis L10 abolished natamycin production and accumulated 4,5-deepoxy-natamycinolide. Deletion of scnG in S. chattanoogensis L10 resulted in production of two new compounds, 4,5-deepoxy-12decarboxyl-12-methyl-natamycin and its dehydration product without natamycin production. Inactivation of the ScnG-associated ferredoxin ScnF resulted in impaired production of natamycin. Bioassay of these natamycin analogs showed that three natamycin analogs remained antifungal activities. We found that homologous glycosyltransferases genes including amphDI and nysDI can partly complement the ΔscnK mutant. Our results here also support that ScnG, ScnK, and ScnD catalyze carboxylation, glycosylation, and epoxidation in turn in the natamycin biosynthetic pathway. Thus this paper provided a method to generate natamycin analogs and shed light on the natamycin biosynthetic pathway. Liu et al. (2015) reported the regulation network of a group 3 sigma factor, WhiGch, from a natamycin industrial strain Streptomyces chattanoogensis L10. WhiGch regulates the growth and morphological differentiation of S. chattanoogensis L10. The whiG ch deletion mutant decreased natamycinproduction by about 30 % and delayed natamycin production more than 24 h by delaying the growth. Overexpression of the whiG ch gene increased natamycin production in large scale production medium by about 26 %. WhiGch upregulated the transcription of natamycinbiosynthetic gene cluster and inhibited the expression of migrastatin and jadomycin analog biosynthetic polyketide synthase genes. WhiGch positively regulated natamycin biosynthetic gene cluster by directly binding to the promoters of scnC and scnD, which were involved in natamycin biosynthesis, and these binding sites adjacent to translation start codon were determined. Thus, this paper further elucidates the high natamycin yield mechanisms of industrial strains and demonstrates that a valuable 114 improvement in the yield of the target metabolites can be achieved through manipulating the transcription regulators. Arima et al. (2014) employed Langmuir monolayers to mimic a cell membrane, whose properties are interrogated with various techniques. They found that natamycin has negligible effects on Langmuir monolayers of dipalmitoyl phosphatidylcholine (DPPC), but it strongly affects cholesterol monolayers. Natamycin causes the surface pressure isotherm of a cholesterol monolayer to expand even at high surface pressures since it penetrates into the hydrophobic chains. It also reduces the compressibility modulus, probably because natamycin disturbs the organization of the cholesterol molecules, as inferred with polarization-modulated infrared reflection absorption spectroscopy (PM-IRRAS). In mixed cholesterol/DPPC monolayers, strong effects from natamycin were only observed when the cholesterol concentration was 50mol% or higher, well above its concentration in a mammalian cell membrane. For a sterol concentration that mimics a real cell membrane in mammals, i.e. with 25mol% of cholesterol, the effects were negligible, which may explain why natamycin has low toxicity when ingested and/or employed to treat superficial fungal infections. Balaguer et al. (2014) prepared gliadin films cross-linked with cinnamaldehyde (1.5, 3, and 5%) and incorporated with natamycin (0.5%) by casting, and their antifungal activity, water resistance, and barrier properties were characterized. Incorporation of natamycin gave rise to films with greater water uptake, weight loss and diameter gain, and higher water vapor and oxygen permeabilities. These results may be associated to a looser packing of the protein chains as a consequence of the presence of natamycin. The different cross-linking degree of the matrices influenced the natamycin migration to the agar test media, increasing from 13.3 to 23.7 (μg/g of film) as the percentage of cinnamaldehyde was reduced from 5% to 1.5%. Antifungal activity of films was assayed against common food spoilage fungi (Penicillium species, Alternaria solani, Colletotrichum acutatum). The greatest effectiveness was obtained for films containing natamycin and treated with 5% of cinnamaldehyde. The level of cinnamaldehyde reached in the head-space of the test assay showed a diminishing trend as a function of time, which was in agreement with fungal growth and cinnamaldehyde metabolization. Developed active films were used in the packaging of cheese slices showing promising results for their application in active packaging against food spoilage. Chandasana et al. (2014) designed a corneal targeted nanoformulation in order to reduce dose and dosing frequency of natamycinand evaluate its pharmacokinetic/pharmacodynamic indices in comparison with clinical marketed preparation. The nanoparticles prepared by nanoprecipitation method were in nanometer size range with high entrapment efficiency and positive surface charge. In-vitro release studies indicated prolonged release of natamycin up to 8h. In-vitro antifungal activity was comparable with marketed preparation. The performance of nanoformulations was evaluated in rabbit eyes. The concentration of natamycin in tear fluid was determined by using LC-MS/MS. The pharmacokinetic parameters such as area under the curve, t½ and mean residence time were significantly higher and clearance was significantly lower for nanoformulations with that of marketed preparation. The optimized dosing schedule to maintain natamycinconcentration above tenfold of MIC90 was one instillation in every 5h. Moreover, 1/5th dose reduction of nanoformulation was also effective. Dervisoglu et al. (2014) investigated the presence of natamycin and quality parameters of yoghurt samples manufactured by small- and large-scale dairy firms in Turkey. Physicochemical and microbiological results revealed that, except Lactobacillus bulgaricus and Streptococcus 115 thermophilus counts, the majority of the yoghurts manufactured by small-scale dairy firms were found to be out of the limits. Natamycin was detected in 31 and 2 yoghurt samples from smalland large-scale brands, respectively. The levels of natamycin in small-scale brand yoghurts were higher than those in large-scale brand yoghurts. Of the analysed samples, 42.3% did not comply with the Turkish Food Codex. Li et al. (2014) investigated the effects of the addition of short-chain fatty acids and lower alcohols on the production of natamycin from Streptomyces natalensis F4-245 was investigated, and propanol was found to be the most effective additive. Under the optimal condition of propanol addition, the maximal natamycin titer reached 10.38 g/l, which was 17 % higher than that of the control. Metabolites analysis showed the concentrations of amino acids and acetylCoA were enhanced while those of organic acids in tricarboxylic acid (TCA) cycle were reduced. This work demonstrates that the addition of propanol is an effective strategy to increase natamycin yield through regulating metabolite node and pools of precursors. Mimouni et al. (2014) carried out a study to compare the efficacy of combined intrastromal injection and topical natamycin 5% to standard topical therapy alone in an experimental rabbit model of Fusarium keratitis. Fungal keratitis was induced in the right eyes of 12 New Zealand rabbits by stromal injection of Fusarium solani spore suspension into the cornea. Four days after inoculation, animals were randomly assigned to 2 different treatment groups (n=6 in each group). The study group received intrastromal injections of natamycin 5% on treatment day 1 and 4, combined with topical natamycin 5% eye drops given hourly between 8:00 and 20:00 for the first 2 days, followed by 4 times daily on days 3-11. The control group received only topical natamycin 5% at identical intervals. Eyes were examined clinically on days 1, 4, 7, and 11 for status of corneal healing, corneal vascularization, and hypopyon. Animals were sacrificed on day 11, and corneas were subjected to histopathological examination. Both groups showed significant improvement in terms of conjunctival hyperemia, size and density of corneal infiltrate, corneal edema, and total clinical score. In the study group, there was a significant improvement in the height of hypopyon in the anterior chamber, while there was also an increased amount of vascularization. This study showed that intrastromal injection of natamycin 5% combined with topical treatment has little beneficial effect over topical therapy in a Fusarium keratitis rabbit model. The addition of intrastromal injection should be reserved to the most severe or recalcitrant cases. Phan et al. (2014) evaluated the uptake and release of the antifungal agent natamycin encapsulated within poly(D,L-lactide)-dextran nanoparticles (Dex-b-PLA NPs) from model contact lens (CL) materials. Six model CL materials (gel 1:poly(hydroxyethyl methacrylate, pHEMA); gel 2:85% pHEMA: 15% [Tris(trimethylsiloxy)silyl]-propyl methacrylate (TRIS); gel 3: 75% pHEMA: 25% TRIS; gel 4: 85% N,N dimethylacrylamide (DMAA): 15% TRIS; gel 5:75% DMAA: 25% TRIS; and gel 6: DMAA) were prepared using a photoinitiation procedure. The gels were incubated in: (1) natamycin dissolved in deionized (DI) water and (2) natamycin encapsulated within Dex-b-PLA NPs in dimethylsulfoxide/DI water. Natamycin release from these materials was monitored using UV-visible spectrophotometry at 304 nm over 7 d. Natamycin uptake by all model CL materials increased between 1 and 7 d (p < 0.001). The uptake of natamycin-NPs was higher than the uptake of the drug alone in DI water (p < 0.05). Drug release was higher in materials containing DMAA than pHEMA (p < 0.05). All gels loaded with natamycin-NPs also released more drug compared to gels soaked with natamycin in DI water (p < 0.001). After 1 h, CL materials loaded 116 with natamycin alone released 28-82% of the total drug release. With the exception of gel 6, this burst released was reduced to 21-54% for CL materials loaded with natamycin-NPs. It was concluded that Model CL materials loaded with natamycin-Dex-b-PLA NPs were able to release natamycin for up to 12 h under infinite sink conditions. DMAA-TRIS materials may be more suitable for drug delivery of natamycin due to the higher drug release observed with these materials. Phan et al. (2014) performed a study to develop contact lens materials functionalized with methacrylated β-CD (MβCD) and methacrylated HP-βCD (MHP-βCD), and to evaluate their ability to deliver natamycin in vitro. Model conventional hydrogel (CH) materials were synthesized by adding varying amounts of MβCD and MHP-βCD (0, 0.22, 0.44, 0.65, 0.87, 1.08% of total monomer weight) to a monomer solution containing 2-hydroxyethyl methacrylate (HEMA). Model silicone hydrogel (SH) materials were synthesized by adding similar concentrations of MβCD and MHP-βCD to N,N-dimethylacrylamide (DMAA)/10% 3methacryloxypropyltris(trimethylsiloxy)silane (TRIS). The gels were cured with UV light, washed with ethanol and then, hydrated for 24 h (h). The model materials were then incubated with 2 mL of 100 μg/mL of natamycin in phosphate buffered saline (PBS) pH 7.4 for 48 h at room temperature. The release of natamycin from these materials in 2 mL of PBS, pH 7.4 at 32 ± 2 °C was monitored using UV-vis spectrophotometry at 304 nm over 24 h. For both CH and SH materials, functionalization with MβCD and MHP-βCD improved the total amount of drugs released up to a threshold loading concentration, after which further addition of methacrylated CDs decreased the amount of drugs released (p < 0.05). The addition of CDs did not extend the drug release duration; the release of natamycin by all model materials reached a plateau after 12 h (p < 0.05). Overall, DMAA/10% TRIS materials released significantly more drug than HEMA materials (p < 0.05). The addition of MHP-βCD had a higher improvement in drug release than MβCD for both HEMA and DMAA/10% TRIS gels (p < 0.05). It was concluded that a high loading concentration of methacrylated CDs decreases overall drug delivery efficiency, which likely results from an unfavorable arrangement of the CDs within the polymer network leading to reduced binding of natamycin to the CDs. HEMA and DMAA/10% TRIS materials functionalized with MHP-βCD are more effective than those functionalized with MβCD to deliver natamycin. Sharma et al. (2014) compared the efficacy of topical 1% voriconazole vs 5% natamycin for the treatment of fungal keratitis. In a prospective, double-masked, randomised, controlled, registered clinical trial, 118 patients with fungal keratitis were treated using identical dosage schedule with either voriconazole (58) or natamycin (60) as inpatients for 7 days and followed up weekly. The outcome measures were percentage of patients with healed or resolving ulcer and final visual acuity at last follow-up (primary) and on day 7 (secondary) in each group. More patients (p=0.005) on natamycin (50/56, 89.2%) had healed or resolving ulcer compared with voriconazole (34/51, 66.6%) at last follow-up. The improvement in vision was marginally greater in patients in the natamycin group compared with the voriconazole group at day 7 (p=0.04) and significantly greater at final visit (p=0.01). In univariate analysis, drug, age and mean size of corneal infiltrate and epithelial defect had a significant effect on the final visual outcome. In multivariate analysis, the effect of drug (voriconazole vs natamycin, adjusted coefficient 0.27 (-0.04 to 0.57), p=0.09) was marginal while the effect of age and epithelial defect was significant (p<0.001 for both). In the group treated with natamycin, the final visual acuity was significantly better (p=0.005, Wilcoxon signed-rank test) in patients with Fusarium keratitis but not with Aspergillus keratitis (p=0.714, paired t test). When compared with 117 voriconazole, natamycin was more effective in the treatment of fungal keratitis, especially Fusarium keratitis. Wang et al (2014) carried a trial to alleviate oxygen limitation and enhance the yield of natamycin, the vgb gene, encoding Vitreoscilla hemoglobin (VHb) was inserted into pSET152 with its native promoter and integrated into the chromosome of Streptomyces gilvosporeus (S. gilvosporeus). The expression of VHb was determined by Western blotting. The activity of expressed VHb was confirmed by the observation of VHb-specific CO-difference spectrum with a maximal absorption at 419 nm for the recombinant. Integration of the empty plasmid pSET152 did not affect natamycin production of S. gilvosporeus. While the vgb-harboring strain exhibited high natamycin productivity, reaching 3.31 g/L in shake flasks and 8.24 g/L in 1-L fermenters. Compared to the wild strain, expression of VHb, increased the natamycin yield of the strain bearing vgb by 131.3 % (jar fermenter scale) and 175 % (shake flask scale), respectively, under certain oxygen-limiting condition. Addition of an extra copy of the vgb gene in S. gilvosporeusvgb2 did not enhance the natamycin production obviously. These results provided a superior natamycin-producing strain which can be directly used in industry and a useful strategy for increasing yields of other metabolites in industrial strains. Wu et al. (2014) performed a study aimed at cloning and overexpressing a natamycin-positive regulator, slnM2, with different promoters in the newly isolated strain Streptomyces lydicus A02, which is capable of producing natamycin. The slnM gene in S. lydicus is highly similar to gene pimM (scnRII), the pathway-specific positive regulator of natamycin biosynthesis in S. natalensis and S. chattanoogensis, which are PAS-LuxR regulators. Three engineered strains of S. lydicus, AM01, AM02 and AM03, were generated by inserting an additional copy of slnM2 with an ermEp* promoter, inserting an additional copy of slnM2 with dual promoters, ermEp* and its own promoter, and inserting an additional copy of slnM2 with its own promoter, respectively. No obvious changes in growth were observed between the engineered and wildtype strains. However, natamycin production in the engineered strains was significantly enhanced, by 2.4-fold in strain AM01, 3.0-fold in strain AM02 and 1.9-fold in strain AM03 when compared to the strain A02 in YEME medium without sucrose. These results indicated that the ermEp* promoter was more active than the native promoter of slnM2. Overall, dual promoters displayed the highest transcription of biosynthetic genes and yield of natamycin. Phan et al. (2013) investigated the uptake and release of the antifungal ocular drug, natamycin from commercially available conventional hydrogel (CH) and silicone hydrogel (SH) contact lens (CL) materials and to evaluate the effectiveness of this delivery method. Five commercial SH CLs (balafilcon A, comfilcon A, galyfilcon A, senofilcon A, and lotrafilcon B) and four CH CLs (etafilcon A, omafilcon A, polymacon, vifilcon A) were examined in this study. These lenses were incubated with natamycin solubilized in dimethyl sulfoxide, and the release of the drug from these lenses, in Unisol 4 pH 7.4 at 32±1°C, was determined using UVvisible spectrophotometry at 305 nm over 24 hours. There was a significant uptake of natamycin between 0 hour and 24 hours (P<0.05) for all CL materials. However, there was no significant difference between any of the lens materials, regardless of their composition (P>0.05). There was a significant difference in release between all the SH materials (P<0.05) and CH materials (P<0.05). All CL materials showed a significant increase in the release of natamycin until 1 hour (P<0.05), which was followed by a plateau (P>0.05). Overall, the release of natamycin was higher in CH than SH lenses (P<0.001). It was concluded that all CLs released clinically relevant concentrations of natamycin within 30 minutes, but this release 118 reached a plateau after approximately 1 hour. Further CL material development will be necessary to produce a slow and sustained drug releasing device for the delivery of natamycin. Prajna et al. (2013) carried out a randomized trial comparing natamycin vs voriconazole. This phase 3, double-masked, multicenter trial was designed to randomize 368 patients to voriconazole (1%) or natamycin (5%), applied topically every hour while awake until reepithelialization, then 4 times daily for at least 3 weeks. Eligibility included smear-positive filamentous fungal ulcer and visual acuity of 20/40 to 20/400. The primary outcome was best spectacle-corrected visual acuity at 3 months; secondary outcomes included corneal perforation and/or therapeutic penetrating keratoplasty.A total of 940 patients were screened and 323 were enrolled. Causative organisms included Fusarium (128 patients [40%]), Aspergillus (54 patients [17%]), and other filamentous fungi (141 patients [43%]). Natamycintreated cases had significantly better 3-month best spectacle-corrected visual acuity than voriconazole-treated cases (regression coefficient=0.18 logMAR; 95% CI, 0.30 to 0.05; P=.006). Natamycin-treated cases were less likely to have perforation or require therapeutic penetrating keratoplasty (odds ratio=0.42; 95% CI, 0.22 to 0.80; P=.009). Fusarium cases fared better with natamycin than with voriconazole (regression coefficient=0.41 logMAR; 95% CI,0.61 to 0.20; P<.001; odds ratio for perforation=0.06; 95% CI, 0.01 to 0.28; P<.001), while non-Fusarium cases fared similarly (regression coefficient=0.02 logMAR; 95% CI, 0.17 to 0.13; P=.81; odds ratio for perforation=1.08; 95% CI, 0.48 to 2.43; P=.86). It wasconcluded that Natamycin treatment was associated with significantly better clinical and microbiological outcomes than voriconazole treatment for smear-positive filamentous fungal keratitis, with much of the difference attributable to improved results in Fusarium cases. Voriconazole should not be used as monotherapy in filamentous keratitis. Kallinteri et al. (2013) evaluated the use of nisin, natamycin and/or their combination as antimicrobial treatments to improve the shelf-life of Galotyri cheese. Samples were treated with nisin [N1 (100 IU/g), N2 (200 IU/g)], natamycin [NA1 (0.01% w/w), NA2 (0.02% w/w)] and their combinations N1-NA1, N1-NA2, N2-NA1 and N2-NA2. A Galotyri control (N0) cheese sample was also tested (absence of nisin or natamycin). Single N1, N2 treatments reduced lactobacilli and lactococci populations, but their effect was less pronounced, as compared to the combined nisin-natamycin treatments between days 14 and 28 of storage. Yeast populations in natamycin-treated Galotyri cheese samples or those additionally treated with nisin were significantly suppressed throughout the entire period of storage. Control N0 or N1, N2 treated samples received significantly lower acceptability scores, as compared to either natamycin or natamycin-nisin treated samples. Natamycin, added either singly or in combination with nisin, efficiently suppressed fungal growth in the Galotyri cheese. The observed shelf life of Galotyri, based on overall acceptability data, was the longest for N1-NA1, N1-NA2, N2-NA1 and N2-NA2 cheese samples (>28 days) followed by the N1, N2 treated samples (18-19 days) whereas for the control N0 a shelf-life of 14-15 days was attained. Zeng et al. (2013) conducted a series of experiments to investigate the solubility of natamycin in some selected organic solvents in order to assess the influence on natamycin extraction yield. Natamycin showed the highest solubility in 75% aqueous methanol under the conditions of pH 2, 30°C and 1 atm. 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In vitro uptake and release of natamycin from conventional and silicone hydrogel contact lens materials. Eye Contact Lens. 2013 Mar;39(2):162-8. 47. Phan CM1, Subbaraman L, Liu S, Gu F, Jones L. In vitro uptake and release of natamycin Dex-bPLA nanoparticles from model contact lens materials. J Biomater Sci Polym Ed. 2014;25(1):1831. 112 48. Phan CM1, Subbaraman LN, Jones L. In vitro drug release of natamycin from β-cyclodextrin and 2-hydroxypropyl-β-cyclodextrin-functionalized contact lens materials. J Biomater Sci Polym Ed. 2014;25(17):1907-19 49. Pintado CMBS, Ferreira MASS, Sousa I. Control of pathogenic and spoilage microorganisms from cheese surface by whey protein films containing malic acid, nisin and natamycin. Food Control. 2010;21:240–246. 50. Pipek P, Rohlík B-A, Lojková A, Staruch L. Suppression of mould growth on dry sausages. Czech J Food Sci. 2010;28:258–263. 51. 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Solution NMR structure of five representative glycosylated polyene macrolide antibiotics with a sterol-dependent antifungal activity. Eur J Biochem. 2002;269:4533– 4541. doi: 10.1046/j.1432-1033.2002.03147.x. 68. Wang S1, Liu F, Hou Z, Zong G, Zhu X, Ling P. Enhancement of natamycin production on Streptomyces gilvosporeus by chromosomal integration of the Vitreoscilla hemoglobin gene (vgb). World J Microbiol Biotechnol. 2014 Apr;30(4):1369-76. 69. Wang M1,2, Wang S1,2, Zong G1,2, Hou Z1,2, Liu F1,2, Liao DJ3, Zhu X1,2. Improvement of Natamycin Production by Cholesterol Oxidase Overexpression in Streptomyces gilvosporeus. J Microbiol Biotechnol. 2016 Feb;26(2):241-7. 70. Wu H1, Liu W, Dong D, Li J, Zhang D, Lu C. SlnM gene overexpression with different promoters on natamycin production in Streptomyces lydicus A02. J Ind Microbiol Biotechnol. 2014 Jan;41(1):163-72. doi: 10.1007/s10295-013-1370-7. Epub 2013 Oct 31. 71. Zeng X1, Danquah MK, Jing K, Woo MW, Chen XD, Xie Y, Lu Y. Solubility properties and diffusional extraction behavior of natamycin from Streptomyces gilvosporeus biomass. Biotechnol Prog. 2013 Jan-Feb;29(1):109-15. doi: 10.1002/btpr.1659. Epub 2012 Dec 4. 4. Selvamicin  Selvamicin is an antifungal compound made by Pseudonocardia bacteria isolated from Apterostigma ants in neighboring colonies at sites in Costa Rica. Background, Van Arnam et al., 2016  Fungus-growing ants range from central Argentina to New York State, and in tropical regions they are the dominant herbivores. 114      The complex web of interactions involving these ants, their fungal crops (Basidiomycetes), specialized pathogens, and symbiotic bacteria has become both a model system for chemical ecology and a productive source of naturally occurring small molecules . Fungus-growing ants collect plant material to feed their fungal crop, which metabolizes the plant matter to provide nutrients for the ants. Pathogenic ascomycetous fungi, especially members of the genus Escovopsis, threaten the fungal crop. In response, the ants maintain antibiotic-producing Actinobacteria (genus Pseudonocardia) to provide chemical defenses. These bacteria produce antifungal and/or antibacterial agents, including representatives of both nonribosomal peptide synthetase and polyketide synthase (PKS) biosynthetic pathways. Apterostigma - Alex Wild Photography Escovopsis sp. parasites from fungus-growing ants. (a) General aspect of Escovopsis sp. isolated from the leaf-cutting ant Atta sexdens rubropilosa (Corumbata´ı, Brazil) cultured in potato dextrose agar (PDA) for 6 days at 25◦C. (b) Close view of Escovopsis sp. Isolated from Acromyrmex lobicornis (Santa F´e, Argentina) in PDA after 5 days at 25◦C. (c) Escovopsis sp. conidiophores from (a). Note the cylindrical vesicles covered with ampulliform phialides. Fernando C. Pagnocca et al. 2012 115 Pseudonocardia carboxydivorans Scanning electron microscope of Pseudonocardia endophytica VUK-10 (×6500) A laboratory culture of Pseudonocardia at the University of Texas. Bacteria in this group live on the surface of leafcutting ants, where they help protect their hosts against disease. Austin, Texas, USA History of the discovery       UCR researcher Adrián Pinto said that scientists started studying ants at La Selva Biological Station in 2009, particularly the Apterostigma ants that cultivate and feed on a genus of fungus known as Leucoagaricus (Agaricaceae, Basidiomycota) As part of a systematic study of Pseudonocardia isolates derived from the basal fungusgrowing ant genus Apterostigma, researchers from the University of Costa Rica, Wisconsin University, and Harvard University discovered an unusual antifungal polyene. Researchers named the molecule Selvamicin in honor of the place where they discovered it: La Selva Biological Station, part of the Organization for Tropical Studies Selvamicin was found in two bacterial isolates from nearby ant nests. Selvamicin shares features with the clinically important antifungal agents amphotericin B and nystatin A The ant bacterium-related antibiotic is included in the polyene antifungal agents group of amphotericin B and nystatin A1. Structures of selvamicin Van Arnam et al., 2016  UCR experts identified the ants‘ habitat, collected bacteria samples and cultivated them at their laboratories. They then selected the best samples, tested the Selvamicin on various types of fungi and found that it is effective in killing those fungi. 116  Selected samples then were sent to Wisconsin for genetic analysis and also to Harvard for chemical analysis.  The discovered molecule can stop the growth of fungal species Candida albicans which can affect the vagina, mouth, intestine, and skin of humans. The information about the discovery of Selvamicin was published in the Proceedings of the National Academy of Science of the United States of America.  Molecular studies    Using genome sequencing and other approaches, the researchers compared selvamicin biosynthesis by Pseudonocardia isolates from ants in neighboring colonies at sites in Costa Rica. The same cluster of selvamicin biosynthesis genes turned up in microbes from both ant colonies, they report, though one of these was located on a plasmid and the other was embedded in a bacterial chromosome. "These alternative genomic contexts illustrate the biosynthetic gene cluster mobility that underlies the diversity and distribution of chemical defenses by the specialized bacteria in this multi-lateral symbiosis," the group writes. This Week in PNAS Nov 08, 2016 Antifungal Activity and Solubility.     Selvamicin has antifungal activity against C. albicans (minimum inhibitory concentration, MIC, = 23 μM), with similar activity observed across a panel of fungi (Saccharomyces cerevisiae, Aspergillus fumigatus, and Trichoderma harzianum, Selvamicin has more modest antifungal activity than clinically used antifungal polyenes such as nystatin A1 (MIC = 1.0 μM against C. albicans). Selvamicin‘s improved solubility, despite its lack of charged carboxylate and ammonium groups, is probably contributed by its second sugar moiety. Glycosylation has been reported to improve solubility dramatically in analogs of nystatin; NPP, a diglycosylated analog bearing N-acetylglucosamine, has more than 300-fold greater aqueous solubility than nystatin A1 Growth inhibition of C. albicans, S. cerevisiae, T. harzianum, and A. fumigatus by selvamicin. 117 Recent reports: de Man et al. (2016) demonstrated that Escovopsis weberi, a fungal parasite of the crops of fungus-growing ants, has a reduced genome in terms of both size and gene content relative to closely related but less specialized fungi. Although primary metabolism genes have been retained, the E. weberi genome is depleted in carbohydrate active enzymes, which is consistent with reliance on a host with these functions. E. weberi has also lost genes considered necessary for sexual reproduction. Contrasting these losses, the genome encodes unique secondary metabolite biosynthesis clusters, some of which include genes that exhibit up-regulated expression during host attack. Thus, the specialized nature of the interaction between Escovopsis and ant agriculture is reflected in the parasite's genome Van Arnam et al. (2016) mentioned that the bacteria harbored by fungus-growing ants produce a variety of small molecules that help maintain a complex multilateral symbiosis. In a survey of antifungal compounds from these bacteria, we discovered selvamicin, an unusual antifungal polyene macrolide, in bacterial isolates from two neighboring ant nests. Selvamicin resembles the clinically important antifungals nystatin A1 and amphotericin B, but it has several distinctive structural features: a noncationic 6-deoxymannose sugar at the canonical glycosylation site and a second sugar, an unusual 4-O-methyldigitoxose, at the opposite end of selvamicin's shortened polyene macrolide. It also lacks some of the pharmacokinetic liabilities of the clinical agents and appears to have a different target. Whole genome sequencing revealed the putative type I polyketide gene cluster responsible for selvamicin's biosynthesis including a subcluster of genes consistent with selvamicin's 4-O-methyldigitoxose sugar. Although the selvamicin biosynthetic cluster is virtually identical in both bacterial producers, in one it is on the chromosome, in the other it is on a plasmid. These alternative genomic contexts illustrate the biosynthetic gene cluster mobility that underlies the diversity and distribution of chemical defenses by the specialized bacteria in this multilateral symbiosis. Meirelles et al. (2015) mentioned that since the formal description of fungi in the genus Escovopsis in 1990, only a few studies have focused on the systematics of this group. For more than two decades, only two Escovopsis species were described; however, in 2013, three additional Escovopsis species were formally described along with the genus Escovopsioides, both found exclusively in attine ant gardens. During a survey for Escovopsis species in gardens of the lower attine ant Mycetophylax morschi in Brazil, we found four strains belonging to the pink-colored Escovopsis clade. Careful examination of these strains revealed significant morphological differences when compared to previously described species of Escovopsis and Escovopsioides. Based on the type of conidiogenesis (sympodial), as well as morphology of conidiogenous cells (percurrent), non-vesiculated conidiophores, and DNA sequences, we describe the four new strains as a new species, Escovopsis kreiselii sp. nov. Phylogenetic analyses using three nuclear markers (Large subunit RNA; translation elongation factor 1-alpha; and internal transcribed spacer) from the new strains as well as available sequences in public databases confirmed that all known fungi infecting attine ant gardens comprise a monophyletic group within the Hypocreaceae family, with very diverse morphological characteristics. Specifically, Escovopsis kreiselii is likely associated with gardens of lower-attine ants and its pathogenicity remains uncertain. 118 References: 1. de Man TJ1, Stajich JE2, Kubicek CP3, Teiling C4, Chenthamara K3, Atanasova L3, Druzhinina IS3, Levenkova N4, Birnbaum SS1, Barribeau SM5, Bozick BA1, Suen G6, Currie CR6, Gerardo NM7. Small genome of the fungus Escovopsis weberi, a specialized disease agent of ant agriculture. Proc Natl Acad Sci U S A. 2016 Mar 29;113(13):3567-72. 2. Meirelles LA1, Montoya QV1, Solomon SE2, Rodrigues A1. New light on the systematics of fungi associated with attine ant gardens and the description of Escovopsis kreiselii sp. nov. PLoS One. 2015 Jan 24;10(1):e0112067 3. Navid Adnani, Scott R. Rajski, Tim S. Bugni. Symbiosis-inspired Approaches to Antibiotic Discovery. Nat Prod Rep. Author manuscript; available in PMC 2018 Jul 6.Published in final edited form as: Nat Prod Rep. 2017 Jul 6; 34(7): 784– 814. doi: 10.1039/c7np00009j 4. Van Arnam EB, Antonio C. Ruzzinia, Clarissa S. Sita, Heidi Hornb, Adrián A. PintoTomásc,d,e,Cameron R. Currieb, and Jon Clardya, Selvamicin, an atypical antifungal polyene from two alternative genomic contexts. PNAS,12940–12945 vol. 113 no. 4 (2016) 5. Nikkomycins           Nikkomycins are a group of peptidyl nucleoside antibiotics produced by Streptomyces ansochromogenes and Streptomyces tendae , Nikkomycins are potent competitive inhibitors of chitin synthase. Nikkomycins are structurally similar to UDP-N-acetylglucosamine which is the natural substrate of chitin synthase. So they can inhibit the growth of insects, acarids, yeasts, and filamentous fungi. Nikkomycin X and Z, main components produced by both S. ansochromogenes and S. tendae, are the most active structures. Nikkomycins are composed of hydoxypyridylhomethreonine (nikkomycin D) and a 5aminohexuronic acid N-glucosidically bound to uracil in nikkomycin Z or to 4-formyl-4imidazolin-2-one (imidazolone) in nikkomycin X. The corresponding nucleoside moieties are designated as nikkomycin Cz and Cx. Nikkomycin I and J, produced as minor components by S. tendae but not by S. ansochromogenes, are structurally analogous to nikkomycin X and nikkomycin Z and contain glutamic acid peptidically bound to the 6'-carboxyl group of aminohexuronic acid Nikkomycin Z had significant activity against the highly chitinous, pathogenic, dimorphic fungi Coccidioides immitis and Blastomyces dermatitidis Nikkomycin Z is in phase I/II clinical research as an orphan product for treatment of occiciodomycosis is undergoing. Nikkomycins Z has synergetic effect with azoles and echinocandins against Candida albicas and Aspergillus fumigatus 119 Chemical structures of nikkomycin X (A) and Z (B), the main components produced by Streptomyces ansochromogenes Mode of Actions Nikkomycin Z acts as an anti-fungal agent by blocking the enzyme responsible for the production of chitin, a building block in fungal cell walls. Chitin synthase is absent in humans and animals making this compound an attractive agent for antifungal drug discovery research. Streptomyces tendae is a bacterium species from the genus of Streptomyces which has been isolated from soil in France. Streptomyces tendae produces carbomycin, streptofactin, geosmin, cervimycin A-D and nikkomycins 121 Micrographs of biosurfactant-producing actinomycetes;Streptomyces sp Recent reports: Shubitz et al. (2014) described here focus on bracketing NikZ doses for phase 2 and 3 clinical trials, using an established mouse respiratory infection as a model and starting treatment 120 hours after infection. A dose of 80 mg/kg/day, divided into 2 doses, nearly eradicated infection, and larger doses did not improve fungal clearance. Increasing the duration of treatment from 1 week to 3 weeks resulted in a greater percentage of culture-negative mice. Comparative data show that plasma levels of NikZ that nearly eradicate Coccidioides in mice are achievable in patients and provide a plausibly effective dose range for initial phase 2 clinical studies. Galgiani and Galgiani (2013) mentioned that coccidioidomycosis (Valley Fever) is an orphan fungal infection endemic to the US southwest, for which approximately 50,000 persons seek medical attention each year. It disproportionately affects Native Americans who live there, and severe infections are much more likely in African-Americans and Filipinos. Also at particular risk are immunosuppressed patients such as those with AIDS or recipients of organ transplants, pregnant women, the elderly and military personnel who train in the endemic desert regions. The fungi that cause Valley Fever are potential agents of bioterrorism. Currently available medical treatments are only partially effective and do not cure infections. Nikkomycin Z is a first-in-class antifungal drug which inhibits fungal cell wall development. The drug's targets, chitin synthases, play important roles to support fungal growth but chitin is not found in mammals and the genes for enzymes that make chitin do not exist in the human genome. Because of this difference, effects of nikkomycin Z should be very selective for its antifungal effect and potentially very safe if administered to humans as a medical therapeutic. In experimental animal infections, nikkomycin Z has been shown to be curative. In ongoing multi-dose human safety Phase I trials nikkomycin Z has thus far showed little or no toxicity. Our hypothesis is that early treatment of coccidioidal infections will safely eradicate infection, thereby preventing serious complications and avoiding the chronic morbidity that now requires many years or even life-long treatment with conventional medications. We will need to continue clinical trials to test this hypothesis in humans. If commercialization of nikkomycin Z is successful, the Valley Fever Solutions 121 business plan projects $250 million annual revenue within 5 years of NDA approval. In order to attract the needed pharmaceutical investment to do this, we propose to reduce the development risk for a partner by 1) creating a less expensive manufacturing process and 2) using the drug produced by the new process in an initial efficacy trial in humans (""""""""Phase II"""""""" in the FDA drug approval sequence). Our new manufacturing process is based upon a strain of the drug-producing bacteria that we have genetically modified. The modifications have interrupted the synthesis of an inactive metabolite (nikkomycin X) that made the previous purification of nikkomycin Z very inefficient, and expensive. By eliminating nikkomycin X, fewer steps will be needed and more of the produced nikkomycin Z will be recovered in the purification process, thus reducing the overall cost of goods. The clinical trial that we propose for our second aim will compare therapeutic responses in groups of subjects receiving one of three different dose/durations of nikkomycin Z or placebo treatments. This should provide the basis for future pivotal trials. References: 1. Galgiani, John N., Larwood, David, Nikkomycin Z. treatment of early coccidioidal pneumonia: Phase II clinical trial. https://arizona.pure.elsevier.com/en/projects/nikkomycin-z-treatment-of-earlycoccidioidal-pneumonia-phase-ii-c 2. Shubitz LF1, Trinh HT2, Perrill RH2, Thompson CM3, Hanan NJ4, Galgiani JN5, Nix DE6. Modeling nikkomycin Z dosing and pharmacology in murine pulmonary coccidioidomycosis preparatory to phase 2 clinical trials. J Infect Dis. 2014 Jun 15;209(12):1949-54. 6. Rimocidin Chemical Names: Rimocidin; Rimocidine; 1393-12-0; UNII-72LLC1Q06O; AC1O5UB6; 72LLC1Q06O Molecular Formula: C39H61NO14 Recent reports: Jeon et al. (2016) performed a study to explore antifungal metabolites targeting fungal cell envelope and to evaluate the control efficacy against anthracnose development in pepper plants. 122 A natural product library comprising 3000 microbial culture extracts was screened via an adenylate kinase (AK)-based cell lysis assay to detect antifungal metabolites targeting the cell envelope of plant-pathogenic fungi. The culture extract of Streptomyces mauvecolor strain BU16 displayed potent AK-releasing activity. Rimocidin and a new rimocidin derivative, BU16, were identified from the extract as active constituents. BU16 is a tetraene macrolide containing a sixmembered hemiketal ring with an ethyl group side chain instead of the propyl group in rimocidin. Rimocidin and BU16 showed broad-spectrum antifungal activity against various plant-pathogenic fungi and demonstrated potent control efficacy against anthracnose development in pepper plants. CONCLUSIONS: Antifungal metabolites produced by S. mauvecolor strain BU16 were identified to be rimocidin and BU16. The compounds displayed potent control efficacy against pepper anthracnose. Rimocidin and BU16 would be active ingredients of disease control agents disrupting cell envelope of plant-pathogenic fungi. The structure and antifungal activity of rimocidin derivative BU16 is first described in this study. References: 1. Jeon BJ1, Kim JD1, Han JW1, Kim BS1,2. Antifungal activity of rimocidin and a new rimocidin derivative BU16 produced by Streptomyces mauvecolor BU16 and their effects on pepper anthracnose. J Appl Microbiol. 2016 May;120(5):1219-28. 7. Filipin      Filipin is a 28-membered ring pentaene macrolide antifungal antibiotic produced by S. filipinensis, S. avermitilis, and S. miharaensis. Filipin is devoid of sugar, and constitutes the archetype of non-glycosylated polyenes. Filipin also interacts with membrane sterols causing the alteration of membrane structure. Filipin shows a similar affinity for both ergosterol (the main sterol in fungal membranes) than for cholesterol-containing membranes (the sterol in mammalian cells). This property makes it useless for its application in human therapy due to its toxic side effects. Recent reports: Payero et al. (2015) described the late biosynthetic steps for filipin III biosynthesis and strategies for the generation of bioactive filipin III derivatives at high yield. A region of 13,778 base pairs of DNA from the S. filipinensis genome was isolated, sequenced, and characterized. 123 Nine complete genes and two truncated ORFs were located. Disruption of genes proved that this genomic region is part of the biosynthetic cluster for the 28-membered ring of the polyene macrolide filipin. This set of genes includes two cytochrome P450 monooxygenase encoding genes, filC and filD, which are proposed to catalyse specific hydroxylations of the macrolide ring at C26 and C1' respectively. Gene deletion and complementation experiments provided evidence for their role during filipin III biosynthesis. Filipin III derivatives were accumulated by the recombinant mutants at high yield. These have been characterized by mass spectrometry and nuclear magnetic resonance following high-performance liquid chromatography purification thus revealing the post-polyketide steps during polyene biosynthesis. Two alternative routes lead to the formation of filipin III from the initial product of polyketide synthase chain assembly and cyclization filipin I, one trough filipin II, and the other one trough 1'-hydroxyfilipin I, all filipin III intermediates being biologically active. Moreover, minimal inhibitory concentration values against Candida utilis and Saccharomyces cerevisiae were obtained for all filipin derivatives, finding that 1'-hydroxyfilipin and especially filipinII show remarkably enhanced antifungal bioactivity. Complete nuclear magnetic resonance assignments have been obtained for the first time for 1'-hydroxyfilipin I References: 1. Payero TD1,2, Vicente CM3,4, Rumbero Á5, Barreales EG6, Santos-Aberturas J7,8, de Pedro A9, Aparicio JF10. Functional analysis of filipin tailoring genes from Streptomyces filipinensis reveals alternative routes in filipin III biosynthesis and yields bioactive derivatives. Microb Cell Fact. 2015 Aug 7;14:114. 124 7.2. Echinocardins Discovery of echinocandins            Discovery of echinocandins stemmed from studies on papulacandins isolated from a strain of Papularia sphaerosperma (Pers.), which were liposaccharide - i.e., fatty acid derivatives of a disaccharide that also blocked the same target, 1,3-? glucan synthase and had action only on Candida spp. (narrow spectrum). Screening of natural products of fungal fermentation in the 1970s led to the discovery of echinocandins, a new group of antifungals with broad-range activity against Candida spp. Echinocandin B is one of the first echinocandins of the pneumocandin type, discovered in 1974, Echinocandin B could not be used clinically due to risk of high degree of hemolysis. Cilofungin was obtained by screening semisynthetic analogs of the echinocandins Cilofungin is the first echinofungin analog to enter clinical trials, in 1980, Cilofungin was later withdrawn for a toxicity due to the solvent system needed for systemic administration. Pneumocandin is a semisynthetic analogs of echinocandins found to have the same kind of antifungal activity, but low toxicity. Caspofungin, micafungin and anidulafungin were the approved echinocandins o January 2001: Caspofungin was approved in by the US Food and Drug Administration (FDA) for the treatment of invasive fungal infections (IFIs) in adults (July 2008 for use in children >3 months of age), o March 2005: Micafungin was approved. o February 2006: Anidulafungin was approved. All these preparations so far have low oral bioavailability, so must be given intravenously only. Echinocandins have now become one of the first-line treatments for Candida before the species are identified, and even as antifungal prophylaxis in hematopoietic stem cell transplant patients. Definition Echinocandins are a new class of antifungal drugs that inhibit the synthesis of glucanin the cell wall, via noncompetitive inhibition of the enzyme 1,3-? glucan synthaseand are thus called "penicillin of antifungals" (a property shared with papulacandins) as penicillin has a similar mechanism against bacteria but not fungi. Beta glucans are carbohydrate polymers that are crosslinked with other fungal cell wall components (The bacterial equivalent is peptidoglycan). Caspofungin, micafungin, and anidulafungin are semisynthetic echinocandin derivatives with clinical use due to their solubility, antifungal spectrum, and pharmacokinetic properties. 125 Spectrum of activity and uses      Echinocandins are fungicidal against some yeasts (most species of Candida, but not against Cryptococcus, Trichosporon, and Rhodotorula). Echinocandins also have displayed activity against Candida biofilms, especially in synergistic activity with amphotericin B and additive activity with fluconazole. Echinocandins are fungistatic against some moulds (Aspergillus, but not Fusarium and Rhizopus), and modestly or minimally active against dimorphic fungi (Blastomyces and Histoplasma). Echinocandins have some activity against the spores of the fungus Pneumocystis carinii. o Caspofungin is used in the treatment of febrile neutropenia and as salvage therapy for the treatment of invasive aspergillosis. o Micafungin is used as prophylaxis against Candida infections in hematopoietic stem cell transplantation patients. Due to their limited oral bioavailability, echinocandins are administered through intravenous infusion. Side effects Echinocandin toxicity is uncommon. Its use has been associated with elevated aminotransferases and alkaline phosphatase levels. Chemistry  The present-day clinically used echinocandins are semisynthetic pneumocandins, which are chemically lipopeptide in nature, consisting of large cyclic (hexa)peptoid.  Caspofungin, micafungin, and anidulafungin are similar cyclic hexapeptide antibiotics linked to long modified N-linked acyle fatty acid chains.  The chains act as anchors on the fungal cell membrane to help facilitate antifungal activity. Mechanism of action   Echinocandins noncompetitively inhibit beta-1,3-D-glucan synthase enzyme complex in susceptible fungi to disturb fungal cell glucan synthesis. Beta-glucan destruction prevents resistance against osmotic forces, which leads to cell lysis. 126   Echinocandins have fungistatic activity against Aspergillus species. and fungicidal activity against most Candida spp., including strains that are fluconazole-resistant. Echinocandins may also enhance host immune responses by exposing highly antigenic beta-glucan epitopes that can accelerating host cellular recognition and inflammatory responses. Resistance  Echinocandins resistance is rare. However, cases studies have shown some resistance in C. albicans, C. glabrata, C. lusitaniae, C. tropicalis, and C. parapsilosis. Resistances include alterations in the glucan synthase (Fks1-Fks2 complex) and overexpression of efflux pumps, as well as alterations and/or overexpressions in Erg3 and Erg11. Pharmacokinetics      Echinocandins have poor oral bioavailability due to their large molecular weight Echinocandins are administered by intravenous infusion. Echinocandins large structures limit penetration into cerebrospinal fluid, urine, and eyes. Echinocandins have a high affinity to serum proteins. Echinocandins do not have primary interactions with CYP450 or P-glycoprotein pumps. o Caspofungin has triphasic nonlinear pharmacokinetics, o Micafungin is hepatically metabolized by arylsulfatase, catechol Omethyltransferase, and hydroxylation) o Anidulafungin is degraded spontaneously in the system and is excreted mostly as a metabolite in the urine Interference    Caspofungin has some interference with ciclosporin metabolism, Micafungin has some interference with sirolimus (rapamycin), Anidulafungin needs no dose adjustments when given with ciclosporin, tacrolimus, or voriconazole. Advantages of echinocandins:        broad range (especially against all Candida), thus can be given empirically in febrile neutropenia and stem cell transplant can be used in case of azole-resistant Candida or use as a second-line agent for refractory aspergillosis long half-life (polyphasic elimination: alpha phase 1-2 hours + beta phase 9-11 hours + gamma phase 40-50 hours) low toxicity: only histamine release (3%), fever (2.9%), nausea and vomiting (2.9%), and phlebitis at the injection site (2.9%), very rarely allergy and anaphylaxis not an inhibitor, inducer, or substrate of the cytochrome P450 system, or P-glycoprotein, thus minimal drug interactions lack of interference from renal failure and hemodialysis no dose adjustment is necessary based on age, gender, race 127  better (or no less effective) than amphotericin B and fluconazole against yeast infections Disadvantages of echinocandins:    embryotoxic (category C) thus should be avoided if possible in pregnancy needs dose adjustment in liver disease poor ocular penetration in fungal endophthalmitis 1. Papulacandins    In the course of screening for new antibiotics a strain of Papularia sphaerosperma (current name: Arthrinium phaeospermum), which belongs to the Deuteromycetes, was found to produce a mixture of new antifungal antibiotics. Five structurally related components, namely papulacandins A, B, C, D and E were isolated and purified by chromatographic techniques. The major components present were papulacandins A, B and C, which are strongly active against Candida albicans and several other yeasts, whereas papulacandins D and E are only minor components with lower activity (Traxler et al., 1977) Arthrinium phaeospermum : A. Colony on MEA after 14 days, B-C. Conidiogenous cells giving rise to conidia, D-E. Conidia; Aspergillus nidulans : F. Colonies incubated at 37° C for 7 days on CYA, G. Colonies incubated at 25° C for 7 days on MEA, H. Cleistothecium, I) Hülle cells, J. Asci, K. Ascospore, L. Conidiophore, M. Conidia; Aspergillus wentii : N. A 7 days old colony on MEA at 25° C, O. Conidial heads, P. Conidiophore, Q. Conidial…( Hergholi et al. (2015) 128 Traxler et al. (1987) Reference: Traxler P, Gruner J, Auden JA. Papulacandins, a new family of antibiotics with antifungal activity, I. Fermentation, isolation, chemical and biological characterization of papulacandins A, B, C, D and E. J Antibiot (Tokyo). 1977 Apr;30(4):289-96. 129 2. Pneumocandin     Pneumocandin Bo, also known as pneumocandinB0, pneumocandin B0, pneumocandin B(0) and hydroxy echinocandin, is an organic chemical compound with formula C50H80N8O\ Pneumocandin is a strong antifungal and inhibits the synthesis of β-(1→3)-D-glucan, which is a fundamental component in most cell walls, like the Candida albicans membrane. Pneumocandin B0 is the starting molecule for the first semisynthetic echinocandin antifungal drug, caspofungin acetate. In the wild-type strain, pneumocandin B0 is a minor fermentation product, and its industrial production was achieved by a combination of extensive mutation and medium optimization. Pneumocandin structures and morphology of Glarea lozoyensis. (a) Chemical structures of pneumocandins. (b) Colony of G. lozoyensis on malt yeast agar (left panel); conidiophores and conidia of G. lozoyensis (right panels). 131 3. Echinocandin B   Echinocandin B was the first echinocandin-type antimycotic isolated independently by the researchers of Ciba-Geigy, Sandoz and Eli Lilli from the fermentation broth of ―Aspergillus nidulans var. echinolatus‖, ―Aspergillus nidulans var. roseus‖ and Aspergillus rugulosus in the 1970s in random screening of the available strain collections (Benz et al. 1974; Keller-Juslén et al. 1976; Nyfeler and Keller 1974). Echinocandin B was followed by the isolation and characterization of more than 20 natural echinocandins. All these secondary metabolites are produced by ascomycota fungi, they have a cyclic lipo-hexapeptide structure and they all act as β-1,3-glucan synthase inhibitors Aspergillus (Emericella) nidulans Aspergillus regulosus Representative members of natural echinocandins and their producers (Emri et al., 2013) Echinocandins producer Reference Echinocandin B-D ―Aspergillus nidulans var. echinulatus‖ a Nyfeler and Keller (1974) ―A. nidulans var. roseus‖b Keller-Juslén et al. (1976) A. rugulosus von Traber et al. (1979) A. aculeatus Mizuno et al. 1977 ―A. japonicusvar. aculeatus‖ Satoi et al. (1977) Aculeacin A-G Hino et al. (2001) Mulundocandin deoxymulundocandin Aspergillus sydowi Roy et al. (1987), Mukhopadhyay et al. (1992) 131 Echinocandins producer Reference Pneumocandin A-E Glarea lozoyensisc Schwartz et al. (1989, 1992) Nobel et al. (1991) Pezicula carpinea Cryptosporiopsissp. Morris et al. (1994), Bills et al. (1999) Sporiofungin A-C Cryptosporiopsissp. Tscherter and Dreyfuss (1982) ―Catechol-sulfate‖ echinocandins (FR901379, FR901381-82, FR190293, FR209602-4, FR220897, FR220899, FR227673) Coleophoma empetri Iwamoto et al. (1994); Kanasaki et al. (2006a, b, c) Cryptocandin Cryptosporiopsis quercina Coleophoma crateriformis Chalara sp. Tolypocladium parasiticum Strobel et al. (1999) a The taxonomical position of Aspergillus subspecies is questionable, and therefore their name is not a validly published name (Geiser et al. 2007; Peterson 2008). b This strain was reclassified as A. rugulosus (Tóth et al. 2011) c Originally described as Zalerion arboricola but later reclassified (Bills et al. 1999) References: 1. Chen L1, Li Y1, Yue Q1, Loksztejn A2, Yokoyama K2, Felix EA3, Liu X4, Zhang N1, An Z1, Bills GF1. Engineering of New Pneumocandin Side-Chain Analogues from Glarea lozoyensis by Mutasynthesis and Evaluation of Their Antifungal Activity. ACS Chem Biol. 2016 Oct 21;11(10):2724-2733. 2. Emri T1, Majoros L, Tóth V, Pócsi I. Echinocandins: production and applications. Appl Microbiol Biotechnol. 2013 Apr;97(8):3267-84. doi: 10.1007/s00253-013-4761-9. Epub 2013 Mar 6. 132 4. Semisynthetic echinocandins 1. Anidulafungin     Anidulafungin is a semi-synthetic lipopeptide of the echinocandin B class, synthesized from a fermentation product of Aspergillus nidulans via substitution of the fatty acid side chain. The chemical name for anidulafungin is 1-[(4R, 5R)-4,5- dihydroxy-N(2)-[[4"(pentyloxy)[1,1':4',1"-terphenyl]-4-l]carbonyl]-L-ornithine] echinocandin B. It also possess the similar mechanism of action & a promising broad-spectrum, antifungal activity in vitro and in vivo as CAS . FDA has given its approval against invasive candidiasis, candidemia and esophageal candidiasis Chemical structure of Anidulafungin. Wikipedia  Spectrum of Activity o Anidulafungin demonstrated the most immediate noticeable activity against Candida species including C. glabrata and C. Krusei but showed negligible activity against Cryptococcus neoformans. o The clinically tested assured activity of ANIDU against Aspergillus spp. and other species of filamentous fungi has also been seen. Against C. albicans, C. tropicalis, C. Glabrata and C. krusei, but less against C. famata and C. parapsilosis o The in vitro activity of ANIDU was found superior compared to ITRA and FLUC.  Pharmacokinetics o Single-dose intravenous administration of anidulafungin 35–100 mg to healthy volunteers shows linear pharmacokinetics, with maximum concentration (Cmax) 133 ranging from 1719 ng/mL to 3825 ng/mL, a large volume of distribution (Vd) of 0.72–0.9 L/kg, and long half-life of approximately 40 hours o In children, differences in clearance based on age have not been found for anidulafungin, unlike caspofungin and micafungin. A single study of safety and pharmacokinetics (PK) of 25 neutropenic children demonstrated that dosages of 0.75 mg/kg and 1.5 mg/kg for those 2–17 years of age have similar PK as doses of 50 mg or 100 mg per day in adults for esophageal candidiasis or invasive candidiasis/candidemia, respectively  Adverse Effects o The relevant combinational adverse event rate was 46%, but only 5% of these were directly related to the anidulafungin (Krause et al. 2004a) has been reported. o The most familiar unfavourable events included hypotension (13%), vomiting (13%), constipation (11%), nausea (11%) and pyrexia (11%), but none of them needs dosification. o No systemic infusion-related undesirable reactions or anaphylactic reactions occurred when 1700 doses of anidulafungin were given. o In another study, treatment related hilarious events were reported in only 9.3% of patients. Mechanism of action  Anidulafungin is a semi-synthetic echinocandin with antifungal activity.  Anidulafungin inhibits glucan synthase, an enzyme present in fungal, but not mammalian cells. This results in inhibition of the formation of 1,3-β-D-glucan, an essential component of the fungal cell wall, ultimately leading to osmotic instability and cell death. Metabolism  Hepatic metabolism of anidulafungin has not been observed.  Anidulafungin is not a clinically relevant substrate, inducer, or inhibitor of cytochrome P450 (CYP450) isoenzymes.  Anidulafungin undergoes slow chemical degradation at physiologic temperature and pH to a ring-opened peptide that lacks antifungal activity. Route of elimination Less than 1% of the administered radioactive dose was excreted in the urine. Anidulafungin is not hepatically metabolized Toxicity During clinical trials a single 400 mg dose of anidulafungin was inadvertently administered as a loading dose. No clinical adverse events were reported. The maximum non-lethal dose of anidulafungin in rats was 50 mg/kg, a dose which is equivalent to 10 times the recommended daily dose for esophageal candidiasis (50mg/day). 134 Prescription Products Name Eraxis Dosage Powder, for solution Strength 100 mg Route Intravenous Labeller Pfizer Marketing Start 2010-01-25 Marketing End Not Applicable Eraxis Injection, powder, 100 lyophilized, for solution mg/30mL Intravenous Roerig 2006-02-17 Not Applicable Eraxis Powder, for solution Intravenous Pfizer 2008-01-25 2013-07-19 Eraxis Injection, powder, 50 lyophilized, for solution mg/15mL Intravenous Roerig 2006-02-17 Not Applicable Gd-anidulafungin Powder, for solution Intravenous Genmed A Not Applicable Division Of Pfizer Canada Inc 100 mg 100 mg International/Other Brands Ecalta (Pfizer) / Eraxis 135 Not Applicable Recent reports: Maseda et al. (2016) describes clinical features of IAC in critical patients treated with anidulafungin in Surgical ICUs (SICUs). A practice-based retrospective study was performed including all adults with IAC admitted to 19 SICUs for ≥24h treated with anidulafungin. IAC was documented (Candida isolation from blood/peritoneal fluid/abscess fluid and/or histopathological confirmation) or presumptive (host factors plus clinical criteria without mycological support). Total population and the subgroup of septic shock patients were analyzed. One hundred and thirty nine patients were included, 94 (67.6%) with septic shock, 112 (86.2%) after urgent surgery. Of them, 77.7% presented peritonitis and 21.6% only intraabdominal abscesses. Among 56.8% cases with documented IAC, C. albicans (52.8%) followed by C. glabrata (27.8%) were the most frequent species. Anidulafungin was primarily used as empirical therapy (59.7%), microbiologically directed (20.9%) and anticipated therapy (15.8%). Favourable response was 79.1% (76.6% among patients with septic shock). Intra-SICU mortality was 25.9% (28.7% among patients with septic shock). CONCLUSIONS: Among IACs managed at SICUs, peritonitis was the main presentation, with high percentage of patients presenting septic shock. C. albicans followed by C. glabrata were the main responsible species. Anidulafungin treatment was mostly empirical followed by microbiologically directed therapy, with a favourable safety profile, even among patients with septic shock. Peter et al. (2016) explored, whether Anidulafungin induces eryptosis. Flow cytometry was employed to estimate phosphatidylserine abundance at the erythrocyte surface from annexin-Vbinding, cell volume from forward scatter, [Ca2+]i from Fluo3-fluorescence, abundance of reactive oxygen species (ROS) from DCFDA dependent fluorescence, and ceramide abundance at the erythrocyte surface utilizing specific antibodies. Hemolysis was quantified by measuring haemoglobin concentration in the supernatant. A 48 hours exposure of human erythrocytes to Anidulafungin (1.5 - 6 µg/ml) significantly increased hemolysis and the percentage of annexin-V-binding cells, and significantly decreased forward scatter. Anidulafungin (6 µg/ml) slightly, but significantly inceased Fluo3-fluorescence and the effect of Anidulafungin on annexin-V-binding was slightly, but significantly blunted by removal of extracellular Ca2+. The effect of Anidulafungin on annexin-V-binding was further significantly blunted by the p38 kinase inhibitor SB203580 (2 µM) and NO donor nitroprusside (1 µM). An increase of extracellular K+ concentration significantly blunted the effect of Anidulafungin on cell volume but not on annexin-V-binding. Anidulafungin rather decreased DCFDA fluorescence and the effect of Anidulafungin on annexin-V-binding was not significantly blunted by the antioxidant N-acetylcysteine (1 mM). Moreover, the effect of Anidulafungin on annexin-V-binding was not paralleled by significant increase of ceramide abundance and was not significantly blunted by PKC inhibitor staurosporine (1 µM), casein kinase 1α inhibitor D4476 (10 µM) or pancaspase 136 inhibitor zVAD (10 µM). CONCLUSIONS: Anidulafungin triggers hemolysis and eryptosis with cell shrinkage and phospholipid scrambling of the erythrocyte cell membrane, an effect in part due to Ca2+ entry and activation of p38 kinase. van der Geest et al. (2016) performed a retrospective study to assess these aspects in critically ill patients with invasive candidiasis. All patients in the intensive care unit (ICU) with invasive candidiasis, who were only treated with anidulafungin or micafungin, between January 2012 and December 2014 were retrospectively included. Baseline demographic characteristics, infection characteristics and patient courses were assessed. A total of 63 patients received either anidulafungin (n = 30) or micafungin (n = 33) at the discretion of the attending intensivist. Baseline characteristics were comparable between the two groups, suggesting similar risk for developing invasive candidiasis. Patients with invasive candidiasis and liver failure were more often treated with anidulafungin than micafungin. Response rates were similar for both groups. No difference was observed in 28-day mortality, but 90-day mortality was higher in patients on anidulafungin. Multivariable cox regression analysis showed that age and serum bilirubin were the best parameters for the prediction of 90-day mortality, whereas APACHE II, Candida score and antifungal therapy did not contribute (P > 0.05). None of the patients developed impaired liver function related to antifungal use and no differences were seen in prothrombin time, serum transaminases and bilirubin levels between the groups, after exclusion of patients with liver injury or failure. CONCLUSION: Micafungin can be safely and effectively used in critically ill patients with invasive candidiasis. The observed increased 90-day mortality with anidulafungin can be explained by intensivists unnecessarily avoiding micafungin in patients with liver injury and failure. Sinnollareddy et al. (2015) described the pharmacokinetics (PK) of fluconazole, anidulafungin, and caspofungin in critically ill patients and to compare with previously published data. We also sought to determine whether contemporary fluconazole doses achieved PK/pharmacodynamic (PD; PK/PD) targets in this cohort of intensive care unit patients. The Defining Antibiotic Levels in Intensive care unit patients (DALI) study was a prospective, multicenter point-prevalence PK study. Sixty-eight intensive care units across Europe participated. Inclusion criteria were met by critically ill patients administered fluconazole (n = 15), anidulafungin (n = 9), and caspofungin (n = 7). Three blood samples (peak, mid-dose, and trough) were collected for PK/PD analysis. PK analysis was performed by using a noncompartmental approach. The mean age, weight, and Acute Physiology and Chronic Health Evaluation (APACHE) II scores of the included patients were 58 years, 84 kg, and 22, respectively. Fluconazole, caspofungin, and anidulafungin showed large interindividual variability in this study. In patients receiving fluconazole, 33% did not attain the PK/PD target, ratio of free drug area under the concentration-time curve from 0 to 24 hours to minimum inhibitory concentration (fAUC(0-24)/MIC) ≥100. The fluconazole dose, described in milligrams per kilogram, was found to be significantly associated with achievement of fAUC(0-24)/MIC ≥100 (P = 0.0003). CONCLUSIONS: Considerable interindividual variability was observed for fluconazole, anidulafungin, and caspofungin. A large proportion of the patients (33%) receiving fluconazole did not attain the PK/PD target, which might be related to inadequate dosing. For anidulafungin and caspofungin, dose optimization also appears necessary to minimize variability. Yáñez et al. (2015) retrospectively analyzed 25 patients with allogeneic hematopoietic stem cell transplantation (HSCT) and GVHD - grade III-IV acute GHVD (n = 15), progressive chronic 137 GVHD (n = 7), and "overlap" GVHD (n = 3) - who received intravenous anidulafungin (200 mg on day 1, followed by 100 mg once daily). If necessary, anidulafungin treatment was followed by oral administration of 200 mg voriconazole twice a day or 200 mg posaconazole 3 times daily until patients were considered not at risk for IFD. Twenty-one patients (85%) received anidulafungin as prophylaxis and 5 patients (15%) received it as treatment. Median duration of intravenous anidulafungin administration was 8 days (range 6-17). Seven patients (28%) presented mild adverse effects, with no significant interactions with calcineurin inhibitors. Sequentially, 4 patients received voriconazole and 6 posaconazole. Two patients (8%) developed IFD after anidulafungin withdrawal: 1 with Candida albicans and the other with Mucor, 8 and 5 days after withdrawal, respectively. CONCLUSIONS: results are of interest owing to the absence of data in the literature on anidulafungin use in HSCT patients with GVHD, and suggest that anidulafungin, because of its spectrum, pharmacological profile, low toxicity, and absence of interactions with immunosuppressants, could be a drug of choice in this setting. References: 1. Maseda E1, Rodríguez-Manzaneque M, Dominguez D, González-Serrano M, Mouriz L, Álvarez-Escudero J, Ojeda N, Sánchez-Zamora P, Granizo JJ, Giménez MJ; Intraabdominal candidiasis in surgical ICU patients treated with anidulafungin: A multicenter retrospective study. Rev Esp Quimioter. 2016 Feb;29(1):32-9. 2. Peter T, Bissinger R, Liu G, Lang F. Anidulafungin-Induced Suicidal Erythrocyte Death. Cell Physiol Biochem. 2016;38(6):2272-84. 3. Sinnollareddy MG1,2,3, Roberts JA4,5, Lipman J6,7, Akova M8, Bassetti M9, De Waele JJ10, Kaukonen KM11, Koulenti D12,13, Martin C14,15, Montravers P16, Rello J17, Rhodes A18, Starr T19, Wallis SC20, Dimopoulos G21; Pharmacokinetic variability and exposures of fluconazole, anidulafungin, and caspofungin in intensive care unit patients: Data from multinational Defining Antibiotic Levels in Intensive care unit (DALI) patients Study. Crit Care. 2015 Feb 4;19:33. 4. van der Geest PJ1, Hunfeld NG2,3, Ladage SE2, Groeneveld AB2. Micafungin versus anidulafungin in critically ill patients with invasive candidiasis: a retrospective study. BMC Infect Dis. 2016 Sep 15;16:490. 5. Yáñez L1, Insunza A1, Ibarrondo P1, de Miguel C1, Bermúdez A1, Colorado M1, LópezDuarte M1, Richard C1, Conde E1. Experience with anidulafungin in patients with allogeneic hematopoietic stem cell transplantation and graft-versus-host disease. Transpl Infect Dis. 2015 Oct;17(5):761-7. 138 2. Caspofungin     Caspofungin is a lipopeptide antifungal drug from Merck & Co., Inc. discovered by James Balkovec, Regina Black and Frances A. Bouffard. Caspofungin is a member of the echinocandins. Caspofungin is a 1-[(4R, 5S)-5-[(2-aminoethyl) amino]15-N2-(10,12-dimethyl-1oxotetradecyl)-4-hydroxy-L-ornithine]-5-[(3R)-3-hydroxy-L-ornithine] pneumocandin B0 diacetate. Caspofungin molecular formula is C52H88N10O15 × 2C2H4O2, and Spectrum of activity  Caspofungin has demonstrated in vitro antifungal activity against Aspergillusf umigatus, A. flavus, Candida albicans (including fluconazole-resistant strains), C. glabrata, C. krusei, C. tropicalis, C. parapsilosis, and other Candida species. Pharmacodynamics  Caspofungin is used to treat Aspergillus and Candida infection, and works by inhibiting cell wall synthesis.  There is a potential for resistance development to occur, however in vitro resistance development to Caspofungin by Aspergillus species has not been studied. Mechanism of action  Caspofungin inhibits the synthesis of beta-(1,3)-D-glucan, an essential component of the cell wall of Aspergillus species and Candida species. beta-(1,3)-D-glucan is not present in mammalian cells.  The primary target is beta-(1,3)-glucan synthase. Route of elimination  After single intravenous administration of [3H] caspofungin acetate, excretion of caspofungin and its metabolites in humans was 35% of dose in feces and 41% of dose in urine. Side effect: 139      pain, swelling, or vein irritation around the IV needle; fever, chills, body aches, flu symptoms; swelling in your hands or feet; weakness, muscle cramps, pounding or uneven heart beats; or nausea, stomach pain, loss of appetite, itching, stools, jaundice (yellowing of the skin or eyes). Less serious side effects include:      vomiting, diarrhea; mild skin rash or itching; headache; dizziness, feeling light-headed; or flushing (warmth, redness, or tingly feeling). 141 dark urine, clay-colored Recent reports: Ellepola et al. (2016) determined the in vitro duration of PAFE on 20 C. dubliniensis isolates following transient exposure to caspofungin. Furthermore the impacts of caspofungin-induced PAFE on adhesion to BEC and DAS, GT formation and CSH of these isolates were also determined. After establishing the minimum inhibitory concentration (MIC) of caspofungin, C. dubliniensis isolates were exposed to sub-lethal concentrations (×3 MIC) of caspofungin for 1 hr. Thereafter the duration of PAFE, adhesion to BEC and DAS, GT formation and CSH were determined by previously described in-vitro assays. MIC (μg/mL) of C. dubliniensis isolates to caspofungin ranged from 0.004 to 0.19. Caspofungin-induced mean PAFE on C. dubliniensis isolates was 2.17 hr. Exposure to caspofungin suppressed the ability of C. dubliniensis isolates to adhere to BEC and DAS, form GT and CSH by 69.97%, 71.95%, 90.06% and 32.29% (P < 0.001 for all), respectively. Thus, transient exposure of C. dubliniensis isolates to caspofungin produces an antifungal effect not only by suppressing its growth but also by altering its adhesion traits. Fothergill et al. (2016) evaluated the influence of treated versus untreated polystyrene microtiter trays on caspofungin MICs using 209 isolates of four Candida species, including 16 C. albicans and 11 C. glabrata isolates with defined FKS mutations. CaspofunginMICs were also determined using the commercially available YeastOne and Etest assays and 102 isolates. All C. glabrata isolates had caspofungin MICs of ≥0.5 μg/ml, the clinical breakpoint for caspofungin resistance in this species, measured using trays made of treated polystyrene, regardless of the FKS status. In contrast, susceptible isolates could readily be distinguished from resistant/non-wild-type isolates when caspofungin MICs were measured using untreated polystyrene trays and both the YeastOne and Etest assays. Similar results were also observed for C. krusei isolates, as all isolates had caspofungin MICs above the threshold for resistance measured using treated polystyrene trays. In contrast, C. albicans isolates could be correctly identified as susceptible or resistant when caspofungin MICs were measured with treated or untreated trays and with the YeastOne and Etest assays. MICs falsely elevated above the resistance breakpoint were also not observed for C. tropicalis isolates. These results demonstrated that the use of treated polystyrene may be one factor that leads to falsely elevated caspofungin in vitro susceptibility results and that this may also be a greater issue for some Candida species than for others. Song and Stevens (2016) summarized the existing published data on caspofungin, under the subject headings of chemistry and mechanism of action, spectrum of activity, pharmacodynamics, pharmacokinetics, clinical studies, safety, drug interactions, dosing, and an overview of the drug's current place in therapy. Walker et al. (2015) tested A. fumigatus mutants with the chs gene (encoding chitin synthase) deleted (ΔAfchs) for their response to these agonists to determine the chitin synthase enzymes that were required for the compensatory upregulation of chitin synthesis. Only the ΔAfchsG mutant was hypersensitive to caspofungin, and all other ΔAfchs mutants tested remained capable of increasing their chitin content in response to treatment with CaCl2 and CFW and caspofungin. The resulting increase in cell wall chitin content correlated with reduced susceptibility to caspofungin in the wild type and all ΔAfchs mutants tested, with the exception of the ΔAfchsG mutant, which remained sensitive to caspofungin. In vitro exposure to the chitin synthase inhibitor, nikkomycin Z, along with caspofungin demonstrated synergistic efficacy that was again AfChsG dependent. Dynamic imaging using microfluidic perfusion chambers demonstrated that treatment with sub-MIC caspofungin resulted initially in hyphal tip lysis. 141 However, thickened hyphae emerged that formed aberrant microcolonies in the continued presence of caspofungin. In addition, intrahyphal hyphae were formed in response to echinocandin treatment. These in vitro data demonstrate that A. fumigatus has the potential to survive echinocandin treatment in vivo by AfChsG-dependent upregulation of chitin synthesis. Chitin-rich cells may, therefore, persist in human tissues and act as the focus for breakthrough infections. Muilwijk et al. (2014) explored caspofungin PK in ICU patients. ICU patients receiving caspofungin were eligible. Patients received a loading dose of 70 mg followed by 50 mg daily (70 mg if body weight >80 kg); they were evaluable upon completion of the first PK curve at day 3. Additionally, daily trough samples were taken and a second PK curve was recorded at day 7. PK analysis was performed using a standard two-stage approach. Twenty-one patients were evaluable. Median (range) age and body weight were 71 (45-80) years and 75 (5099) kg. PK sampling on day 3 (n = 21) resulted in the following median (IQR) parameters: AUC0-24 88.7 (72.2-97.5) mg·h/L; Cmin 2.15 (1.40-2.48) mg/L; Cmax 7.51 (6.05-8.17) mg/L; V 7.72 (6.12-9.01) L; and CL 0.57 (0.54-0.77) L/h. PK sampling on day 7 (n = 13) resulted in AUC0-24 107.2 (90.4-125.3) mg·h/L, Cmin 2.55 (1.82-3.08) mg/L, Cmax 8.65 (7.16-9.34) mg/L, V 7.03 (5.51-7.73) L and CL 0.54 (0.44-0.60) L/h. We did not identify any covariates significantly affecting caspofungin PK in ICU patients (e.g. body weight, albumin, liver function). Caspofungin was well tolerated and no unexpected side effects were observed. CONCLUSIONS: Caspofungin PK in ICU patients showed limited intraindividual and moderate interindividual variability, and caspofungin was well tolerated. A standard two-stage approach did not reveal significant covariates. Our study showed similar caspofungin PK parameters in ICU patients compared with non-critically ill patients. Shen et al. (2014) determined the elimination rate and retinal toxicity of caspofungin in this study to assess its pharmacokinetics and safety in the treatment of fungal endophthalmitis. Intravitreal injections of 50 μg/0.1 ml of caspofungin were administered to rabbits. Levels of caspofungin in the vitreous and aqueous humors were determined using high-performance liquid chromatography (HPLC) at selected time intervals (10 min and 1, 2, 4, 8, 16, 24, and 48 h), and the half-lives were calculated. Eyes were intravitreally injected with caspofungin to obtain concentrations of 10 μg/ml, 50 μg/ml, 100 μg/ml, and 200 μg/ml. Electroretinograms were recorded 4 weeks after injections, and the injected eyes were examined histologically. The concentrations of intravitreal caspofungin at various time points exhibited an exponential decay with a half-life of 6.28 h. The mean vitreous concentration was 6.06 ± 1.76 μg/ml 1 h after intravitreal injection, and this declined to 0.47 ± 0.15 μg/ml at 24 h. The mean aqueous concentration showed undetectable levels at all time points. There were no statistical differences in scotopic a-wave and b-wave responses between control eyes and caspofungin-injected eyes. No focal necrosis or other abnormality in retinal histology was observed. Intravitreal caspofungin injection may be considered to be an alternative treatment for fungal endophthalmitis based on its antifungal activity, lower retinal toxicity, and lower elimination rate in the vitreous. More clinical data are needed to determine its potential role as primary therapy for fungal endophthalmitis. References: 142 1. Ellepola AN1, Chandy R2, Khan ZU2, Samaranayake LP3. Caspofungin-induced invitro post-antifungal effect and its impact on adhesion related traits of oral Candida dubliniensis and Candida albicans isolates. Microbiol Immunol. 2016 Mar;60(3):160-7. 2. Fothergill AW1, McCarthy DI1, Albataineh MT1, Sanders C1, McElmeel M1, Wiederhold NP2. Effects of Treated versus Untreated Polystyrene on Caspofungin In Vitro Activity against Candida Species. J Clin Microbiol. 2016 Mar;54(3):734-8. 3. McCormack PL1, Perry CM. Caspofungin: a review of its use in the treatment of fungal infections. Drugs. 2005;65(14):2049-68. 4. Muilwijk EW1, Schouten JA2, van Leeuwen HJ3, van Zanten AR4, de Lange DW5, Colbers A6, Verweij PE7, Burger DM8, Pickkers P9, Brüggemann RJ8. Pharmacokinetics of caspofungin in ICU patients. J Antimicrob Chemother. 2014 Dec;69(12):3294-9. 5. Shen YC1, Liang CY1, Wang CY1, Lin KH1, Hsu MY1, Yuen HL1, Wei LC2. Pharmacokinetics and safety of intravitreal caspofungin. Antimicrob Agents Chemother. 2014 Dec;58(12):7234-9. 6. Song JC1,2, Stevens DA2,3. Caspofungin: Pharmacodynamics, pharmacokinetics, clinical uses and treatment outcomes Crit Rev Microbiol. 2016 Sep;42(5):813-46. 7. Walker LA1, Lee KK1, Munro CA1, Gow NA2. Caspofungin Treatment of Aspergillus fumigatus Results in ChsG-Dependent Upregulation of Chitin Synthesis and the Formation of Chitin-Rich Microcolonies. Antimicrob Agents Chemother. 2015 Oct;59(10):5932-41. 3. Micafungin     Micafungin is a new lipopeptide echinocandin with a broad-spectrum in vitro and in vivo antifungal activity, against both Aspergillus and Candida species. comes to successfully meet in micafungin. Micafungin is derived from Coleophoma empetri through cleavage of a naturally occurring hexapeptide from the fungus and the addition of fatty-N-acyl side-chain. Micafungin sodium is chemically designated as pneumocandin A0, 1-[(4R, 5R)-4, 5dihydroxy-N2 -[4-[5-[4-(pentyloxy)phenyl]-3–24 isoxazolyl]benzoyl]-L-ornithine]-4[(4S)-4-hydroxy-4-[4-hydroxy-3- (sulfooxy) phenyl]-25 L-threonine], monosodium salt. Chemical Names: Micafungin; Mycamine; 235114-32-6; UNII-R10H71BSWG; Micafungin [INN]; R10H71BSWG Molecular formula is C56H70N9NaO23S, 143 Coleophoma empedri, A pathogen of cranberry plants (image from Dr. Patricia McManus, University of WisconsinMadison) from which micafungin is fermented. Mode of action  Micafungin, like other cyclic lipopeptides, noncompetitively inhibits the fungal specific enzyme 1,3-beta-D-glucan synthase, an enzyme essential for fungal cell wall synthesis. Inhibition of this enzyme weakens of the cell wall, thereby leading to osmotic lysis and eventually, fungal cell death.  Spectrum of activity o Aspergillus species are the most diverse group of prominent species against which the MICA are found to be most effective in its action o it is active against the dematiaceous fungi Cladosporium trichoides, Exophiala spinifera, Fonsecaea pedrosoi, and Exophiala dermatitidis. o No activity against Fusarium solani, Pseudallescheria boydii, and the zygomycetes Absidia corymbifera, Cunninghamella elegans, Rhizopus oryzae and Rhizopus microsporus var. rhizopodiformis had been found. o The infections caused by the Candida and Aspergillus species and dematiaceous fungi are particularly treated by Micafungin.  Pharmacokinetics o Micafungin exhibits linear PK over the therapeutic dosing range of 50–150 mg once a day. o No loading dose is required, and doses of 100 mg and 150 mg provide trough concentrations of approximately 2 µg/mL and 2.5 µg/mL on day 1 of therapy. o Micafungin is metabolized into 3 metabolites: M1, M2, and M5.  The M1 metabolite is formed by metabolism of micafungin by arylsulfatase;  M1 is further broken down by catechol-O-methyl-transferase to M2.  The third metabolite, M5, is formed as the side-chain of micafungin is hydrolyzed by the cytochrome P450 isoenzymes (mostly Cytochrome P450, family 3, subfamily A). o Dosing for children has been approved by the FDA; 144 o data suggest linear PK with an inverse relationship between age and clearance, such that dosages of 3–4 mg/kg once daily for children aged 2–8 years, and 2–3 mg/kg once daily for those aged 9–17 years yield similar exposure of drug observed in adults. o Studies in pediatric patients with <15 kg body weight suggest larger volumes of distribution and higher clearance than in children and adults, such that neonatal doses of 10 mg/kg/day may be necessary.  Safety and efficacy o At a dose of 2-10 mg/ kg body weight, MICA was tested enormously effective than AMB or FLUC against an AMB and FLUC-resistant C. tropicalis specimen (Warn et al. 2002). o Although MICA appears to be a validated promising agent for invasive fungal infections it requires further clinical evaluation & confirmatory testings. Recent reports: Auriti et al. (2016) treated 18 preterm neonates and infants with systemic candidiasis, three of whom had meningitis, for at least 14 days with 8 to 15 mg/kg of body weight/day of intravenous micafungin. Plasma micafungin concentrations (four measurements for each patient) were determined after the third dose, and the cerebrospinal fluid (CSF) micafungin concentrations in three patients were also obtained. Population PK analyses were used to identify the optimal model, and the model was further validated using external data (n = 5). The safety of micafungin was assessed by measurement of the levels of liver and kidney function biomarkers. The mean age and weight at the initiation of treatment were 2.33 months (standard deviation [SD], 1.98 months) and 3.24 kg (SD, 1.61 kg), respectively. The optimal PK model was one that scaled plasma clearance to weight and the transaminase concentration ratio. The CSF of three patients was sampled, and the observed concentrations were between 0.80 and 1.80 mg/liter. The model-predicted mean micafungin area under the concentration-time curve 145 over 24 h was 336 mg · h/liter (SD, 165 mg · h/liter) with the 10-mg/kg/day dosage. Eighteen of the 23 subjects (78.2%) had clinical resolution of their infection, but 5 had neurologic impairments. Among the transaminases, alkaline phosphatase measurements were significantly higher posttreatment, with a geometric mean ratio of 1.17 (90% confidence interval, 1.01, 1.37). Furthermore, marked elevations in the gamma-glutamyltransferase (GGT) level were observed in three patients treated with 10- to 15-mg/kg/day doses, and improvement of the GGT level was noted after a dose reduction. Higher weight-based doses of micafungin were generally well tolerated in neonates and infants and achieved pharmacokinetic profiles predictive of an effect Jeong et al. (2016) conducted a prospective randomized study to compare clinical outcomes between micafungin and intravenous itraconazole as an empirical therapy for febrile neutropenia in hematological malignancies. The antifungal drug (micafungin100 mg or itraconazole 200 mg IV once daily) was given for high fever that was sustained despite the administration of appropriate antibiotics. Treatment success was determined by composite end points based on breakthrough invasive fungal infection (IFI), survival, premature discontinuation, defervescence, and treatment of baseline fungal infection. Duration of fever, hospital stay, and overall survival (OS) were studied. A total of 153 patients were randomized to receive micafungin or itraconazole. The overall success rate was 7.1 % point higher in the micafungin group (64.4 vs. 57.3 %, p = 0.404), satisfying the statistical criteria for the non-inferiority of micafungin. The duration of fever and hospital stay were significantly shorter in the micafungin group (6 vs. 7 days, p = 0.014; 22 vs. 27 days, p = 0.033, respectively). Grade 3 adverse events including hyperbilirubinemia (2 vs. 7), elevation of transaminase levels (2 vs. 4), electrolyte imbalance (1 vs. 2), atrial fibrillation (1 vs. 0), and anaphylaxis (1 vs. 0) occurred in 7 and 13 patients in the micafungin (10.4 %) and itraconazole (18.8 %) groups, respectively. Micafungin, when compared with itraconazole, had favorably comparable success rate and toxicity profiles on febrile neutropenia in patients with hematological malignancies. In addition, it showed superior effect on shortening the hospital stay. Schneeweiss et al. (2016) performed a multicentre cohort study of adult and paediatric patients who received micafungin or other PAFs between 2005 and 2012 at seven tertiary care hospitals from six centres in the USA. PAF cohort controls were selected through propensity score (PS) matching to micafungin recipients using clinical characteristics, other treatments, procedures and hospital service where PAF treatment was initiated. Analysis was restricted to patients without chronic liver and kidney conditions at the time of cohort entry. Treatment-emergent hepatic and renal injury was documented by changes in liver enzymes or estimated glomerular filtration rate through 30 days following completion of PAF treatment. Comparisons were quantified using the HR from a proportional hazards analysis. There were 2970 micafungin recipients PS matched to 6726 recipients of comparator PAFs. Balance was achieved in all baseline covariates between treatment groups. There were similar rates of hepatic injury (micafungin, 13 events per 100 patients and other PAF, 12 per 100; HR = 0.99; 95% CI 0.86-1.14) and lower rates of renal injury (micafungin, 63 events per 100 patients and other PAF, 65 per 100; HR = 0.93; 95% CI 0.870.99) for micafungin recipients versus PAF comparators. CONCLUSION: For a wide spectrum of underlying conditions, we observed no increase in liver injury by micafungin and possibly a reduced risk of renal dysfunction in comparison with other PAF medications. Timsit et al. (2016) carried out a study to determine whether empirical micafungin reduces invasive fungal infection (IFI)-free survival at day 28. Multicenter double-blind placebocontrolled study of 260 nonneutropenic, nontransplanted, critically ill patients with ICU-acquired 146 sepsis, multiple Candida colonization, multiple organ failure, exposed to broad-spectrum antibacterial agents, and enrolled between July 2012 and February 2015 in 19 French ICUs. Empirical treatment with micafungin (100 mg, once daily, for 14 days) (n = 131) vs placebo (n = 129). The primary end point was survival without proven IFI 28 days after randomization. Key secondary end points included new proven fungal infections, survival at day 28 and day 90, organ failure, serum (1-3)-β-D-glucan level evolution, and incidence of ventilator-associated bacterial pneumonia. Among 260 patients (mean age 63 years; 91 [35%] women), 251 (128, micafungin group; 123, placebo group) were included in the modified intent-to-treat analysis. Median values were 8 for Sequential Organ Failure Assessment (SOFA) score, 3 for number of Candida-colonized sites, and 99 pg/mL for level of (1-3)-β-D-glucan. On day 28, there were 82 (68%) patients in the micafungin group vs 79 (60.2%) in the placebo group who were alive and IFI free (hazard ratio [HR], 1.35 [95% CI, 0.87-2.08]). Results were similar among patients with a (1-3)-β-D-glucan level of greater than 80 pg/mL (n = 175; HR, 1.41 [95% CI, 0.85-2.33]). Day-28 IFI-free survival in patients with a high SOFA score (>8) was not significantly different when compared between the micafungin vs placebo groups (HR, 1.69 [95% CI, 0.96-2.94]). Use of empirical micafungin decreased the rate of new invasive fungal infection in 4 of 128 patients (3%) in the micafungin group vs placebo (15/123 patients [12%]) (P = .008). CONCLUSIONS AND RELEVANCE: Among nonneutropenic critically ill patients with ICU-acquired sepsis, Candida species colonization at multiple sites, and multiple organ failure, empirical treatment with micafungin, compared with placebo, did not increase fungal infection-free survival at day 28. References: 1. Auriti C1, Falcone M2, Ronchetti MP3, Goffredo BM4, Cairoli S3, Crisafulli R3, Piersigilli F3, Corsetti T5, Dotta A3, Pai MP6. High-Dose Micafungin for Preterm Neonates and Infants with Invasive and Central Nervous System Candidiasis. Antimicrob Agents Chemother. 2016 Nov 21;60(12):7333-7339. 2. Jeong SH1, Kim DY2, Jang JH3, Mun YC4, Choi CW5, Kim SH6, Kim JS7, Park JS8. Efficacy and safety of micafungin versus intravenous itraconazole as empirical antifungal therapy for febrile neutropenic patients with hematological malignancies: a randomized, controlled, prospective, multicenter study. Ann Hematol. 2016 Jan;95(2):337-44. 3. Schneeweiss S1, Carver PL2, Datta K3, Galar A4, Johnson MD5, Johnson MG5, Marty FM3, Nagel J2, Najdzinowicz M6, Saul M7, Shoham S3, Silveira FP7, Varughese CA8, Wilck M6, Weatherby L9, Auton T10, Walker AM9. Short-term risk of liver and renal injury in hospitalized patients using micafungin: a multicentre cohort study. J Antimicrob Chemother. 2016 Oct;71(10):2938-44. 4. Timsit JF1, Azoulay E2, Schwebel C3, Charles PE4, Cornet M5, Souweine B6, Klouche K7, Jaber S8, Trouillet JL9, Bruneel F10, Argaud L11, Cousson J12, Meziani F13, Gruson D14, Paris A15, Darmon M16, Garrouste-Orgeas M17, Navellou JC18, Foucrier A19, Allaouchiche B20, Das V21, Gangneux JP22, Ruckly S23, Maubon D5, Jullien V24, Wolff M1; EMPIRICUS Trial Group. Empirical Micafungin Treatment and Survival Without Invasive Fungal Infection in Adults With ICU-Acquired Sepsis, Candida Colonization, and Multiple Organ Failure: The EMPIRICUS Randomized Clinical Trial. JAMA. 2016 Oct 18;316(15):1555-1564. 147 4. Aminocandin      Aminocandin (IP960; HMR3270; NXL201) is a new echinocandin with broad-spectrum in vitro activity against Aspergillus and Candida spp. Aminocandin is produced from deoxymulundocandin, both via chemical modification of the hexapeptide scaffold is undergoing clinical evaluation and substitution of the fatty acid side chain (Mishra and Tiwari 2011) Aminocandin (IP-960 [formerly HMR3270; Indevus, Lexington, MA and now NXL201; Novexel, Romainville, France]) is an investigational echinocandin currently undergoing preclinical development. Aminocandin, like the other members of the echinocandin class, is a large cyclic semisynthetic lipopeptide that binds to and noncompetitively inhibits the (1→3)-β-Dglucan synthase enzyme located within the cell membrane. Aminocandin inhibits the production of (1→3)-β-D-glucan, a major and essential component of the fungal cell wall that contributes to its shape and integrity Spectrum of activity  Aminocandin has been shown to be a relatively broadspectrum antifungal agent with the greatest activity against Candida and Aspergillus species.  Against Candida non-albicans species, aminocandin MIC values range from 0.03 to 4 μg/mL, with MIC90 values between 1 and 2 μg/mL, and this activity is maintained against isolates that are resistant to fluconazole.  Chemical Formula: C56H79N9O13 B Radha Krishnan1,2, Kenneth D James1,2, Karen Polowy2, B J Bryant2, Anu Vaidya2, Reference: 1. Steve Smith2 and Christopher P Laudeman. CD101, a novel echinocandin with exceptional stability properties and enhanced aqueous solubility. The Journal of Antibiotics (2017) 70, 130–135 148 5. Echinocandin CD101, Krishnan et al. 2017 A novel echinocandin, CD101 acetate (CD101; Figure 1), is presently being developed as a onceweekly i.v. formulation for the treatment and prevention of invasive fungal infections and also as a topical formulation for acute and recurrent vulvovaginal candidiasis. Characteristic of the echinocandins, CD101 is a cyclic hexapeptide with a lipophilic tail. It displays potency and 8, 9 spectrum of activity in vitro typical of the echinocandins. However, it has a distinct structural feature that confers much greater stability, leading to an exceptionally longer half10, 11,12 13 life and an improved safety profile. In this study, we present thermal and solution stability data for CD101 as a lyophilized powder and in various solutions, including prototype i.v. solutions. Solubility data are also presented. The stability and solubility features of CD101 not only provide advantages for manufacturing and storage, but also enable expansion of echinocandin use to include weekly i.v. infusions and topical and s.c. dosage forms. Stability CD101 is a novel echinocandin with a choline moiety at the C5 ornithine residue of the cyclic echinocandin core. The structural modification affords an echinocandin with increased solubility and exceptional stability in plasma, in aqueous and buffered solutions, and as a lyophilized powder. The exceptional stability in plasma and lack of degradation products likely contribute to the long half-lives across species and increased safety observed for CD101. The stability and solubility properties of CD101 suggest benefits to manufacturing and storage as well as flexibility regarding i.v. preparation in pharmacies. These properties may also enable dosage forms new to echinocandins, such as topical, s.c. and fast i.v. push preparations.    A novel echinocandin, CD101 acetate is presently being developed as a once-weekly i.v. formulation for the treatment and prevention of invasive fungal infections and also as a topical formulation for acute and recurrent vulvovaginal candidiasis. The U.S. Food and Drug Administration (FDA) has designated CD101 IV as a Qualified Infectious Disease Product (QIDP) with Fast Track status and orphan drug designation. The designations are for the use of CD101 IV in the treatment of candidemia and invasive candidiasis. The seven-year period of marketing exclusivity provided through orphan designation combined with an additional five years of marketing exclusivity provided by the QIDP designation positions CD101 IV for a total of 12 years of potential marketing exclusivity to be granted at the time of FDA approval. Characteristic of the echinocandins, CD101     CD101 is a cyclic hexapeptide with a lipophilic tail. CD101 displays potency and spectrum of activity in vitro typical of the echinocandins.8, 9 However, CD101 has a distinct structural feature that confers much greater stability, leading to an exceptionally longer half-life10, 11,12 and an improved safety profile.13 In this study, we present thermal and solution stability data for CD101 as a lyophilized powder and in various solutions, including prototype i.v. solutions. Solubility data are also presented. The stability and solubility features of CD101 not only provide advantages for manufacturing 149 and storage, but also enable expansion of echinocandin use to include weekly i.v. infusions and topical and s.c. dosage forms. Structures of CD101 (1) and anidulafungin (2). The primary means of elimination in vivo for anidulafungin is chemical degradation that occurs initially at the hemiaminal region shown in the box. For CD101, the hemiaminal is replaced with a choline aminal ether that imparts greater stability and solubility to the product compound. Animal pharmacokinetics. Ong et al., 2017     CD101 PK profile across all animal species tested (mice, rats, dogs, and nonhuman primates) consistently exhibited a long half-life (i.e., low clearance) following i.v. administration, with a half-life of 81 h in the chimpanzee following a 1-mg/kg dose. Data in the chimpanzee can provide interesting insight for projection and comparison with human PK. CD101 has demonstrated a longer half-life than the currently approved echinocandins, CD101 half-life in human is about 3-fold longer (about 90 h) than that of anidulafungin (about 30 h)\ CD101distribution in tissue as evaluated in rats showed that the mean AUC0–t was lowest in brain tissue and highest in kidney tissue. o CD101 passage across the blood-brain barrier appears to be very low. o CD101 tissue distribution appears similar to that of anidulafungin in terms of having fairly constant levels across major organs of elimination. o CD101 tissue/plasma ratio in the liver was lower than that of other echinocandins, which, together with the lack of toxic/reactive intermediates, may contribute to the lack of hepatotoxicity with CD101. o CD101 has also been shown to be highly protein bound, similar to anidulafungin, and consistent between animal species and human plasma (from 97.8% to 99.1% 151 in CD-1 mouse, Sprague-Dawley rat, cynomolgus monkey, and chimpanzee and 98.7% in human). o The relationship between echinocandin distribution and efficacy and the clinical relevance of differences in tissue levels remain equivocal.  The excretion of CD101 in the bile/feces (∼50%) is highly comparable to that of anidulafungin  CD101 consistently exhibited a favorable linear PK profile across all species, mainly attributable to very low clearance resulting in a longer half-life. Additionally, there was little to no drug accumulation of CD101 and no sex-based differences (in the rat and monkey) after multiple doses.  These data support the characterization of CD101 as a novel echinocandin candidate for the treatment of serious, life-threatening, invasive fungal infections. In vitro activity Recent reports Chang et al. (2017) mentioned that the echinocandins-caspofungin, anidulafungin and micafungin-are semi-synthetic cyclic hexapeptide antimicrobial agents with modified N-linked acyl lipid side chains which anchor the compounds to the phospholipid bilayer of the fungal cell membrane, thereby inhibiting synthesis of fungal cell wall glucan. Over the last 10 years, echinocandins have become the first-line antifungal treatment of candidaemia and other forms of invasive candidiasis (IC). Echinocandins are generally well tolerated, but their use is limited by their requirement for daily intravenous dosing, lack of oral formulation and limited spectrum. In critically ill patients, it is also recognised that achievement of their pharmacokinetic/pharmacodynamic targets shows large inter-individual variability. As a drug class, they are safe to use and are associated with few adverse reactions and few drug-drug interactions of significance. Recent discovery of their ability to prevent and treat Candida biofilm formation particularly in the presence of invasive medical devices and also their ability to penetrate into mucosal surfaces such as vulvovaginal candidiasis has opened up new opportunities for research into their drug delivery. New dosing intervals are being explored to 151 allow less frequent intravenous dosing in the ambulatory setting, and a new longacting echinocandin, CD101, is being developed for weekly and topical administration. Hall et al. (2017) determined the MIC of CD101 and comparators against 500 recent clinical Candida isolates per Clinical and Laboratory Standards Institute guidelines. For select isolates, the minimum fungicidal concentration (MFC; n=49) and time-kill (n=9) of CD101 and comparators was evaluated. The MIC50/90s (μg/mL; n=100/species) for CD101, anidulafungin, fluconazole, and amphotericin B, respectively, were: C. albicans (0.008/0.03, 0.004/0.008, 0.25/4, 0.25/0.5), C. tropicalis (0.008/0.03, 0.004/0.015, 0.5/2, 0.5/1), C. parapsilosis (1/1, 0.5/2, 0.5/1, 0.5/1), C. glabrata (0.03/0.03, 0.03/0.03, 8/>32, 0.5/0.5), and C. krusei (0.03/0.03, 0.03/0.03, 32/>32, 1/1). CD101 MICs were comparable to anidulafungin and both maintained potency against fluconazole-resistant isolates. Against rare anidulafungin-resistant isolates, the MICs of CD101 and anidulafungin were elevated vs. anidulafungin-susceptible isolates. Similar to anidulafungin, CD101 was fungicidal with an MFC:MIC ratio ≤4 for 95% of evaluable isolates and resulted in 3-log killing by 24-48h for all isolates evaluated by time-kill. The potent fungicidal activity of CD101 highlights the potential clinical utility of CD101 IV for the treatment of invasive candidiasis and candidemia. James et al. (2017) sought to discover a novel echinocandin with properties that would enable more flexible dosing regimens, alternate routes of delivery, and expanded utility. Derivatives of known echinocandin scaffolds were generated, and an iterative process of design and screening led to the discovery of CD101, a novel echinocandin that has since demonstrated improved chemical stability and pharmacokinetics. Here, we report the structure-activity relationships (including preclinical efficacy and pharmacokinetic data) for the series of echinocandin analogs from which CD101 was selected. In a mouse model of disseminated candidiasis, the test compounds displayed clear dose responses and were generally associated with lower fungal burdens than that of anidulafungin. Single-dose pharmacokinetic studies in beagle dogs revealed a wide disparity in the half-lives and volumes of distribution, with one compound (now known as CD101) displaying a half-life that is nearly 5-fold longer than that of anidulafungin (53.1 h versus 11.6 h, respectively). In vitro activity data against panels of Candida spp. and Aspergillus spp. demonstrated that CD101 behaved similarly to approved echinocandins in terms of potency and spectrum of activity, suggesting that the improved efficacy observed in vivo for CD101 is a result of features beyond the antifungal potency inherent to the molecule. Factors that potentially contribute to the improved in vivo efficacy of CD101 are discussed. Ong et al. (2017) presented the pharmacokinetics (PK) of CD101 administered intravenously to mice, rats, dogs, cynomolgus monkeys, and chimpanzees. CD101 consistently exhibited very low clearance, a modest volume of distribution at steady state (Vss), and a long half-life (t1/2) across all species tested. In mouse, rat, dog, cynomolgus monkey, and chimpanzee, CD101 clearance was 0.10, 0.47, 0.30, 0.41, and 0.06 ml/min/kg, respectively; Vss was 206, 1,390, not determined, 597, and 400 ml/kg, respectively; and t1/2 was 25, 39, 53, 40, and 81 h, respectively. CD101 demonstrated a lower clearance and correspondingly longer half-life than those of anidulafungin, with more pronounced differences in higher species (anidulafungin t1/2, 8 h in cynomolgus monkey and 30 h in chimpanzee). In the rat, tissue/plasma area under the concentration-time curve (AUC) ratios, in descending order, were 4.62 (kidney), 4.33 (lung), 4.14 (liver), 3.87 (spleen), 1.09 (heart), and 0.609 (brain), indicating that CD101 exposure relative to plasma levels was comparable for major organs (approximately 4-fold higher in tissue than in plasma), with the exception of the heart and brain. 152 Biliary elimination of intact CD101 was the predominant route of excretion; the mean cumulative amount of CD101 excreted into the bile and feces over the course of 5 days accounted for 22.6% and 27.7% of the total dose administered, respectively. There were no sex differences in the pharmacokinetics of CD101. Given its low clearance, long half-life, and wide tissue distribution, CD101 once weekly is expected to provide appropriate systemic levels for treatment and prevention of invasive fungal infections. Pfaller et al. (2017a) evaluated the activity of CD101 and comparator antifungal agents against 606 invasive fungal isolates collected worldwide during 2014 using the Clinical and Laboratory Standards Institute (CLSI) method. All Candida albicans (n = 251), Candida tropicalis (n = 51), Candida krusei (n = 16), and Candida dubliniensis (n = 11) isolates were inhibited by ≤0.12 μg/ml of CD101 and were susceptible or showed wild-type susceptibility to the other echinocandins tested. Five C. glabrata isolates (n = 100) displayed CD101 MIC values of 1 to 4 μg/ml, had elevated MICs of caspofungin (2 to >8 μg/ml), anidulafungin (2 to 4 μg/ml), and micafungin (2 to 4 μg/ml), and carried mutations on fks1 and fks2Candida parapsilosis (n = 92) and Candida orthopsilosis (n = 10) displayed higher CD101 MIC values (ranges, 0.5 to 4 μg/ml and 0.12 to 2 μg/ml, respectively), and similar results were observed for the other echinocandins tested. Fluconazole resistance was noted among 11.0% of Candida glabrata isolates, 4.3% of C. parapsilosis isolates, and 2.0% of C. albicans and C. tropicalis isolates. The activity of CD101against Aspergillus fumigatus (n = 56) was similar to that of micafungin and 2-fold greater than that of caspofungin but less than that of anidulafungin. These isolates had wild-type susceptibility to itraconazole, voriconazole, and posaconazole. The echinocandins had limited activity against Cryptococcus neoformans (n = 19). CD101 was as active as the other echinocandins against common fungal organisms recovered from patients with invasive fungal infections. The long half-life profile is very desirable for the prevention and treatment of serious fungal infections, especially in patients who can then be discharged from the hospital to complete antifungal therapy on an outpatient basis. Pfaller et al. (2017b) evaluated the activity of CD101 and comparators using CLSI broth microdilution methods against 713 invasive fungal isolates, including 589 Candida spp. (6 species), 14 C. neoformans, 97 A. fumigatus and 13 A. flavus species complex collected worldwide during 2015. All C. tropicalis, C. krusei and C. dubliniensis, 99.7% of C. albicans and 98.3% of C. glabrata were inhibited by ≤0.12 µg/mL of CD101, and these isolates were susceptible/wild type to other echinocandins using CLSI clinical breakpoint and epidemiological cutoff value (ECV) interpretive criteria. C. parapsilosis displayed higher MIC values (range 0.25-2 µg/mL), but similar results were observed for other echinocandins. One C. glabrata and one C. albicans with CD101 MIC value at 1 and 0.25 µg/mL possessed F625S and S645P alterations on FKS1, respectively. These isolates also displayed elevated MIC values for at least one clinically available echinocandin. Fluconazole resistance was noted for 6.6% of C. glabrata and 3.6% C. parapsilosis. Echinocandins had limited activity against C. neoformans. CD101 activity against A. fumigatus and A. flavus (MEC ≤0.03 µg/mL) was comparable to other echinocandins (MEC ≤0.03 µg/mL). These moulds had MIC values below ECVs for the mould-active azoles. CD101 was as active as other echinocandins against common fungal organisms recovered from invasive fungal infections. The extended half-life profile is very desirable as less frequent dosing of this agent should facilitate shorter and more costeffective hospital stays, improve compliance for outpatients, and provide more convenient outpatient prophylaxis. 153 Locke et al. (2016) investigated the potential for and mechanisms underlying the development of resistance to CD101 in Candida species by using spontaneous resistance and serial passage selection methodologies. Four Candida spp. (C. albicans, C. glabrata, C. parapsilosis, and C. krusei) were chosen for resistance characterization with CD101, anidulafungin, and caspofungin. The frequency of spontaneous, single-step mutations conferring reduced susceptibility to CD101 at 1× the agar growth inhibition concentration was low across all species, with median frequencies ranging from 1.35 × 10(-8) to 3.86 × 10(-9), similar to ranges generated for anidulafungin and caspofungin. Serial passage of Candida spp. on agar plates containing drug gradients demonstrated a low potential for resistance development, with passage 20 CD101selected strains possessing increases in MICs equivalent to or lower than those for the majority of strains generated under selection with anidulafungin and caspofungin. References: 1. Chang CC1, Slavin MA2,3, Chen SC4,5. New developments and directions in the clinical application of the echinocandins. Arch Toxicol. 2017 Apr;91(4):1613-1621. 2. Hall D1, Bonifas R1, Stapert L1, Thwaites M1, Shinabarger DL1, Pillar CM2. In vitro potency and fungicidal activity of CD101, a novel echinocandin, against recent clinical isolates of Candida spp. Diagn Microbiol Infect Dis. 2017 Jul 21. pii: S07328893(17)30223-7. 3. James KD1, Laudeman CP2, Malkar NB2, Krishnan R2, Polowy K2. Structure-Activity Relationships of a Series of Echinocandins and the Discovery of CD101, a Highly Stable and Soluble Echinocandin with Distinctive Pharmacokinetic Properties. Antimicrob Agents Chemother. 2017 Jan 24;61(2). pii: e01541-16. 4. Locke JB1, Almaguer AL2, Zuill DE2, Bartizal K2. Characterization of In Vitro Resistance Development to the Novel Echinocandin CD101 in Candida Species. Antimicrob Agents Chemother. 2016 Sep 23;60(10):6100-7. 5. Ong V1, James KD2, Smith S2, Krishnan BR2. Pharmacokinetics of the Novel Echinocandin CD101 in Multiple Animal Species. Antimicrob Agents Chemother. 2017 Mar 24;61(4). pii: e01626-16. 6. Pfaller MA1,2, Messer SA1, Rhomberg PR1, Castanheira M3. Activity of a LongActing Echinocandin (CD101) and Seven Comparator Antifungal Agents Tested against a Global Collection of Contemporary Invasive Fungal Isolates in the SENTRY 2014 Antifungal Surveillance Program. Antimicrob Agents Chemother. 2017 Feb 23;61(3). pii: e02045-16 7. Pfaller MA1, Messer SA2, Rhomberg PR2, Castanheira M3. CD101, a longacting echinocandin, and comparator antifungal agents tested against a global collection of invasive fungal isolates in the SENTRY 2015 Antifungal Surveillance Program. Int J Antimicrob Agents. 2017b Sep;50(3):352-358. 154 7.3. Azoles Azoles are a class of five-membered heterocyclic compounds containing a nitrogen atom and at least one other non-carbon atom (i.e. nitrogen, sulfur, or oxygen) as part of the ring. Classification of azole antifungals  Classification according to thechemical structures o Imidazole is an organic compound with the formula C3N2H4. It is a white or colourless solid that is soluble in water, producing a mildly alkaline solution. In chemistry, it is an aromatic heterocycle, classified as a diazole, and having nonadjacent nitrogen atoms. . o A triazole (Htrz) refers to any of the heterocyclic compounds with molecular formula C2H3N3, having a five-membered ring of two carbon atoms and three nitrogen atoms. There are two sets of isomers that differ in the relative positions of the three nitrogen atoms. Each of these has two tautomers that differ by which nitrogen has a hydrogen bonded to it 1H-1,2,3-Triazole 2H-1,2,3-Triazole 1H-1,2,4-Triazole 4H-1,2,4-Triazole o Thiazole, or 1,3-thiazole, is a heterocyclic compound that contains both sulfur and nitrogen. 155 Imidazoles 1. Bifonazole, 2. Butoconazole, 3. Clotrimazole, 4. Croconazole 5. Eberconazole 6. Econazole, 7. Enilconazole 8. Fenticonazole, 9. Flutrimazole 10. Isoconazole, 11. Ketoconazole, 12. Lanoconazole 13. Luliconazole, 14. Miconazole, 15. Omoconazole, 16. Oxiconazole, 17. Miconazole, 18. Omoconazole, 19. Oxiconazolem 20. Serticonazole, 21. Sulconazole Triazoles 1. Albaconazole, 2. Cyproconazole 3. Difenoconazole 4. Efinaconazole, 5. Epoxiconazole, 6. Fluconazole, 7. Flusilazole 8. Flutriafol 9. Fosfluconazole 10. Hexaconazole 11. Isavuconazole, 12. Itraconazole, 13. Metconazole 14. Myclobutanil 15. Posaconazole, 16. Propiconazole, 17. Prothioconazole 18. Ravuconazole, 19. Tebuconazole 20. Terconazole, 21. Voriconazole Thiazoles Abfangin Thiabendazole Classification of antifungal azoles according to the route of administration Topical antifungal azoles:  Bifonazole. used for the topical treatment of dermatophytoses and pityriasis versicolor.  Butoconazole. used for the topical treatment of vaginal candidosis.  Clotrimazole. used for the topical treatment of dermatophytoses, and oral, cutaneous and genital candidosis.  Econazole nitrate. used for the topical treatment of dermatophytoses, and oral, cutaneous and genital candidosis. It has also been used to treat corneal infection.  Fenticonazole nitrate. used for the topical treatment of vaginal candidosis.  Isoconazole nitrate. used for the topical treatment of dermatophytoses, and cutaneous and vaginal candidosis.  Miconazole nitrate. used for the topical treatment of dermatophytoses, pityriasis versicolor, and oral, cutaneous and genital candidosis. (Formerly also available for intravenous use.)  Oxiconazole. used for the topical treatment of dermatophytoses and cutaneous candidosis.  Sertaconazole nitrate. used for the topical treatment of dermatophytoses and vaginal candidosis 156    Sulconazole nitrate. used for the topical treatment of dermatophytoses and cutaneous candidosis. Terconazole. used for the topical treatment of dermatophytoses, and cutaneous and vaginal candidosis. Tioconazole. used for the topical treatment of dermatophytoses (including nail infections), and cutaneous and vaginal candidosis. Systemic antifungal azoles:  Fluconazole, used for the systemic treatment of of superficial and invasive candidiasis, including infections in neutropenic patients. It is the drug of choice for treatment of coccidioidal meningitis  Itraconazole, used for both prophylaxis and treatment of systemic fungal infections  Ketoconazole, used for the systemic treatment f susceptible systemic fungal infections, including blastomycosis, histoplasmosis, paracoccidioidomycosis, coccidioidomycosis, and chromomycosis in patients who have failed or who are intolerant to other antifungal therapies  Posaconazole, is indicated as a prophylactic treatment in patients at high risk of invasive fungal infections (IFI), such as those receiving remission-induction chemotherapy for acute myelogenous leukaemia (AML) or myelodysplastic syndromes (MDS) and hematopoietic stem cell transplant (HSCT) recipients undergoing high-dose immunosuppressive therapy for graftversus-host disease (GVHD).   Isavuconazole, is the first antifungal specifically indicated for the treatment of invasive fungal infections caused by Mucormycetes (or Mucorales) or mucormycosis. Voriconazole, European guidelines on leukaemia treatment now recommend voriconazole for first-line treatment of aspergillosis, and posaconazole or fluconazole for prophylaxis Classification according to the generations First generation of imidazole antifungals:  Clotrimazole o Clotrimazole in-vitro activity against dermatophytes, yeasts, and dimorphic as well as filamentous fungi, is well-established and comparable to that of amphotericin B for many pathogens.  Clotrimazole side-effects following oral administration and unpredictable pharmacokinetics as a result of the induction of hepatic microsomal enzymes have limited the use of clotrimazole to the topical treatment of dermatophytic infections and superficial candida infections, including oral thrush and vaginal candidiasis.  Miconzole o Miconzole has a limited spectrum of activity including dermatophytes, Candida species, dimorphic fungi, and Pseudallescheria boydii. 157     Miconzole has proven to be an effective topical antifungal agent, Miconzole toxicity associated with the vehicle used for intravenous administration has limited its parenteral use. Miconzole has been used successfully in the treatment of systemic candida infections, pseudallescheriasis and some refractory cases of cryptococcal meningitis Miconzole has recently been withdrawn from the market. Second generation of Imidazole: Janssen sought to improve upon miconazole and econazole, but keeps hold of the important advantages of the early imidazoles, namely, high antimycotic activity and broad spectrum of activity. Their main aim was to provide a drug that was bioavailable, i.e. that was more soluble in water and could be used for systemic infections either by injection or as a tablet.  ketoconazole o ketoconazole was indicated as the drug of choice in chronic mucocutaneous candidiasis and as an effective alternative to amphotericin B in less severe (nonimmunocompromised) cases of blastomycosis, histoplasmosis, and paracoccidioidomycosis; in coccidioidomycosis, the relapse rate after discontinuation of the drug was high. o Over the years, a number of clinically relevant shortcomings of ketoconazole became evident:  The absorption of orally administered ketoconazole showed considerable interindividual variation and was markedly influenced by gastric pH.  ketoconazole intravenous formulation was not available.  ketoconazole penetrated the blood–brain barrier poorly and could therefore not be recommended for the treatment of fungal meningitis.  Ketoconazole was largely fungistatic and proved to be less effective in immunocompromised patients.  ketoconazole use was associated with several dose-related (gastrointestinal) side-effects; in addition,  ketoconazole could cause symptomatic, even fatal, drug-induced hepatitis  The first generation of triazoles o The introduction of the first generation triazoles, fluconazole and itraconazole represented a major advance in the treatment of IFIs. o Both triazoles displayed a broader spectrum of antifungal activity than the imidazoles and had a markedly improved safety profile compared with amphotericin B and ketoconazole. o Fluconazole and itraconazole were first synthesised in 1981 and 1989, respectively, and obtained European and the FDA licensures between 1987 and 1992. 158 o Both drugs continued to be widely used for the treatment of superficial and deep seated fungal infections; Fluconazole, a fungistatic agent, is active against Candida albicans, Candida tropicalis, and Candida glabrata. o Fluconazole is also used for the treatment of meningitis, cryptococcal meningitis, and systemic and mucosal candidiasis in both normal and immunecompromised patients. o Fluconazole is also used to treat coccidioidal meningitis, histoplasmosis, and infections due to chemotherapy or radiation therapy prior to a bone marrow transplant. o Fluconazole circulates in plasma as the free form and is excreted unchanged through the kidneys. o Fluconazole is also orally bioavailable because it shows negligible hepatic metabolism. Almost 94 % fluconazole is absorbed and its oral bioavailability is not affected by food or gastric pH. Itraconazole is largely metabolised in the liver by cytochrome P450 3A4, an active metabolite produced which is excreted in an inactive form via the liver and kidneys. o Itraconazole has strain-dependent fungicidal activity against filamentous fungi with the exception of some strains of Cryptococcus neoformans. o Itraconazole is taken orally as a capsule to treat fungal infections that start in the lungs and spread throughout the body. o Itraconazole can also be used to treat fungal infections of the nails and its oral solutions are useful to treat oral candidiasis. o Itraconazole most common side effects are constipation, heartburn, bleeding gums, headache, and dizziness. o Itraconazole more severe side effects can include excessive tiredness, nausea, vomiting, loss of appetite, tingling or numbness in the extremities, and difficulty in breathing or swallowing.  The ‘first generation’ triazoles – fluconazole and itraconazole – are a milestone in the treatment of superficial and invasive mycoses either in immunocompetent or immunocompromised subjects. However, these drugs continue to have some crucial drawbacks which limit the proper management of several IFIs.  The lack of activity against filamentous fungi and against a variable rate of Candida isolates represents well-known limits of fluconazole.  The unpredictable absorption of the oral formulations, particularly capsules, and the variability in the metabolism determine a wide and dangerous interpatient kinetic variation of itraconazole.  Furthermore, both drugs are not active against zygomycetes, Fusarium spp. and Scedosporium spp., which are rare pathogens but probably with an underestimated epidemiological impact. Girmenia, 2009 159  The second generation of triazoles To overcome these limitations, several analogues have been developed. These so-called ‗second generation‘ triazoles, including voriconazole, posaconazole, ravuconazole, isavuconazole and albaconazole, have greater potency and possess increased activity against resistant and emerging pathogens. Voriconazole was first marketed and accepted as a first-line cure of oesophageal candidiasis; candidaemia; invasive aspergillosis; candidal infections of the skin; infections in the abdomen, kidney, and bladder wall and wounds; and infections caused by Scedosporium apiospermumand Fusarium spp. o Voriconazole is available for both oral and intravenous (i.v.) administration. Although o Voriconazole is metabolised in the liver, and, in case of renal failure, its excretion is not affected. \ o Voriconazole interacts with drugs that are substrates of cytochrome P450 3A4 (terfenadine, cisapride, etc.), by increasing their serum levels. o Voriconazole intake should be avoided in those patients who are taking cyclosporine, rifampicin, carbamazepine, ritonavir, and long-acting barbiturates. Posaconazole is a hydroxylated analogue of itraconazole, which became available in Europe in 2005 and was approved by the Food and Drug Administration (FDA) in 2006. o Posaconazole has a wide range of antifungal activity against various fungal strains, viz. Candida spp. resistant to older azoles, Cryptococcus neoformans, Aspergillus spp., Rhizopus spp., Blastomyces dermatitidis, Coccidiodes immitis, Histoplasma capsulatum, and other opportunistic filamentous and dimorphic fungi . o Posaconazole is available only for oral administration, and it is 8–47 % bioavailable on an empty stomach, which increases by 400 % with the ingestion of a fatty meal. It is primarily metabolised by the liver, and approximately 77 % of the unaltered drug is excreted in the faeces and small amount in the urine. o Posaconazole shows good efficiency for the treatment of zygomycosis, invasive fusariosis, cryptococcal meningitis, coccidioidomycosis, and other central nervous system fungal infections. o Posaconazole common side effects associated with posaconazole are nausea, vomiting, headache, abdominal pain, and diarrhoea. Ravuconazole is another second-generation azole antifungal agent, which is highly active against a wide range of fungi, including Candida spp., Candida neoformans, and other yeast species, as well as isolates that are resistant to fluconazole o Ravuconazole is highly active against Aspergillus spp. and has inhibitory activity against other species of hyaline filamentous fungi and zygomycetes and black moulds. 161 o Ravuconazole is active against 56.2 % of Mucorales tested o Ravuconazole shows linear pharmacokinetics over the anticipated dosage range and undergoes hepatic metabolism, ‗ o Ravuconazole has a significant potential for drug-drug interactions through the cytochrome P450 enzyme system Isavuconazole (Cresemba [formerly BAL4815]; Astellas Pharma US, Inc., Northbrook, IL), administered as isavuconazonium (BAL8857), was approved by the U.S. Food and Drug Administration on March 8, 2015, for the treatment of invasive aspergillosis and invasive mucormycosis. \ o Isavuconazole is the first antifungal specifically indicated for the treatment of invasive fungal infections caused by Mucormycetes (or Mucorales) or mucormycosis. o Isavuconazole available in both oral and cyclodextrin-free intravenous formulations. o Isavuconazole has a broad spectrum of activity including yeast, dimorphic fungi, and various molds, as well as a favorable adverse effect profile and less substantial drug-drug interactions than other triazoles. o Isavuconazole is currently indicated for the treatment of invasive aspergillosis and invasive mucormycosis, and the agent is currently being investigated for an indication in the treatment of candidemia and invasive candidiasis.  Albaconazole o Albaconazole a novel triazole antifungal that was originally developed by Palau Pharma in Barcelona, Spain, with a potent broad-spectrum antifungal activity, and an excellent safety profile, that has demonstrated high efficacy in patients suffering from vulvo-vaginitis, and onychomycosis. o Albaconazole was subjected to Phase IIb study testing of multiple doses. 161 Chemical structures of the three generations of systemic azoles developed for use in humans. The structures and drug names in black and gray are of the marketed and experimental azoles, respectively. The numbering of some of the heteroatoms in clotrimazole, posaconazole, and voriconazole is also shown. Mast et al., 2013 Classification according to uses Azoles usedfor human animal treatment Albaconazole, Bifonazole, Butoconazole, Clotrimazole, Croconazole, Eberconazole, Econazole, Efinaconazole, Fenticonazole, Fluconazole, Flutrimazole, Fosfluconazole, Isavuconazole, traconazole, Ketoconazole, Lanoconazole, Luliconazole, Miconazole, Omoconazole, Omoconazole, Posaconazole, Ravuconazole, Sertaconazole, Sulconazole, Terconazole, Tioconazole, Voriconazole Azoles used for plant protection, agricultural fungicide Cyproconazole,Difenoconazole,Enilconazole,Epoxiconazole, Flusilazole, Flutriafol, Hexaconazole, Metconazole, Myclobutanil, Propiconazole, Prothioconazole, Tebuconazole, Thiabendazole, 162 The mechanism of action       The mechanism of action of all antifungal azoles is based on the inhibition of the fungal cytochrome P450 (P450) from family 51 (CYP51 or sterol 14α-demethylase) that is essential for the biosynthesis of ergosterol, the major sterol of the fungal plasma membranes. Inhibition of fungal CYP51 leads to blockage of ergosterol synthesis, sterol depletion from the membranes, and accumulation of 14α-methylated precursors. Changes in the membrane sterol composition alter the fluidity and integrity of the fungal membranes and affect the activity of several membrane-bound enzymes. The ultimate result is cell lysis and death. CYP51, however, is present not only in fungi but in many other species, including humans, in which this enzyme is involved in the biosynthesis of cholesterol, the major sterol of mammalian membranes. Thus, one of the requirements for the antifungal azoles is to inhibit fungal CYP51 but avoid or minimize the inhibition of the human ortholog that metabolizes the same substrate lanosterol. In addition, at therapeutic concentrations, antifungal azoles should also not inhibit other P450 isoforms present in humans that play important roles in the metabolism of endogenous and exogenous compounds. 1. Albaconazole      Albaconazole is a novel triazole antifungal that was originally developed by Palau Pharma in Barcelona, Spain, with a potent broad-spectrum antifungal activity, and an excellent safety profile, that has demonstrated high efficacy in patients suffering from vulvo-vaginitis, and onychomycosis. Albaconazole was later licensed to Stiefel, the US based-dermatology company. Albaconazole was acquired by GlaxoSmithKline (GSK) Albaconazole was subjected to Phase IIb study testing of multiple doses. Albaconazole was returned to Palau Pharma, in spite of the successful results of the trial, when GSK decided not to pursue further development of the drug for the US market.  In August 2013, Palau Pharma granted worldwide rights to Actavis.to test albaconazole in Phase III trials and bring it to market.  Albaconazole is also known as: UNII-YDW24Y8IAB; UR-9825; 187949-02-6; UR 9825, W-0027 Molecular Formula: C20H16ClF2N5O2 Molecular Weight: 431.823146 Chemical structure :(1R,2R)-7-chloro-3-[2-(2,4-difluorophenyl)-2-hydroxy-1-methyl-3-(1H1,2,4-triazol-1 yl)propyl]quinazolin-4(3H)-one7-chloro-3-[(2R,3R)-3-(2,4-difluorophenyl)-3hydroxy-4-(1,2,4-triazol-1-yl)butan-2-yl]quinazolin-4-one 163 Clinical trials   A phase I clinical trial has been completed in the US by Stiefel Laboratories in 40 healthy subjects to compare albaconazole in a tablet formulation and in a capsule formulation (NCT01039883). The company reported in February 2010 that the study had been completed; the tablet formulation was intended for use in further development Onychomycosis       the corporate fact sheet of Palau Pharma for Spring 2011 stated that albaconazole had completed phase IIb trials for the treatment of fungal infections. A phase II clinical trial of oral albaconazole was conducted in the US, Canada, and Iceland in 584 patients with distal subungual onychomycosis, or toenail fungus (NCT00730405). Stiefel reported in August 2010 that the trial had been completed A phase I tolerability and pharmacokinetic study of escalating doses of albaconazole in 24 healthy volunteers was conducted in the US (NCT01014962). The drug doses were those intended for the treatment of onychomycosis; the purpose of the study was to determine an upper dose of albaconazole to be administered in a thorough QTc study. Stiefel reported in February 2010 that the study had been completed Tinea pedis  A phase I trial of albaconazole capsules was completed in patients with moccasin type tinea pedis in the US and Australia in the third quarter of 2008 (NCT00509275).  The randomised, double-blind, placebo-controlled trial, conducted by Stiefel, had been initiated in mid-2007 and enrolled 120 patients Vulvovaginal candidiasis  A phase II trial of albaconazole versus fluconazole in patients with acute non-recurrent vulvovaginal candidiasis was initiated by Uriach in June 2004 in Argentina (NCT00199264).  the trial was subsequently terminated, but it has been reported that development in this indication will continue 164 Pharmacodynamics  Albaconazole has shown potent activity against a broad range of organisms, including pathogens resistant to other antifungals, such as fluconazole or itraconazole. It will be developed as an oral and topical formulation, and is expected to be available to the medical community for a variety of dermatological indications and fungal infections, including vulvovaginal candidiasis. Formulation: Capsule, Liquid, unspecified Recent reports Dietz et al. (2014), in a randomized, double-blind, placebo-controlled, phase 1 study, evaluated the safety, tolerability, pharmacokinetics, and effects on electrocardiogram parameters of albaconazole administered orally at escalating supratherapeutic doses. Healthy subjects received 400 mg albaconazole every 24, 12, or 8 hours for 5 days. Albaconazole was absorbed rapidly (2.5-22.5 hours) after oral administration, reaching a maximal mean peak plasma concentration of 11,993.3 ng/mL (standard deviation [SD], 2,413.85 ng/mL) after 5 days of dosing every 8 hours. Systemic exposure of albaconazole increased proportionally with dose frequency. Albaconazole was safe and well tolerated at all doses administered. No significant changes in ECG intervals or morphology were observed. In none of the three dosing groups was the slope of a study-specific correction for QT interval (QTcSS) on log plasma concentration statistically different from 0. The results of this study were to be used to inform the design of a thorough QT study using supratherapeutic doses. A dose regimen of 400 mg, every 8 hours for 5 days appears suitable for this purpose. Guillon et al. (2013) developed a strict structural analogue of albaconazole in which the quinazolinone ring was replaced by a thiazoloquinazolinone scaffold (compounds I and II, via Appel salt chemistry. In vitro antifungal activities of compounds I and II against Candida species (yeasts) and filamentous fungi (molds) were compared with those of fluconazole, voriconazole, itraconazole, and albaconazole. Evaluations against Candida spp. and Aspergillus fumigatus strains were realized by Le Pape‘s previously reported method and those against other filamentous fungi according to the CLSI Broth Microdilution Susceptibility Method (M38). Against the fluconazole-suceptible C. albicans CAAL93 and CAAL97 isolates, compounds I and II displayed a high level of activity with MIC values ranging from of 0.001 to 0.011 μg mL–1, comparable to voriconazole and albaconazole values. Compound I exhibited high antifungal activities similar to those of voriconazole and slightly inferior to those of albaconazole, On the other hand, a significant broad-spectrum antifungal activity was also observed for compound I against C. krusei, C. glabrata, and C. parapsilosisisolates with MIC values ranging from <0.005 (for CAKR8) to 0.182 μg mL–1 (for CAKR7), confirming its interest for fluconazole low-susceptible strains and fluconazole intrinsically resistant Candida species. In particular, for the acquired-resistant C. parapsilosis CAPA1 and CAPA2 isolates, compound I was almost as active as albaconazole and 7–70-fold more active than voriconazole. Compound II has a narrow spectrum of activity with a high level of potency against C. glabrata and C. parapsilosis strains (MICs ranging from 0.001 165 to 0.095 μg mL–1) but not against C. krusei strains (MICs > 2.5 μg mL–1). Compound I was active against A. fumigatus isolates susceptible (ASFU7) or resistant to itraconazole (ASFU13, ASFU17, ASFU19, ASFU20, and ASFU23), with MIC values ranging from 0.27 (for ASFU23) to 4.5 μg mL–1 (for ASFU20), which were comparable to those of albaconazole and slightly superior to those of voriconazole, the first-line agent for the treatment of invasive aspergillosis. Sigurgeirsson et al. (2013) evaluated efficacy and safety of albaconazole, a novel triazole, for once-weekly treatment of distal subungual onychomycosis of the great toenail.This double-blind, phase II study randomized 584 patients to receive albaconazole 100 to 400 mg or placebo weekly for 24 or 36 weeks. Effective treatment was measured as mycologic cure and clear or almost clear nail at week 52. All treatment groups achieved greater effective treatment rates (21%-54%) compared to placebo (1%; P < .001 for all groups) at week 52. Effective treatment was attained at week 24 in ≥5% of patients in most groups. Most adverse events were mild or moderate, and treatment-related adverse events were all ≤3%. No treatment-related hepatic or cardiac serious adverse events were observed. LIMITATIONS: The follow-up period was likely too short to detect maximal efficacy; cure rates were increasing at study end. The efficacy and tolerability of albaconazole were not compared with other available treatments, and the global change in target toenail scale was subjective. CONCLUSIONS: Albaconazole was well tolerated at all doses and resulted in high cure rates for onychomycosis van Rossem et al. (2013) compared four 100-mg albaconazole capsules to one 400mg albaconazole tablet for bioavailability, bioequivalence, tolerability, and safety. Forty participants were enrolled in this Phase I, open-label, two-sequence crossover study. Twenty participants were exposed to a single 400-mg tablet dose of albaconazole before being crossed over to a single dose of four 100-mg albaconazolecapsules. The second group of 20 participants received the study products in reverse order. Blood samples were taken over 15 days post-dose to assess the plasma concentrations and pharmacokinetic parameters of albaconazole and its primary metabolite, 6-hydroxyalbaconazole. Safety was assessed throughout the study. The area under the curve (AUC) and maximum measured plasma concentration (C(max)) of the albaconazole tablet were approximately 10% and 22% lower, respectively, than for the albaconazole capsules. Statistical significance was reached for the C(max) but not for the AUC measurements (AUC(0-t) and AUC(0-inf)). Because the 90% confidence intervals based on the differences between the tablet and capsule were outside the 80%-125% range for both the C(max) and AUC, we concluded that the formulations were not bioequivalent with respect to the rate or extent of absorption. Both formulations were safe and well-tolerated in this study. All adverse events (AEs) were generally mild and were mainly gastrointestinal- or nervous systemrelated (eg, dizziness, headache). No electrocardiogram findings were reported as an AE, and no serious AEs or deaths were reported. CONCLUSION: The AUC and C(max) of albaconazole after a single 400-mg oral dose administered as a tablet formulation were lower than those of a capsule formulation. Albaconazole tablets and capsules cannot, therefore, be considered bioequivalent. References 1. Dietz AJ1, Barnard JC2, van Rossem K3. A randomized, double-blind, multiple-dose, placebo-controlled, dose escalation study with a 3-cohort parallel group design to 166 investigate the tolerability and pharmacokinetics of albaconazolein healthy subjects. Clin Pharmacol Drug Dev. 2014 Jan;3(1):25-33. 2. Guillon R, Pagniez F, Picot C, et al. Discovery of a Novel Broad-Spectrum Antifungal Agent Derived from Albaconazole. ACS Medicinal Chemistry Letters. 2013;4(2):288292. doi:10.1021/ml300429p 3. Sigurgeirsson B1, van Rossem K, Malahias S, Raterink K. A phase II, randomized, double-blind, placebo-controlled, parallel group, dose-ranging study to investigate the efficacy and safety of 4 dose regimens of oral albaconazole in patients with distal subungual onychomycosis. J Am Acad Dermatol. 2013 Sep;69(3):416-25. 4. van Rossem K1, Lowe JA. A Phase 1, randomized, open-label crossover study to evaluate the safety and pharmacokinetics of 400 mg albaconazole administered to healthy participants as a tablet formulation versus a capsule formulation. Clin Pharmacol. 2013;5:23-31 2. Bifonazole Bifonazole is an imidazole antifungal drug used in form of ointments. There are also combinations with carbamide for the treatment of onychomycosis. Wikipedia Chemical Names Bifonazole; 60628-96-8; Mycospor; Bifonazol; Trifonazole; Amycor etc Molecular Formula: C22H18N2 Chemical structure Mechanism of action Bifonazole works by inhibiting the production of a substance called ergosterol, which is an essential component of fungal cell membranes.It acts to destabilize the fungal cyctochrome p450 51 enzyme (also known as Lanosterol 14-alpha demethylase). This is vital in the cell membrance 167 structure of the fungus. Its inhibition leads to cell lysis. The disruption in production of ergosterol disrupts the cell membrane and causes holes to appear. The cell membranes of fungi are vital for their survival. They keep unwanted substances from entering the cells and stop the contents of the cells from leaking out. As bifonazole causes holes to appear in the cell membranes, essential constituents of the fungal cells can leak out. This kills the fungi. Adverse effects. The most common side effect is aburning sensation at the application site. Other reactions, such as itching, eczema or skin dryness, are rare International Brands Amycor (Merck) / Azolmen (Menarini) / Bayclear Seiyaku) / Canespor (Bayer) / Mycospor (Bayer) Plus (Bayer) / Bifonol (Mayado List of Bifonazole substitutes (brand and generic names): Bifonazol-SL (Bulgaria, Lithuania) Bifonazole 1% F (Japan) Bifonazole 1% Sawai (Japan) Bifonazole 1% Taiyo (Japan) Bifonazole 1% YD (Japan) Bifonazole Sinphar (Taiwan) Bifonazole Taiyo (Japan) Bifonazole-Teva (Israel) Bifonol (Japan) Bifonol 1% (Japan) Bifosin (Russian Federation) Cream; Topical; Bifonazole 1% (Sintez) More: http://www.ndrugs.com/?s=bifonazole      Powder; Topical; o Bifonazole 1% (Sintez) Solution; Topical; o Bifonazole 1% (Sintez) Spray; Topical; o Bifonazole 1% (Sintez) o Bifunal (Bulgaria, Georgia) Bifuzol (Ecuador) o Bilmitin (Japan) Bilmitin 1% (Japan) o Bimicot (Argentina) o Biocitronil (Chile) o Biscopor (Japan) Biscopor 1% (Japan) o Biszole (Taiwan) Biszole 10 mg/1 g x 1 g Biszole 10 mg/1 g x 5 g Biszole 10 mg/1 g x 10 g Biszole 10 mg/1 g x 20 g o Canespie Bifonazol (Spain) o Canespor (Bulgaria, Czech Republic) o Canesten AF Once Daily (United Kingdom) Cream; Topical; o Bifonazole 1% (Bayer consumer) o Canesten Anti-Dandruff Shampoo Plus Shampoo; Topical; o Bifonazole Canesten o Bifonazol (Austria) o Canesten Bifonazol 1% (Malta) Canesten Bifonazol 168   Ointment; Topical; o Bifonazole 1% / Patch; Topical o Canesten 1% Canesten Bifonazole Once Daily Athlete's Foot Cream Topical; o Bifonazole 1% Canesten Extra o Bifonazole 1% Canesten Extra 確膚寧特效 (Hongkong) o Canesten Extra cream 1 % 20 g x 1's (Bayer) $ 94.00 o Canesten Once Daily (Australia) o Canesten Plus (Hungary, New Zealand) US Brand Name Generic Name Other Brand Name Packing Manufacturer Form Strength Canespor Bifonazole Mycospor 7.5 gm Bayer Cream 0.01 List of Bifonazole substitutes (brand and generic names): Aeroderma (Greece) Aicozale (Japan) Aicozale 1% (Japan) Amycor (France) Cream; Topical; Bifonazole 1% (Merck) Powder; Topical; Bifonazole 1% (Merck) Solution; Topical; Bifonazole 1% (Merck) Amycor 1 % x 1 tube 15g (Merck) Amycor 1% (France) Antifungol HEXAL Extra (Germany) Antifungol HEXAL Extra 1% (Germany) Azolmen (Italy) sponsored B.& N. exfungus (Taiwan) B.& N. exfungus 10 mg/1 g x 15 g Baritona (South Korea) Bayclear Plus (China) Befone (Taiwan) Befone 10 mg/1 g x 1 g Befone 10 mg/1 g x 5 g Befone 10 mg/1 g x 10 g Befone 10 mg/1 g x 15 g Bi Fu (China) Biazol (Romania) Bicos (Taiwan) Bicos 10 mg/1 g x 10 g Bicronol (Japan) Bicronol 1% (Japan) Bicutrin (Serbia) Bifazol (Italy) Bifized (Greece) Bifo Bifo 10 gm Cream (Ciens Laboratories (Adonis Labs Pvt Ltd)) BIFO 1% CREAM 1 tube / 10 GM cream each (Ciens Laboratories (Adonis Labs Pvt Ltd)) $ 0.95 Bifo 1% Cream (Ciens Laboratories (Adonis Labs Pvt Ltd)) $ 0.95 Bifo BD Bifo BD 10 gm Cream (Ciens Laboratories (Adonis Labs Pvt Ltd)) Bifokey (Spain) Bifomyk (Germany, Pakistan) Bifon (Georgia, Germany) Bifona (Taiwan) Bifona 10 mg/1 mL x 1 mL Bifona-Z (Taiwan) Bifona-Z 10 mg/1 g x 1 g Bifona-Z 10 mg/1 g x 5 g Bifona-Z 10 mg/1 g x 10 g Bifona-Z 10 mg/1 g x 15 g Bifonal (Argentina) Bifonazol (Chile) Cream; Topical; Bifonazole 1% Bifonazol Andromaco (Chile) Bifonazol Aristo (Germany) Bifonazol Genfar (Colombia) Bifonazol Hexal (Germany) Bifonazol L.CH. (Chile) Bifonazol Ramos (Nicaragua) Bifonazol-SL (Bulgaria, Lithuania) Bifonazole 1% F (Japan) Bifonazole 1% Sawai (Japan) Bifonazole 1% Taiyo (Japan) Bifonazole 1% YD (Japan) Bifonazole Sinphar (Taiwan) Bifonazole Taiyo (Japan) Bifonazole-Teva (Israel) Bifonol (Japan) Bifonol 1% (Japan) Bifosin (Russian Federation) Cream; Topical; Bifonazole 1% (Sintez) Powder; Topical; Bifonazole 1% (Sintez) Solution; Topical; Bifonazole 1% (Sintez) Spray; Topical; Bifonazole 1% (Sintez) Bifunal (Bulgaria, Georgia) Bifuzol (Ecuador) Bilmitin (Japan) Bilmitin 1% (Japan) Bimicot (Argentina) Biocitronil (Chile) Biscopor (Japan) Biscopor 1% (Japan) Biszole (Taiwan) Biszole 10 mg/1 g x 1 g Biszole 10 mg/1 g x 5 g Biszole 10 mg/1 g x 10 g Biszole 10 mg/1 g x 20 g Canespie Bifonazol (Spain) Canespor (Bulgaria, Czech Republic) Canesten AF Once Daily (United Kingdom) Cream; Topical; Bifonazole 1% (Bayer consumer) Canesten Anti-Dandruff Shampoo Plus Shampoo; Topical; Bifonazole Canesten Bifonazol (Austria) Canesten Bifonazol 1% (Malta) Canesten Bifonazol Creme Cream; Topical; Bifonazole 1% Canesten Bifonazol Nagelset Ointment; Topical; Bifonazole 1% / Patch; Topical Canesten Bifonazol Spray Spray; Topical; Bifonazole 10 mg / dose Canesten Bifonazole (United Kingdom) 169 Canesten Bifonazole Once Daily Anti-Fungal Body Cream Cream; Topical; Bifonazole 1% Canesten Bifonazole Once Daily Athlete's Foot Cream Cream; Topical; Bifonazole 1% Canesten Extra Bifonazol Cream; Topical; Bifonazole 1% Canesten Extra 確膚寧特效 (Hongkong) Canesten Extra cream 1 % 20 g x 1's (Bayer) Canesten Once Daily (Australia) Canesten Plus (Hungary, New Zealand) Canesten Plus Bifonazol (Hungary) Canesten Ultra (Colombia) Canesten Unidie (Italy) Canestene Derm Bifonazole (Belgium) Canestene Onychoset Bifonazole (Luxembourg) Compaser (Greece) Comybor (Taiwan) Comybor 10 mg/1 g x 1 g Comybor 10 mg/1 g x 5 g Comybor 10 mg/1 g x 10 g Comybor 10 mg/1 g x 15 g Comybor 10 mg/1 g x 20 g Comybor 10 mg/1 g x 900 g Comybor 10 mg/1 g x 1 kg Dermokey (Spain) Foohol (Taiwan) Foohol 10 mg/1 g x 1 g Foohol 10 mg/1 g x 10 g Foohol 10 mg/1 g x 15 g Foohol 10 mg/1 g x 450 g Foohol 10 mg/1 g x 1 kg Fospoal (Japan) Fospoal 1% (Japan) Fu Qi (China) Fukang (China) Fungiderm 1% (Cyprus) Fungin (Bangladesh, Taiwan) Fungin 10 mg/1 g x 1 g (Drakt International) Fungin 10 mg/1 g x 10 g (Drakt International) Fungin 10 mg/1 g x 15 g (Drakt International) Fungin 10 mg/1 g x 450 g (Drakt International) Fungin 150 mg Tablet (Drakt International) $ 0.19 Fungin 50 mg Tablet (Drakt International) $ 0.07 Futezole (Taiwan) Futezole 1 % x 1 g Futezole 1 % x 5 g Futezole 1 % x 10 g Futezole 1 % x 15 g Futezole 1 % x 20 g Futezole 1 % x 450 g Futezole 1 % x 1 kg Gloryskin (Greece) Helpovion (Greece) Hui Fu De (China) Kavaderm (Greece) Kemezimin (Taiwan) Kemezimin 10 mg/1 g x 5 g Kemezimin 10 mg/1 g x 10 g Lenchence (Japan) Lenchence 1% (Japan) Levelina (Spain) Lie He Suo (China) Marinzoal (Japan) Marinzoal 1% (Japan) Micosol (Argentina) Micotopic (Chile) Moldina (Spain) Moldine (Japan) Monostop (Spain) Multifung (Chile) Cream; Topical; Bifonazole 1% (Rider) Powder; Topical; Bifonazole 1% (Rider) Multifung Atomizador Solution; Topical; Bifonazole 1% Myco - flusemidon (Romania) Myco-Flusemidon (Greece, Romania) Mycoson (Taiwan) Mycoson 10 mg/1 g x 1 g Mycoson 10 mg/1 g x 10 g Mycoson 10 mg/1 g x 450 g Mycoson 10 mg/1 g x 1 kg Mycoson 10 mg/1 mL x 1 mL Mycoson 10 mg/1 mL x 20 mL Mycoson 10 mg/1 mL x 40 mL Mycoson 10 mg/1 mL x 3.8 L Mycosor (South Africa) Mycospor (Aruba, Australia, Bahamas, Bahrain, Barbados, Belize, Bermuda, Brazil, Cayman Islands, China, Colombia, Costa Rica, Cyprus, Czech Republic, Dominican Republic, Ecuador, Egypt, El Salvador, Georgia, Germany, Greece, Guatemala, Haiti, Honduras, Hong Kong, Hungary, Indonesia, Iran, Jamaica, Japan, Jordan, Kenya, Kuwait, Lebanon, Luxembourg, Mexico, Netherlands, Netherlands Antilles, Nicaragua, Oman, Panama, Peru, Poland, Portugal, Qatar, Romania, Russian Federation, Saudi Arabia, Slovakia, Slovenia, South Africa, Spain, Sudan, Suriname, Taiwan, Tanzania, Trinidad & Tobago, Turkey, Uganda, United Arab Emirates) Cream; Topical; Bifonazole 1% (Bayer) Powder; Topical; Bifonazole 1% (Bayer) Solution; Topical; Bifonazole 1% (Bayer) Mycospor 1,000% 15g - 1 Cream (Bayer) $ 26.00 Mycospor 10mg CRM / 10g (Bayer) $ 0.79 10 mg x 10g (Bayer) Mycospor 1 % x 5 g (Bayer) Mycospor 1 % x 20 g (Bayer) Mycospor 1 % x 1's (Bayer) Mycospor 1 % x 5 g x 1's (Bayer) $ 3.82 Mycospor 1 % x 15 g x 1's (Bayer) $ 7.52 MYCOSPOR CREAM 1 tube / 10 GM cream each (Bayer) $ 1.03 MYCOSPOR cream 10 mg x 10g (Bayer) $ 0.79 Mycospor 1% (Egypt, Japan) Mycospor 1% Cream (Bayer Pharmaceuticals Pvt Ltd) $ 1.12 Mycosporan (Chile) Cream; Topical; Bifonazole 1% (Bayer) Mycosporin (Austria) Mycozole (Georgia, Japan, Thailand) Mycozole 1 % x 50 g (Osoth Interlab) Mycozole 1 % x 5 g (Osoth Interlab) Mycozole 1 % x 450 g (Osoth Interlab) Mycozole cream 1 % 1 lb x 1's (Osoth Interlab) Mycozole cream 1 % 5 g x 1's (Osoth Interlab) Mycozole cream 1 % 450 g x 1's (Osoth Interlab) Mycozole topical powd 1 % 50 g x 1's (Osoth Interlab) Mycozole cap 150 mg 20's (Osoth Interlab) Mycozole cap 50 mg 20's (Osoth Interlab) Mycozole 1% (Japan) Neltolon (Greece) Neltolon 1 % x 1 Bottle 15 mL Neltolon 10 mg/1 mL x 1 Bottle 15 mL Rye (Greece) Sinamida plus (Argentina) Sugenfu (Taiwan) Sugenfu 10 mg/1 g x 20 g Topical (Portugal) Trifonazole Unesia (Mexico) Zerus (Japan) Zerus 1% (Japan) 171 Recent reports Kryczyk et al. (2017) investigated the effect of ZnO or/and TiO2 on the stability of bifonazole in solutions under UVA irradiation. To this end, a simple and reproducible UPLC method for the determination of bifonazole in the presence of its photocatalytic degradation products was developed. Linearity was studied in the range of 0.0046-0.15 mg mL-1 with a determination coefficient of 0.9996. Bifonazole underwent a photocatalytic degradation process under the experimental conditions used. Comparative studies showed that combination of TiO2 /ZnO (1:1 w/w) was a more effective catalyst than TiO2 or ZnO with a degradation rate of up to 67.57% 171 after 24 h of irradiation. Further, kinetic analyses indicated that the photocatalytic degradation of bifonazole in the mixture of TiO2 /ZnO can be described by a pseudo-first order reaction. Statistical comparison clearly indicated that the presence of TiO2 /ZnO also affected the stability of bifonazole from a cream preparation after 15 h of UVA exposure (p < 0.05). Ten photodegradation products of bifonazole were identified for the first time and their plausible fragmentation pathways, derived from MS/MS data, were proposed. The main pathway in the photocatalytic transformation of bifonazole in the presence of ZnO or/and TiO2 involves hydroxylation of the methanetriyl group and/or adjacent phenyl rings and cleavage of the imidazole moiety. Syu et al. (2017) described the design and synthesis of a novel family of bifunctional, chiral bicyclo[2.2.1]heptadiene ligands bearing aryl and secondary amido groups, and demonstrate their usefulness in the RhI -catalyzed enantioselective addition reaction of arylboronic acids to N-diphenylphosphinyl (N-DPP)-protected aldimines. Unlike the analogous RhI -catalysts comprising diene ligands substituted with aryl and carboxylic ester groups, or only with aryl groups, the addition reaction proceeded with high stereoselectivity. The protocol tolerated a range of N-DPP-aldimines and arylboronic acids, producing the desired optically active N-DPPprotected amines with yields between 31-99 % and with ee values up to 91-99 %. The synthetic utility of the method was demonstrated by the conversion of N-DPP-protected amine 3 ae into the antifungal agent, bifonazole. Chen et al. (2015) investigated the drug crystallization mechanism within PEG, PPG, and poloxamer matrix, and the resultant microstructure of various solid dispersions of acetaminophen (ACM) and bifonazole (BFZ) in the aforementioned polymers was characterized by differential scanning calorimetry (DSC), polarized optical microscopy (POM), and wide/small-angle X-ray diffraction (WAXD/SAXS). With a stronger molecular interaction with the PEG segments, ACM decreased the crystallization onset temperature and crystallinity of PEG and poloxamers much more than BFZ. The stronger molecular interaction and better miscibility between ACM and PEG also induced a more defective lamellar structure in the ACM solid dispersions compared with that in the BFZ systems, as revealed by DSC and SAXS investigation. Observed under polarized optical microscopy, PEG, PPG, and poloxamer could all significantly improve the crystallization rate of ACM and BFZ, because of the largely reduced Tg of the solid dispersions by these low Tg polymers. Moreover, when the drug loading was below 60%, crystallization of BFZ in PEG or poloxamer occurred preferably along the radial direction of PEG spherulite, rather than the perpendicular direction, which was attributed to the geometric restriction of wellordered polymer lamellar structure in the BFZ solid dispersions. Similar phenomena were not observed in the ACM solid dispersions regardless of the drug loading, presumably because ACM could diffuse freely across the perpendicular direction of the PEG spherulite, through the wellconnected interlamellar or interfibrillar spaces produced by the defective PEG lamellar structure. The different drug-polymer interaction also caused a difference in the microstructure of polymer crystal, as well as a difference in drug distribution within the polymer matrix, which then synergistically facilitated a "confined crystallization" process to reduce the drug crystallite size below 100 nm. Cheng et al. (2014) explored the effect of bifonazole on cytosolic free Ca(2+) concentrations ([Ca(2+)]i) and viability in PC3 human prostate cancer cells was explored. The Ca(2+)-sensitive fluorescent dye, fura-2, was applied to measure [Ca(2+)]i. Bifonazole at concentrations of 530 µM induced a [Ca(2+)]i rise in a concentration-dependent manner. The response was reduced 172 by 50% by removing extracellular Ca(2+). Bifonazole-evoked [Ca(2+)]i rise was not altered by nifedipine, econazole, SK&F96365 and protein kinase C activator, but was inhibited by 75% by GF109203X, a protein kinase C inhibitor. In Ca(2+)-free medium, treatment with the endoplasmic reticulum Ca(2+) pump inhibitor 2,5-di-tert-butylhydroquinone (BHQ) nearly abolished bifonazole-evoked [Ca(2+)]i rise. Conversely, treatment with bifonazole abolished BHQ-evoked [Ca(2+)]i rise. Inhibition of phospholipase C with U73122 abolished bifonazoleinduced [Ca(2+)]i rise. At 30-100 µM, bifonazole decreased cell viability concentrationdependently, which was not reversed by chelating cytosolic Ca(2+) with 1,2-bis(2aminophenoxy)ethane-N,N,N″,N'-tetraacetic acid/acetoxy methyl. Annexin V/propidium iodide staining data suggest that bifonazole (30-100 µM) induced apoptosis concentration-dependently. Together, in PC3 human prostate cancer cells, bifonazole induced [Ca(2+)]i rises by inducing phospholipase C- and protein kinase C-dependent Ca(2+) release from the endoplasmic reticulum and Ca(2+) influx via non-store-operated pathways. Bifonazole induced cell death that might involve apoptosis. Lahfa et al. (2013) compared two treatment modalities to obtain diseased nail chemical avulsion in toenail onychomycosis. In this European, multicenter, randomized, parallel-group, open-label, active-controlled study, male or female adult patients with distal-lateral or lateral subungual dermatophyte onychomycosis on at least 12.5% of the great toenail were randomized either to a 40% urea ointment with plastic dressing group (n = 53) or to a bifonazole-urea ointment group (n = 52). The ointments were applied daily for a maximum of 3 weeks according to the summary of product characteristics. After assessment of infected nail debridement, topical antifungal treatment with bifonazole cream was applied daily in both groups for 8 weeks. 102 patients were evaluated, i.e. 51 in the 40% urea ointment with plastic dressing group and 51 in the bifonazoleurea group. The primary end point was complete removal of the nail plate at day 21 (D21). Secondary end points were: complete cure and mycological cure evaluated at D105. Ease of use and local tolerability were also assessed. Complete removal of the clinically infected target nail plate area, assessed by blinded evaluators, was significantly higher in the 40% urea ointment with plastic dressing group (61.2%) than in the control group (39.2%), showing the superiority of 40% urea ointment with plastic dressing (p = 0.028). The same results were observed in the perprotocol population (63.0 vs. 36.6%; p = 0.014). Complete removal of the infected area assessed by the investigator at D21 showed a significantly higher success rate in patients treated with 40% urea ointment with plastic dressing (86.3%) as compared to patients treated with bifonazole-urea (60.8%), confirming the superiority of 40% urea ointment with plastic dressing (p = 0.004). At D105, the complete cure of onychomycosis, a criterion combining clinical and mycological assessments, showed a success rate of 27.7% for 40% urea ointment with plastic dressing versus 20.8% for the control group. No statistical difference was observed between the two treatment groups. The number of patients with at least one adverse event was twice as high in the bifonazole-urea group in comparison to the 40% urea ointment with plastic dressing group. Overall assessment of local tolerability by the investigator was considered good/very good in 98.0% of the 40% urea ointment with plastic dressing patients versus 90.4% of the bifonazoleurea patients, at D21, with no significant difference between both groups. Tietz et al. (2013) evaluated efficacy and safety of bifonazole cream vs. placebo in onychomycosis treatment after non-surgical nail ablation with urea paste. Fifty-one study centres randomized 692 subjects with mild-to-moderate onychomycosis to receive bifonazole 1% cream or placebo for 4 weeks following non-surgical nail ablation with urea 40% paste over 2-4 173 weeks. Efficacy of the two phase treatment was evaluated by overall cure of the target nail comprising clinical and mycological cure 2 weeks, 3 and 6 months after end of treatment. At 2 weeks (primary endpoint), overall cure rate was superior in bifonazole-treated group (54.8% vs. 42.2% for placebo; P = 0.0024). The clinical cure rate was high in both treatment groups (86.6% bifonazole vs. 82.8% placebo), but proportion with mycological cure was higher with bifonazole treatment (64.5%) vs. placebo treatment 49.0%, (P = 0.0001). References 1. Chen Z1, Liu Z, Qian F. Crystallization of bifonazole and acetaminophen within the matrix of semicrystalline, PEO-PPO-PEO triblock copolymers. Mol Pharm. 2015 Feb 2;12(2):590-9. 2. Cheng JS1, Chou CT, Liang WZ, Kuo CC, Shieh P, Kuo DH, Jan CR. The mechanism of bifonazole-induced [Ca(2+)]i rises and non-Ca(2+)-triggered cell death in PC3 human prostate cancer cells. J Recept Signal Transduct Res. 2014 Dec;34(6):493-9. 3. Kryczyk A1, Żmudzki P2, Hubicka U1. Determination of bifonazole and identification of its photocatalytic degradation products using UPLC-MS/MS. Biomed Chromatogr. 2017 Sep;31(9). 4. Lahfa M1, Bulai-Livideanu C, Baran R, Ortonne JP, Richert B, Tosti A, Piraccini BM, Szepietowski JC, Sibaud V, Coubetergues H, Voisard JJ, Paul C. Efficacy, safety and tolerability of an optimized avulsion technique with onyster® (40% urea ointment with plastic dressing) ointment compared to bifonazole-urea ointment for removal of the clinically infected nail in toenail onychomycosis: a randomized evaluatorblinded controlled study. Dermatology. 2013;226(1):5-12 5. Syu JF1, Lin HY1, Cheng YY1, Tsai YC1, Ting YC1, Kuo TS1, Janmanchi D1, Wu PY2, Henschke JP3, Wu HL1. Design and Synthesis of Chiral Diene Ligands for RhI Catalyzed Enantioselective Arylation of N-DPP-protected Aldimines: Synthesis of the Antifungal Agent Bifonazole. Chemistry. 2017 Aug 1. doi: 10.1002/chem.201702509. [Epub ahead of print] 6. Tietz HJ1, Hay R, Querner S, Delcker A, Kurka P, Merk HF. Efficacy of 4 weeks topical bifonazole treatment for onychomycosis after nail ablation with 40% urea: a double-blind, randomized, placebo-controlled multicenter study. Mycoses. 2013 Jul;56(4):414-21. 174 3. Butoconazole    Butoconazole is an imidazole antifungal used in gynecology. Butoconazole is used for the local treatment of vulvovaginal candidiasis (infections caused by Candida) Butoconazole has fungicidal activity in vitro against Candida spp. and has been demonstrated to be clinically effective against vaginal infections due to Candida albicans. Candida albicans has been identified as the predominant species responsible for vulvovaginal candidasis. Molar mass: 411.776 g/mol Formula: C19H17Cl3N2S Trade name: Gynazole-1, Mycelex-3 Pharmacodynamics Butoconazole is an imidazole derivative that has fungicidal activity in vitro against Candida spp. and has been demonstrated to be clinically effective against vaginal infections due to Candida albicans. Candida albicans has been identified as the predominant species responsible for vulvovaginal candidasis. Mechanism of action The exact mechanism of the antifungal action of butoconazole is unknown, however, it is presumed to function as other imidazole derivatives via inhibition of steroid synthesis. Imidazoles generally inhibit the conversion of lanosterol to ergosterol via the inhibition of the enzyme cytochrome P450 14α-demethylase, resulting in a change in fungal cell membrane lipid composition. This structural change alters cell permeability and, ultimately, results in the osmotic disruption or growth inhibition of the fungal cell. Clinical pharmacology  Following vaginal administration of butoconazole nitrate vaginal cream, 2% to 3 women, 1.7% (range 1.3-2.2%) of the dose was absorbed on average.  Peak plasma levels (13.6-18.6 ng radioequivalents/mL of plasma) of the drug and its metabolites are attained between 12 and 24 hours after vaginal administration. 175 Indications and usage  GYNAZOLE • 1® Butoconazole Nitrate Vaginal Cream USP, 2% is indicated for the local treatment of vulvovaginal candidiasis (infections caused by Candida).  GYNAZOLE • 1® Butoconazole Nitrate Vaginal Cream USP, 2% is safe and effective in non-pregnant women List of Butoconazole substitutes (brand and generic names): http://www.ndrugs.com Butoconazole 2% (Egypt) Butoconazole Cream Femstal (Mexico) Femstat (Colombia, Costa Rica, Dominican Republic, El Salvador, Guatemala, Honduras, Nicaragua, Panama, Peru, Taiwan, United States) Cream; Topical; Vaginal; Butoconazole Nitrate 2% (Bayer) Suppositories; Rectal; Vaginal; Butoconazole Nitrate 100 mg (Bayer) Femstat 100 mg x 30's (Bayer) Femstat 100 mg x 60's (Bayer) Gynafem (Mexico) Gynazol (Bulgaria, Hungary, Poland, Slovakia) GYNAZOL Capsule/ Tablet / 50mg / 10 units (Indian Drugs & Pharmaceuticals Ltd.) $ 1.49 GYNAZOL Capsule/ Tablet / 100mg / 10 units (Indian Drugs & Pharmaceuticals Ltd.) $ 2.48 GYNAZOL Capsule/ Tablet / 200mg / 10 units (Indian Drugs & Pharmaceuticals Ltd.) $ 4.68 sponsored Gynazol 50mg CAP / 30 (Indian Drugs & Pharmaceuticals Ltd.) $ 3.41 Gynazol 100mg CAP / 30 (Indian Drugs & Pharmaceuticals Ltd.) $ 6.75 Gynazol 200mg CAP / 30 (Indian Drugs & Pharmaceuticals Ltd.) $ 11.35 50 mg x 30's (Indian Drugs & Pharmaceuticals Ltd.) $ 3.41 100 mg x 30's (Indian Drugs & Pharmaceuticals Ltd.) $ 6.75 200 mg x 30's (Indian Drugs & Pharmaceuticals Ltd.) $ 11.35 Gynazol 200 mg Capsule (Indian Drugs & Pharmaceuticals Ltd.) $ 0.47 Gynazol 100 mg Capsule (Indian Drugs & Pharmaceuticals Ltd.) $ 0.26 Gynazol 50 mg Capsule (Indian Drugs & Pharmaceuticals Ltd.) $ 0.14 GYNAZOL 100 MG CAPSULE 1 strip / 10 capsules each (Indian Drugs & Pharmaceuticals Ltd.) $ 3.74 GYNAZOL 200 MG CAPSULE 1 strip / 10 capsules each (Indian Drugs & Pharmaceuticals Ltd.) $ 5.76 GYNAZOL 50 MG CAPSULE 1 strip / 10 capsules each (Indian Drugs & Pharmaceuticals Ltd.) $ 1.72 GYNAZOL cap 50 mg x 10's (Indian Drugs & Pharmaceuticals Ltd.) $ 1.97 GYNAZOL cap 100 mg x 10's (Indian Drugs & Pharmaceuticals Ltd.) $ 3.56 GYNAZOL cap 200 mg x 10's (Indian Drugs & Pharmaceuticals Ltd.) $ 5.76 Gynazol 50mg Capsule (Indian Drugs & Pharmaceuticals Ltd.) $ 0.19 Gynazol 2% (Slovakia) Gynazole (China, Peru) Gynazole 1 Gynazole 1 cream 100 mg/5g (Perrigo New York Inc (US)) Gynazole-1 Vaginal Cream Cream; Vaginal; Butoconazole Nitrate 100 mg / application Gyno Myk (Belgium) Gynofort (Georgia, Indonesia, Latvia, Malaysia, Romania, Russian Federation, Singapore, Vietnam) Cream; Vaginal; Butoconazole Nitrate 2% (Gedeon Richter) Gynofort 2 % x 5 g x 1's (Gedeon Richter) $ 12.28 Gynofort 2 % x 1 tube bГґm duГёng 1 laГ n 5 g (Gedeon Richter) Gynomyk (Belgium, France, Luxembourg, Netherlands) Ovules; Vaginal; Butoconazole Nitrate 100 mg (Will) 176 Recent reports Jia et al. (2014) developed liquid chromatography-tandem mass spectrometry (LC-MS/MS) method and validated for the determination of butoconazole in human plasma. Human plasma samples of 0.2 μL were pretreated by a single step protein precipitation procedure and analyzed using a high performance liquid chromatography (HPLC) electrospray tandem mass spectrometer system. The compounds were eluted isocratically on an Inertsil ODS-SP column (100 mm×2.1 mm, 3 μm), ionized using a positive ion atmospheric pressure electrospray ionization source and analyzed using multiple reaction monitoring (MRM) mode. The ion transitions monitored were m/z 412.8→165.1 for butoconazole and m/z 453.4→230.3 for the internal standard. The chromatographic run time was 3.5 min per injection, with retention time of 2.47 min and 2.15 min for butoconazole and repaglinide, respectively. The method was validated to be linear over the range of 20 to 8000 pg/mL (r>0.999) by using a weighted (1/x(2)) quadratic regression. The mean recovery rate was more than 86.7%, and the intra- and inter-day precision of the quality control samples (QCs) was less than 8.3% and the accuracy ranged from 96.0% to 110.2%, which indicated that the quantitative method was reliable and accurate. The method is simple, rapid, and has been applied successfully to a pharmacokinetics study of butoconazole nitrate suppositories in healthy Chinese females. Heng et al. (2012) described the efficacy and the successful use of a butoconazole-SR formulation in the treatment of two cases of RVVC. They reported 2 cases. Case 1: A 31-yearold sexually active Chinese woman presented to our centre with symptoms of vulvar itching and vaginal discharge, which she had been experiencing for two years. She selfmedicated with overthe-counter antifungal pessaries. However, there was no resolution of the symptoms. The patient was treated with butoconazole-SR pessary 2% (5 g) intravaginally twice a week for two weeks 177 and followed up weekly for another three weeks. At the patient‘s three- and six-month followups, she was asymptomatic and the vaginal swab was negative for Candida. Case 2 A 52-yearold perimenopausal Chinese woman with a history of recurrent VVC in the past year had been treated with topical antimycotic azole agents by various doctors. She presented with another episode of vaginal itching and discharge. On examination, she had vaginal erythema and a whitish vaginal discharge typical of candidiasis. She was first started on weekly butoconazoleSR pessary 2% (5 g) for two weeks, followed by maintenance treatment of weekly dose for the next three weeks. The patient‘s symptoms resolved and she remained asymptomatic for the next six months. Senchenko et al. (2009) developed a method for determining this drug in the blood of experimental animals based on capillary electrophoresis. Samples were prepared using sedimentation of plasma proteins by acetonitrile. The separation was carried out at 27°C in a quartz capillary (75 μm diameter, 65 cm working length) at 20 kV. The leading electrolyte was a phosphate buffer solution at pH 3.6. Detection was performed by spectrophotometry at 210 nm. The proposed technique was used to study the pharmacokinetics of butoconazole nitrate in rats upon a single intraperitoneal injection at a dose of 80 mg/kg. The kinetic curves of butoconazole nitrate concentration in the blood were constructed and were typical of drug removal with bile. References 1. Heng LZ1, Chen Y, Tan TC. Treatment of recurrent vulvo-vaginal candidiasis with sustained-released butoconazole pessary. Singapore Med J. 2012 Dec;53(12):e269-71. 2. Jia MM1, Zhou Y, He XM, Wu YL, Li HQ, Chen H, Li WY. Development of a liquid chromatography-tandem mass spectrometry method for determination of butoconazole nitrate in human plasma and its application to a pharmacokinetic study. J Huazhong Univ Sci Technolog Med Sci. 2014 Jun;34(3):431-6. doi: 10.1007/s11596014-1296-y. Epub 2014 Jun 18. 3. S. P. Senchenko, K. S. Checheneva, M. V. Gavrilin, L. S. Ushakova. Butoconazole nitrate pharmacokinetics studied by capillary electrophoresis Pharmaceutical Chemistry Journal November 2009, Volume 43, Issue 11, pp 597–600 4. Clotrimazole, Crowley and      Gallagher, 2014 Clotrimazole is an imidazole derivative with a broad-spectrum antimycotic activity. Clotrimazole is used for the treatment of Candida albicans and other fungal infections. I Clotrimazole antimycotic properties were discovered in the late 1960s. Clotrimazole is marketed as a generic drug under various different trade names and by various companies worldwide. Clotrimazole is also used in the treatment of metronidazole-resistant Trichomoniasis to relieve symptoms and displays activity against certain Gram-positive bacteria Mode of action  Clotrimazole inhibits the microsomal cytochrome P450 (CYP450)-dependent event 14α-lanosterol demethylation, which is a vital step in ergosterol biosynthesis by fungi. 178  o The resultant depletion of ergosterol and its replacement with the aberrant sterol species, 14-α-methylsterol, perturb normal membrane permeability and fluidity. o Downstream effects include decreased activity of membrane-bound enzymes, including those involved in cell wall synthesis, increased cell wall leakiness and leaking of cell contents. o Moreover, because ergosterol directly stimulates growth of fungal cells in a hormone-like fashion, rapid onset of these events results in a dose- and timedependent inhibition of fungal growth. Clotrimazole is generally considered to be a fungistatic rather than a fungicidal drug, although as for many antimicrobials, this distinction is not absolute as it exhibits fungicidal effects at higher concentrations. Pharmaceutical dosage forms and administration       Within the European Union, clotrimazole is available in topical cream and pessary formulations under a variety of trade names. In the USA, additional formulations are available, including clotrimazole lotions, powders, lozenges, topical solutions and vaginal inserts/tablets. Clotrimazole is sometimes formulated with the steroids hydrocortisone or bethamethasone, and in some cases, these compounded preparations may be labelled as coclimasone (Sweetman 2007). Typical excipients in clotrimazole creams include benzyl alcohol, cetostearyl alcohol, medium-chain triglycerides and triceteareth-4 phosphate. o In products aimed at the treatment of fungal skin infections, clotrimazole is usually formulated as a 1% cream, lotion, spray or solution. o In the treatment of vulvovaginal candidiasis, the normal dosage forms are either 100 mg, 200 mg or 500 mg pessaries which are administered daily for 6, 3 or 1 days, respectively. Similar doses may be obtained by application of 1, 2 or 10% creams to the vaginal area. o In the treatment of oropharyngeal candidiasis, clotrimazole lozenges are usually formulated to contain 10 mg of the active drug and these are sucked slowly until dissolved, five times daily for 14 days. o In the prophylactic prevention of oropharyngeal candidiasis in immunosuppressed individuals, this dose is reduced to 10 mg, three times daily, for the duration of the immunosuppressive therapy. According to the USP, o clotrimazole should contain not less than 98·0% and not more than 102·0% clotrimazole o clotrimazole creams, lotions, lozenges, topical solutions and vaginal inserts should contain not less than 90·0% and not more than 110·10% of the labelled amount of clotrimazole. According to the British and European Pharmacopoeias, o clotrimazole should contain not less than 98·5% and not more than 100·5% of clotrimazole with reference to the dried substance. 179 Side effects, interactions and contraindications        Topical forms of clotrimazole are considered reasonably safe and without serious side effects. there have been limited case reports of contact allergic dermatitis with clotrimazole creams that are not attributable to allergies to the vehicles or excipients, but are caused by the active ingredient itself. Intravaginal clotrimazole applied via a pessary may damage latex contraceptives (condoms) necessitating the use of additional contraceptive measures during the period of administration. The most prominent side effects of clotrimazole preparations in current use are those associated with the use of oral lozenges for the treatment of oral candidiasis. These include nausea, vomiting, unpleasant mouth sensations, pruritus and elevation of liver enzymes. Clotrimazole tablets or capsules designed for swallowing, as opposed to sucking, are no longer used as they were associated with GIT disturbances, dysuria and mental depression. Pessaries are not recommended for use in children or infants, although the drug itself poses no special risk to this subpopulation. Clotrimazole is also safe for use in the elderly population and in breast-feeding mothers. Pharmacodynamics  Along with econazole and miconazole, clotrimazole is the drug of choice for the topical treatment of tinea pedis (athlete's foot), tinea cruris and tinea corporis caused by isolates of Trichophyton rubrum, Trichophyton mentagrophytes, Epidermophyton floccosum, Microsporum canis and C. albicans.  It is also widely used in the topical treatment of vulvovaginal and oropharyngeal candidiasis. New approaches to formulation of clotrimazoleNew approaches to formulation of clotrimazole include o a buccal bioadhesive film containing clotrimazole, which was found to inhibit oral candidiasis for up to 6 h o a thermosensitive vaginal gel formulation formed by complexation of clotrimazole with beta-cyclodextrin, which has been shown to reduce the release rate of clotrimazole in comparison with standard preparations o This type of slow-release formulation may exhibit increased efficacy over other vaginal delivery systems, as traditional vaginal creams, pessaries and tablets tend to have short residency times in the vagina due to the natural cleansing process that takes place there. 181 o The use of liposomes containing clotrimazole may also provide increased residency in the vagina, thereby improving gel formulations for treatment. o RS 100 nano-capsules have recently been studied in the treatment of C. albicansand C. glabrata, and these have been reported as more active than free clotrimazole alone. o Nano-fibre mats for oral applications are also superior in efficacy and have reduced toxicity over lozenges and powders in current use, although further pharmaceutics investigations are needed Brand names, http://www.antimicrobe.org/drugpopup/Clotrimazole%20-%20Brand%20names.htm 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. ABTRIM (Ashbourne, UK UNITED KINGDOM) ACNECOLOR (Spirig SWITZERLAND) AGISTEN - (Agis - ISRAEL) AKNECOLOR (Spirig, CZECH REPUBLIC) ANTIFUNGOL - (Hexal GERMANY) ANTIMICOTICO (Savoma ITALY) ANTIMYK (Pfleger - GERMANY) APOCANDA (Apogepha GERMANY) A-POR (Aspen - SOUTH AFRICA) ARNELA (Andromaco - CHILE) ARU C (Chauvin ankerpharm GERMANY) AXASOL - (Silesia - CHILE) AZUTRIMAZOL (Azupharma GERMANY) BABY AGISTEN (Agis - ISRAEL) BAYCUTEN (Bayer - CHILE) BAYCUTEN (Bayer – PORTUGAL, BRAZIL, MEXICO, GERMANY) BAYCUTEN HC (Bayer GERMANY) BAYCUTEN N (Bayer - MEXICO) BAYCUTEN N (Bayer MALAYSIA) BAYCUTEN SD (Bayropharm, Ger.) BENZODERM MYCO (Athenstaedt, Ger. - GERMANY) CAGINAL (Pond's, Thai. THAILAND) CANADINE (TNP - THAILAND) CANALBA (Aspen - SOUTH AFRICA) CANAZOL (TO-Chemicals THAILAND) CANAZOL (Durascan DENMARK) CANDACORT (Hoe, Malaysia MALAYSIA) CANDASPOR (Be-Tabs- SOUTH AFRICA) CANDAZOLE (Hoe - MALAYSIA) CANDAZOL (Apogepha GERMANY) CANDIBENE (RatiopharmAUSTRIA, HUNGARY and Merckle – Czech Republic) 80. CORISOL - (Ecosol SWITZERLAND) 81. COTREN (Biolab, THAILAND, SINGAPORE, MALAYSIA) 82. COTREN (Biopharm, Hong Kong) 83. COTRISAN (Sanitas - CHILE) 84. COVOSPOR (Covan, SOUTH AFRICA) 85. CREMINEM (Mintlab - CHILE) 86. CRISTAN (Shin Poong, SINGAPORE) 87. CST (Pose- THAILAND) 88. CUTANIL (ITF- CHILE) 89. CUTISTAD (Stada- GERMANY and Helepharm SWITZERLAND) 90. DEFUNGO (Siam Bheasach, THAILAND) 91. DERMASTEN (Offenbach MEXICO) 92. DERMATEN (Pharmasant THAILAND) 93. DERMOBENE (Legrand BRAZIL) 94. DESAMIX EFFE (Savoma ITALY) 95. DESENEX (Taro - CANADA) 96. DIGNOTRIMAZOL (Luitpold GERMANY) 97. DIOMICETE (Edol PORTUGAL) 98. DURAFUNGOL (Merck dura GERMANY) 99. DYNASPOR (Salters – SOUTH AFRICA) 100. EUROSAN (FM) (Mepha SWITZERLAND) 101. FACTODIN (Faran - GREECE) 102. FEMCARE (Schering-Plough, USA) 103. FEMCARE (Schering-Plough, USA) 104. FLOREGIN COMPOSTO (Abbott - BRAZIL) 105. FUNGEDERM (Nucare UNITED KINGDOM) 106. FUNGICON (Continental Pharma - THAILAND) 107. FUNGIDERM (Terra-BioGERMANY and Greater Pharma THAILAND) 108. FUNGIDERMO (Cinfa - SPAIN) 109. FUNGIDEXAN (Hermal - 181 154. LORIDERM (Pharmaniaga MALAYSIA) 155. LOTREMIN (Schering-Plough - HONG KONG, SINGAPORE, MALAYSIA) 156. LOTREMIN (Schering-Plough - AUSTRALIA) 157. LOTRIMIN (Schering-Plough – MEXICO, USA) 158. LOTRIMIN AF (ScheringPlough, USA) 159. LOTRI VON CT (Tempelhof, GERMANY) 160. MANOMAZOLE (March THAILAND) 161. MASNODERM - (Dominion UK) 162. MECLON (Farmigea - ITALY) 163. MEDASPOR (Medpro, SOUTH AFRICA) 164. MEDISPORT ATHLETE'S FOOT (Medisport - UNITED KINGDOM) 165. MICLONAZOL (Cazi BRAZIL) 166. MICOMISAN (Restan SOUTH AFRICA) 167. MICOMISAN (FM) (Hosbon SPAIN) 168. MICOSTEN (Hexal - BRAZIL) 169. MICOTER (FM) (Cusi, Spain) 170. MICOTRAT (Delta - BRAZIL) 171. MICOTRIZOL (Eurofarma BRAZIL) 172. MONO BAYCUTEN (Bayropharm, GERMANY) 173. MYCELEX (ALZA PHARMACEUTICALS) 174. MYCELEX-7 (DI) (Bayer, USA) 175. MYCELEX-G (Bayer, USA) 176. MYCIL GOLD (Crookes Healthcare - UK) 177. MYCLO-DERM (Boehringer Ingelheim – CANADA) 178. MYCLO-GYNE (Boehringer Ingelheim – CANADA) 179. MYCLO-GYNE (Boehringer Ingelheim - CANADA) 180. MYCOBAN (Rolab - SOUTH AFRICA) 181. MYCOFUG (Hermal GERMANY) 182. MYCOFUG (Merck- 32. CANDID (Glenmark – THAILAND and Neves - PORTUGAL ) 33. CANDIDEN (Akita - UK) 34. CANDIMON (AndromacoMEXICO) 35. CANDINOX (Charoen THAILAND) 36. CANDIZOLE (Aspen, S.Afr. SOUTH AFRICA) 37. CANESTEN - (Bayer – UK, ITALY, SPAIN, GERMANY,CANADA, IRELAND, NETHERLANDS, SOUTH AFRICA, SWEDEN, NORWAY, AUSTRIA,DENMARK,PORTUGAL, BRAZIL, HONG KONG, THAILAND, SINGAPORE, FINLAND, NEW ZEALAND, AUSTRALIA, GREECE, CHILE, HUNGARY, CZECH REPUBLIC, MALAYSIA, GERMANY) 38. CANEX (Alliance - SOUTH AFRICA) 39. CANIFUG (Wolff – GERMANY, HUNGARY, CZECH REPUBLIC) 40. CESTOP (Drag - CHILE) 41. CHEMISTS OWN CLOZOLE (Herron - AUSTRALIA) 42. CHINGAZOL (Chinta THAILAND) 43. CINABEL (Columbia - MEXICO) 44. CLOCIM (Cimex SWITZERLAND) 45. CLOCREME (Pacific – HONG KONG, NEW ZEALAND) 46. CLODERM (Dermapharm GERMANY) 47. CLOFEME (Hexal, - AUSTRALIA) 48. CLOFUNGIN (Hexal GERMANY)) 49. CLOGEN (UCI, Braz. - BRAZIL) 50. CLOMADERM (Parke-Med, S.Afr.) 51. CLOMAZEN (Uniao Quimica BRAZIL) 52. CLONASTEN (Teuto - BRAZIL) 53. CLONEA (AlphapharmAUSTRALIA) 54. CLOSCRIPT (Ranbaxy- SOUTH AFRICA) 55. CLOSTRIN (Iwaki, JAPAN) 56. CLOT-BASAN (Schonenberger SWITZERLAND) 57. CLOTREME - (Hexal AUSTRALIA) 58. CLOTREN (Teuto - BRAZIL) 59. CLOTRI (Polipharm - THAILAND) 60. CLOTRICIN (Seng, THAILAND) 61. CLOTRI-DENK (Denk, HONG KONG) 62. CLOTRIFERM (Fermenta SWEDEN) 63. CLOTRIFUG (Wolff - GERMANY) 64. CLOTRIGALEN (Galen GERMANY) 65. CLOTRIHEXAL (Hexal - NEW ZEALAND) 66. CLOTRIMADERM (Taro – CANADA, ISRAEL) 67. CLOTRIMAZOLE a. TOPICAL CREAM - 1% GERMANY) 110. FUNGISTEN (Weifa NORWAY) 111. FUNGIZID (Ratiopharm – GERMANY, HONG KONG) 112. FUNGIZID (Douglas - NEW ZEALAND) 113. FUNGOID (Pedinol, USA) 114. FUNGOTOX (MephaSWITZERLAND) 115. FUNZAL (Gynopharm, CHILE) 116. GILT (Lacoer, GERMANY) 117. GINE CANESTEN (Bayer SPAIN) 118. GINO-CANESTEN (Bayer PORTUGAL) 119. GINO CLOTRIMIX (Eversil BRAZIL) 120. GINO-LOTREMINE (ScheringPlough - PORTUGAL) 121. GROMAZOL (Grossman SWITZERLAND) 122. GYNEBO (Chew - THAILAND) 123. GYNE-LOTREMIN (ScheringPlough, Hong Kong - HONG KONG, SINGAPORE, MALAYSIA) 124. GYNE-LOTRIMIN (ScheringPlough – AUSTRALIA, USA) 125. GYNESTIN (Kenyaku THAILAND) 126. GYNEZOL (Parke-Med – SOUTH AFRICA) 127. GYNOCANESTEN (Bayer, Chile - CHILE) 128. GYNO-CANESTEN (Bayer ITALY) 129. GYNO-CANESTENE (Bayer – BELGIUM, SWITZERLAND) 130. GYNO-CANESTEN (Bayer GERMANY) 131. GYNO-TRIMAZE (Garec SOUTH AFRICA) 132. HIDERM (Baypharm AUSTRALIA) 133. HOLFUNGIN (Hollborn GERMANY) 134. HYDROAGISTEN (Agis ISRAEL) 135. HYDROZOLE (Stiefel AUSTRALIA) 136. ICTAN (Sanofi - SPAIN) 137. IMACORT (Spirig SWITZERLAND) 138. IMAZOL (Spirig – SWITZERLAND and Karrer GERMANY) 139. IMAZOL COMP (Karrer GERMANY) 140. IMAZOL (Spirig – CZECH REPUBLIC) 141. IMAZOL PLUS (Spirig - CZECH REPUBLIC) 142. JENAMAZOL (Jenapharm – CZECH REPUBLIC) 143. JENAMAZOL (Jenapharm GERMANY) 144. KADEFUNGIN (Kade GERMANY) 145. KAMICIN (Christo - HONG 182 AUSTRIA) 183. MYCOHAUG C (Betapharm GERMANY) 184. MYCO-HERMAL (Hermal, ISRAEL and SINGAPORE) 185. MYCOHEXAL (Hexal SOUTH AFRICA) 186. MYCORIL (Remedica, HONG KONG and SINGAPORE) 187. MYCOTRIM (Lagap – SWITZERLAND) 188. MYCOZOLE (Osoth THAILAND) 189. MYKO CORDES (Ichthyol – AUSTRIA, GERMANY) 190. MYKO CORDES PLUS (Ichthyol, Ger. GERMANY) 191. MYKOFUNGIN (Riemser GERMANY) 192. MYKOHAUG (Betapharm GERMANY) 193. NEO CLOTRIMAZYL (Neo Quimica - BRAZIL) 194. NEO-ZOL (Neolab CANADA) 195. NESTIC (Asian Pharm THAILAND) 196. NORMOSPOR (Propan, SOUTH AFRICA) 197. NOVACETOL (Prater CHILE) 198. ONYMYKEN (Schuck GERMANY) 199. ORALTEN TROCHE (Agis ISRAEL) 200. OVIS NEU (Pfizer GERMANY) 201. PAN-FUNGEX (Sanofi Synthelabo - PORTUGAL) 202. PARVEMAXOL (Chefaro NETHERLANDS) 203. PEDIKUROL (Ratiopharm AUSTRIA) 204. PEDISAFE (BASF GERMANY) 205. PLIMYCOL (Pliva, CZECH REPUBLIC) 206. POLYCUTAN (Agis ISRAEL) 207. PRESCRIPTION STRENGTH DESENEX (Ciba, USA) 208. PRIVACOM (Typharm, UK) 209. RADIKAL (Maurer, GERMANY) 210. SASTID ANTI-FUNGAL (Stiefel, SINGAPORE) 211. SD-HERMAL (Hermal GERMANY) 212. STIEMAZOL (FM) (Stiefel GERMANY) 213. SYNCO-CFN (Synco - HONG KONG) 214. TARATEN (Polipharm THAILAND) 215. TELUGREN (Alpes Chemie CHILE) 216. TELUGREN PLUS (Alpes Chemie - CHILE) 217. TEVACUTAN (Teva - 68. 69. 70. 71. 72. 73. 74. 75. 76. 77. 78. 79. (Schering, Taro pharmaceuticals, Bergen, others ) CLOTRIMIN (Medipharm- CHILE) CLOTRIMIX (Eversil - BRAZIL) CLOTRINOLON (Jean-Marie HONG KONG) CLOTRI OPT (Optimed GERMANY) CLOTRIZAN (Prodotti - BRAZIL) CLOZOLE (Jean-Marie - HONG KONG) CLOZOLE (Jean-Marie, SINGAPORE, AUSTRALIA) COMAT - (Milano - THAILAND) CONTRAFUNGIN (Pharmagalen, GERMANY) VANESTEN (Atlantic – THAILAND and SINGAPORE) WARIMAZOL (Ritter, HONG KONG) XERASPOR (Qestmed - SOUTH AFRICA KONG) 146. KANEZIN (Swiss Pharm THAILAND) 147. KLAMACIN (Hua THAILAND) 148. KLOTRICID (FM) (Pharmacia Upjohn, FINLAND) 149. KONIFUNGIL (Koni-Cofarm CHILE) 150. LABOTEROL (Labomed CHILE) 151. LOGOMED HAUTPILZ-SALBE (Logomed - GERMANY) 152. LOKALICID (Dermapharm GERMANY) 153. LONESTIN (Rayere - MEXICO) 183 ISRAEL) 218. TINADERM EXTRA (Schering-Plough AUSTRALIA) 219. TRIAZOL (Ducray, FRANCE) 220. TRIBESONA (ITF - CHILE) 221. TRICLODERM (Merck HONG KONG) 222. TRICOSTEN (FM) (Farmion BRAZIL) 223. TRIMAZE (Garec - SOUTH AFRICA) 224. TRIMAZOL (Upha MALAYSIA) 225. TRIMYSTEN (Bellon, FRANCE) 226. UNDEX (Melisana SWITZERLAND) 227. UROMYKOL (Maxmedic GERMANY) 228. VAMAZOLE (Nakornpatana THAILAND) 184 Recent reports Hazuchova et al. (2017) evaluated outcomes for dogs with mycotic rhinitis-rhinosinusitis (MRR) treated by meticulous debridement and topical application of 1% clotrimazole cream and investigate potential prognostic factors that could help predict whether 1 or multiple treatments would be needed for clinical resolution of the condition. DESIGN Retrospective case series. Medical records were reviewed to identify dogs treated for MRR by meticulous debridement and topical application of 1% clotrimazole cream. Signalment, clinical signs, previous treatments, CT findings, presence of unilateral or bilateral disease, predisposing factors, number and type of treatments, and complications were recorded. Outcome information was obtained from records or by telephone interview with owners. Association of selected factors with the number of treatments needed for clinical resolution was evaluated. Clotrimazole was instilled via the trephination site (n = 42) or under endoscopic guidance (22). Thirteen dogs underwent a 5minute flush with 1% clotrimazolesolution prior to cream application, and 34 received adjunctive oral itraconazole treatment. The MRR was deemed resolved in 58 dogs, and clinical signs persisted in 1 dog. Five dogs died (2 of causes unrelated to MRR) ≤ 1 month after treatment. The first treatment was successful in 42 of 62 (68%) dogs; overall success rate was 58 of 62 (94%). No prognostic factors for the number of treatments needed to provide clinical resolution were identified. Seven dogs with reinfection were successfully retreated. CONCLUSIONS AND CLINICAL RELEVANCE Topical treatment by meticulous debridement and 1% clotrimazole cream application had results similar to or better than those described in other studies of dogs with MRR. Trephination or adjunctive itraconazole treatment did not influence the number of treatments needed for a successful outcome. Kumari and Kesavan (2017) studied the effect of chitosan-coated microemulsion (CME) for topical delivery of CTZ and also evaluate its in vitro antifungal efficacy, ex vivo permeation and retention ability on the skin surface. The pseudo-ternary phase diagrams were developed using clove oil as oil phase, Tween 80 and propylene glycol as surfactant and co-surfactant, respectively, and distilled water as aqueous phase. CME was prepared by the drop wise addition of chitosan solution to the optimized microemulsion. Physicochemical parameters (globule size, zeta potential, drug content, viscosity and pH) and in vitro release of CME were studied. The in vitro antifungal efficacy of CME and ME was studied by cup-plate method against Candida albicans. Ex vivo drug permeation study was also carried out in a modified diffusion cell, using rat skin. The developed CME displayed an average globule size less than 50 nm and a positive surface charge, acceptable physico-chemical behavior, and exhibited sustained drug release in in vitro study. In in vitro anti-fungal study, CME showed greater values of zone of inhibition as compared to ME due to its prolonged action as well as fungistatic nature of chitosan. In ex vivo study, CME showed better retention and sustained permeation property than ME due to the mucoadhesive property of chitosan. These results suggest that positively charged CMEs could be used as novel topical formulation for its ability to retain on the skin and its ability to sustain the release of the drug. Rençber et al. (2017) developed a suitable mucoadhesive in situ gel formulation of clotrimazole (CLO) for the treatment of vaginal candidiasis. For this aim, the mixture of poloxamer (PLX) 407 and 188 were used to prepare in situ gels. Hydroxypropyl methylcellulose (HPMC) K100M or E50 was added to in situ gels in 0.5% ratio to improve the mucoadhesive and mechanical properties of formulations and to prolong the residence time in vaginal cavity. After the preparation of mucoadhesive in situ gels; gelation temperature/time, viscosity, 185 mechanical, mucoadhesive, syringeability, spreadibility and rheological properties, in vitro release behavior, and anticandidal activities were determined. Moreover vaginal retention of mucoadhesive in situ gels was investigated with in vivo distribution studies in rats. Based on the obtained results, it was found that gels prepared with 20% PLX 407, 10% PLX 188 and 0.5% HPMC K100M/E50 might be suitable for vaginal administration of CLO. In addition, the results of in vivo distribution studies showed that gel formulations remained on the vaginal mucosa even 24 h after application. In conclusion, the mucoadhesive in situ gels of CLO would be alternative candidate for treatment of vaginal candidiasis since it has suitable gel properties with good vaginal retention. Suñer et al. (2017) designed a new formulation containing clotrimazole (CLT) loaded into multiple emulsions by two-step emulsification method for transdermal delivery. Different ingredients and quantities like primary and secondary co-emulsifiers and the nature of oily phase were assayed in order to optimize the best system for good. Resulting formulations were characterized in terms of droplet size, conductivity, pH, entrapment efficiency, rheological behavior, and stability under various storage conditions for 180 days. pH values of multiple emulsions containing CLT ranged from 7.04 ± 0.03 to 6.23 ± 0.04. Droplet size increased when increasing concentration of sorbitan stearate. The addition of polysorbate 80 resulted in significant decrease of oil droplet size comparing with those prepared without this. CLT entrapment efficiency ranged between 85.64% and 97.47%. All formulations exhibited nonNewtonian pseudoplastic flow with some apparent thixotropic behavior. Cross and HerschelBulkley equations were the models that best fitted experimental data. In general, the addition of 1% polysorbate 80 resulted in a decrease of viscosity values. No signals of optical instability were observed, and physicochemical properties remained almost constant when samples were stored at room temperature after 180 days. On the contrary, samples stored at 40°C exhibited pronounced increase in conductivity values 24 h after elaboration and some of them were unstable after 180 days of storage. JMLP01 was proposed as an innovative and stable system to incorporate CLT as active pharmaceutical ingredient. Tonglairoum et al. (2017) developed Clotrimazole (CZ)-loaded N-naphthyl-N,O-succinyl chitosan (NSCS) micelles have as an alternative for oral candidiasis treatment. NSCS was synthesized by reductive N-amination and N,O-succinylation. CZ was incorporated into the micelles using various methods, including the dropping method, the dialysis method, and the O/W emulsion method. The size and morphology of the CZ-loaded micelles were characterized using dynamic light scattering measurements (DLS) and a transmission electron microscope (TEM), respectively. The drug entrapment efficiency, loading capacity, release characteristics, and antifungal activity against Candida albicans were also evaluated. The CZ-loaded micelles prepared using different methods differed in the size of micelles. The micelles ranged in size from 120 nm to 173 nm. The micelles prepared via the O/W emulsion method offered the highest percentage entrapment efficiency and loading capacity. The CZ released from the CZ-loaded micelles at much faster rate compared to CZ powder. The CZ-loaded NSCS micelles can significantly hinder the growth of Candida cells after contact. These CZ-loaded NSCS micelles offer great antifungal activity and might be further developed to be a promising candidate for oral candidiasis treatment. El-Asmar et al. (2016) described a unique case of a 65-year-old man with poor-risk acute myeloid leukemia who underwent a matched-sibling hematopoietic cell allograft. Sirolimus and tacrolimus were used for graft-versus-host disease prophylaxis. He developed oral thrush 186 requiring treatment with clotrimazole troches, which subsequently resulted in serious renal toxicity attributed to supratherapeutic levels of sirolimus and tacrolimus. Patient renal function improved after temporarily holding both immune suppressants, and administering phenytoin to help induce sirolimus and tacrolimus metabolism. This case highlights sudden and serious toxicities that resulted from clotrimazole-sirolimus and clotrimazole-tacrolimus drug-drug interactions, even when administered topically. Herasym et al. (2016) compared the efficacy and ototoxicity of Locacorten-Vioform (Paladin Labs Inc., Montreal, Quebec, Canada) and clotrimazole in the treatment of patients with otomycosis. Embase, Cumulative Index to Nursing and Allied Health Literature, MEDLINE, World Health Organization International Clinical Trials Registry Platform, European Union Clinical Trials Register, Cochrane Library databases of clinical trials, and ClinicalTrials.gov. They included any randomized controlled trials or nonrandomized studies (case-control, cohort, and case series) assessing the topical use of Locacorten-Vioform (Paladin Labs Inc.) and/or clotrimazole in adult and/or pediatric immunocompetent patient population with otomycosis. DerSimonian and Laird's random effects approach was used for meta-analysis, followed by an assessment of heterogeneity and subgroup analysis. Of 226 reviewed articles, 14 were retained. Clotrimazole efficacy rate was 85% (95% confidence interval [CI]: 79.7-89.0%), whereas Locacorten-Vioform (Paladin Labs Inc.) was 73% (95% CI: 56.0-84.5%). Overall, study quality was low. There was high heterogeneity in both groups (I(2) of 47 and 49). There were only three studies assessing Locacorten-Vioform (Paladin Labs Inc.); therefore, comparative assessment was not possible. A one-way meta-analysis involving 13 clotrimazole studies was performed. Heterogeneity across studies was high; however, studies using objective analysis assessing treatment efficacy, randomized controlled trials, studies using drops, studies performed in Asia, and studies where Candida was the major fungus at diagnosis demonstrated low heterogeneity. CONCLUSION: Although both are safe and effective, there is insufficient evidence supporting increased efficacy of either clotrimazole or Locacorten-Vioform (Paladin Labs Inc.) for the treatment of otomycosis. High-quality comparative studies are required. Madgulkar et al. (2016) prepared solid dispersion of poorly soluble BCS class II drug, clotrimazole, with the aim of enhancing its dissolution profile. Solid dispersions were prepared using various sugars as carriers at different weight ratio to drug-like d-mannitol, dfructose, d-dextrose and d-maltose by fusion method. The solubility of plain clotrimazole in different percent of sugar solutions was measured. Also, its solubility in solid dispersion and their physical mixture were assessed. The dissolution of all the prepared SD tablets, direct compressed clotrimazole tablet and plain drug were tested using the U.S. Pharmacopeia convention (USP) apparatus II. The dissolution profiles were characterized by parameters like area under curve (AUC), mean residence time (MRT), mean dissolution time (MDT) and percent dissolution efficiency (% DE). The release kinetics study was performed using DD Solver TM software. The selected solid dispersions (SDs) were evaluated for antifungal activity. A 100% solution of mannitol showed 806-fold increases in solubility as compared with plain clotrimazole in water. It was observed that the dissolution profile of clotrimazole was improved by mannitol SD at drug to sugar ration of 1:3. The percent DE value for mannitol SD tablet was found to be 77.3516% as against plain drug and directly compressed tablet of clotrimazole at 50.9439% and 31.33%, respectively. Also the antifungal activity indicated by inhibition zone was found to be 54 mm indicating enhance activity against Candida albicans as compared with plain CTZ at 6.6 mm. Thus, it can be concluded that the sugar alcohol, that is, 187 mannitol is a more promising hydrophilic carrier for solid dispersion preparation to improve the solubility and dissolution of poorly soluble drugs. Montemiglio et al. (2016) solved OleP in complex with clotrimazole, an inhibitor of P450s used in therapy, and the complex formation dynamics was characterized by equilibrium and kinetic binding studies and compared to ketoconazole, another azole differing for the N1-substituent. Clotrimazole coordinates the heme and occupies the active site. Most of the residues interacting with clotrimazole are conserved and involved in substrate binding in MycG, the P450 epoxigenase with the highest homology with OleP. Kinetic characterization of inhibitor binding revealed OleP to follow a simple bimolecular reaction, without detectable intermediates. CONCLUSIONS: Clotrimazole-bound OleP adopts an open form, held by a π-π stacking chain that fastens helices F and G and the FG loop. Affinity is affected by the interactions of the N1 substituent within the active site, given the one order of magnitude difference of the off-rate constants between clotrimazole and ketoconazole. Based on structural similarities with MycG, we propose a binding mode for both oleandomycin intermediates, that are the candidate substrates of OleP. Pais et al. ( 2016) mentioned that, since resistance often relies on the action of membrane transporters, including drug efflux pumps from the ATP-binding cassette family or from the Drug:H(+) antiporter (DHA)(1) family, an iTRAQ-based membrane proteomics analysis was performed to identify all the membrane-associated proteins whose abundance changes in C. glabrata cells exposed to the azole drug clotrimazole. Proteins found to have significant expression changes in this context were clustered into functional groups, namely: glucose metabolism, oxidative phosphorylation, mitochondrial import, ribosome components and translation machinery, lipid metabolism, multidrug resistance transporters, cell wall assembly, and stress response, comprising a total of 37 proteins. Among these, the DHA transporter CgTpo1_2 (ORF CAGL0E03674g) was identified as overexpressed in the C. glabrata membrane in response to clotrimazole. Functional characterization of this putative drug:H(+) antiporter, and of its homolog CgTpo1_1 (ORF CAGL0G03927g), allowed the identification of these proteins as localized to the plasma membrane and conferring azole drug resistance in this fungal pathogen by actively extruding the drug to the external medium. The cell wall protein CgGas1 was also shown to confer azole drug resistance through cell wall remodeling. Finally, the transcription factor CgPdr1 in the clotrimazole response was observed to control the expression of 20 of the identified proteins, thus highlighting the existence of additional unforeseen targets of this transcription factor, recognized as a major regulator of azole drug resistance in clinical isolates. Sepaskhah et al. (2016) evaluated the efficacy of topical tacrolimus (a calcineurin inhibitor agent with proven in vitro anti-Malassezia effect) for PV treatment generally and its effect on PV-induced hypopigmentation specifically. Fifty PV patients were randomly allocated into two equal groups applying either topical clotrimazol or tacrolimus twice daily for 3 weeks. They were evaluated at the beginning of study, in the third and fifth weeks clinically and mycologically (direct smear). Although both treatments resulted in global, clinical, and mycological cure of PV, there was no significant difference regarding the mentioned aspects of cure between tacrolimus and clotrimazole treated patients. (P-value: .63, .45, and .26, respectively) Tacrolimus had no significant effect on hypopigmentation in the fifth week followup. (P-value: .62). CONCLUSIONS: In spite of the lack of efficacy of tacrolimus on PV-induced hypopigmentation, the therapeutic effect on PV introduces tacrolimus as a therapeutic option for 188 PV, especially when early vitiligo is among the differential diagnoses without concerning the aggravating effect of topical corticosteroids on PV. Tara et al. ( 2016) compared the effects of ozononated olive oil and clotrimazole in the treatment of vulvovaginal candidiasis. Design • Patients were randomly assigned either to an ozone group or to a clotrimazole group in a randomized, controlled trial. The study took place in the Department of Gynecology of the School of Medicine at Mashhad University of Medical Sciences in Mashhad, Iran. Participants were 100 female patients who had been referred to the women's gynecology clinic at the Omolbanin and Ghaem Hospitals and who had confirmed vulvovaginal candidiasis. Patients in the ozone group were treated with ozonated olive oil or those in the clotrimazolegroup were treated with clotrimazole for 7 d. \ Patients were evaluated through an interview and a paraclinical examination at baseline and postintervention. The study measured changes in itching, burning, and leucorrhea using a questionnaire that patients completed at the end of the study and determined the presence of an infection with vaginal candidiasis through a culture both before acceptance into the study and after the treatments, if accepted. Ozone and clotrimazole both reduced symptoms significantly and led to a negative culture for vaginal candidiasis (P < .05). No significant differences existed between the 2 groups in their effects on the symptom of itching and leucorrhea and on the results of the culture (P > .05). However, clotrimazole decreased the burning sensation significantly more than did ozone (P < .05). Conclusions :Considering the potential efficacy of ozonated olive oil in the improvement of the clinical and paraclinical aspects of treatment of patients with vulvovaginal candidiasis, the research team suggests that the treatment can be an effective topical treatment for those patients. Viesselmann et al. (2016) examined the clinical significance of clotrimazole troche discontinuation on tacrolimus trough levels and risk of allograft rejection after pancreas transplantation. Sixty-five pancreas transplant recipients (simultaneous pancreas-kidney transplants [39 patients], pancreas after kidney transplants [4 patients], and pancreas transplant alone [22 patients]) who were discharged after transplantation receiving a maintenance immunosuppressive regimen of tacrolimus, mycophenolate, and prednisone, and a clotrimazole troche to prevent oral mucosal candidiasis; per protocol, the clotrimazole troche was discontinued at 3 months after transplantation. Patients were followed for 1 year after transplantation. The primary outcome measure was the difference in tacrolimus trough level before and after discontinuation of the clotrimazole troche. The secondary outcome measure was the difference in tacrolimus trough level when patients were stratified by the cohort that had a documented rejection episode 3-12 months after transplantation (rejection group) and the cohort that did not experience a rejection episode (no-rejection group). The incidence of rejection was evaluated in relation to mean tacrolimus trough concentrations above or below a protocoldefined level of significance (6 ng/ml). For the primary outcome, the mean tacrolimus trough level before discontinuation of the clotrimazole troche was significantly higher than the mean trough level after discontinuation (mean ± SD 9.6 ± 3.0 ng/ml vs 7.1 ± 2.6 ng/ml, p = 0.000003). For the secondary outcome, the mean tacrolimus trough level difference before and after clotrimazole troche discontinuation remained significant in both the no-rejection group (9.5 ± 3.0 ng/ml vs 7.4 ± 2.4 ng/ml, p = 0.00007) and rejection group (10.9 ± 3.3 ng/ml vs 4.1 ± 2.5 ng/ml, p = 0.0008). Between groups, the mean tacrolimus serum trough level after clotrimazole troche discontinuation was lower in the rejection group (4.1 ± 2.5 ng/ml) than that in the no-rejection group (7.4 ± 2.4 ng/ml; p = 0.005). The mean tacrolimus trough level 189 difference between before and after discontinuation was greater in the rejection group (6.8 ± 1.5 ng/ml) versus the no-rejection group (2.1 ± 3.8 ng/ml, p = 0.009). Tacrolimus trough levels below 6 ng/ml (19 patients) after clotrimazole troche discontinuation were associated with an increased incidence of rejection episodes within 3-12 months after transplantation (odds ratio 12, 95% confidence interval 1.24-115.91, p = 0.032) versus trough levels of 6 ng/ml or higher (46 patients). CONCLUSION: Clotrimazole troche discontinuation at 3 months after transplantation may cause significant tacrolimus trough level reductions. In addition, when trough levels are below 6 ng/ml, these fluctuations may contribute to the occurrence of allograft rejection. Zhou et al. (2016) compared the efficacy and safety of two doses of clotrimazole vaginal tablet 500 mg with two doses of oral fluconazole 150 mg in treating severe vulvovaginal candidiasis (SVVC), 240 consecutive patients with SVVC were studied at the Department of Obstetrics and Gynaecology of Peking University Shenzhen Hospital between June 2014, and September 2015. Patients were randomly assigned in a 1 : 1 ratio to receive treatment with either two doses of clotrimazole vaginal tablet or two doses of oral fluconazole. The clinical cure rates in the clotrimazole group and the fluconazole group at days 7-14 follow-up were 88.7% (102/115) and 89.1% (98/110) respectively; the clinical cure rates at days 30-35 in the two groups were 71.9% (82/114) and 78.0% (85/109) respectively. The mycological cure rates at days 7-14 follow-up in the two groups were 78.3% (90/115) and 73.6% (81/110) respectively. The mycological cure rates of the patients at days 30-35 in the two groups were 54.4% (62/114) and 56.0% (61/109) respectively (P > 0.05). The adverse events of clotrimazole were mainly local. This study demonstrated that two doses of clotrimazole vaginal tablet 500 mg were as effective as two doses of oral fluconazole 150 mg in the treatment of patients with SVVC and could be an appropriate treatment for this disorder. References 1. Crowley PD1, Gallagher HC. Clotrimazole as a pharmaceutical: past, present and future. J Appl Microbiol. 2014 Sep;117(3):611-7. 2. El-Asmar J1, Gonzalez R2, Bookout R2, Mishra A3, Kharfan-Dabaja MA4. Clotrimazole troches induce supratherapeutic blood levels of sirolimus and tacrolimus in an allogeneic hematopoietic cell-transplant recipient resulting in acute kidney injury. Hematol Oncol Stem Cell Ther. 2016 Dec;9(4):157-161. 3. Hazuchova K, Neiger R, Stengel C. Topical treatment of mycotic rhinitis-rhinosinusitis in dogs with meticulous debridement and 1% clotrimazole cream: 64 cases (2007-2014). J Am Vet Med Assoc. 2017 Feb 1;250(3):309-315. 4. Herasym K1, Bonaparte JP2, Kilty S2. A comparison of Locacorten-Vioform and clotrimazole in otomycosis: A systematic review and one-way meta-analysis. Laryngoscope. 2016 Jun;126(6):1411-9. 5. Kumari B1, Kesavan K1. Effect of chitosan coating on microemulsion for effective dermal clotrimazole delivery. Pharm Dev Technol. 2017 Jun;22(4):617-626 6. Madgulkar A1, Bandivadekar M1, Shid T1, Rao S1. Sugars as solid dispersion carrier to improve solubility and dissolution of the BCS class II drug: clotrimazole. Drug Dev Ind Pharm. 2016 Jan;42(1):28-38. 7. Montemiglio LC1, Parisi G1, Scaglione A1, Sciara G1, Savino C2, Vallone B3. Functional analysis and crystallographic structure of clotrimazole bound OleP, a cytochrome P450 191 epoxidase from Streptomyces antibioticus involved in oleandomycin biosynthesis. Biochim Biophys Acta. 2016 Mar;1860(3):465-75. 8. Pais P1, Costa C1, Pires C1, Shimizu K2, Chibana H2, Teixeira MC3. Membrane Proteome-Wide Response to the Antifungal Drug Clotrimazole in Candida glabrata: Role of the Transcription Factor CgPdr1 and the Drug:H+ Antiporters CgTpo1_1 and CgTpo1_2. Mol Cell Proteomics. 2016 Jan;15(1):57-72. 9. Rençber S1, Karavana SY1, Şenyiğit ZA1, Eraç B2, Limoncu MH2, Baloğlu E1. Mucoadhesive in situ gel formulation for vaginal delivery of clotrimazole: formulation, preparation, and in vitro/in vivo evaluation. Pharm Dev Technol. 2017 Jun;22(4):551-561 10. Sepaskhah M1, Sadat MS1, Pakshir K2, Bagheri Z3. Comparative efficacy of topical application of tacrolimus and clotrimazole in the treatment of pityriasis versicolor: A single blind, randomised clinical trial. Mycoses. 2017 May;60(5):338-342 11. Suñer J1, Calpena AC1, Clares B2, Cañadas C1, Halbaut L1. Development of Clotrimazole Multiple W/O/W Emulsions as Vehicles for Drug Delivery: Effects of Additives on Emulsion Stability. AAPS PharmSciTech. 2017 Feb;18(2):539-550 12. Tara F, Zand-Kargar Z, Rajabi O, Berenji F, Akhlaghi F, Shakeri MT, Azizi H. The Effects of Ozonated Olive Oil and Clotrimazole Cream for Treatment of Vulvovaginal Candidiasis. Altern Ther Health Med. 2016 Jul;22(4):44-9. 13. Tonglairoum P1, Woraphatphadung T1, Ngawhirunpat T1, Rojanarata 1 1 2 1 T , Akkaramongkolporn P , Sajomsang W , Opanasopit P . Development and evaluation of N-naphthyl-N,O-succinyl chitosan micelles containing clotrimazole for oral candidiasis treatment. Pharm Dev Technol. 2017 Mar;22(2):184-190. 14. Viesselmann CW1, Descourouez JL1, Jorgenson MR1, Radke NA2, Odorico JS3. Clinically Significant Drug Interaction Between Clotrimazole and Tacrolimus in Pancreas Transplant Recipients and Associated Risk of Allograft Rejection. Pharmacotherapy. 2016 Mar;36(3):335-41. 15. Zhou X1,2, Li T1, Fan S1,2,3, Zhu Y1, Liu X4, Guo X1, Liang Y1. The efficacy and safety of clotrimazole vaginal tablet vs. oral fluconazole in treating severe vulvovaginal candidiasis. Mycoses. 2016 Jul;59(7):419-28. 191 5. Croconazole  Croconazole (710674-S; cloconazole) is an imidazole derivative with antifungal activity developed by Shionogi Research Laboratories (Osaka, Japan).  Chemical Name: CROCONAZOLE. Synonyms o Pilzcin;710674S; o CLOCONAZOLE; o CROCONAZOLE; o Viniconazole; o Croconazole o (Cloconazole);1-[1-[2-(3-Chlorobenzyloxy)phenyl]vinyl]-1H-imidazole;1-[1-[2[(3-Chlorobenzyl)oxy]phenyl]vinyl]-1H-imidazole;1-[1-[2-[(3Chlorobenzyl)oxy]phenyl]ethenyl]-1H-imidazole;1-(1H-Imidazole-1-yl)-1-[2-(3chlorobenzyloxy)phenyl]ethane  Molecular formula: C18H16Cl2N2O    Croconazole is indicated in the topical treatment of dermatomycoses and candidiasis Croconazole has broad-spectrum antifungal activity in vitro. Croconazole ranges of MICs against isolates of T. mentagrophytes, T. rubrum, M. canis, Microsporum gypseum, and Epidermophyton floccosum were 0.16 to 1.25 ,ug/ml. Croconazole ranges of MICs against isolates of Aspergillus and Penicillium species were 0.63 to 5.0,ug/ml. Croconazole was less active (MICs, 10 to 80 ,ug/ml) against yeast-like fungi, including isolates of C. albicans, Candida species, Torulopsis glabrata, and Cryptococcus neoformans. Croconazole was compared in vitro with clotrimazole, econazole, and miconazole against a large panel of dermatophytes. o The geometric mean MICs of croconazole were comparable to those of clotrimazole and econazole when tested against isolates of T. mentagrophytes and o quantitatively superior to all three imidazoles when tested against isolates of T. rubrum. o When tested against isolates of C. albicans, croconazole was superior to clotrimazole, but less active than miconazole and econazole. o croconazole and econazole were fungicidalto T. rubrum at 40 ,ug/ml; miconazole and clotrimazole were not fungicidal at the same concentration.    192     Croconazole gel formulation was more effective than clotrimazole tincture in the treatment of Trichophyton asteriodes-induced dermatomycosis in guinea pigs. Croconazole 1.0% cream was comparable to clotrimazole 1.0% cream . Croconazole had no marked effects on pharmacologic parameters following oral administration in experimental animals a Croconazole did not produce any notable contact sensitivity, phototoxicity, or photoallergy following topical application in guinea pigs. Generic Names  Cloconazole (IS)  Croconazole Hydrochloride (OS: JAN)  S 710674 (IS: Shionogi)  Croconazole Hydrochloride (PH: JP XV) Brand Name  Pilzcin Shionogi Seiyaku, Japan Reports: El-Badry et al. (2014) developed liposomal-based (LBGF) and micro-emulsion-based (MBGF) gel formulations of croconazole to compare their topical delivery potential. Conventional gels were also prepared using various polymers such as sodium carboxymethyl cellulose (SCMC), Poloxamer 407, Carbopol 971P and chitosan. The in vitro release of croconazole from conventional gel formulations, LBGF and MBGF were carried out using cellophane membrane as permeation membrane. However, in vitro skin permeations studies of all formulations were carried out using rat skin. The results of the drug release/skin permeation studies indicated that the highest release was obtained from SCMC followed by chitosan, Poloxamer 407 and finally Carbopol 971P gel. Therefore, liposomes and micro-emulsions were loaded on Carbopol 971P gel. The drug release and skin permeation of croconazole from different LBGF and MBGF showed that MBGF had superior release/permeation than LBGF. MBGF having ethanol as cosurfactant showed higher release/permeation of drug than MBGF-containing propylene glycol. The analysis of data according to different kinetic models indicated that the release of drug from different LBGF and MBGF followed the Higuchi model. Beierdörffer et al. (1995) investigated a 1% croconazole cream (Pilzcin, Merz + Co., DFrankfurt/Main) in a multicentre trial involving 132 patients (mean age 46.7 +/- 15.5 years; 69 men, 63 women) suffering from tinea pedis (interdigital space, n = 86; other foot sites, n = 46). The fungal infections were caused predominantly by Trichophyton rubrum (interdigital space, n = 43; other foot sites, n = 33), followed by other Trichophyton and Candida species. The patients were treated once daily for a period of up to 3 weeks. In the majority of cases complete cure was achieved at both locations. On fungal microscopy no fungi were seen after 3 weeks in 82.6% of patients in the 'interdigital space' group and in 80.4% of patients in the 'other foot sites' group. Two weeks after the end of the treatment no fungi could be found in culture in 81.4% of the patients in the 'interdigital space' group and in 80.4% of patients in the other group. All skin symptoms of the mycoses (itching, scaling, erosions, reddening) decreased during the 193 observation period. In 82.6% of patients in the 'interdigital space' group and in 76.1% of patients treated in the 'other foot sites' group efficacy was rated by the physician as good or very good. Nakano et al. (1990) reported that, following subcutaneous administration of 1-(2-(3chlorobenzyloxy)phenyl)vinyl)-1H-imidazole (croconazole) to rats, four metabolites were identified by comparison of their mass and n.m.r. spectra, g.l.c., and t.l.c. with those of synthetic compounds and enzyme hydrolysis. These compounds are o-hydroxyacetophenone sulphate (M1S), 1-(1-(2-hydroxyphenacyl)vinyl)-1H-imidazole sulphate (M12S), 2-(3chlorobenzyloxy)phenacyl alcohol (M2), and 2-(3-chlorobenzyloxy)benzoic acid (M9-1). 2. At 10 mg/kg dosing of croconazole the elimination rate of the unchanged drug from plasma was faster in male than in female rats. 3. The percentage of excretion of M12S in 24 h urine was 17% for males and 7.5% for females, and that of M1S was 6.6% for males and 6.5% for females. The percentage of excretion of M2 in 24 h bile was 14% for males and 22% for females, and that of M9-1 was 3.7% for males and 1.6% for females. Nakano et al. (1989) studied the biotransformation of croconazole, a potent new antimycotic agent in the rabbit. Croconazole was excreted in the urine primarily as conjugates. Most of the radioactive metabolites in the urine could be extracted with organic solvent after hydrolysis with beta-glucuronidase. As many as 16 metabolites in the organic extracts were separated by TLC. Thirteen were identified by comparison of their mass and/or proton NMR spectra with those of synthetic samples. Aromatic ring hydroxylation of each benzene ring, O-dechlorobenzylation, and loss of the imidazole ring were found to occur. Shono et al. (1989) reported 6 cases of contact sensitivity to croconazole hydrochloride, a new imidazole antimycotic drug introduced to the Japanese market in 1986, and available as 1% gel and cream. 6 sensitized patients reacted on patch testing to croconazole hydrochloride down to 0.5 to 0.1% pet, and 3 appeared to be cross-sensitized to sulconazole nitrate. In Japan, allergic contact dermatitis to this drug has now been detected in 12 cases, including our own 6. Prescribers should be aware of contact sensitivity to this drug. References 1. Beierdörffer H1, Michel G, Kehr K. Croconazole in the treatment of tinea pedis. Mycoses. 1995 Nov-Dec;38(11-12):501-7. 2. El-Badry M1, Fetih G, Shakeel F. Comparative topical delivery of antifungal drug croconazole using liposome and micro-emulsion-based gel formulations. Drug Deliv. 2014 Feb;21(1):34-43. 3. Nakano M1, Nakajima Y, Iwatani K, Ikenishi Y, Nakagawa Y, Sugeno K. Metabolism of the antimycotic agent, croconazole, in rabbits. Drug Metab Dispos. 1989 MayJun;17(3):323-9. 4. Nakano M1, Takeuchi M, Kawahara S, Mizojiri K. Croconazole metabolism in rats. Xenobiotica. 1990 Apr;20(4):385-93. 5. Shono M1, Hayashi K, Sugimoto R. Allergic contact dermatitis from croconazole hydrochloride. Contact Dermatitis. 1989 Oct;21(4):225-7. 194 6. Cyproconazole    Cyproconazole is an agricultural fungicide of the class of azoles, used on cereal crops, coffee, sugar beet, fruit trees and grapes, on sod farms and golf courses and on wood as a preservative. Cyproconazole was introduced to the market by then Sandoz in 1994. Cyproconazole; 94361-06-5; 2-(4-chlorophenyl)-3-cyclopropyl-1-(1H-1,2,4-triazol1-yl)butan-2-ol; Alto; Cyproconazol; Atem Chemical formula: C15H18ClN3O Mechanism of action. Cyproconazole inhibits demethylation, a particular step in the synthesis of a component of the fungal cell wall called sterol.  Biological description Broad spectrum triazole fungicide. Mutagenic agent. Inhibits CYP51. Induces CAR activation and shows liver hypertrophic effects in vivo. Orally active.  Plant metabolism studies o Cyproconazole was identified as the major residue in apples, grapes, wheat forage and straw, accounting for 44–76% of the TRR, and accounting for 5– 45% of the TRR in wheat grain. o The major identified residues in wheat grain were TA (62% TRR) in the 14Ctriazole-labeled study, and M9/M14 (14% TRR) and glycoside conjugates of M11/M18 (15% TRR) in the 14C-phenyl-labeled study. 195 o A number of minor metabolites have been identified in plants, including M9/M14, M11/M18, M15, M16 and various glycoside conjugates of parent and these primary metabolites.  Toxicity: o Cyproconazole exhibits hepatotoxicity in rodent studies and is tumorigenic following chronic exposure. o Cyproconazole is suspected to act via a CAR (constitutive and rostane receptor)/PXR (pregnane-X-receptor)-dependent mechanism.  Human Health Effects: o Evidence for Carcinogenicity o Skin, Eye and Respiratory Irritations o Probable Routes of Human Exposure Brands: 196 Recent reports: Jakl et al. (2017) suggeste a simple experimental and theoretical approach for the prediction of pesticides behavior. Cu/Cyp complexes are explored because of the typical Cu(II) reduction in complexes. Its level and the stability of Cu-ligand bond depend on the type and the number of the surrounding ligands. Zn/Cyp complexes were compared as it is not expected that Zn(II) will reduce. The complexations were studied by means of electrospray ionization ion trap mass spectrometry and MS/MS collision induced dissociations with comparative and explicative density functional theory calculations. Cyp ligand allows both, Cu(II) reduction as well as, in specific cases, it protects the higher Cu oxidation state. The reduction is observed in the complexes with solely neutral Cyp where the ligands number is below 3, higher number protects the Cu(II) state. The metal atom binds to Cyp via 2N of the triazole ring as well as via πelectrons of the benzene ring, additional stabilization brings the interaction with deprotonated OH group. CONCLUSIONS: the character of Cyp interactions with doubly charged metals (Cu(II), Zn(II)) clarified the creation of Cyp metabolites. The phenyl and triazole rings are bounded to metal cation and take accessible the isopropyl ring to be cleaved leaving the common metabolite (CAS Number: 58905-19-4). Marx-Stoelting et al. (2017) conducted a 28-day toxicity study in mice with humanized CAR and PXR (hCAR/hPXR) with two dose levels (50 or 500 ppm) of both substances, using the model CAR activator phenobarbital as a reference. Results were compared to wild-type mice. A treatment-related increase in liver weights was observed for all three substances at least at the high-dose level. Changes in the expression of classic CAR/PXR target genes such as Cyp2b10 were induced by cyproconazole and phenobarbital in both genotypes, while prochloraz treatment resulted in gene expression changes indicative of additional aryl hydrocarbon receptor activation, e.g. by up-regulation of Cyp1a1 expression. Cyproconazole-induced effects on CAR-dependent gene expression, liver weight, and hepatic lipid accumulation were more prominent in wild-type mice, where significant genotype differences were observed at the high-dose level. Moreover, high-dose cyproconazole-treated mice from the wild-type group responded with a marked increase in hepatocellular proliferation, while hCAR/hPXR mice did not. In conclusion, our data demonstrate that cyproconazole and PB induce CAR/PXR downstream effects in hepatocytes in vivo via both, the murine and human receptors. At high doses of cyproconazole, however, the responses were clearly more pronounced in wild-type mice, indicating increased sensitivity of rodents to CAR agonist-induced effects in hepatocytes. Huang et al. (2016) investigated Tetrahymena thermophila as experimental models, the oxidative stress of triazole fungicides myclobutanil (MYC) and cyproconazole(CYP). Results showed that 24-h EC50 values for MYC and CYP were 16.67 (13.37-19.65) and 20.44 (18.8521.96) mg/L, respectively; 48-h EC50 values for MYC and CYP were 14.31 (13.13-15.42) and 18.76 (17.09-20.31) mg/L, respectively. Reactive oxygen species was significantly induced and cytotoxicity was caused by MYC and CYP by increasing propidium iodide (PI) fluorescence. Damage of regular wrinkles and appearing of small holes on the cell surface were observed by SEM. Furthermore, MYC and CYP also caused notable changes in enzyme activities and mRNA levels. Overall, the present study points out that MYC and CYP lead to oxidative stress on T. thermophila. The information presented in this study will provide insights into the mechanism of triazoles-induced oxidative stress on T. thermophila. 197 Zhang et al. (2016) studied enantioselectivity in ecotoxicity, digestion and uptake of chiral pesticide cyproconazole to Chlorella pyrenoidosa. The 96h-EC50 values of rac- and the four enantiomers were 9.005, 6.616, 8.311, 4.290 and 9.410 mg/L, respectively. At the concentrations of 8 mg/L and 14 mg/L, the contents of pigments exposed in rac-, enantiomer-2 and 4 were higher than that exposed in enantiomer-1 and 3. The superoxide dismutase (SOD) and catalase (CAT) activity of algae exposed to enantiomer-1 and 3 was higher than that exposed to the rac-, enantiomer-2 and 4 at three levels. In addition, the malondialdehyde (MDA) concentrations in algae disposed with enantiomer-1 and 3 were increased remarkably at three levels. For the digestion experiment, the half-lives of four enantiomers in algae suspension were 28.06, 19.10, 21.13, 15.17 days, respectively. During the uptake experiment, the order of the concentrations of cyproconazole in algae cells was enantiomer-4, 2, 3 and 1. Based on these data, we concluded that ecotoxicity, digestion and uptake of chiral pesticide cyproconazole to C. pyrenoidosa were enantioselective, and such enantiomeric differences must be taken into consideration when assessing the risk of cyproconazole to environment. References: 1. Huang AG1, Tu X1, Liu L1, Wang GX2, Ling F3. The oxidative stress response of myclobutanil and cyproconazole on Tetrahymena thermophila. Environ Toxicol Pharmacol. 2016 Jan;41:211-8. 2. Jakl M1, Fanfrlík J2, Dytrtová JJ2,3. Mimicking of cyproconazole behavior in the presence of Cu and Zn. Rapid Commun Mass Spectrom. 2017 Sep 12 3. Marx-Stoelting P1,2, Ganzenberg K3, Knebel C1, Schmidt F1, Rieke S1, Hammer H4, Schmidt F4, Pötz O4, Schwarz M3, Braeuning A5,6. Hepatotoxic effects of cyproconazole and prochloraz in wild-type and hCAR/hPXR mice. Arch Toxicol. 2017 Aug;91(8):2895-2907 4. Zhang W1, Cheng C1, Chen L1, Di S1, Liu C1, Diao J1, Zhou Z2. Enantioselective toxic effects of cyproconazole enantiomers against Chlorella pyrenoidosa. Chemosphere. 2016 Sep;159:50-57. 198 7. Difenoconazole    Difenoconazole, a broad-spectrum fungicide, Difenoconazole is a broad-spectrum fungicide used for disease control in many fruits, vegetables, cereals and other field crops. Difenoconazole has preventive and curative action. Difenoconazole acts by inhibition of demethylation during ergosterol synthesis. Identity ISO common name difenoconazole Synonyms: CGA 169374 IUPAC name 1-[2-[2-chloro-4-(4-chloro-phenoxy)-phenyl]-4methyl[1,3]dioxolan-2-ylmethyl]-1H-1,2,4-triazole Chemical name 1-[[2-[2-chloro-4-(4-chlorophenoxy)phenyl]-4-methyl-1,3- dioxolan-2yl]methyl]-1H-1,2,4-triazole CAS Number 119446-68-3 CIPAC Number 687 Molecular formula C19H17Cl2N3O3 Mode of action Difenoconazole is a sterol demethylation inhibitor which prevents the development of the fungus by inhibiting cell membrane ergosterol biosynthesis. Formulations   Difenoconazole is available as emulsifiable concentrate, suspension concentrate, water dispersible granules and water dispersible granules. Some products are mixtures with other fungicides. Uses    Difenoconazole is a broad spectrum fungicide that controls a wide variety of fungi. Difenoconazole acts as a seed treatment, foliar spray and systemic fungicide. Difenoconazole acts as a seed treatment, foliar spray and systemic fungicide. Toxicity   Difenoconazole possesses low acute toxicity by the oral, dermal and inhalation routes of exposure. Difenoconazole is considered to be a mild eye irritant and a slight skin irritant and is not a dermal skin sensitizer. 199 Animal metabolism, FAO   Difenoconazole, in rats, lactating goats and laying hens, is rapidly metabolized, initially to CGA 205375 and then with cleavage of the triazole moiety from the chlorophenoxyphenyl moiety. TRR levels are higher in the liver than in other tissues. Most of the TRR is rapidly excreted.  In rats o Difenoconazole metabolites in rats after oral dosing with [14Ctriazole]difenoconazole and [14C-phenyl]difenoconazole identified in excreta were: CGA 205375, 1,2,4-triazole, CGA 189138, Metabolites A1 and A2 and Metabolites B (diastereomers), NOA 448731, sulphate conjugates of CGA 205375 and sulphate conjugates of Metabolites A in urine.  In lactating goats after dosing orally once daily for 10 consecutive days by gelatin capsule with 7.5 mg/animal/day of [14C-triazole] difenoconazole, equivalent to 5.6 ppm in the feed for a 1.35 kg/day feed consumption or once daily for 10 consecutive days by gelatin capsule with 7.5 mg/animal/day of [14C-phenyl]difenoconazole, equivalent to 4.7 ppm in the feed for a 1.80 kg/day feed consumption, milk and excreta were collected daily. The animals were slaughtered approximately 22 and 23 hours after the final dose for tissue collection. o Recoveries of administered 14C were 107% and 89% for the [14C]triazole and [14C]phenyl labels respectively. o The majority of the administered 14C was present in the excreta (31% in urine, 75% in faeces for [14C]triazole label; 21% in urine, 67% in faeces for [14C]phenyl label). o Milk accounted for 0.50% and 0.18% and tissues for 0.90% and 0.44% of the administered 14C. o Residues of 14C were higher in liver (0.28 and 0.26 mg/kg) than in other tissues. o Residues in milk reached a plateau by day 2 (0.007 mg/kg) for the [14C]phenyl label and by days 4-7 (0.032-0.043 mg/kg) for the [14C]triazole label. o The concentration of 14C appearing in milk and milk fat was higher for the [14C]triazole label. Of the 14C in milk, 19% and 32% were distributed into the fat portion for the [14C]triazole and [14C]phenyl labels respectively.  Laying hens: A group of laying white leghorn hens (4 birds), mean body weight 1.5 kg at study initiation, were dosed orally once daily via gelatin capsule for 14 consecutive days with 0.55 mg/bird/day of [ 14C]difenoconazole (2 birds with [14C]phenyl label and 2 birds with [14C]triazole label), equivalent to 5 ppm in the feed for a 108 g/day mean feed consumption (Madrid, 1989, ABR-89051). Eggs were collected daily. The birds were slaughtered approximately 22 hours after the final dose for tissue collection (lean meat, liver, kidney, skin and attached fat and peritoneal fat). o Recovery of administered 14C ranged from 91.5% to 97.5%. o Most of the 14C (over 89% of administered dose) was eliminated via the excreta. 211 o Tissues, egg whites and egg yolks were subjected to biphasic extraction, producing organic, aqueous and none extractable fractions. Plant metabolism  Difenoconazole is generally slowly absorbed and metabolized in tomatoes, wheat, potatoes, grapes and oilseed rape o In most cases, particularly for parts of the plant directly exposed to the treatment, the parent difenoconazole is the dominant part of the residue. o The residue in parts of the plant not directly exposed are more likely to contain a residue dominated by a mobile water-soluble metabolite such as triazolylalanine. o The following plant metabolites apparently do not occur as animal metabolites of difenoconazole: triazolylalanine (2-amino-3-(1,2,4]triazol)-1-yl-propionic acid), triazolyl acetic acid (1,2,4-triazol-1-yl-acetic acid) and triazolyl-lactic acid (1,2,4triazol-1-yl-lactic acid). Environmental fate in soil     Difenoconazole residues are reasonably persistent in soils and are expected to be present in the soil at harvest time for treated root and tuber crops. Difenoconazole residues are also expected to persist in the soil until the sowing of rotational crops. Difenoconazole itself does not appear as a residue in the rotational crop. The water soluble and mobile metabolites triazolylalanine, triazolylacetic acid and triazolyl-lactic acid have been identified in the rotational crops. Brands 211 Recemt reports: Szpyrka and Walorczyk (2017) studied dissipation of fungicide difenoconazole (3-chloro-4[(2RS,4RS;2RS,4SR)-4-methyl-2-(1H-1,2,4-triazol-1-ylmethyl)-1,3-dioxolan-2-yl]phenyl 4chlorophenyl ether) following its application on apples intended for production of baby food. The apples (varieties: Jonagold Decosta, Gala and Idared) were sprayed with the formulation to control pathogens causing fungal diseases: powdery mildew (Podosphaera leucotricha ELL et Ev./Salm.) and apple scab (Venturia inaequalis Cooke/Aderh.). A validated gas chromatographybased method with simultaneous electron capture and nitrogen phosphorus detection (GCECD/NPD) was used for the residue analysis. The analytical performance of the method was highly satisfactory, with expanded uncertainties ≤ 19% (a coverage factor, k = 2, and a confidence level of 95%). The dissipation of difenoconazole was studied in pseudo-first-order kinetic models (for which the coefficients of determination, R2, ranged between 0.880 and 0.977). The half-life of difenoconazole was 12-21 days in experiments conducted on three apple varieties. In these experiments, the initial residue levels declined gradually and reached the level of 0.01 mg kg-1 in 50-79 days. For the residue levels to remain below 0.01 mg kg-1 (the maximum acceptable concentration for baby foods), difenoconazole must be applied approximately 3 months before harvest, at a dose of 0.2 L ha-1 (50 g of an active ingredient per ha). He et al. (2016) introduced new combined difenoconazole and fluxapyroxad fungicide formulation, as an 11.7 % suspension concentrate (SC), as part of a resistance management strategy. The dissipation of difenoconazole and fluxapyroxad applied to apples and the residues remaining in the apples were determined. The 11.7 % SC was sprayed onto apple trees and soil in Beijing, Shandong, and Anhui provinces, China, at an application rate of 118 g a.i. ha(-1), then the dissipation of difenoconazole and fluxapyroxad was monitored. The residual difenoconazoleand fluxapyroxad concentrations were determined by ultrahighperformance liquid chromatography tandem mass spectrometry. The difenoconazole half-lives in apples and soil were 6.2-9.5 and 21.0-27.7 days, respectively. The fluxapyroxad half-lives in apples and soil were 9.4-12.6 and 10.3-36.5 days, respectively. Difenoconazole and fluxapyroxad residues in apples and soil after the 11.7 % SC had been sprayed twice and three times, with 10 days between applications, at 78 and 118 g a.i. ha(-1) were measured. Representative apple and soil samples were collected after the last treatment, at preharvest intervals of 14, 21, and 28 days. The difenoconazole residue concentrations in apples and soil were 0.002-0.052 and 0.002-0.298 mg kg(-1), respectively. The fluxapyroxad residue concentrations in apples and soil were 0.002-0.093 and 0.008-1.219 mg kg(-1), respectively. The difenoconazole and fluxapyroxad residue concentrations in apples were lower than the 212 maximum residue limits (0.5 and 0.8 mg kg(-1), respectively). An application rate of 78 g a.i. ha(-1) is therefore recommended to ensure that treated apples can be considered safe for humans to consume. Mohapatra (2016) studied residue dynamics of difenoconazole and propiconazole on pomegranate after application at the recommended and double doses of 125 and 250 g active ingredient (a.i.) ha(-1) during August-October 2012. The study was repeated during the same period in 2013. QuEChERS method, in conjunction with gas chromatography (GC), was used for analysis of the fungicides after carrying out the method validation. The recoveries of the fungicides from pomegranate and soil were between 80.3 and 96.2 %; the limit of detection (LOD) and limit of quantification (LOQ) were 0.016 and 0.05 mg kg(-1), respectively. The uncertainties of measurement were between 9.7 and 16.3 %. The initial residue deposits of difenoconazole were 0.875 and 1.205 mg kg(-1) from treatment at the recommended dose and 1.54 and 1.672 mg kg(-1) from treatment at the double dose from the first- and second-year studies. Propiconazole residues were 0.663 and 0.864 mg kg(-1) from recommended dose treatments and 1.474 and 2.045 mg kg(-1) from double dose treatments from the first- and second-year studies. The half-lives of degradation of difenoconazole were 6.4-8.4 days and propiconazole 7.9-8.5 days over the 2 years. Residues of difenoconazole and propiconazole remained on the pomegranate fruit surface and did not move to the edible part (aril). The preharvest intervals (PHIs), the time required for the residues to reduce below their respective EU maximum residue limits (MRLs), were 25.4 and 30.8 days for difenoconazole and 33.3 and 43.8 days for propiconazole from treatments at the recommended and double doses, respectively. Keeping in view consumer safety, the longer PHI from the two studies has been selected. Mu et al. (2016) were exposed zebrafish embryos to 0.5 and 2.0 mg/L difenoconazole for 96 h. The morphological and physiological indicators of embryo development were tested. The total cholesterol (TCHO) level, triglyceride (TG) level and malondialdehyde (MDA) content were measured at 96 hpf (hours post-fertilization). In addition, the transcription of genes related to embryo development, the antioxidant system, lipid synthesis and metabolism was quantified. Our results showed that a large suite of symptoms were induced by difenoconazole, including hatching regression, heart rate decrease, growth inhibition and teratogenic effects. 0.5 mg/L difenoconazole could significantly increase the TG content of zebrafish embryos at 96 hpf, while no apparent change in the TCHO and MDA level was observed post 96 h exposure. Q-PCR (quantitative real-time polymerase chain reaction) results showed that the transcription of genes related to embryonic development was decreased after exposure. Genes related to hatching, retinoic acid metabolism and lipid homeostasis were up-regulated by difenoconazole. Mu et al. (2015) reported an investigation of the mechanisms contributing to the divergent sensitivity toward the triazole fungicide difenoconazole of zebrafish (Danio reio) during different life stages. Adult and embryonic zebrafish were exposed to three different concentrations of difenoconazole (0.01, 0.5 and 1.0mg/L). The death rate, bioaccumulation of difenoconazole, oxidative stress parameters and transcription of related genes were tested at 4 and 8 days postexposure (dpe). The death rate for adult zebrafish was much higher than that of the embryos at an exposure concentration of 1.0mg/L at both 4 and 8 dpe. The concentrations of difenoconazole in both the embryos and adult fish were similar, except for the group exposed to 0.01mg/L difenoconazole. A decrease in antioxidant enzyme activities was observed in both the embryos and the livers of adult fish after exposure to difenoconazole. Significant lipid peroxidation was found in the livers of adult fish in all exposure groups at 8 dpe, but was not 213 observed in the treated embryos. The gene transcription response of the embryos toward difenoconazole was different from that in the livers of adult fish at 4 dpe. At 8 dpe, the modification in the transcription of the tested genes in the embryos and adult fish was similar, except for the genes related to the synthesis of sterols. References: 1. FAO,http://www.fao.org/fileadmin/templates/agphome/documents/Pests_Pesticides/JMP R/Evaluation07/Difenoconazole.pdf 2. He M1,2, Jia C1, Zhao E1, Chen L1, Yu P1, Jing J1, Zheng Y3. Concentrations and dissipation of difenoconazole and fluxapyroxad residues in apples and soil, determined by ultrahigh-performance liquid chromatography electrospray ionization tandem mass spectrometry. Environ Sci Pollut Res Int. 2016 Mar;23(6):5618-26. 3. Lazić S, Šunjka D. Determination of azoxystrobin and difenoconazole in pesticide products. Commun Agric Appl Biol Sci. 2015;80(3):375-80. 4. Mohapatra S1. Dynamics of difenoconazole and propiconazole residues on pomegranate over 2 years under field conditions. Environ Sci Pollut Res Int. 2016 Mar;23(6):5795806. 5. Mu X1, Chai T2, Wang K3, Zhang J4, Zhu L5, Li X6, Wang C7. Occurrence and origin of sensitivity toward difenoconazole in zebrafish (Danio reio) during different life stages. Aquat Toxicol. 2015 Mar;160:57-68. 6. Mu X1, Chai T2, Wang K3, Zhu L2, Huang Y4, Shen G4, Li Y4, Li X5, Wang C6. The developmental effect of difenoconazole on zebrafish embryos: A mechanism research. Environ Pollut. 2016 May;212:18-26. 7. Szpyrka E1, Walorczyk S2. Dissipation of difenoconazole in apples used for production of baby food. J Environ Sci Health B. 2017 Feb;52(2):131-137. 214 8. Eberconazole      Eberconazole is an imidazole antifungal drug. As a 1% topical cream, it is an effective treatment for dermatophytosis, candidiasis, and pityriasis. Eberconazole was approved for use in Spain in 2015 and is sold under the trade name Ebernet. Eberconazole prevents the fungal ergosterol synthesis by inhibiting lanosterol 14αdemethylase enzyme that is responsible for the formation of 14 α-methylsterols (precursor of ergosterols). Studies have shown that eberconazole binds to the phospholipid fraction of the cell and affects sterol synthesis intracellularly. Synonyms: 1-(1,3-dichloro-6,11-dihydro-5H-dibenzo[1,2-a:1',4'-e][7]annulen-11-yl)imidazole; Eberconazole; eberconazole[inn]; 128326-82-9; CHEBI:83584; Eberconazole(INN) Molecular formula: C18H14Cl2N2 Spectrum of activity, Moodahadu-Bangera et al., 2012    Eberconazole has been shown to have broad antimicrobial spectrum of activity in vitro, to be effective in dermatophytosis, candidiasis, infection by other yeasts such as Malassezzia furfur and causative agents of pityriasis versicolor in in vitro and animal studies. Eberconazole has been shown to be effective against most triazole resistant yeasts (Candida krusei and Candida glabrata) and also fluconazole resistant Candida albicans has been demonstrated in vitro.[7] It has also been shown to be effective against Gram-positive bacteria. Eberconazole is distinct from other imidazoles as it has been to shown to have antiinflammatory activity, which favors its use in the management of inflamed dermatophytic infections. Mechanism of action, Moodahadu-Bangera et al., 2012   Eberconazole exerts fungicidal or fungistatic activity depending on concentration, being fungicidal at higher concentration and fungistatic at lower concentrations. Eberconazole prevents fungal growth by inhibiting ergosterol synthesis, an essential component of the fungal cytoplasmic membrane leading to structural and functional changes. 215    Eberconazole prevents the fungal ergosterol synthesis by inhibiting lanosterol 14αdemethylase enzyme that is responsible for the formation of 14 α-methylsterols (precursor of ergosterols). Eberconazole binds to the phospholipid fraction of the cell and affects sterol synthesis intracellularly. At high concentrations, it causes the leakage of small molecules such as potassium ions, amino acids, inorganic phosphate and nucleotides from the fungal cell leading to cell death. The anti-inflammatory activity comparable to acetyl salicylic acid and ketoprofen, shown in vivo by eberconazole is attributable to the inhibition of 5lipooxygenase and to a lesser extent of cyclooxygenase-2. Preclinical studies, Moodahadu-Bangera et al., 2012   In preclinical studies using experimental models of superficial fungal infections, eberconazole has been shown to exhibit similar efficacy to clotrimazole, ketoconazole and better efficacy than bifonazole. The studies showed that eberconazole is well tolerated without any delayed hypersensitivity or photosensitivity reactions. Also, no phototoxic effects were seen and no significant systemic absorption was observed with eberconazole. Human pharmacokinetics, Moodahadu-Bangera et al., 2012   After topical application of eberconazole 2% cream in healthy volunteers, its concentration in human plasma and urine were below the lower limits of detection (<1.1 ng/ml for plasma and <1.0 ng/ml for urine) when analyzed by high performance liquid chromatography. \ However, data on metabolism and excretion of topical eberconazole are not available. Efficacy  Efficacy and safety of topical eberconazole have been established by a number of studies. o Twice daily application of eberconazole 1% was found to be as efficacious as eberconazole 2% in 60 patients with mycologically proven tinea corporis and tinea cruris, in a phase II pilot study, but the measured parameters did not show any statistical significance. o Overall clinical cure rate post therapy was 73.3-93.3% in different groups. Adverse effects were seen more with eberconazole 2% than with 1%, but without any statistical significance. \  Efficacy of eberconazole has been compared with the widely used topical antifungals in various studies. o In a double blind study, eberconazole 1% cream's therapeutic efficacy and safety profile was similar to miconazole. After 4 weeks of therapy, 76.09% patients on eberconazole showed effective response compared to 75.0% in miconazole group. 216 o In another multicentric double blind randomized study, the efficacy of eberconazole 1% cream with miconazole 2% cream in the treatment of dermatophytosis was compared.  Eberconazole showed similar efficacy and safety profile with miconazole in the treatment of dermatophyte infection. o Another double blind, randomized control study showed that the overall efficacy and safety of eberconazole cream in patients with cutaneous mycoses including dermatophytosis, candidiasis and pityriasis versicolor, was slightly higher in comparison to clotrimazole o In another study, eberconazole was more effective against dermatophytosis with a response rate of 61% (for clotrimazole 46%) than candidiasis (effective response for clotrimazole 73% and eberconazole 50%). Safety    In a phase I study of single and multiple doses of topical eberconazole 2% use, no significant and evaluable changes were noted in vital signs, blood or urine biochemical parameters of the volunteers. Eberconazole was not detected either in plasma or urine indicating no significant systemic absorption. Another phase I study demonstrated that topical eberconazole 1% (0.1 g), does not induce photosensitivity and phototoxicity indicating its good tolerability. o On topical application, safety, tolerability and adverse event (AE) profile of eberconazole was similar to that of placebo. o On single dose application, mild symptoms which were common to eberconazole and placebo were reported within the first hour. o On multiple dose application, mild pruritus, occasional burning sensation, and mild skin dryness were seen with eberconazole and placebo as well, without showing a dose effect relationship. Formulations   Eberconazole has been marketed as a cream with a characteristic lipophilic-hydrophilic molecular structure for better penetration of fungal cell membrane and prolonged duration of action. The galenic components of this topical azole favor and optimize the drug's action in the skin, fatty acid esters facilitate penetration in the skin and make the cream easy to spread, while polyacrylamides produce a filmogenous effect and facilitate the continuance of the active principle in the skin. Generic Names  WAS-2160 (IS)  WAS 2160 (IS: E) Brand Names  Ebernet Mustafa Nevzat, Turkey; Salvat, Spain 217  Ebernet Salvat, Malta 1% Recent reports: Gnaneshwar et al. (2015) assessed the efficacy and safety of fixed dose combination (FDC) of Eberconazole nitrate 1% and Mometasone furoate 0.1% w/w cream, in subjects with ICM. This was a multi-centric, non-comparative study conducted in 155 eligible adult Indian subjects with ICM. They were treated with study medication for 21 days (D21) and followed up on day 35 (D35). Efficacy (by Investigator's Static Global Assessment-ISGA, symptom severity scores) and safety were assessed to evaluate the therapeutic response. Of 155 subjects, 129 completed the study. Lesions healed completely in 77.52% and improved markedly in 22.48% patients by D21. There was a statistically significant reduction (p<0.001) in total symptom score (TSS) and mean severity scores of erythema, scaling and pruritus on days 7 and 21 compared to baseline. There was no treatment failure. Only 11 patients remained culture positive on D21 compared to 68 at baseline. Physicians evaluated the drug as 'Good' in 72% and 'Excellent' in 28% of subjects; adverse events were reported in 27.74% subjects and none was severe. Bothiraja et al. (2014) investigated ethyl cellulose microsponges as topical carriers for the controlled release and cutaneous drug deposition of eberconazole nitrate (EB). EB microsponges were prepared using the quasiemulsion solvent diffusion method. The effect of formulation variables (drug:polymer ratio, internal phase volume and amount of emulsifier) and process variables (stirring time and stirring speed) on the physical characteristics of microsponges were investigated. The optimized microsponges were dispersed into a hydrogel and evaluated. Spherical and porous EB microsponge particles were obtained. The optimized microsponges possessed particle size, drug content and entrapment efficiency of 24.5 µm, 43.31% and 91.44%, respectively. Microsponge-loaded gels demonstrated controlled release, nonirritancy to rat skin and antifungal activity. An in vivo skin deposition study demonstrated fourfold higher retention in the stratum corneum layer as compared with commercial cream. CONCLUSION: Developed 218 ethyl cellulose microsponges could be potential pharmaceutical topical carriers of EB in antifungal therapy. Choudhary et al. (2014) compared the efficacy and safety of topical terbinafine hydrochloride 1% cream and eberconazole nitrate 1% cream in localized tinea corporis and cruris. Patients were randomized after considering various inclusion and exclusion criteria into two groups. Group A (treated with terbinafine 1% cream for 3 weeks) and group B (treated with eberconazole 1% cream for 3 weeks). The sample size was of 30 patients with 15 patients in each group. Assessment of clinical improvement, KOH mount and culture was done weekly up to 3 weeks to assess complete cure. On comparison between the two groups, it was observed that eberconazole nitrate 1% cream was as effective as terbinafine hydrochloride 1% cream at the end of first (Non-sisgnificant (NS); P = 0.608, 1.00), second (NS; P = 0.291,0.55), and third (P = 1.00, 1.00) weeks with statistically nonsignificant clinical and mycological values. In both the groups, clinically no significant local side effects were noticed. Sharma et al. (2013) studied the degradation behaviour of eberconazole nitrate and mometasone furoate under different International Conference on harmonisation recommended stress condition using reverse phase high performance liquid chromatographic method and to establish validated stability-indicating high performance liquid chromatographic method to determine purity of eberconazole nitrate and mometasone furoate in presence of its impurities, forced degradation products and placebo in pharmaceutical dosage forms. The method was developed using Hypersil BDS, C18, 150Χ4.6 mm, 5 μ as stationary phase with mobile phase containing a gradient mixture of solvent A and B. 0.01 M phosphate buffer with 0.1% triethyl amine, adjusted pH 7.0 with phosphoric acid was used as buffer. Buffer pH 7.0 was used as solvent A and methanol:acetonitrile in 150:850 v/v ratios were used as solvent B. References: 1. Bothiraja C1, Gholap AD, Shaikh KS, Pawar AP. Investigation of ethyl cellulose microsponge gel for topical delivery of eberconazole nitrate for fungal therapy. Ther Deliv. 2014 Jul;5(7):781-94 2. Choudhary SV1, Aghi T1, Bisati S1. Efficacy and safety of terbinafine hydrochloride 1% cream vs eberconazole nitrate 1% cream in localised tinea corporis and tinea cruris. Indian Dermatol Online J. 2014 Apr;5(2):128-31 3. Gnaneshwar R, Kumar AS, Carol F, Martis J, Jerajani HR, Kuruvila M, Latha MS1, Krishnankutty B. The Efficacy and Safety of Eberconazole Nitrate 1% and Mometasone Furoate 0.1% w/w Cream in Subjects with Inflamed Cutaneous Mycoses. Rev Recent Clin Trials. 2015;10(2):161-70. 4. Moodahadu-Bangera LS, Martis J, Mittal R, Krishnankutty B, Kumar N, Bellary S, Varughese S, Rao PK. Eberconazole - Pharmacological and clinical review. Indian J Dermatol Venereol Leprol [serial online] 2012 [cited 2017 Oct 9];78:217-22. Available from: http://www.ijdvl.com/text.asp?2012/78/2/2 5. Sharma N1, Rao SS, Vaghela B. Validated Stability-indicating High-performance Liquid Chromatographic Method for Estimation of Degradation Behaviour of Eberconazole Nitrate and Mometasone Furoate in Cream Formulation. Indian J Pharm Sci. 2013 Jan;75(1):76-82 219 9. Econazole   Econazole is an antifungal medication of the imidazole class. It is sold under the brand names Spectrazole and Ecostatin, among others. Econazole is a broad spectrum antimycotic with some action against Gram positive bacteria. It is used topically in dermatomycoses also orally and parenterally. Chemical Formula C18H15Cl3N2O Indication For topical application in the treatment of tinea pedis, tinea cruris, and tinea corporis caused by Trichophyton rubrum, Trichophyton mentagrophytes, Trichophyton tonsurans, Microsporum canis, Microsporum audouini, Microsporum gypseum, and Epidermophyton floccosum, in the treatment of cutaneous candidiasis, and in the treatment of tinea versicolor. Mechanism of action Econazole interacts with 14-α demethylase, a cytochrome P-450 enzyme necessary to convert lanosterol to ergosterol. As ergosterol is an essential component of the fungal cell membrane, inhibition of its synthesis results in increased cellular permeability causing leakage of cellular contents. Econazole may also inhibit endogenous respiration, interact with membrane phospholipids, inhibit the transformation of yeasts to mycelial forms, inhibit purine uptake, and impair triglyceride and/or phospholipid biosynthesis. Pharmacodynamics Econazole is an antifungal medication related to fluconazole (Diflucan), ketoconazole (Nizoral), itraconazole (Sporanox), and clotrimazole (Lotrimin, Mycelex). Econazole prevents fungal organisms from producing vital substances required for growth and function. This medication is effective only for infections caused by fungal organisms. It will not work for bacterial or viral infections. 211 Econazole Cream - Clinical Pharmacology After topical application to the skin of normal subjects, systemic absorption of econazole nitrate is extremely low. Although most of the applied drug remains on the skin surface, drug concentrations were found in the stratum corneum which, by far, exceeded the minimum inhibitory concentration for dermatophytes. Inhibitory concentrations were achieved in the epidermis and as deep as the middle region of the dermis. Less than 1% of the applied dose was recovered in the urine and feces. Absorption After topical application to the skin of normal subjects, systemic absorption of econazole nitrate is extremely low. Although most of the applied drug remains on the skin surface, drug concentrations were found in the stratum corneum which, by far, exceeded the minimum inhibitory concentration for dermatophytes. Common side effects of Econazole nitrate Cream include: Burning, stinging, swelling, irritation, redness,pimple-like bumps, tenderness, or. flaking of the treated skin List of Econazole substitutes (brand and generic names): http://www.ndrugs.com/?s=econazole&showfull=1 Amicel (Italy) Amyco (Italy) Benezole 150 Biodermin (Italy) Bismultin (Greece) Chemionazolo (Italy) Conatrate 1% (Egypt) Confort (China) Dermazol 1% (France) Dermazole (Australia, South Africa) Dermazole 150 mg Tablet (Devbhoomi Pharmaceuticals) $ 0.24 Dermazole shampoo 20 mg/mL 50 mL x 1's (Devbhoomi Pharmaceuticals) Dermazole shampoo 20 mg/mL 100 mL x 1's (Devbhoomi Pharmaceuticals) Dermocitran (Argentina) Diconate (Bangladesh) Ecalin (Croatia (Hrvatska), Georgia, Serbia) Ecanol (India) Ecanol Vaginal (India) Ecanol Vaginal 150mg TAB / 3 (AHPL) $ 0.88 150 mg x 3's (AHPL) $ 0.88 ECANOL VAGINAL vag tab 150 mg x 3's (AHPL) $ 0.88 Eccelium (Italy) Eco Mi (Italy) Ecodax (Russian Federation) Cream; Topical; Econazole Nitrate 1% (Unique) Ecodergin (Italy) Ecoderm (Bangladesh, Sri Lanka) Ecoderm 5 g (Chew) Ecoderm 15 g (Chew) Ecoderm 100 g (Chew) Ecoderm 450 g (Chew) Ecomesol (Italy) Ecomi (Hong Kong, Italy, Lithuania) Ecomi 150 mg x 6 Tablet Ecomi 150 mg x 3's Ecomi 150 mg x 6's Ecomikole (Russia) EcomГ¬ (Italy) Econ (Taiwan, Thailand) Econ 1 % x 5 g (General Drugs House) Econ 40 mg (General Drugs House) Econ cream 1 % 5 g x 1's (General Drugs House) Econal-C (South Africa) Econate (Bangladesh) Econate-G (Bangladesh) Econazol (Romania) Econazol Rominko (Romania) Econazole 1% (Egypt) Econazole Arrow (France) Econazole Arrow 1% (France) Econazole Arrow LP (France) Econazole Biogaran (France) Econazole Biogaran LP (France) Econazole Cream Econazole EG (France) Econazole EG 1% (France) Econazole EG LP (France) Econazole LP Ovules, Prolonged Release; Vaginal; Econazole Nitrate 150 mg Econazole Mylan (France) Econazole Mylan 1% (France) Econazole Mylan LP (France) Econazole Nitrate Fougera (United States) Econazole Nitrate Perrigo (United States) Econazole Nitrate Prasco (United States) Econazole Nitrate Taro (United States) Econazole Opalia (Tunisia) Econazole Qualimed (France) Econazole Ranbaxy (France) Econazole Ranbaxy LP (France) Econazole Ratiopharm (France) Econazole Ratiopharm 1% (France) Econazole RPG (France) Econazole RPG 1% (France) Econazole Sandoz (France) Econazole Sandoz 1% (France) Econazole Sandoz LP (France) Econazole Sopharma (Bulgaria) Econazole Sunward (Singapore) Econazole Sunward 1 % w/w x 1's Econazole Tai Yu (Taiwan) Econazole Teva (France) Econazole Teva 1% (France) Econazole Teva LP (France) Econazole Teva Sante 1% (France) Econazole Winthrop (France) Econazole YSP (Malaysia) Econazole YSP 150 mg x 1 Box Econazole YSP 150 mg x 10's x 5 Econazole Yung Sine (Taiwan) Econazole Zentiva (France) Econazole Zydus (France) Econazole Zydus LP (France) Econazolo 211 Sandoz (Italy) Econite (Hong Kong) Econol (Taiwan) Econol 1 % x 1 g Econol 1 % x 5 g Econol 1 % x 10 g Econol 1 % x 500 g Econol 1 % x 900 g Econtin (Taiwan) Econtin 150 mg Ecoren (Bangladesh) Ecoren VT (Bangladesh) Ecorex (Bahrain, Iraq, Italy, Jordan, Lebanon, Libya, Qatar, Saudi Arabia, Sudan, Tunisia, United Arab Emirates, Yemen) Ecorex LP (Tunisia) Ecorin (Taiwan) Ecorin 150 mg (USV) Ecorin EC tab 150 mg 10 x 10's (USV) Ecorin EC tab 325 mg 10 x 10's (USV) Ecorin EC tab 75 mg 10 x 10's (USV) Ecostatin (Ireland, United Kingdom) Cream; Topical; Econazole Nitrate 1% (Bristol-Myers Squibb) Suppositories; Vaginal; Econazole Nitrate 150 mg (Bristol-Myers Squibb) Ecostatin cream Ecostatin Twin Pack Cream; Topical; Econazole Nitrate 1% / Suppositories; Vaginal; Econazole Nitrate 150 mg Ecostatin Vaginal Ovules Suppositories; Vaginal; Econazole Nitrate 150 mg Ecostatin-1 Suppositories; Vaginal; Econazole Nitrate 150 mg Ecosteril (Italy) Ecotam (Spain) Ecozol (Bangladesh, Taiwan) Ecozol / Weidar 150 mg x 6 x 10's Ecozol-VT (Hong Kong) Ecozyl (Tunisia) Ecreme (New Zealand) Ekona (Taiwan) Ekona 150 mg Epi-Pevaryl (Germany) Cream; Topical; Econazole Nitrate (Mcneil) Lotion; Topical; Econazole Nitrate (Mcneil) Powder; Topical; Econazole Nitrate (Mcneil) Solution; Topical; Econazole Nitrate (Mcneil) Spray; Topical; Econazole Nitrate (Mcneil) Epi-Pevaryl PV (Germany) Etramon (Spain) Fongéryl (France) Cream; Topical; Econazole Nitrate 1% Fongeryl (France) Cream; Topical; Econazole Nitrate 1% (Aclae) Fongicil (Tunisia) Fongileine (France) Cream; Topical; Econazole Nitrate 1% Powder; Topical; Econazole Nitrate 1% Fongileine 1% (France) Fungeum (Peru) Fungicidon (Taiwan) Fungicidon 150 mg Fungilyse (Tunisia) Fungistat (Colombia, Greece, Venezuela) Cream; Fungistat 150 mg Tablet (Group Pharmaceuticals Ltd.) $ 0.44 Fungryl (Egypt) Ganazolo (Italy) Gyno Pevaryl 1% (Egypt) Gyno-Coryl (Bahrain, Iraq, Jordan, Lebanon, Libya, Qatar, Saudi Arabia, Sudan, United Arab Emirates, Yemen) Gyno-Pevaryl (Antigua & Barbuda, Aruba, Austria, Bahamas, Bahrain, Bangladesh, Barbados, Bermuda, Bulgaria, Cayman Islands, Congo, Czech Republic, Estonia, France, Georgia, Germany, Grenada, Guyana, Hungary, Ireland, Israel, Jamaica, Latvia, Lithuania, Malaysia, Oman, Poland, Russian Federation, Saint Lucia, Saint Vincent & The Grenadines, Singapore, Slovakia, South Africa, Suriname, Switzerland, Trinidad & Tobago, Tunisia, United Kingdom, Venezuela, Vietnam) Cream; Vaginal; Econazole Nitrate 1% (Janssen) Pessaries; Vaginal; Econazole Nitrate 150 mg (Janssen) Suppositories; Vaginal; Econazole Nitrate 50 mg (Janssen) Suppositories; Vaginal; Econazole Nitrate 150 mg (Janssen) GynoPevaryl 50 mg - 15 Suppositories (Janssen) $ 31.20 Gyno-Pevaryl 150 mg - 3 Suppositories (Janssen) $ 19.80 Gyno-Pevaryl 150 mg x 30's (Janssen) Gyno-Pevaryl 150 mg x 2's (Janssen) Gyno-Pevaryl 50 mg x 15's (Janssen) Gyno-Pevaryl 150 mg x 3's (Janssen) Gyno-Pevaryl Depot ovule 150 mg 2's (Janssen) Gyno-Pevaryl ovule 150 mg 3's (Janssen) Gyno-Pevaryl 1 Pessaries; Vaginal; Econazole Nitrate 150 mg Gyno-Pevaryl 1 Depot Pessaries; Vaginal; Econazole Nitrate Gyno-Pevaryl 150 GynoPevaryl 3 Kombipackung Cream; Vaginal; Econazole Nitrate / Pessaries; Vaginal; Econazole Nitrate Gyno-Pevaryl 6 Pessaries; Vaginal; Econazole Nitrate Gyno-Pevaryl 6 Kombipackung Cream; Vaginal; Econazole Nitrate / Pessaries; Vaginal; Econazole Nitrate Gyno-Pevaryl Depot (Austria, Switzerland) Pessaries; Vaginal; Econazole Nitrate 150 mg Gyno-Pevaryl Depot 150 mg x 1 Blister x 2 Tablet Gyno-Pevaryl LP (France) Ovules, Prolonged Release; Vaginal; Econazole Nitrate 150 mg Gynomiconax (Venezuela) Gynopura 1% (France) Gynopura Gé (France) Gynopura LP (France) Gynopura LP Gé (France) Gynoryl (Egypt) Gynosep 150 Halog E Halog E Skin 10 gm Cream (Nicholas Piramal India Ltd.) $ 0.31 Heads Shampoo (Hong Kong) Hupicon (Taiwan) Hupicon 1 mg/1 g x 5 g Hupicon 10 mg/1 g x 10 g Ifenec (Georgia, Italy, Russian Federation) Cream; Topical; Econazole Nitrate 1% (Italfarmaco) Powder; Topical; Econazole Nitrate 1% (Italfarmaco) Solution; Topical; Econazole Nitrate 1% (Italfarmaco) Ifenec 1% (Georgia) Ledernin (Taiwan) Ledernin 10 mg/1 g x 1 g Ledernin 10 mg/1 g x 5 g Ledernin 10 mg/1 g x 10 g Ledernin 10 mg/1 g x 15 g Ledernin 10 mg/1 g x 100 g Ledernin 10 mg/1 g x 450 g Ledernin 10 mg/1 g x 1 kg Limpele (Brazil) Micoespec (Spain) Micoespec Topico (Spain) Micofitex (Argentina) Micogin (Italy) Micolis (Argentina, Chile, Peru) Cream; Topical; Econazole Nitrate 1% (Pharma investi) Ovules; Vaginal; Econazole Nitrate 150 mg (Pharma investi) Powder; Topical; Econazole Nitrate 1% (Pharma investi) Solution; Topical; Econazole Nitrate 1% (Pharma investi) Micolis Novo (Argentina) Miconax (Venezuela) Micos (Italy) Micoseptil (Spain) Micostin (Peru) Micostyl (Brazil) Micotex (Argentina) Cream; Topical; Aluminum Zirconium Glycine Hydroxytetrachloride 0.5%; Undecylenic Acid 4%; Zinc Undecylenate 10% (Sertex) Powder; Topical; Aluminum Zirconium Glycine Hydroxytetrachloride 20%; Undecylenic Acid 2%; Zinc Undecylenate 17% (Sertex) Myco Apaisyl (France) Cream; Topical; Econazole Nitrate 1% Emulsion; Topical; Econazole Nitrate 1% MycoApaisyl (France) Powder; Topical; Econazole Nitrate 1% (Merck medication familiale) Solution; Topical; Econazole Nitrate 1% (Merck medication familiale) Mycoapaisyl 1% (France) Mycobacter (Greece) Mycosedermil (France) Mycosedermyl 1% (France) Myleugin (France) Myleugyn (France) Myleugyn LP Ovules, Prolonged Release; Vaginal; Econazole Nitrate 150 mg Myleugyne 1% (France) Myleugyne LP (France) 212 Nectarmicin (Greece) Nomicon (Argentina) Novo Paramicon (Argentina) Novo-Paramicon (Argentina) Palavale (Japan) Palavale 1% (Japan) Pargin (Italy) Penicomb (Greece) Pevalip (Austria) Pevaryl (Algeria, Antigua & Barbuda, Aruba, Australia, Austria, Bahamas, Bangladesh, Barbados, Belgium, Benin, Bermuda, Burkina Faso, Cameroon, Cayman Islands, Central African Republic, Chad, Congo, Cote D'ivoire, Cyprus, Czech Republic, Denmark, Finland, France, Gabon, Greece, Grenada, Guinea, Guyana, Hungary, Iceland, Israel, Jamaica, Jordan, Luxembourg, Madagascar, Mali, Mauritania, Mauritius, Netherlands, Netherlands Antilles, New Zealand, Niger, Norway, Oman, Philippines, Poland, Portugal, Saint Lucia, Saint Vincent & The Grenadines, Saudi Arabia, Senegal, South Africa, Sri Lanka, Sudan, Suriname, Sweden, Switzerland, Taiwan, Togo, Trinidad & Tobago, Tunisia, United Arab Emirates, United Kingdom, Venezuela, Zaire) Cream; Topical; Econazole Nitrate 1% (Janssen) Emulsion; Topical; Econazole Nitrate 1% (Janssen) Lipogel; Topical; Econazole Nitrate 1% (Janssen) Lotion; Topical; Econazole Nitrate 1% (Janssen) Milk; Topical; Econazole Nitrate 1% (Janssen) Paste; Topical; Econazole Nitrate 1% (Janssen) Powder; Topical; Econazole Nitrate 1% (Janssen) Shampoo; Topical; Econazole Nitrate 1% (Janssen) Solution; Topical; Econazole Nitrate 1% (Janssen) Spray; Topical; Econazole Nitrate 1% (Janssen) Pevaryl 1 % x 5 g (Janssen) $ 5.00 Pevaryl 1 % x 1 Bottle 70mL (Janssen) Pevaryl 1 % x 15 g x 1's (Janssen) Pevaryl 1 % x 30 g x 1's (Janssen) Pévaryl (France) Cream; Topical; Econazole Nitrate 1% Emulsion; Topical; Econazole Nitrate 1% Lipogel; Topical; Econazole Nitrate 1% Lotion; Topical; Econazole Nitrate 1% Milk; Topical; Econazole Nitrate 1% Paste; Topical; Econazole Nitrate 1% Powder; Topical; Econazole Nitrate 1% Shampoo; Topical; Econazole Nitrate 1% Solution; Topical; Econazole Nitrate 1% Spray; Topical; Econazole Nitrate 1% Pevaryl 1 % x 5 g $ 5.00 Pevaryl 1 % x 1 Bottle 70mL Pevaryl 1 % x 15 g x 1's Pevaryl 1 % x 30 g x 1's Pevaryl 1% (Egypt, France, United Kingdom) Pevaryl Bb Farma (Italy) Pevaryl D.A.C. (Iceland) Pevaryl Depot (Iceland, Norway, Sweden) Pevaryl Farma 1000 (Italy) Pevaryl Lipogel (Costa Rica, Dominican Republic, El Salvador, Guatemala, Honduras, Mexico, Nicaragua, Panama) Gel; Topical; Econazole 1% Pevaryl Programmi Sanitari (Italy) Pevazol (Poland) Phepix (Taiwan) Phepix 150 mg x 100's Phepix 10 mg/1 g x 5 g Phepix 10 mg/1 g x 10 g Phepix 10 mg/1 g x 20 g Phepix 10 mg/1 g x 30 g Phepix 10 mg/1 g x 100 g Phepix 10 mg/1 g x 500 g Picola (Peru) Polinazolo (Italy) Sebolith (Switzerland) Foam; Topical; Econazole (Widmer) Sinamida Econazol (Argentina) Skilar (Italy) Spectazole Topical Tigna (Colombia) Unifungin (Greece) Vari-Econazole Nitrate (South Africa) Zoliderm (Malaysia) More: http://www.ndrugs.com/?s=econazole&showfull=1 213 Recent reports Abd El-Gawad et al. (2017) prepared inclusion complexes of EC with cyclodextrins to enhance its solubility, dissolution, and ocular bioavailability. To achieve this goal, EC was complexed with β-CyD/HP-β-CyD using kneading, co-precipitation, and freeze-drying techniques. Phasesolubility studies were performed to investigate the complexes in the liquid form. Additionally, the complexes in the solid form were characterized with Fourier transform infrared spectroscopy (FT-IR), differential scanning calorimetry (DSC), powder X-ray diffraction (PXRD), and transmission electron microscopy (TEM). Furthermore, different eye drops containing EC-CyD complexes were prepared using different polymers and then characterized regarding their drug contents, pH, viscosity, mucoadhesive strength, and in vitro release characteristics. The results showed that stable EC-CyD complexes were formed in 1:1 molar ratio as designated by BS-type diagram. Econazole nitrate water solubility was significantly increased in about three- and fourfold for β-CyD and HP-β-CyD, respectively. The results showed that the prepared complexes were spherical in shape having an average particle diameter from 110 to 288.33 nm 214 with entrapment efficiency ranging from 64.24 to 95.27%. DSC investigations showed the formation of real inclusion complexes obtained with co-precipitation technique. From the in vitro studies, all eye drops containing co-precipitate complexes exhibited higher release rate than that of other complexes and followed the diffusion-controlled mechanism. In vivo study proved that eye drops containing EC-CyD complexes showed higher ocular bioavailability than EC alone which indicated by higher AUC, Cmax, and relative bioavailability values. Qiu et al. (2017) determined the inhibitory effect of eight antifungal drugs on S. mutans growth, biofilm formation and virulence factors. The actions of antifungal drugs on S. mutans were determined by recovery plates and survival kinetic curves. Biofilms were observed by scanning electron microscopy and the viable cells were recovered on BHI plates, meanwhile biofilms were stained by BacLight live/dead kit to investigate the biofilm viability. Bacteria/extracellular polysaccharides staining assays were performed to determine the EPS production of S. mutans biofilms. Acidogenicity and acidurity of S. mutans were determined using pH drop and acid tolerance assays, and the expression of ldh gene was evaluated using qPCR.It was found that clotrimazole (CTR) and econazole (ECO) showed antibacterial activities on S. mutans UA159 and S. mutans clinical isolates at 12.5 and 25mg/L, respectively. CTR and ECO could also inhibit S. mutans biofilm formation and reduce the viability of preformed biofilm. CTR and ECO affected the live/dead ratio and the EPS/bacteria ratio of S. mutans biofilms. CTR and ECO also inhibited the pH drop, lactate acid production, and acid tolerance. The abilities of CTR and ECO to inhibit S. mutans ldh expression were also confirmed. Shah (2017) et al. investigated the suitability of microwave-assisted microemulsion technique to encapsulate selected ionic drug substances such as miconazole nitrate and econazole nitrate. The microwave-produced SLNs had a small size (250-300nm), low polydispersity (<0.20), high encapsulation efficiency (72-87%) and loading capacity (3.6-4.3%). Differential scanning calorimetry (DSC) and X-ray diffraction (XRD) studies suggested reduced crystallinity of stearic acid in SLNs. The release studies demonstrated a slow, sustained but incomplete release of drugs (<60% after 24h) from microwave-produced SLNs. Data fitting of drug release data revealed that the release of both drugs from microwave-produced SLNs was governed by non-Fickian diffusion indicating that drug release was both diffusion- and dissolution- controlled. Anti-fungal efficacy of drug-loaded SLNs was evaluated on C. albicans. The cell viability studies showed that cytotoxicity of SLNs was concentration-dependent. These encouraging results suggest that the microwave-assisted procedure is suitable for encapsulation of ionic drugs and that microwave-produced SLNs can act as potential carriers of antifungal drug Suñeter-Carbó et al. (2016) compared an 1% ECN hydrophilic ME with a commercial formulation in terms of rheology, droplet size and in vitro antifungal activity against Candida species. Comparative in vitro drug release, human skin permeation and drug retention were investigated using vertical diffusion cells. Rheology demonstrated a pseudoplastic shear thinning with thixotropy facilitating skin residence. No significant aggregation or droplet size variations were observed during a 6-month stability storage. Both formulations exhibited similar release levels achieving asymptotic values in 5 h. ECN skin permeation levels from the multiple emulsion resulted to be significantly higher than those of the commercial formulation, attributable to differences in formulation polarity and excipients composition. Conversely, similar drug accumulation levels in skin were obtained (40-130 ppm). These concentrations resulted to be comparable with obtained MIC values (2-78 ppm), confirming the in vitro 215 antimicrobial efficacy of both formulations. A similar skin retention and a higher permeation rate over the existing formulations is considered an improved approach to target the drug to deep epidermis. Fleischer and Raymond (2016) compared with foam vehicle in subjects with interdigital tinea pedis. A thin, uniform layer of study treatment was applied once daily to all clinically affected interdigital regions of both feet for four weeks. At baseline, at least 69% of all subjects had moderate to severe itch. Throughout the duration of both studies, numerically econazole foam was numerically superior to vehicle in achieving absence of itch. After the cessation of treatment, from day 29, itching continues to improve until day 43 in the active treatment group, whereas there is no evident continued improvement within the vehicle foam groups. At day 43, in the active treatment groups, 83% in Study 1 and 71% in Study 2 achieved complete absence of itching. Using less stringent criteria, for the econazole nitrate foam arm, achieving no itch or mild itch (0 or 1), in Study 1, 95% and 86.8% in Study 2 achieved this outcome. Tolerability of the products was excellent with few treatment-related adverse events. In summary, econazole foam decreased the burden of itch as early as day 8 in patients with interdigital tinea pedis, and this improvement continued after cessation of treatment. Hossain et al. (2016) proposed pharmaceutical textiles imprinted with lipid microparticles of Econazole nitrate (ECN) as a mean to improve patient compliance while maintaining drug activity. Lipid microparticles were prepared and characterized by laser diffraction (3.5±0.1 μm). Using an optimized screen-printing method, microparticles were deposited on textiles, as observed by scanning electron microscopy. The drug content of textiles (97±3 μg/cm(2)) was reproducible and stable up to 4 months storage at 25 °C/65% Relative Humidity. Imprinted textiles exhibited a thermosensitive behavior, as witnessed by a fusion temperature of 34.8 °C, which enabled a larger drug release at 32 °C (temperature of the skin) than at room temperature. In vitro antifungal activity of ECN textiles was compared to commercial 1% (wt/wt) ECN cream Pevaryl®. ECN textiles maintained their antifungal activity against a broad range of Candida species as well as major dermatophyte species. In vivo, ECN textiles also preserved the antifungal efficacy of ECN on cutaneous candidiasis infection in mice. Ex vivo percutaneous absorption studies demonstrated that ECN released from pharmaceutical textiles concentrated more in the upper skin layers, where the fungal infections develop, as compared to dermal absorption of Pevaryl®. Overall, these results showed that this technology is promising to develop pharmaceutical garments textiles for the treatment of superficial fungal infections. Ivaskiene et al. (2016) evaluated the efficacy of newly developed topical formulations in the treatment of cats with dermatophytosis. Evaluation of clinical efficacy and safety of terbinafine and econazole formulations administered topically twice a day was performed in 40 cats. Cats, suffering from the most widely spread Microsporum canis-induced dermatophytosis and treated with terbinafine hydrochloride 1% cream, recovered within 20.3±0.88 days; whereas when treated with econazole nitrate 1% cream, they recovered within 28.4±1.14 days. A positive therapeutic effect was yielded by combined treatment with local application of creams and whole coat spray with enilconazole 0.2% emulsion "Imaverol". Most cats treated with econazole cream revealed redness and irritation of the skin at the site of application. This study demonstrates that terbinafine tended to have superior clinical efficacy (p<0.001) in the treatment of dermatophytosis in cats compared to the azole tested. Maged et al. (2016) explored the effect of using methyl-β-cyclodextrin and hydroxypropyl-βcyclodextrin as carriers for econazole nitrate nanoparticles prepared by nano spray dryer. 216 Stabilizers, namely, poly(ethylene oxide), polyvinylpyrrolidone k30, poloxamer 407, Tween 80, and Cremophor EL, were used. The nano spray dried formulations revealed almost spherical particles with an average particle size values ranging from 121 to 1565 nm and zeta potential values ranging from -0.8 to -2.5 mV. The yield values for the obtained formulations reached 80%. The presence of the drug in the amorphous state within the nanosuspension matrix system significantly improved drug release compared to that for pure drug. Combination of hydroxypropyl-β-cyclodextrin with Tween 80 achieved an important role for preserving the econazole nanosuspension from aggregation during storage for one year at room temperature as well as improving drug release from the nanosuspension. This selected formulation was suspended in chitosan HCl to increase drug release and bioavailability. The in vivo evaluation on albino rabbit's eyes demonstrated distinctly superior bioavailability of the selected formulation suspended in chitosan compared to its counterpart formulation suspended in buffer and crude drug suspension due to its mucoadhesive properties and nanosize. The nano spray dryer could serve as a one step technique toward formulating stable and effective nanosuspensions. Mathivanan et al. (2016) reported that exposure of primary cultures of rat nociceptors to econazoleaugments neuronal excitability. This effect appears mediated by increments in the intracellular Ca2+ by stimulating Ca2+ entry and release from the endoplasmic reticulum. Ca2+ entry was not due to activation of thermo transient receptor potential (TRP) channels, suggesting a different ion channel targeted by the azole. Noteworthy, econazole-evoked responses were potentiated by a pro-inflammatory agent, which resulted in an increase in neuronal excitability. Econazole-elicited action potential firing was significantly abolished by the inflammatory cytokine inhibiting drug benzydamine via blockade of voltage-gated Na+ (Nav) channels. Collectively, our results indicate that the burning sensation of econazole is due at least in part to modulation of nociceptor excitability, and such sensation is increased in the presence of pro-inflammatory stimuli and blocked by benzydamine. These findings imply that a combination of the azole with benzydamine has the potential to reduce significantly the unpleasant symptoms related to infection and to the adverse effects of topical econazole formulations. Abastabar et al (2015) compared in vitro susceptibility of 100 clinical Candida isolates belonging to 6 species from superficial candidiasis of Iran towards to econazole was compared with three other common antifungal agents including itraconazole, fluconazole, and miconazole. Minimum inhibitory concentrations (MICs) values were analyzed according to the Clinical and Laboratory Standards Institute (CLSI) M38-A3 document. All isolates were previously identified to the species level, using polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) on ITS region. The MIC of econazole, itraconazole, miconazole, and fluconazole were within the range of 0.016-16, 0.032-16, 0.016-16, and 0.25-64 μg/ml, respectively. In general, econazole and miconazole were more active against Candida isolates, compared to the other two agents. CONCLUSION: The present study demonstrated that for Candida albicans isolates, miconazole and econazole had the best effect, but in non-albicans Candida species, itraconazole and miconazole displayed more activity than other antifungal agents References 1. Abastabar M1, Shokohi T1, Rouhi Kord R2, Badali H1, Hashemi SJ3, Ghasemi Z3, Ghojoghi A4, Baghi N2, Abdollahi M2,5, Hosseinpoor S2, Rahimi N2, Seifi Z2, Gholami S1, Haghani I1, Jabari MR2, Pagheh A2,4. In vitro activity of econazole in 217 comparison with three common antifungal agents against clinical Candida strains isolated from superficial infections. Curr Med Mycol. 2015 Dec;1(4):7-12. 2. Abd El-Gawad AEH1, Soliman OA2, El-Dahan MS2, Al-Zuhairy SAS2. Improvement of the Ocular Bioavailability of Econazole Nitrate upon Complexation with Cyclodextrins. AAPS PharmSciTech. 2017 Jul;18(5):1795-1809. Abd El-Gawad AEH1, Soliman OA2, El-Dahan MS2, Al-Zuhairy SAS2. Improvement of the Ocular Bioavailability of Econazole Nitrate upon Complexation with Cyclodextrins. AAPS PharmSciTech. 2017 Jul;18(5):1795-1809. 3. Fleischer AB Jr, Raymond I. Econazole Nitrate Foam 1% Improves the Itch of Tinea Pedis. J Drugs Dermatol. 2016 Sep 1;15(9):1111-4. 4. Hossain MA1, Lalloz A1, Benhaddou A2, Pagniez F3, Raymond M4, Le Pape P3, Simard P2, Théberge K2, Leblond J5. Econazole imprinted textiles with antifungal activity. Eur J Pharm Biopharm. 2016 Apr;101:137-44. 5. Ivaskiene M, Matusevicius AP, Grigonis A, Zamokas G, Babickaite L. Efficacy of Topical Therapy with Newly Developed Terbinafine and Econazole Formulations in the Treatment of Dermatophytosis in Cats. Pol J Vet Sci. 2016 Sep 1;19(3):535-543 6. Maged A1, Mahmoud AA1,2, Ghorab MM3. Nano Spray Drying Technique as a Novel Approach To Formulate Stable Econazole Nitrate Nanosuspension Formulations for Ocular Use. Mol Pharm. 2016 Sep 6;13(9):2951-65. 7. Mathivanan S1, de la Torre-Martinez R2, Wolf C2, Mangano G3, Polenzani L3, Milanese C3, Ferrer-Montiel A2. Effect of econazole and benzydamine on sensory neurons in culture. J Physiol Pharmacol. 2016 Dec;67(6):851-858. 8. Qiu W1, Ren B1, Dai H2, Zhang L2, Zhang Q3, Zhou X4, Li Y5. Clotrimazole and econazole inhibit Streptococcus mutans biofilm and virulence in vitro. Arch Oral Biol. 2017 Jan;73:113-120. 9. Shah RM1, Eldridge DS2, Palombo EA2, Harding IH3. Microwave-assisted microemulsion technique for production of miconazole nitrate- and econazole nitrateloaded solid lipid nanoparticles. Eur J Pharm Biopharm. 2017 Aug;117:141-150. 10. Suñer-Carbó J1, Boix-Montañés A1, Halbaut-Bellowa L1, Velázquez-Carralero N1, Zamarbide-Ledesma J1, Bozal-de-Febrer N2, Calpena-Campmany AC1. Skin permeation of econazole nitrate formulated in an enhanced hydrophilic multiple emulsion. Mycoses. 2017 Mar;60(3):166-177. 218 10. Efinaconazole    Efinaconazole is a triazole antifungal. It is approved for use in Canada and the USA, JAPAN as a 10% topical solution for the treatment of onychomycosis. Efinaconazole 10% topical solution), is the first topical triazole antifungal agent developed for distal lateral subungual onychomycosis (DLSO). Canadian approval is the first regulatory approval world-wide. Efinaconazole acts as a 14α-demethylase inhibitor. Physicochemical properties: - white to pale yellow crystals or crystalline powder - melting point: 86 to 89 °C - pH of a saturated solution is between 5.5 and 7.5 - practically insoluble or insoluble in water Chemical name: ((2R,3R)-2-(2,4-difluorophenyl)-3-(4-methylenepiperidin-1-yl)-1-(1H- 1,2,4triazol-1-yl) butan-2-ol) Formula: C18H22F2N4O Microbiology Activity   Efinaconazole is active in vitro against strains of Candida albicans Trichophyton tonsurans Trichophyton verrucosum Trichophyton schoenleinii Epidermophyton floccosum Scopulariopsis brevicaulis Acremonium spp. Fusarium spp. Candida parapsilosis Candida krusei Candida tropicalis Microsporum canis Efinaconazole drug resistance development was studied in vitro against T. mentagrophytes, T. rubrum and C. albicans. Serial passage of fungal cultures in the presence of sub-growth inhibitory concentrations of efinaconazole suggested low resistance development potential. Mode of action, Tatsumi et al., 2013  The primary mechanism of action of efinaconazole is blockage of ergosterol biosynthesis, presumably through sterol 14α-demethylase inhibition, leading to secondary degenerative changes. 219   Efinaconazole dose-dependently decreased ergosterol production and accumulated 4,4dimethylsterols and 4α-methylsterols at concentrations below its MICs. Efinaconazole induced morphological and ultrastructural changes in T. mentagrophytes hyphae that became more prominent with increasing drug concentrations.. Indications and usage  Efinaconazole topical solution, 10% is an azole antifungal indicated for the topical treatment of onychomycosis of the toenail(s) due to Trichophyton rubrum and Trichophyton mentagrophytes. Dosage and administration  Efinaconazole is applied to affected toenails once daily for 48 weeks, using the integrated flow-through brush applicator.  Efinaconazole is for topical use only and not for oral, ophthalmic, or intravaginal use. Pharmacokinetics , Valeant Canada LP. October 2, 2013 Absorption:        Administration of efinaconazole by the topical route leads to low systemic concentrations. Systemic absorption of efinaconazole in 18 patients with severe onychomycosis was determined after application of JUBLIA once daily for 28 days to patients‘ 10 toenails and adjacent skin. The concentration of efinaconazole in plasma was determined at multiple time points over the course of 24-hour periods on days 1, 14, and 28. Efinaconazole mean plasma Cmax on Day 28 was 0.67 ng/mL. The mean plasma concentration versus time profile was generally flat over the course of treatment. In onychomycosis patients, the steady state plasma concentration range was 0.1-1.5 ng/mL for efinaconazole and 0.2-7.5 ng/mL for H3 metabolite. In a separate study of healthy volunteers, the plasma half-life of JUBLIA at day 10 following repeat treatment applications repeated to all 10 toenails was 29.9 hours. Distribution:  Efinaconazole in vitro binding to human plasma proteins is high, 95.8% - 96.5%. Because of low systemic levels, efinaconazole plasma protein binding is not expected to be clinically relevant.  Efinaconazole in vitro bound to human serum albumin (95.2%), α1-acid glycoprotein (85.5%) and to γ-globulin (4.4%). As albumin concentration is high in plasma relative to other proteins, efinaconazole is expected to be mainly bound to human serum albumin in vivo.  Efinaconazole penetrates through nails in vitro after JUBLIA administration, suggesting drug penetrations to the site of fungal infection in the nail and the nail bed, though clinical relevance is unknown. 221 Metabolism and Excretion:  Efinaconazole is extensively metabolized through oxidative/reductive processes, with the potential of additional metabolite glucuronidation. Analysis of human plasma confirmed that H3 is the only major efinaconazole metabolite.  Efinaconazole is considered a non inhibitor and non inducer of the CYP450 enzyme family.  Efinaconazole metabolites are excreted in urine and bile/feces. Adverse reactions, FDA  Adverse events that were reported were generally mild and transient and were similar between subjects treated with Jublia® and vehicle. The most commonly reported adverse events in patients treated with Jublia® were application site dermatitis and application site vesicles.  In two clinical trials, 1227 subjects were treated with JUBLIA, 1161 for at least 24 weeks and 780 for 48 weeks. Adverse reactions reported within 48 weeks of treatment and in at least 1% of subjects treated with JUBLIA and those reported in subjects treated with the vehicle are o o o o Ingrown toenail 28 (2.3%) Application site dermatitis 27 (2.2%) Application site vesicles 20 (1.6%) Application site pain 13 (1.1%) Toxicology   Efinaconazole acute toxicity studies were conducted in rat via dermal and subcutaneous (SC) administration, in mice via intraperitoneal administration, and in dog via dermal administration. o Efinaconazole was well tolerated in both genders of all 3 species, with all LD50 values higher than 0.5 to 2 grams/kg. Efinaconazole long term toxicity was evaluated in minipig and mouse via dermal administration and in rats via subcutaneous administration. o Efinaconazole was generally well tolerated in rats with repeated daily doses of up to 30 (males) and 40 (females) mg/kg. o The high doses were the maximum tolerated doses, based on increased frequency of severe injection site reactions and a 17% average lower body weight in males compared to controls. o No target organs of toxicity were identified at any dose level. Generic name: Efinaconazole Brand names:  JUBLIA® (efinaconazole) topical solution, 10% For topical use Initial U.S. Approval: 2014 221  CLENAFIN® (efinaconazole) topical solution 10% is the country‘s first topical treatment for onychomycosis, launched in Japan in September 2014. Efinaconazole Recent reports Adigun et al. (2016) determined through in vitro release testing (IVRT) whether polyureaurethane 16% allows for penetration of efinaconazole 10% or tavaborole 5%. Results could spur subsequent clinical studies which would have implications for the addition of an antifungal based on fungal confirmation, after addresssing the underlying nail dystrophy primarily.<br/>A vertical diffusion cell system was used to evaluate the ability of efinaconazole 10% and tavaborole 5% to penetrate across poly-ureaurethane 16%. The diffusion cells had a 1.0 cm² surface area and approximately 8 mL receptor volume. Poly-ureaurethane 16% was applied to a 0.45 &mu;m nylon membrane and allowed to dry before use. Efinaconazole 10% or tavaborole 5% was then applied to the poly-ureaurethane 16% coated membrane, and samples were pulled from the receptor chamber at various times. Reverse phase chromatography was then used to assess the penetration of each active ingredient across the membrane.. The flux and permeability of efinaconazole or tavaborole across poly-ureaurethane 16% were determined from efinaconazole 10% or tavaborole 5%, respectively. The flux and permeability of efinaconazole were determined to be 503.9 +/- 31.9 &mu;g/cm²/hr and 14.0 +/- 0.9 nm/sec. The flux and permeability of tavaborole were determined to be 755.5 +/- 290.4 &mu;g/cm²/hr and 42.0 +/- 16.1 nm/sec. <br/> CONCLUSION: In addition to the treatment of onychoschizia, onychorrhexis, and other signs of severe dessication of the nail plate, a barrier that regulates TOWL should be considered in the management 222 onychomycosis to address barrier dysfunction and to promote stabilization of the damaged nail. Previously published flux values across the nail are reported to be 1.4 &mu;g/cm²/day for efinaconazole and 204 &mu;g/cm²/day for tavaborole. These values are substantially lower than the herein determined flux for both molecules across poly-ureaurethane 16%. A comparison of the data suggests that polyureaurethane 16%, if used prior to efinaconazole or tavaborole, would not limit the ability of either active ingredient to access the nail, and therefore, would be unlikely to reduce their antifungal effect. Onychodystrophy is inherent in, and often precedes onychomycosis, and consideration should be given for initiation of treatment in the same sequence: stabilizing and protecting the nail plate barrier primarily, and subsequently adding oral or topical antifungals after laboratory confirmation. Future clinical studies will be needed to determine combination efficacy for in vivo use. <br /><br /> <em> Del Rosso et al. (2016) reviewed results achieved in Phase 3 pivotal studies with topical efinaconazole 10% Solution applied once daily for 48 weeks with a focus on how the aforementioned factors influenced therapeutic outcomes. It is important for clinicians treating patients for onychomycosis to evaluate severity, treat concomitant tinea pedis, address control of diabetes if present by encouraging involvement of the patient's primary care physician, and consider longer treatment courses when clinically relevant Evans et al. (2016) presented a case of successfully treated onychomycosis caused by P. lilacinus with efinaconazole and tavaborole in a patient who had failed treatment with oral fluconazole, itraconazole, terbinafine, and topical ciclopirox and naftifine. Gupta and Paquet (2016) reviewed the evidence supporting the usefulness of efinaconazole monotherapy in onychomycosis management. In vitro, efinaconazole possesses a broad antifungal activity similar or superior to that of other antifungals. Its low affinity for keratin results in good nail penetration. Efinaconazole 10% nail solution administered daily for 36 or 48 weeks to treat mild to moderate toenail onychomycosis caused by dermatophytes results in complete and mycologic cure rates of 15 to 25% and 53 to 87%, respectively. No serious skin reaction is associated with its use. CONCLUSION: Efinaconazole 10% nail solution is a promising new treatment for onychomycosis. Gupta and Studholme (2016) reported an update on Efinaconazole 10% Topical Solution for the Treatment of Onychomycosis. Two Phase III trials were completed using efinaconazole 10% nail solution, where 17.8% and 15.2% of patients achieved complete cure, and 55.2% and 53.4% achieved mycological cure. Several post hoc analyses were carried out using data from Phase III trials to determine the efficacy of efinaconazole with respect to disease duration, disease progression, and comorbidities of diabetes or tinea pedis with onychomycosis. Efinaconazole produced higher efficacy rates with patients presenting onychomycosis in a small portion of the toenail (≤25%) for a shorter duration of time (<1 year and 1-5 years). When patients presenting with both onychomycosis and tinea pedis underwent concurrent treatment, efficacy of efinaconazole increased from 16.1% to 29.4%, suggesting combination therapy improved results. Most interestingly, there was no difference in efinaconazole efficacy between diabetic and non-diabetic groups, indicating efinaconazole could be a safe and effective form of treatment for diabetics. Overall, efinaconazole 10% nail solution shows potential as an antifungal therapy for the treatment of onychomycosis. 223 Saunders et al. (2016) mentioned that previous generations of topical agents were not efficacious, owing to poor penetration of the nail bed. Oral antifungal drugs, such as itraconazole, terbinafine, and fluconazole, not only give better response rates but also inhibit a host of CYP450 enzymes. Oral antifungals can exacerbate drug-drug interactions for patients taking other medications concurrently. Newer topical agents might recognize improved efficacy and provide therapeutic alternatives when the use of oral antifungal agents is contraindicated. Recently, the Food and Drug Administration (FDA) approved efinaconazole and tavaborole for the treatment of onychomycosis. Additionally, the FDA approved luliconazole for the treatment of tinea pedis, tinea cruris, and tinea corporis. This review examines the mechanism of action, spectrum of activity, pharmacokinetics, and clinical trials data and considers the place in therapy for these 3 new antimycotic agents. Vlahovic et al. (2016) evaluated nail polish appearance after application of tavaborole (dropper) or efinaconazole (brush); respective applicator appearance; presence of color transfer from respective applicators; and color transfer to remaining solutions after dosing of polished nails. Twelve ex vivo human cadaver fingernails were cleaned, polished with two coats of L'Oréal® Nail Color, Devil Wears Red #420, and mounted on floral foam. Nails were treated with tavaborole or efinaconazole solutions once daily for 7 days. Dropper and brush applicators were applied to white watercolor paper immediately after dosing to evaluate color transfer from polished nails. On day 7, remaining solutions were transferred to clear glass vials to evaluate color transfer from applicators to solutions. Nails, applicators, and papers were photographed daily following application; remaining solutions were photographed after 7 days of dosing Tavaborole-treated polished nails showed no polish discoloration, and tavaborole applicators did not change in appearance during treatment. No color transfer from polished nails was evident to applicator, paper, or remaining solution. Efinaconazole-treated polished nails showed substantial polish changes after the first day of treatment, with polish appearance and discoloration progressively worsening over 7 days of treatment. Color transfer from nails was evident to applicator, paper, and remaining solution. Daily dropper application of tavaborole to ex vivo polished nails did not alter polish appearance. Brush application of efinaconazole produced visible changes in polish appearance and color transfer to applicators, paper, and remaining solution. Tavaborole topical solution, 5% may not alter nail polish appearance; the impact of nail polish on tavaborole clinical efficacy has not been evaluated. Glynn et al. (2015) mentioned that the reproductive and developmental toxicity of efinaconazole was characterized in fertility and early embryonic development (rat), embryofetal development (rat and rabbit), and peri/post-natal development (rat) studies in accordance with current ICH guidances. In the fertility study, maternal reproductive toxicity was noted as estrous cycle prolongation (NOAEL=5mg/kg/day) but there were no male reproductive effects even in the presence of paternal toxicity (NOAEL=25mg/kg/day). Rat embryo-fetal and perinatal pup lethality was the most sensitive (NOAEL=5mg/kg/day) efinaconazoledevelopmental toxicity and was noted at maternally toxic doses. Efinaconazole did not affect rabbit embryo-fetal development at maternally toxic doses (NOAEL=10mg/kg/day). No malformations were induced by efinaconazole in rats or rabbits. When compared with systemic exposures observed in onychomycosis patients, embryo-fetal toxicity in rats was noted at high (>100-fold) multiples of systemic exposure 224 Lipner and Scher (2015) summarized the mechanism of action, in vitro and in vivo data, clinical trials, safety, and quality-of-life data of efinaconazole as it applies to the treatment of onychomycosis. Markinson and Caldwell (2015) evaluated the efficacy of efinaconazole topical solution, 10%, in patients with onychomycosis and coexisting tinea pedis. They analyzed 1,655 patients, aged 18 to 70 years, randomized (3:1) to receive efinaconazole topical solution, 10%, or vehicle from two identical multicenter, double-blind, vehicle-controlled 48-week studies evaluating safety and efficacy. The primary end point was complete cure rate (0% clinical involvement of the target toenail and negative potassium hydroxide examination and fungal culture findings) at week 52. Three groups were compared: patients with onychomycosis and coexisting interdigital tinea pedis on-study (treated or left untreated) and those with no coexisting tinea pedis. Treatment with efinaconazole topical solution, 10%, was significantly more effective than vehicle use irrespective of the coexistence of tinea pedis or its treatment. Overall, 352 patients with onychomycosis (21.3%) had coexisting interdigital tinea pedis, with 215 of these patients (61.1%) receiving investigator-approved topical antifungal agents for their tinea pedis in addition to their randomized onychomycosis treatment. At week 52, efinaconazole complete cure rates of 29.4% were reported in patients with onychomycosis when coexisting tinea pedis was treated compared with 16.1% when coexisting tinea pedis was not treated. Both cure rates were significant compared with vehicle (P = .003 and .045, respectively), and in the latter subgroup, no patients treated with vehicle achieved a complete cure. Rich (2015) evaluated efficacy of efinaconazole topical solution, 10% in onychomycosis patients with early and long-standing disease. An analysis of 1655 patients, aged 18-70 years, randomized to receive efinaconazole topical solution, 10% or vehicle from two identical multicenter, double-blind, vehicle-controlled 48-week studies evaluating safety and efficacy. The primary end point was complete cure rate (0% clinical involvement of target toenail, and both negative potassium hydroxide examination and fungal culture) at Week 52. Three groups were compared: those with early disease (<1year), patients with a baseline disease of 1-5 years, and those with long-standing onychomycosis (>5years). The majority of patients had long-standing disease; were older, male and white. While nail involvement of the target toenail did not differ noticeably amongst the three groups, the number of nails involved did increase progressively with disease duration. Differences were seen in terms of infecting pathogens in early disease that might have important treatment implications. Efinaconazole was more effective in treating early disease, however more than 40% of patients with long-standing disease were considered treatment successes. LIMITATIONS:A period of 52 weeks may be too brief to evaluate a clinical cure in onychomycosis. CONCLUSIONS:Treatment of onychomycosis early to avoid disease progression to other toenails is important. Once daily efinaconazoletopical solution, 10% is particularly effective in these patients. Rodriguez (2015) evaluated efficacy, safety, and tolerability of efinaconazole topical solution, 10%, in patients with mild (≤25% nail involvement) and moderate (>25% nail involvement) toenail onychomycosis. Methods: A subgroup analysis of patients, aged 18 to 70 years, randomized to receive efinaconazole topical solution, 10%, or vehicle from two identical multicenter, double-blind, vehicle-controlled, 48-week studies evaluating safety and efficacy. The primary endpoint was complete cure rate (0% clinical involvement of target toenail and both negative potassium hydroxide examination and fungal culture) at Week 52. Results: Mycologic cure rates were similar in mild and moderate onychomycosis patients treated with efinaconazole 225 (58.2% and 55.5%, respectively), but markedly different with vehicle (25.0% and 14.1%, respectively). The primary endpoint, complete cure, was achieved in 25.8 percent of mild onychomycosis patients and 15.9 percent of moderate onychomycosis patients compared to 11.3 and 2.7 percent, respectively, with vehicle (both P<0.001). Treatment success (percent affected target toenail ≤10%) for efinaconazole was 65.7 and 40.7 percent, respectively, depending on disease severity. Adverse events associated with efinaconazole were local site reactions and clinically similar to vehicle. Gupta and Simpson (2014) mentioned that Efinaconazole is an emerging antifungal therapy for the topical treatment of onychomycosis. Efinaconazole is an inhibitor of sterol 14α-demethylase and is more effective in vitro than terbinafine, itraconazole, ciclopirox and amorolfine against dermatophytes, yeasts and non-dermatophyte molds. Phase II studies indicate that efinaconazole 10% nail solution is more effective than either the 5% strength or 10% solution with semi-occlusion. In duplicate Phase III clinical trials, complete cure rates of 17.8% and 15.2% were demonstrated. The mean mycological cure rate for efinaconazole is similar to the oral antifungal itraconazole and exceeds the efficacy of topical ciclopirox. Efinaconazole showed minimal localized adverse events, which ceased upon stopping treatment. Pollak (2014) reviewed the preclinical and clinical data on efinaconazole topical solution, 10%. Efinaconazole has a broad spectrum of antifungal activity in vitro and is more potent than ciclopirox against common onychomycosis pathogens. It has a more optimal keratin affinity than ciclopirox, and it exhibits significantly greater in vivo activity owing to its superior nail penetration. Mycologic cure rates at week 52 were 55.2% (study 1) and 53.4% (study 2) with efinaconazole topical solution, 10% compared with 16.8% and 16.9%, respectively, with vehicle (P<.001 for both). In addition, efinaconazole is well tolerated. Sugiura (2014) investigated these properties for efinaconazole, a new topical antifungal for onychomycosis, compared with those of the existing topical drugs ciclopirox and amorolfine. The efinaconazole free-drug concentration in keratin suspensions was 14.3%, significantly higher than the concentrations of ciclopirox and amorolfine, which were 0.7% and 1.9%, respectively (P < 0.001). Efinaconazole was released from keratin at a higher proportion than in the reference drugs, with about half of the remaining keratin-bound efinaconazoleremoved after washing. In single-dose in vitro studies, efinaconazole penetrated full-thickness human nails into the receptor phase and also inhibited the growth of Trichophyton rubrum under the nail. In the presence of keratin, efinaconazole exhibited fungicidal activity against Trichophyton mentagrophytes comparable to that of amorolfine and superior to that of ciclopirox. In a guinea pig onychomycosis model with T. mentagrophytes infection, an efinaconazole solution significantly decreased nail fungal burden compared to that of ciclopirox and amorolfine lacquers (P < 0.01). References 1. Adigun CG, Vlahovic TC, McClellan MB, Thakker KD, Klein RR, Elstrom TA, Ward DB. Efinaconazole 10% and Tavaborole 5% Penetrate Across Poly-ureaurethane 16%: Results of In Vitro Release Testing and Clinical Implications of Onychodystrophy in Onychomycosis. J Drugs Dermatol. 2016 Sep 1;15(9):1116-20. 226 2. Del Rosso JQ1. Onychomycosis of Toenails and Post-hoc Analyses with Efinaconazole 10% Solution Once-daily Treatment: Impact of Disease Severity and Other Concomitant Associated Factors on Selection of Therapy and Therapeutic Outcomes. J Clin Aesthet Dermatol. 2016 Feb;9(2):42-7. 3. Evans JM1, Wang AL2, Elewski BE2. Successful Treatment of Paecilomyces lilacinus Onychomycosis with Efinaconazole and Tavaborole. Skin Appendage Disord. 2016 May;1(4):169-71 4. Glynn M1, Jo W2, Minowa K3, Sanada H4, Nejishima H5, Matsuuchi H6, Okamura H7, Pillai R8, Mutter L9. Efinaconazole: Developmental and reproductive toxicity potential of a novel antifungal azole. Reprod Toxicol. 2015 Apr;52:18-25. 5. Gupta AK, Paquet M. Efinaconazole 10% nail solution: a new topical treatment with broad antifungal activity for onychomycosis monotherapy. 6. Gupta AK1, Simpson FC. Efinaconazole: a new topical treatment for onychomycosis. Skin Therapy Lett. 2014 Jan-Feb;19(1):1-4. 7. Gupta AK1, Studholme C2. Update on Efinaconazole 10% Topical Solution for the Treatment of Onychomycosis. Skin Therapy Lett. 2016 Nov;21(6):7-11. 8. Lipner SR1, Scher RK1. Efinaconazole in the treatment of onychomycosis. Infect Drug Resist. 2015 Jun 1;8:163-72. 9. Markinson B, Caldwell B. Efinaconazole Topical Solution, 10% Efficacy in Patients with Onychomycosis and Coexisting Tinea Pedis. J Am Podiatr Med Assoc. 2015 Sep;105(5):407-11 10. Pollak RA. Efinaconazole topical solution, 10%: the development of a new topical treatment for toenail onychomycosis. J Am Podiatr Med Assoc. 2014 Nov;104(6):568-73. 11. Rich P. Efinaconazole topical solution, 10%: the benefits of treating onychomycosis early. J Drugs Dermatol. 2015 Jan;14(1):58-62. Rodriguez DA. Efinaconazole Topical Solution, 10%, for the Treatment of Mild and Moderate Toenail Onychomycosis. The Journal of Clinical and Aesthetic Dermatology. 2015;8(6):24-29. 12. Saunders J1, Maki K1, Koski R2, Nybo SE3. Tavaborole, Efinaconazole, and Luliconazole: Three New Antimycotic Agents for the Treatment of Dermatophytic Fungi. J Pharm Pract. 2016 Aug 3. pii: 0897190016660487. 13. Sugimoto N2, Hosaka S2, Katafuchi-Nagashima M3, Arakawa Y3, Tatsumi Y3, Jo Siu W4, Pillai R4. The low keratin affinity of efinaconazole contributes to its nail penetration and fungicidal activity in topical onychomycosis treatment. Antimicrob Agents Chemother. 2014 Jul;58(7):3837-42 14. Vlahovic TC, Coronado D, Chanda S, Merchant T, Zane LT. Evaluation of the Appearance of Nail Polish Following Daily Treatment of Ex Vivo Human Fingernails With Topical Solutions of Tavaborole or Efinaconazole. J Drugs Dermatol. 2016 Jan;15(1):89-94 227 11. Enilconazole         Uses     Enilconazole is an Agricultural fungicide Enilconazole is a fungicide widely used in agriculture, particularly in the growing of citrus fruits. It is also called Imazalil, . Trade names include Freshgard, Fungaflor, and Nuzone. Enilconazole is also used in veterinary medicine as a topical antimycotic. Enilconazole (synonyms imazalil, chloramizole) is a fungicide widely used in agriculture, particularly in the growing of citrus fruits. Trade names include Freshgard, Fungaflor, and Nuzone. Enilconazole is also used in veterinary medicine as a topical antimycotic Formula: C14H14Cl2N2O Solubility in water: 1.4 kg/m³ Appearance: Slightly yellow to brown solidified oil Enilconazole is a topical mycotic agent used as a topical application for fungal infections. Enilconazole, in dogs, has primarily been used to treat Microsporum spp[and Aspergillus spp infections, either as a single topical agent or in combination with oral itraconazole or griseofulvin. Enilconazole long-term outcomes is good, with most dogs being asymptomatic throughout the treatment period, with only some showing signs of rhinitis/sinusitis. Enilconazole is usually applied as a 5% solution (1:1 in water) topically every 12 hours for 7 - 10 days, or as an instillation into the nasal sinuses as a 10 - 20 mg/kg solution (10% solution: 50:50 in water), irrigated twice daily for 10 - 14 days Toxicity    Enilconazole is classified as ―Likely to be carcinogenic in humans,‖ according to EPA‘s July 1999 Draft Guidelines for Carcinogenic Assessment. Enilconazole is carcinogenic to male Swiss albino mice and Wistar rats based on a significant increase in liver adenomas and combined adenomas/carcinomas. Enilconazole in rats, there was also an increased incidence of combined thyroid follicular cell adenomas/carcinomas. 228  Enilconazole is highly irritating to the eye (Category I), but is not a skin irritant (Category IV) or a dermal sensitizer. Environmental Fate  Enilconazole is moderately water soluble, very stable to hydrolysis, photo degrades relatively rapidly, degrades very slowly in soil under aerobic conditions, is immobile in soils, is not expected to volatilize, and has a high octanol water partition coefficient. Risks to Terrestrial and Aquatic Organisms    Enilconazole does not exceed acute or chronic levels of concern (LOCs) for freshwater fish, invertebrate, avian, and mammalian species due to extremely low exposure, which is attributable to the low application rate (0.01 lbs. a.i./A) and the seed treatment end-use (only 1% residue was left on soil surfaces). Enilconazole is practically non-toxic to seed eating avian and mammalian species. In addition to the seed treatment, all other uses occur within contained areas or structures and no exposure is expected. Enilconazole acute risk quotients (RQs) for freshwater fish (0.00005), invertebrate (0.00002), avian (0.00003), and mammal species (0.0002) are all below the endangered species LOC. Because of the extremely low exposure and relatively low toxicity to freshwater organisms, all acute and chronic toxicity testing has been waived Generic Names  Enilconazole (OS: USAN, BAN)  Imazalil (IS)  R 23979 (IS)  Enilconazole (PH: BP vet. 2015)  Enilconazole for veterinary use (PH: Ph. Eur. 8)  Enilconazolum ad usum veterinarium (PH: Ph. Eur. 8) Brand Names  Clinafarm (veterinary use) Janssen, South Africa; Lilly-Elanco, Italy  Imaveral (veterinary use) Lilly Vet, France  Imaverol (veterinary use) Bayer AH, South Africa; Elanco, Germany; Elanco Animal Health, Austria; Elanco Animal Health, Australia; Elanco Animal Health, Ireland; Eli Lilly Benelux, Belgium; Janssen-Cilag, Poland; Lilly, United Kingdom; Lilly Nederland, Netherlands; Lilly-Elanco, Italy; Orion Pharma Eläinlääkkeet, Finland; Provet, Switzerland 229 \ Recent reports: Gogolashvili et al. (2017) investigated the enantiomer migration order (EMO) of enilconazole in the presence of various cyclodextrins (CDs) by capillary electrophoresis (CE). Opposite EMO of enilconazole were observed when β-CD or the sulfated heptakis(2-O-methyl-3,6-di-O-sulfo)β-CD (HMDS-β-CD) was used as the chiral selectors. Nuclear magnetic resonance (NMR) spectroscopy was used to study the mechanism of chiral recognition between enilconazole enantiomers and those two cyclodextrins. On the basis of rotating frame nuclear Overhauser (ROESY) experiments, the structure of an inclusion complex between enilconazole and β-CD was derived, in which (+)-enilconazole seemed to form a tighter complex than the (-)-enantiomer. This correlates well with the migration order of enilconazoleenantiomers observed in CE. No evidence of complexation between enilconazole and HMDS-β-CD could be gathered due to lack of intermolecular nuclear Overhauser effect (NOE). Most likely the interaction between enilconazole and HMDS-β-CD 231 leads to formation of a shallow external complex that is sufficient for separation of enantiomers in CE but cannot be evidenced based on ROESY experiment. Kirmizigul et al. (2016) investigated the efficacy of pomades containing different concentrations of enilconazole for the treatment of bovine dermatophytosis. Dermatophytosis was confirmed in 120 cattle from farm in Gole region of Turkey. Animals were divided into six groups (n = 20 in each). Pomades containing 1%, 2%, 3%, 4% and 5% enilconazole were applied topically to individual lesions in groups I-V, respectively, once a day for 3 days. Group VI animals were used as a control group. Animals were monitored clinically once a week for a two month period. Cows treated with pomades containing 4% and 5% enilconazole recovered; adverse topical reactions occurred in 40% and 55% of animals, respectively. The success rate for cows treated with pomades containing 3% enilconazole was 95% and they recovered with no adverse reactions. Success rates for treatment were 25% and 50% for cows treated with pomades containing 1% and 2% enilconazole, respectively. No improvement was observed in the control group. Billen et al. (2010) evaluated the effect of 1% bifonazole cream in the treatment of canine sinonasal aspergillosis (SNA). The cream was instilled through perendoscopically placed catheters into the frontal sinuses and was used either as single therapy after debridement (DC) or as adjunctive therapy after 2% enilconazole infusion (DEC). Twelve dogs were treated initially with DEC: 7 and 3 of these dogs were free of disease after 1 and 2 procedures, respectively, while 2 dogs were cured after DC was used as a second procedure. Five dogs were treated with DC only: in 3 dogs with moderate disease, cure was obtained after a single procedure while, in 2 debilitated patients, cure could not be confirmed. Topical administration of 1% bifonazole cream appears as an effective therapy in SNA, either as an adjunctive therapy to enilconazole infusion or as sole therapy in moderately affected patients. References: 1. Billen F1, Guieu LV, Bernaerts F, Mercier E, Lavoué R, Tual C, Peeters D, Clercx C. Efficacy of intrasinusal administration of bifonazole cream alone or in combination with enilconazole irrigation in canine sino-nasal aspergillosis: 17 cases. Can Vet J. 2010 Feb;51(2):164-8. 2. Gogolashvili A1, Tatunashvili E1, Chankvetadze L1, Sohajda T2, Szeman J2, Salgado A3, Chankvetadze B1. Separation of enilconazole enantiomers in capillary electrophoresis with cyclodextrin-type chiral selectors and investigation of structure of selector-selectand complexes by using nuclear magnetic resonance spectroscopy. Electrophoresis. 2017 Aug;38(15):1851-1859. 3. Kirmizigul AH1, Erkilic EE1, Buyuk F2, Gokce E1, Citil M1. Efficacy of pomades containing different percentages of enilconazole in the treatment of bovine dermatophytosis. Vet Dermatol. 2016 Jun;27(3):181-e45. 231 12. Epoxiconazole      Epoxiconazole is a fungicidal active ingredient of the azoles class developed to protect cultures. Epoxiconazole inhibits the metabolism of fungal cells that can infest useful plants, thus preventing the growth of mycelium (mitotic cells). Epoxiconazole also limits the production of conidiophores (mitospores). Epoxiconazole was first introduced on the market by BASF SE in 1993 and is found in many products and product mixtures against pathogens in various crops. Examples of these crops are cereals (mainly wheat, barley, rye and triticale), soybeans, bananas, rice, coffee, turnips, red beets and sugar. Chemical names: Epoxiconazole; 135319-73-2; CHEBI:83758; 1-[[3-(2-chlorophenyl)2-(4-fluorophenyl)oxiran-2-yl]methyl]-1,2,4-triazole; (2RS,3SR)-1-[3-(2-Chlorophenyl)2,3-epoxy-2-(4-fluorophenyl)propyl]-1H-1,2,4-triazole; 133855-98-8  Generic Name: rel-1-[[(2R,3S)-3-(2-chlorophenyl)-2-(4-fluorophenyl) oxiranyl]methyl]-1H-1,2,4triazole  Molecular Formula: C17H13ClFN3O Use Pattern and Formulations     Epoxiconazole is proposed for control of Black Sigatoka (Mycosphaerella fijiensis) and Yellow Sigatoka (Mycosphaerella musicola) in bananas and Coffee Rust (Hamileia vastatrix) in coffee. Epoxiconazole is formulated as an emulsifiable concentrate (EC), Opal® 7.5 EC Fungicide and as a flowable concentrate (FlC), OPUS® 125 g/L, intended for use in the banana-producing countries of Central and South America. Epoxiconazole EC formulation is proposed for broadcast foliar/fruit applications at a target rate of 1 liter per ha (equivalent to 75 g ai per ha), and Epoxiconazole FlC formulation is proposed for broadcast foliar/fruit applications at a target rate of 1 liter per ha (equivalent to 125 g ai per ha). http://enfo.agt.bme.hu/drupal/sites/default/files/epoxiconazole 232 Mode of Action.   Epoxiconazole actively stops the production of new fungi spores and inhibits the biosynthesis of existing hostile cells. Epoxiconazoleworks as an eradicant by encapsulating fungal haustoria, which are then cut off from their nutrient supply and therefore die. Adverse effect  Two main adverse effects of epoxiconazole on development are considered as critical for the classification on developmental toxicity: o post implantation losses and resorptions and o malformations (cleft palates) . 233 Recent reports: Drážovská et al. (2016) investigated the potential genotoxic/cytotoxic effects of the epoxiconazole/fenpropimorph-based fungicide using single cell gel electrophoresis and cytogenetic assays: chromosomal aberrations, sister chromatid exchanges, micronuclei and fluorescence in situ hybridization in cultured bovine lymphocytes. No statistically significant elevations of DNA damage and increases in cytogenetic endpoints were seen. However, evident cytotoxic effect presented as a decrease in mitotic and proliferation indices were recorded after exposure of bovine lymphocytes to the fungicide for 24 and 48 h at concentrations ranging from 3 to 15 µg mL(-1) (P < 0.05, P < 0.01, P < 0.001 Li et Al. (2016) used the nematode Caenorhabditis elegans (C. elegans) to assess effects of epoxiconazole on spermatogenesis in male nematodes after 48 h of exposure to concentrations of 0.1, 1.0, or 10.0 μg/L. The results demonstrated that epoxiconazole exposure affected spermatogenesis, decreasing the number of total germ cells, mitotic cells, meiotic cells and spermatids, spermatid diameter, and cross-sectional area, and inducing mitotic germ cell proliferation arrest, premature entry into meiosis, and sperm activation inhibition; however, sperm transfer showed no abnormal changes. In addition, the results showed that epoxiconazole activated the transforming growth factor-β (TGFβ) signaling pathway and increased the expression levels of gene daf-1, daf-3, daf-4, daf-5 and daf-7 in nematodes. Nélieu et al.(2016) proposed a mild extraction method to evaluate the bioavailability of the fungicide epoxiconazole to the earthworm Aporrectodea icterica. Experiments were conducted in soils presenting various textures and organic carbon contents, spiked with formulated epoxiconazole 7 to 56 days prior to their extraction. In parallel, the epoxiconazole concentration was determined in exposed earthworms and the fungicide's effects were evaluated by measuring weight gain, enzymatic activities and total protein contents. Among the various mild chemical solvents tested to evaluate the environmental availability of the fungicide, the 50 mM hydroxypropyl-β-cyclodextrin solution allowed to extract around 30% of epoxiconazole. This percentage corresponded to the ratio determined in exposed A. icterica under similar soil conditions. Furthermore, this mild method was demonstrated to be sensitive to soil sorption capacities and to ageing. The mild extraction method was then applied to explore the relationship between total and (bio)available concentrations in soil and in A. icterica, over 7- or 28-day exposure time. Pelosi et al. (2016) assessed the effects of different doses of a commercial formulation of epoxiconazole (Opus®), a persistent and widely used fungicide, on the earthworm Aporrectodea icterica. A laboratory study was conducted in a natural soil in order to measure effects of Opus® on earthworm mortality, uptake, weight gain, enzymatic activities (catalase and glutathione-S-transferase), and energy resources (lipids and glycogens). The estimated LC50 was 45.5 mg kg(-1), or 268 times the recommended dose. Weight gains were 28, 19, and 13% of the initial weight after 28 days of exposure in the control and D1 and D10 (1 and 10 times the recommended dose) treatments, respectively. No difference was observed for catalase activity between the three treatments, at 7, 14, or 28 days. The glutathion-S-transferase (GST) activity was two times as high in D1 as in D0 at 14 days. At 28 days, glycogen concentration was lower in D10 than in the D1 treatment. Yan et al. (2015) developed a method employing liquid chromatography-tandem mass spectrometry for determination of epoxiconazole in brown rice, straw, rice hull, paddy water and 234 soils. Epoxiconazoleresidues in rice hull, brown rice, straw and soil were also determined. The limit of quantitation was set at 0.01 mg kg(-1) for the matrices studied. Epoxiconazole degradation in straw, paddy water and soil was studied. The epoxiconazole residues in brown rice, straw, hull and paddy soil were determined. Concurrent recoveries were between 89.2 and 104.1%, with relative standard deviations ranging from 4.6 to 14.4% at three fortification levels between 0.01 and 5.0 mg kg(-1). The half-lives in straw, paddy water and soils were found to be 4.7-5.9, 2.9-6.0 and 2.9-6.4 days respectively. The maximum residues in brown rice, straw, hull and paddy soil samples were 0.18, 2.47, 2.54 and 0.09 mg kg(-1) respectively. References: 1. Drážovská M1, Šiviková K1, Holečková B1, Dianovský J1, Galdíková M1, Schwarzbacherová V1. Evaluation of potential genotoxic/cytotoxic effects induced by epoxiconazole and fenpropimorph-based fungicide in bovine lymphocytes in vitro. J Environ Sci Health B. 2016 Nov;51(11):769-76. 2. Li Y1, Zhang M2, Li S3, Lv R4, Chen P5, Liu R6, Liang G7, Yin L8. The Use of the Nematode Caenorhabditis elegans to Evaluate the Adverse Effects of Epoxiconazole Exposure on Spermatogenesis. Int J Environ Res Public Health. 2016 Oct 8;13(10). pii: E993. 3. Nélieu S1,2, Delarue G3,4, Ollivier E3,4,5, Awad P3,6, Fraillon F3, Pelosi C3,4. Evaluation of epoxiconazole bioavailability in soil to the earthworm Aporrectodea icterica. Environ Sci Pollut Res Int. 2016 Feb;23(4):2977-86. 4. Pelosi C1,2, Lebrun M3,4, Beaumelle L3,4, Cheviron N3,4,5, Delarue G3,4, Nélieu S3,4. Sublethal effects of epoxiconazole on the earthworm Aporrectodea icterica. Environ Sci Pollut Res Int. 2016 Feb;23(4):3053-61. 5. Yan B1, Ye F, Gao D. Residues of the fungicide epoxiconazole in rice and paddy in the Chinese field ecosystem. Pest Manag Sci. 2015 Jan;71(1):65-71. 235 13. Fenticonazole   Fenticonazole [alpha-(2,4-dichlorophenyl)-beta, N-imidazolylethyl 4-phenylthiobenzyl ether nitrate] is an imidazole derivative that was developed for the topical treatment of fungal infections. Fenticonazole is active against a range of organisms including dermatophyte pathogens, Malassezia furfur, and Candida albicans. Molar mass: 455.4 g/mol Formula: C24H20Cl2N2OS Mode of action, Veraldi and Veraldi (2008)     Fenticonazole presents a wide spectrum of activity against dermatophytes and yeasts Fenticonazole exerts antifungal activity by three different mechanisms: o inhibition of the release of protease acid by Candida albicans o alteration of the cytoplasmic membrane, via inhibition of the fungal P450 isozyme, which is necessary to convert lanosterol to ergosterol, an essential component of fungal cell membrane synthesis o blockade of cytochrome oxidases and peroxidases Fenticonazole has also been shown to exhibit antibacterial action, with a spectrum of activity that includes bacteria commonly associated with superinfected fungal skin and vaginal infections, Fenticonazole has also antiparasitic action against the protozoan Trichomonas vaginalis.  Therefore, fenticonazole may be an ideal topical alternative to multi-agent treatment of mixed infections involving mycotic, bacterial, dermatophyte and/or Trichomonas spp. Pharmacology, Tumietto and Giacomelli (2017)   A scanning electron microscopic study of the effect of fenticonazole on cells of C. albicans revealed the induction of cytoskeletal changes and alterations in the structure of plasma membrane, more evident with increasing concentrations of the molecule. at concentrations close to the Minimal Inhibitory Concentration (MIC), the inhibition of the formation of pseudohyphae of C. albicans is observed 236       Fenticonazole exerts also an interesting antibacterial activity, with a spectrum that comprises Gram-positive bacteria (such as Staphylococcus aureus, Staphylococcus epidermidis, Streptococcus spp.), which often super-infect the skin and vaginal infections Fenticonazole exerts also an antiparasitic action against Trichomonas vaginalis. The acute toxicity after oral and topical sub-chronic toxicity intake were studied in animal models. o The acute oral LD50 in dogs, mice and rats ranged between 1,000 mg/kg and 3,000 mg/ kg. o Topical sub-chronic toxicity was studied in rats and dogs, showing no histopathological abnormalities following the administration of fenticonazole. Fenticonazole does not affect release and activity of histamine, adrenaline, noradrenaline and acetylcholine, and vital functions such as blood pressure, heart rate, and pulmonary ventilation. Fenticonazole is retained in the stratum corneum of the skin for a long time, and it has peculiar pharmacokinetic properties that allow its accumulation in the mucosal tissue as active drug up to 72 hours, this allowing the formation of a reservoir of fenticonazole and delaying consecutive administrations. Fenticonazole is poorly absorbed at a systemic level Clinical Studies in Dermatology, Tumietto and Giacomelli (2017)   A number of open, controlled trials on fenticonazole are available in the dermatology setting. Overall, clinical evidence shows that the different formulations of fenticonazole are effective in the treatment of cutaneous fungal infection, and that the side effects are rare and of mild severity. Clinical Studies in Gynaecology  In the gynaecological setting, fenticonazole was studied in the treatment of Candida vulvovaginitis and mixed infections. In all studies, the diagnosis was based on clinical history and presentation, direct mycological examinations and cultures.  Vaginal capsules (600 mg or 1 g as a single dose or 200 mg/day for three days), 2% cream for 3 or 7 days, or a combination of capsules with cream or vaginal lavage, were effective in the treatment of infections in 75-100% of patients and allowed the eradication of Candida spp. in 70-100% of patients. Eradication was obtained within one week in most studies.  Fenticonazole 600 mg or 1 g as a single dose or 200 mg/day for three days has shown a similar efficacy profile. Adverse events are generally mild to moderate in severity and transient. o The most frequent adverse events are burning sensation/cutaneous irritation and itch when applied to the skin. 237 o In a large, open-label study in superficial mycoses of the skin, the incidence of adverse events was <5% and these were rarely responsible for treatment discontinuation. o Burning sensation is the most common with fenticonazole when administered intravaginally.  adverse event seen Given the rising incidence of superficial fungal, and possibly mixed, infections, topical fenticonazole represents an important part of the topical antimycotic armamentarium. Generic Names         Fenticonazole (OS: DCF, BAN) Fenticonazolo (OS: DCIT) Fenticonazole Nitrate (OS: BANM, USAN) Rec 15/1476 (IS: Recordati) Fenticonazole (nitrate de) (PH: Ph. Eur. ... Fenticonazole Nitrate (PH: BP 2016) Fenticonazole nitrate (PH: Ph. Eur. ... Fenticonazoli nitras (PH: Ph. Eur. Brand Names  Lomexin Algorithm, Bahrain; Algorithm, Oman; Catalent, Bosnia & Herzegowina; Herbacos Recordati, Slovakia; Pharmaplan, South Africa; Recordati, Lebanon; Recordati, Taiwan  Lomexin T Recordati, Lebanon Recordati, Italy  Falvin T Recordati, Italy  Fenizolan Velvian, Germany  Fentizol Ache, Brazil  Gyno-Lomexin Recordati, Turkey  Gynoxin Recordati, Hungary; Recordati, Netherlands; Recordati, Poland; Recordati Pharmaceutical, United Kingdom; Zambon, Belgium  Gynoxin 2% Recordati, Hungary; Recordati Pharmaceutical, United Kingdom  Laurimic Effik, Spain  Lomexin Catalent, Georgia; Catalent, Serbia; Effik, France; G.L. Pharma, Austria; Galenica, Greece; Innova Pharma, Italy; Jaba, Portugal; PharmaSwiss, Latvia; Recordati, Bulgaria; Recordati, Czech Republic; Recordati, Spain; Recordati, Georgia; Recordati, Lithuania; Recordati, Romania; Takeda México, Mexico; Tecnoquimicas, Colombia  Lomexin 2% Effik, France; Recordati, Hungary; Recordati, Slovakia  Lorenil Effik Italia, Italy  Terlomexin Effik, France 238 239 Recent reports Tumietto and Giacomelli (2017) mentioned that In the last decade, an impressive outbreak of candidiasis due to non-albicans strains (with variable patterns of resistance to azoles) was observed. This outbreak was likely associated with inappropriate use of oral azoles for the treatment of non-complicated candidiasis, such as vulvovaginal candidiasis or Candida dermatitis. In this setting, fenticonazole may represent an effective topical drug for the treatment of mycotic infections of skin and mucosa. Topical treatment of superficial mycoses still holds a major importance as it helps reduce the exposure to oral systemic azoles - mainly fluconazole and itraconazole - of intestinal microbiota, which represents the main human reservoir of yeasts. This strategy can contribute to reduce the selection of resistant strains of Candida, within the context of a really-effective antifungal stewardship program. Veraldi et al. (2014) in their review article discussed the treatment of cutaneous and vulvovaginal candidosis with topical fenticonazole, an imidazole derivative with a wide spectrum of activity against dermatophytes and yeasts. The main mechanism of action of fenticonazole is based on the inhibition of the synthesis of aspartate acid proteinase, a virulence enzyme of Candida albicans correlated with the adherence of the yeast to epithelial cells. This activity is quite peculiar as it was not observed with fluconazole, ketoconazole and miconazole. Topical treatment (1 application/day for 4 weeks) is recommended, while in widespread or everlasting mycotic infections, fenticonazole must be associated with an oral antimycotic. Fenticonazole in monotherapy is also effective in treating vulvovaginal candidosis (ovules, cream or douche; 1 application/day for 7 days). In addition, all pharmaceutical formulations of fenticonazole are well tolerated. Limitations: Although fenticonazole is one of the earliest imidazoles developed in Europe, no experimental and clinical data on development of Candida albicans resistance have been published. Conclusions: Literature data demonstrated that fenticonazole is effective in Candida albicans infections of the skin and female genitalia. Murina et al. (2012) compared the efficacy of fluconazole 150 mg and intravaginal fenticonazole 600mg in short-course treatment of the acute episode of vulvovaginal candidiasis (VVC) In a prospective study, 80 patients with clinical and mycological (SavvyCheck™ test) confirmed VVC were enrolled and divided randomly in two groups. Forty patients received oral fluconazole (150 mg), whereas 40 patients received intra-vaginal tablet fenticonazole(600 mg). Two sequential doses of azole agents were given 3 days apart (short-course treatment). Second and third visits were done for all patients seven and 30±5 days after treatment. At the second visit, 31 patients (77.5%) were cured clinically (Sobel score <4) in fluconazole group and 32 patients (80%) in fenticonazole group (P=0.876). The vulvovaginal pruritus was reduced in lower time in fenticonazole patients than in fluconazole group (mean 2.3 days versus 4.5 days, P=0.047). At the third visit, three patients in fluconazole group and two patients in fenticonazole group had clinical sign of VVC. CONCLUSION: Fluconazole and intravaginal fenticonazole are both effective to cure symptoms of VVC but fenticonazole appears to reduce the pruritus in less time. Veraldi and Veraldi (2008) mentioned that Fenticonazole is an imidazole derivative with a broad spectrum of antimycotic activity against dermatophytes and yeasts in in vitro and clinical studies. Fenticonazole exerts its unique antimycotic mechanism of action in the following three 241 ways: (i) inhibition of the secretion of protease acid by Candida albicans; (ii) damage to the cytoplasmic membrane; and (iii) by blocking cytochrome oxidases and peroxidises. Fenticonazole has also been shown to exhibit antibacterial action, with a spectrum of activity that includes bacteria commonly associated with superinfected fungal skin and vaginal infections, and antiparasitic action against the protozoan Trichomonas vaginalis. Therefore, fenticonazole may be an ideal topical alternative to multi-agent treatment of mixed infections involving mycotic, bacterial, dermatophyte and/or Trichomonas spp.Open-label clinical studies show that fenticonazole, in different pharmaceutical preparations administered once or twice daily, is effective in the treatment of superficial mycoses of the skin. In particular, fenticonazole is very effective (often with 100% of patients achieving a negative mycological assay) in pityriasis versicolor and candidiasis. For example, a large (n = 760) study showed fenticonazole 2% cream, spray or powder to be associated with a mycological response in 100% of patients with pityriasis versicolor, 96.3% of those with tinea infections and 95.2% of patients with Candida infections. Comparative clinical studies show fenticonazole once or twice daily to be at least as effective as six different topical antimycotics (miconazole, clotrimazole, econazole, bifonazole, naftifine and cyclopyroxolamine) in the treatment of superficial mycoses of the skin. Intravaginal administration of fenticonazole is associated with a high rate of microbiological efficacy in patients with vaginal candidiasis, trichomoniasis, mixed infection and bacterial vaginosis. Intravaginal fenticonazole is at least as effective as clotrimazole and shows similar efficacy to miconazole in patients with vaginal candidiasis. Fenticonazole has a rapid onset of action and clinical efficacy is generally observed within days of commencing treatment.Topical fenticonazole is very well tolerated; adverse events are generally mild to moderate in severity and transient. The most frequent adverse events are burning sensation/cutaneous irritation and itch when applied to the skin. In a large, open-label study in superficial mycoses of the skin, the incidence of adverse events was <5% and these were rarely responsible for treatment discontinuation. Burning sensation is the most common adverse event seen with fenticonazole when administered intravaginally. However, this symptom of vaginal fungal infection was often present in patients prior to drug administration.Given the rising incidence of superficial fungal, and possibly mixed, infections, topical fenticonazole represents an important part of the topical antimycotic armamentarium. References 1. Murina F1, Graziottin A, Felice R, Di Francesco S, Mantegazza V. [Short-course treatment of vulvovaginal candidiasis: comparative study of fluconazole and intravaginal fenticonazole]. Minerva Ginecol. 2012 Apr;64(2):89-94. 2. Tumietto F1, Giacomelli L. Fenticonazole: an effective topical treatment for superficial mycoses as the first-step of antifungal stewardship program. Eur Rev Med Pharmacol Sci. 2017 Jun;21(11):2749-2756. 3. Veraldi,S., Ermira Çuka, and Gianluca Nazzaro. Fenticonazole for the treatment of Candida albicans infections. 2014 October-December; 2(4): 161–165. ISSN: 22824103 4. Veraldi S1, Milani R. Topical fenticonazole in dermatology and gynaecology: current role in therapy. Drugs. 2008;68(15):2183-94.Fenticonazole for vaginal thrush (Gynoxin) . 241 14. Fluconazole        Fluconazole is a triazole antifungal agent that inhibits the fungal cytochrome P450– dependent enzyme lanosterol 14 α-demethylase, disrupts the fungal cell membrane, and impairs cell replication. Fluconazole has high oral bioavailability (> 90%), low protein binding, and good tissue penetration. Fluconazole terminal elimination half-life is approximately 30 hours and it is mostly (approximately 80%) excreted unchanged in urine. Fluconazole has high in vivo and in vitro activity against most Candida strains and is used in a variety of doses (usually 1 to 12 mg/kg daily in children and 100 to 400 mg daily in adults) and durations (days to months) for different types of fungal infection in preterm infants, neonates, children, and adults Fluconazole is structurally related to the antifungal agents that are imidazole-derivatives. However, fluconazole differs markedly from other imidazoles in its pharmacokinetic properties. Fluconazole is less lipophilic and more hydrophilic when compared to other azole antifungal agents. The presence of two triazole rings (bis-triazole) makes this compound less lipophilic and protein bound. The presence of a halogenated phenyl ring increases its antifungal activity Fluconazole acts as a fungistatic agent. \ The discovery of fluconazole, Alekha et al., 2001     The discovery of fluconazole (originally known as UK-49,858) is credited to a group of scientists led by Ken Richardson at Pfizer Central Research in Sandwich, Kent (UK) in 1981. The drug was approved by the FDA for use in the United States on January 9, 1990. The discovery team of this drug received numerous awards for their outstanding discovery of the world‘s leading anti fungal drug including the Queen‘s Award for Science and Technology 1991, and the Discoverers Award of the PhRMA in 1994. This drug is highly effective against a variety of fungal pathogens that lead to systemic mycoses. Formulations  Fluconazole Oral Suspension: 50 mg/5 mL Diflucan, (Pfizer), 200 mg/5 mL Diflucan, (Pfizer);  Fluconazole Tablets: 50 mg Diflucan (with povidone),, 100mg Diflucan (with povidone), 150 mg Diflucan (with povidone), (Pfizer), 200 mg Diflucan (with povidone),  Fluconazole (Intravenous Route) Diflucan IV  Fluconazole Eye drops: Zocon Eye Drops (Fluconazole) - 0.3% (5mL), Fluconazole BP 0.3% (or 3mg/ml)  Fluconazole Gel. Diflucan Gel, Zocon, Flucos, 0.5 % 15 gm 242 Chemical properties: Chemical Name α-(2,4-Difluorophenyl)-α-(1-H-1,2,4-triazol-1-ylmethyl)-1H-1,2,4-triazole-1-ethanol 2,4-difluro- α, - α -bis (1H-1,2,4-triazole-1-ylmethyl)benzyl alcohol 2-(2,4-difluorophenyl)-1,3-bis (1H-1,2,4-triazol-1-yl)-propane-2-ol Molecular Formula: C13H12F2N6O Molecular Weight: 306.277 g/mol Mode of action: Fluconazole preferentially inhibits fungal cytochrome P-450 sterol C-14 alpha-demethylation, resulting in the accumulation of fungal 14 alpha-methyl sterols, the loss of normal fungal sterols, and fungistatic activity. Mammalian cell demethylation is much less sensitive to fluconazoleinhibition. Indications, Shoham et al. (2017)  Fluconazole is effective for treatment of superficial and invasive candidiasis, including infections in neutropenic patients.  Fluconazole is also indicated for treatment of consolidation therapy for chronic disseminated candidiasis, cryptococcal meningitis and infections by Trichosporon spp.  Fluconazole is the drug of choice for treatment of coccidioidal meningitis  Fluconazole has effectiveness in non-meningeal coccidioidal infections.  Fluconazole is less active than itraconazole against paracoccidioidomycosis, blastomycosis, histoplasmosis and sporotrichosis, fluconazole.  Fluconazole has proven efficacy for primary prevention of invasive candidiasis in highrisk patients with acute leukemia, bone marrow and liver transplantation, for primary prevention of cryptococcosis in AIDS, and for secondary prevention of cryptococcosis and coccidioidomycosis in AIDS.  Fluconazole is not active against filamentous fungi and should not be used for prevention or empiric therapy if there is a high-risk invasive infection. 243 Tolerability Fluconazole is a well-tolerated triazole, with good activity against Candida spp. except C. krusei and C. glabrata. All five studies that compared fluconazole (200–800 mg/day) and AmBdeoxycholate (D-AmB) (0.3–1.2 mg/kg/day) for therapy of candidemia374-378showed that fluconazole was as effective as and better tolerated than D-AmB. The combination of fluconazole with D-AmB resulted in faster microbiologic clearance compared to fluconazole alone. Brand names/Manufacturer: AFUNGIL (Senosiain MEXICO) APO-FLUCONAZOLE (Apotex, CANADA) AZOFLUNE (Decomed PORTUGAL) BEAGYNE (Effik - FRANCE) BIOXEL (Bioresearch MEXICO) BIOZOLE (Biolab THAILAND) CANDIZOL (Ache – BRAZIL and Fustery, MEXICO) CANESTEN ORAL (Bayer UK) CONASOL (United Nordic DENMARK) DIFLAZOLE (Pinewood IRELAND) DIFLAZON (KRKA – HUNGARY, CZECH REPUBLIC) DIFLUCAN (Pfizer – ITALY, USA, GERMANY, NETHERLANDS, SOUTH AFRICA, SWEDEN, SWITZERLAND, CANADA, BELGIUM, SPAIN, AUSTRIA, AUSTRALIA, NORWAY, IRELAND, DENMARK, PORTUGAL, HONG KONG, MEXICO, ISRAEL, THAILAND, SINGAPORE, FINLAND, NEW ZEALAND, JAPAN, MALAYSIA, CHILE, HUNGARY, UK, CZECH REPUBLIC, CANADA) DIFLUZOL (Stada AUSTRIA) DOMFLUCONAZOLE (dominion Pharmacal CANADA) ELAZOR (Sigma-Tau ITALY) FELSOL (Pasteur - CHILE) FIGALOL (BiomedicaChemica - GREECE) FLUC (Hexal - GERMANY) FLUCONAZOLE (Greenstone, Apotex, Greenstone, Barr laboratories) FLUCOZEN (Cazi BRAZIL) FLUCOZOLE (Siam Bheasach, THAILAND) FLUCTIN (Osteolab, CHILE) FLUDIZOL (M & H THAILAND) FLUDOCEL (CPH PORTUGAL) FLUKAZOL (Kener MEXICO) FLUKENOL (Kendrick MEXICO) FLUNAZOL (Sintofarma BRAZIL) FLUNAZUL (Pfleger GERMANY) FLUNCO (TO-Chemicals THAILAND) FLUCONAZOLE OMEGA (Omega Laboratories, CANADA) FLUCONEO (Neo Quimica BRAZIL) FLUCOSEPT (Kwizda AUSTRIA) FLUCOXAN (Sanitas CHILE) FLUCOZAL (Aegis, HONG KONG) FLUOTEC (Bergam BRAZIL) FLUSAN (Eurofarma BRAZIL) FLUSENIL (Anfarm GREECE) FLUTEC (Hexal - BRAZIL) FLUZOR (Collins MEXICO) FUNA (LBS - THAILAND) FUNGAL (Durascan DENMARK) FUNGATA (Mack, GERMANY and Pfizer - 244 CHILE) KYRIN (Silom - THAILAND LAVISA (Lesvi - SPAIN) LERTUS (Gunther - BRAZIL) LOITIN (Vita - SPAIN) MICOFIN (Andromaco CHILE) MONIPAX (Haller- BRAZIL) MYCOMAX (Leciva, CZECH REPUBLIC) MYCOSYST (Gedeon Richter – HUNGARY and CZECH REPUBLIC) NEOFOMIRAL (Silanes MEXICO) NESPORAC (Cusi - SPAIN) NOVO-FLUCONAZOLE (Novopharm CANADA)) NU-FLUCON (Nu-pharm CANADA) OXIFUNGOL (Armstrong MEXICO) PANTEC (Cifarma - BRAZIL) PLUSGIN (Raffo - CHILE) PMS-FLUCONAZOLE (Pharmascience CANADA) PRONAZOL (Diffucap BRAZIL) REFORCE (Atral PORTUGAL) RICONAZOL (Bunker BRAZIL) SOLACAP (SAT - SPAIN) STABILANOL (Farmaten GREECE) STALENE (Unison THAILAND and HONG KONG) SUPREMASE (Tecnimede PORTUGAL) TAVOR (Tecnofarma CHILE) TECZOL (Hexal - BRAZIL) TIERLITE (Bros - GREECE) TRIAZOL (Biolab Sanus BRAZIL) TRICAN (Pfizer - ISRAEL) TRIFLUCAN (Pfizer – FRANCE and ISRAEL) FLUCANDID (Ivax IRELAND) FLUCANOL (Rafa – ISRAEL and Zeus - BRAZIL) FLUCAZOL (Cristalia BRAZIL) FLUCOBETA (Betapharm GERMANY) FLUCOL (Rowex, IRELAND) FLUCOLICH (Lichtenstein GERMANY) FLUCOLTRIX (Gallia BRAZIL) FLUCONABENE (AB-Consult - AUSTRIA) FLUCONAL (Libbs - BRAZIL) AUSTRIA) FUNGUSTATIN (Pfizer GREECE) FUNGUSTERIL (Zekides GREECE) GEN-FLUCONAZOLE (Genpharm CANADA) GLYFUCAN (Legrand, BRAZIL) GYNOSANT (Gerolimatos GREECE) HADLINOL (Help GREECE) HELMICIN (Sanval BRAZIL) IBARIN (Laboratorios Chile, 245 UNIZOL (Farmoquimica BRAZIL) WAYNAZOL - (Wayne MEXICO) ZELIX (Ativus - BRAZIL) ZIDONIL (Rafarm GREECE) ZOLANIX (Stiefel - BRAZIL) ZOLDICAM (Rayere MEXICO) ZOLMIC (Delta - BRAZIL) ZOLSTATIN (Aurantis BRAZIL) ZOLTEC (Pfizer - BRAZIL) ZOLTREN (Teuto - BRAZIL) ZONAL (Galen, MEXICO) The pharmacokinetics of fluconazole, McEvoy, 2006  The pharmacokinetics of fluconazole are similar following IV or oral administration.  The drug is rapidly and almost completely absorbed from the GI tract, and there is no evidence of first-pass metabolism.  Oral bioavailability of fluconazole exceeds 90% in healthy, fasting adults; Peak plasma concentrations  peak plasma concentrations of the drug generally are attained within 1-2 hours after oral administration. ...  The rate and extent of GI absorption of fluconazole are not affected by food. The manufacturer states that the commercially available fluconazole suspensions are bioequivalent to the 100-mg fluconazole tablets.  Peak plasma fluconazole concentrations and AUCs increase in proportion to the dose over the oral dosage range of 50-400 mg.  Steady-state plasma concentrations of fluconazole are attained within 5-10 days following oral doses of 50-400 mg given once daily. ...  When fluconazole therapy is initiated with a single loading dose equal to twice the usual daily dosage and followed by the usual dosage given once daily thereafter, plasma concentrations of the drug reportedly approach steady state by the second day of therapy. o In healthy, fasting adults who received a single 1-mg/kg oral dose of fluconazole, peak plasma concentrations of the drug averaged 1.4 mcg/mL. Following oral administration of a single 400-mg dose of fluconazole in healthy, fasting adults, peak plasma concentrations average 6.72 mcg/mL (range: 4.12-8.1 mcg/mL). o In healthy adults receiving 50- or 100-mg doses of fluconazole given once daily by IV infusion over 30 minutes, serum concentrations of the drug 1 hour after dosing on the sixth or seventh day of therapy ranged from 2.14-2.81 or 3.864.96 mcg/mL, respectively. o In children 9 months to 13 years of age, oral administration of a single 2- or 8-mg/kg dose of fluconazole resulted in mean peak plasma concentrations of 2.9 or 9.8 mcg/mL, respectively. o In a multiple-dose study in children 5-15 years of age, IV administration of 2, 4-, or 8-mg/kg doses of fluconazole resulted in mean peak plasma concentrations of 5.5, 11.4, or 14.1 mcg/mL, respectively. o In a limited study in premature neonates who received 6-mg/kg doses of fluconazole IV every 72 hours, peak serum concentrations of the drug ranged from 3.7-10.2 mcg/mL after the first dose and from 6-17.8 mcg/mL after the third dose (day 7). Distribution  Fluconazole is widely distributed into body tissues and fluids following oral or IV administration. o Studies in mice using IV doses of radiolabeled fluconazole indicate that the drug is evenly distributed throughout body tissues. 246 o In adult humans with normal renal function, concentrations of the drug attained in urine and skin may be 10 times higher than concurrent plasma concentrations; concentrations attained in saliva, sputum, nails, blister fluid, blister skin, and vaginal tissue are approximately equal to concurrent plasma concentrations. o Concentrations attained in vaginal secretions following administration of a single 150-mg oral dose reportedly are about 40-86% of concurrent plasma concentrations. Fluconazole concentrations in prostatic tissue reportedly average about 30% of concurrent plasma concentrations. o In adults with bronchiectasis who received a single 150-mg oral dose of fluconazole, sputum concentrations of the drug in samples obtained at 4 and 24 hours after the dose averaged 3.7 and 2.23 mcg/mL, respectively, and were approximately equal to concurrent plasma concentrations. o Studies in rabbits indicate that high concentrations of fluconazole are attained in the cornea, aqueous humor, and vitreous body following IV administration; these concentrations were higher in inflamed than uninflamed eyes.      Fluconazole, unlike some azole-derivative antifungal agents (eg, itraconazole, ketoconazole), distributes readily into CSF following oral or IV administration; CSF concentrations of fluconazole may be 50-94% of concurrent plasma concentrations regardless of the degree of meningeal inflammation. The apparent volume of distribution of fluconazole approximates that of total body water and has been reported to be 0.7-1 L/kg. In a limited study, the estimated volume of distribution at steady state of fluconazole was slightly lower in HIV-infected adults than in healthy adults. Fluconazole is distributed into human milk at concentrations similar to those achieved in plasma. Administration of a single 150-mg oral dose to several nursing women resulted in peak plasma fluconazole concentrations of 2.61 ug/mL (range: 1.57-3.65 ug/mL). In patients with impaired renal function, plasma concentrations of fluconazole are higher and the half-life prolonged; elimination half-life of the drug is inversely proportional to the patient's creatinine clearance. In addition, there is limited evidence that elimination of the drug may be impaired in geriatric patients. The drug crosses the placenta in rats, and concentrations in amniotic fluid, placenta, fetus, and fetal liver are approximately equal to maternal plasma concentrations. Elimination  In healthy adults, fluconazole is eliminated principally by renal excretion. o Renal clearance of the drug averages 0.27 mL/minute per kg in adults with normal renal function. o In a limited, single-dose study, renal clearance of fluconazoleaveraged 0.79 L/hour in healthy adults, 0.58 L/hour in HIV-infected adults with CD4+ T-cell counts greater than 200 cu m, and 0.2 L/hour in those with CD4+ T-cell counts less than 200 cu m. o Approximately 60-80% of a single oral or IV dose of fluconazole is excreted in urine unchanged, and about 11% is excreted in urine as metabolites. Small amounts of the drug are excreted in feces. 247  Fluconazole is removed by hemodialysis and peritoneal dialysis. o The amount of the drug removed during hemodialysis depends on several factors (eg, type of coil used, dialysis flow rate). o A 3-hour period of hemodialysis generally decreases plasma concentrations of the drug by 50%. In 2 adults with fungal peritonitis undergoing continuous ambulatory peritoneal dialysis (CAPD) and receiving an oral fluconazole dosage of 100 mg/kg daily, concentrations of the drug in peritoneal dialysis fluid ranged from 2.3-9 mcg/mL and concurrent plasma concentrations ranged from 3.2-9 mcg/mL. Toxicological Information Heptatoxicity Transient mild-to-moderate elevations in serum aminotransferase levels occur in up to 5% of patients treated with fluconazole, but these abnormalities are usually asymptomatic and resolve even with continuation of the medication. ALT elevations above 8 times the upper limit of normal are reported to occur in 1% of patients taking fluconazole and to represent the most common adverse event leading to early discontinuation of treatment. Clinically apparent hepatotoxicity due to fluconazole is rare, but well described. The liver injury is typically hepatocellular, arises within the first few weeks of therapy and can be accompanied by signs of hypersensitivity such as fever, rash and eosinophilia. Fatal instances of fluconazole induced liver injury have been reported (Case 1), but most cases are self-limited, although recovery may be delayed for several weeks after stopping fluconazole and may be slow requiring 2 to 3 months. Human data in breastfeeding  Fluconazole has been reported to be excreted in human milk.  Schilling et al described a woman who was taking 200 mg of oral fluconazole per day for 30 days (Schilling et al., 1993). o Milk samples were obtained 8 days post partum (the 18th day of treatment). o The maximum level of fluconazole detected in the milk was 4.1 mg/L, measured 2 hours after the dose. o The estimated RID calculated with this value was 17%. The fluconazole elimination half-life in breast milk was calculated to be 26.9 hours in this report.4  In another report (Force, 1995) o breast milk concentrations of fluconazole after oral administration of 150 mg were 2.93 µg/mL, 2.66 µg/mL, 1.76 µg/mL, and 0.98 µg/mL at 2 hours, 5 hours, 24 hours, and 48 hours, respectively. o The estimated RID was 17% in this case. The terminal half-life in breast milk was calculated to be 30 hours.  It is important to note that the RIDs calculated in the above studies used the highest level of fluconazole in the breast milk, not the average level; therefore, these are overestimates, as the infant would not be exposed to this amount with each feeding. 248  Chetwynd et al (2002) persistent Candida mastitis. described a breastfeeding mother with o After 2 weeks of use and failure of topical nystatin, 200 mg of oral fluconazole per day was added to her treatment regimen. o She continued breastfeeding her infant, who at 13 weeks of age also received 18 mg of oral fluconazole per day for 10 days after positive oral culture results for Candida albicans. o During the mother‘s 11-week treatment and the simultaneous treatment of the baby and mother, no adverse events were reported in the infant  Bodley and Powers (1997) reported a case in which a mother took fluconazole (mostly 200 mg daily) for 6 weeks. o Liver function tests were ordered for her 9-week-old baby at the end of treatment, and a slight increase in lactate dehydrogenase levels was reported; however, this was not deemed to be of clinical concern.  Moorhead et al (2011) followed 96 breastfeeding mothers who were taking oral fluconazole for the treatment of Candida mastitis. o The women took a mean of 7.3 (range 1 to 29) 150-mg doses of oral fluconazole. The mean age of their babies was 7.2 weeks (range 1 to 42 weeks). o Adverse events were reported in 7 babies including flushed cheeks, abdominal pain, possible diarrhea, mucous feces, tiredness, and eczema (which improved with a change in detergent and maternal diet). Safety of fluconazole in children  Novelli and Holzel (1999) reported 562 children (aged 0 to 17 years), most of whom were immunocompromised, were treated with 1 to 12 mg/kg of fluconazole per day for 1 to 20 days. o Adverse events were reported in 10.3% of children, with the most common being gastrointestinal (GI) symptoms; o No evidence of substantial hepatotoxicity was recorded, and transient increases in liver enzyme levels occurred in less than 5% of patients.  A systematic review including 90 studies demonstrated the relative safety of fluconazole use in neonates and other pediatric age groups (birth to 17 years of age). The review included 4209 children, 2354 of whom were preterm neonates ( Egunsola et al., 2013). o Fluconazole was administered either as prophylaxis (interquartile range [IQR] 3 to 6 mg/kg) or therapeutically (IQR 5 to 6 mg/kg daily). o The IQR for the duration of treatment was between 14 and 67 days. The relative risk (RR) of all adverse events in the fluconazole group did not differ significantly when compared with the placebo group (RR = 1.30, 95% CI 0.84 to 2.03) and the other antifungal drugs group (RR = 1.05, 95% CI 0.62 to 1.80). 249 o Hepatotoxicity was the most commonly observed adverse event (37.1%); however, it was not significantly more frequent than in the placebo group (RR = 1.36, 95% CI 0.87 to 2.14) or other antifungal group (RR = 1.43, 95% CI 0.67 to 3.03). o Gastrointestinal findings, such as anorexia, gastritis, dyspepsia, GI upset, nausea, vomiting, diarrhea, and abdominal pain, were the second most common adverse events; o however, these findings were also not significantly different from groups taking placebo or other antifungal drugs. Spectrum of Activity and Clinical Use  Fluconazole is the least active azole antifungal drug and has the narrowest spectrum.  The activity of fluconazole is limited to some Candida spp., Cryptococcus spp., Malassezia spp., and some dimorphic fungi.  Fluconazole has poor activity against molds, and Aspergillus species are intrinsically resistant to fluconazole.  Some Cryptococcus isolates are resistant to fluconazole, and resistance can develop during treatment.  Itraconazole is preferable to fluconazole for treatment of histoplasmosis, blastomycosis, sporotrichosis, and dermatophytosis Fluconazole usage in animals, Papich , 2016  Fluconazole is used in dogs, cats, horses, and exotic animals to treat systemic fungal infections, yeast infections, and dermatophytes, including Malassezia dermatitis.  In cats, it has been used to treat Cryptococcus and histoplasmosis.  In dogs, it is not as active against coccidioidomycosis as other azole antifungal drugs, but it has been effective in some patients.  Higher doses may be needed (e.g., 10 mg/kg q12h) for coccidioidomycosis.  It has been as effective as for treatment of blastomycosis in dogs with efficacy similar to itraconazole. Because it is water soluble, it has been used to treat fungal cystitis. Recent reports Gharibian and Mueller (2016) used previously-published fluconazole clearance data and PK data of critically-ill patients with acute kidney injury to develop a PK model with the goal of determining a therapeutic dosing regimen for critically-ill patients receiving PIRRT. Monte Carlo simulations were performed to create a virtual cohort of patients receiving different fluconazole dosing regimens. Plasma drug concentration-time profiles were evaluated on the probability of attaining a mean 24-hour area under the drug concentration-time curve to minimum inhibitory concentration ratio (AUC24h : MIC) of 100 during the initial 48 hours of antifungal therapy. At the susceptibility breakpoint of Candida albicans (2 mg/L), 93 - 96% of simulated subjects receiving PIRRT attained the pharmacodynamic target with a fluconazole 800-mg loading dose plus 400 mg twice daily (q12h or pre and post PIRRT) 251 regimen. Monte Carlo simulations of a PK model of PIRRT provided a basis for the development of an informed fluconazole dosing recommendation when PK data was limited. This finding should be validated in the clinical setting. Govendir et al. (2016) reported three asymptomatic koalas serologically positive for cryptococcosis and two symptomatic koalas that were treated with 10 mg/kg fluconazoleorally, twice daily for at least 2 weeks. The median plasma Cmax and AUC0-8 h for asymptomatic animals were 0.9 μg/mL and 4.9 μg/mL·h, respectively; and for symptomatic animals 3.2 μg/mL and 17.3 μg/mL·h, respectively. An additional symptomatic koala was treated with fluconazole (10 mg/kg twice daily) and a subcutaneous amphotericin B infusion twice weekly. After 2 weeks the fluconazole Cmax was 3.7 μg/mL and the AUC0-8 h was 25.8 μg/mL*h. An additional three koalas were treated with fluconazole 15 mg/kg twice daily for at least 2 weeks, with the same subcutaneous amphotericin protocol co-administered to two of these koalas (Cmax : 5.0 μg/mL; mean AUC0-8 h : 18.1 μg/mL*h). For all koalas, the fluconazole plasma Cmax failed to reach the MIC90 (16 μg/mL) to inhibit C. gattii. Fluconazoleadministered orally at either 10 or 15 mg/kg twice daily in conjunction with amphotericin is unlikely to attain therapeutic plasma concentrations. Suggestions to improve treatment of systemic cryptococcosis include testing pathogen susceptibility to fluconazole, monitoring plasma fluconazole concentrations, and administration of 2025 mg/kg fluconazole orally, twice daily, with an amphotericin subcutaneous infusion twice weekly. Kratzer et al. (2016) developed an ultrafiltration method in order to determine the free concentrations of linezolid or fluconazole, both neutral and moderately lipophilic antiinfective drugs for parenteral as well as oral administration, in plasma of patients. Whereas both substances behaved relatively insensitive in human plasma regarding variations in pH (7.0-8.5), temperature (5-37°C) or relative centrifugal force (1000-10.000xg), losses of linezolid were observed with the Nanosep Omega device due to adsorption onto the polyethersulfone membrane (unbound fraction 75% at 100mg/L and 45% at 0.1mg/L, respectively). No losses were observed with Vivacon which is equipped with a membrane of regenerated cellulose. With fluconazole no differences between Nanosep and Vivacon were observed. Applying standard conditions (pH 7.4/37°C/1000xg/20min), the mean unbound fraction of linezolid in pooled plasma from healthy volunteers was 81.5±2.8% using Vivacon, that of fluconazole was 87.9±3.5% using Nanosep or 89.4±3.3% using Vivacon. The unbound fraction of linezolid was 85.4±3.7% in plasma samples from surgical patients and 92.1±6.2% in ICU patients, respectively. The unbound fraction of fluconazole was 93.9±3.3% in plasma samples from ICU patients. Rençber et al. (2016) developed a suitable buccal mucoadhesive nanoparticle (NP) formulation containing fluconazole for the local treatment of oral candidiasis. The suitability of the prepared formulations was assessed by means of particle size (PS), polydispersity index, and zeta potential measurements, morphology analysis, mucoadhesion studies, drug entrapment efficiency (EE), in vitro drug release, and stability studies. Based on the optimum NP formulation, ex vivo drug diffusion and in vitro cytotoxicity studies were performed. Besides, evaluation of the antifungal effect of the optimum formulation was evaluated using agar diffusion method, fungicidal activity-related in vitro release study, and time-dependent fungicidal activity. The effect of the optimum NP formulation on the healing of oral candidiasis was investigated in an animal model, which was employed for the first time in this study. The zeta potential, mucoadhesion, and in vitro drug release studies of various NP formulations revealed that chitosan-coated NP 251 formulation containing EUDRAGIT(®) RS 2.5% had superior properties than other formulations. Concerning the stability study of the selected formulation, the formulation was found to be stable for 6 months. During the ex vivo drug diffusion study, no drug was found in receptor phase, and this is an indication of local effect. The in vitro antifungal activity studies showed the in vitro efficacy of the NP against Candida albicans for an extended period. Also, the formulation had no cytotoxic effect at the tested concentration. For the in vivo experiments, infected rabbits were successfully treated with local administration of the optimum NP formulation once a day. This study has shown that the mucoadhesive NP formulation containing fluconazole is a promising candidate with once-a-day application for the local treatment of oral candidiasis. Santos et al. (2016) developed and validated a suitable liquid chromatography-electrospray ionization tandem mass spectrometry method for PK studies of fluconazole in the serum, lungs, and brain of uninfected mice. Mice were infected with susceptible or resistant C. gattii, and the effects of different doses of fluconazole on the pulmonary and central nervous system fungal burden were determined. The peak levels in the serum, lungs, and brain were achieved within 0.5h. The AUC/MIC index (area under the curve/minimum inhibitory concentration) was associated with the outcome of anti-cryptococcal therapy. Interestingly, the maximum concentration of fluconazole in the brain was lower than the MIC for both strains. In addition, the treatment of mice infected with the resistant strain was ineffective even when high doses of fluconazole were used or when amphotericin B was tested, confirming the cross-resistance between these drugs. Altogether, our novel data provide the correlation of PK/PD parameters with antifungal therapy during cryptococcosis caused by resistant C. gattii. Sharma et al. (2016) designed a study to explore the localized delivery of fluconazole using mucoadhesive polymeric nanofibers. Drug-loaded polymeric nanofibers were fabricated by the electrospinning method using polyvinyl alcohol (PVA) as the polymeric constituent. The prepared nanofibers were found to be uniform, non-beaded and non-woven, with the diameter of the fibers ranging from 150 to 180 nm. Further drug release studies indicate a sustained release of fluconazole over a period of 6 h. The results of studies on anti-microbial activity indicated that drug-loaded polymeric nanofibers exhibit superior anti-microbial activity against Candida albicans, when compared to the plain drug. Singh (2016) described a 42-year-old woman with a history of severe eczema who developed fluconazole-induced type 1 Kounis syndrome. Review of literature indicates that this as the first case reported of fluconazole-induced type 1 Kounis syndrome. Gandra et al. (2015) developed thermosensitive gels using poloxamers for topical delivery of fluconazole (FLZ). Eight different formulations containing 1% FLZ in poloxamer and a particular co-solvent (propylene glycol (PG) or Transcutol-P) of various concentrations were prepared. The gels were characterized for transition temperatures, rheological and mechanical properties. FLZ permeability and antifungal effect of the gels were also evaluated. Except for one formulation, all gels exhibited thermosensitive property, i.e. transformed from Newtonian (liquid-like) behavior at 20 °C to non-Newtonian (gel-like) behavior at 37 °C. Transcutol-P increased the transition temperature of the formulations, while the opposite effect was observed for PG. At 37 °C, formulations with high poloxamer concentrations (17%) resulted in high viscosity, compressibility and hardness. Formulations containing 17% poloxamer and 20% Transcutol-P and 10% PG, respectively, exhibited high adhesiveness. No significant differences in the in vitro antifungal activity of FLZ were observed among the formulations suggesting that 252 the gel vehicles did not influence the biological effect of FLZ. FLZ permeability decreased with increasing poloxamer concentration. Formulations containing 17% poloxamer and 20% Transcutol-P and 10% PG seemed to be promising in situ gelling systems for the topical delivery of FLZ. Gonzalez et al. (2015) used the neutropenic mice model of disseminated candidiasis to challenge the therapeutic equivalence of three generic products of fluconazole compared with the innovator in terms of concentration of the active pharmaceutical ingredient, analytical chemistry (liquid chromatography/mass spectrometry), in vitro susceptibility testing, single-dose serum pharmacokinetics in infected mice, and in vivo pharmacodynamics. Neutropenic, five week-old, murine pathogen free male mice of the strain Udea:ICR(CD-2) were injected in the tail vein with Candida albicans GRP-0144 (MIC = 0.25 mg/L) or Candida albicans CIB-19177 (MIC = 4 mg/L). Subcutaneous therapy with fluconazole(generics or innovator) and sterile saline (untreated controls) started 2 h after infection and ended 24 h later, with doses ranging from no effect to maximal effect (1 to 128 mg/kg per day) divided every 3 or 6 hours. The Hill's model was fitted to the data by nonlinear regression, and results from each group compared by curve fitting analysis. All products were identical in terms of concentration, chromatographic and spectrographic profiles, MICs, mouse pharmacokinetics, and in vivo pharmacodynamic parameters. In conclusion, the generic products studied were pharmaceutically and therapeutically equivalent to the innovator of fluconazole. Hashemi et al. (2015) designed a series of triazole alcohols in which one of the 1,2,4-triazol-1-yl group in fluconazole structure has been replaced with 4-amino-5-aryl-3-mercapto-1,2,4-triazole motif. In this paper, they focused on the structural refinement of the primary lead, by removing the amino group from the structure to achieve 5-aryl-3-mercapto-1,2,4-triazole derivatives 10a-i and 11a-i. The in vitro antifungal susceptibility testing of title compounds demonstrated that most compounds had potent inhibitory activity against Candida species. Among them, 5-(2,4dichlorophenyl)triazole analogs 10h and 11h with MIC values of <0.01 to 0.5μg/mL were 4-256 times more potent than fluconazole against Candida species. Liao et al. (2015) designed and synthesized a novel series of fluconazole based mimics incorporating 1,3,4-oxadiazole moiety. All the title compounds were characterized by (1)HNMR, (13)C-NMR, and Q-TOF-MS. Preliminary results revealed that most of analogues exhibited significant antifungal activity against seven pathogenic fungi. Compounds 9g and 9k (MIC80 ≤ 0.125 μg/mL, respectively) were found more potent than the positive controls itraconazole and fluconazole as broad-spectrum antifungal agents. The observed docking results showed that the 1,3,4-oxadiazole moiety enhanced the affinity binding to the cytochrome P450 14α-demethylase (CYP51). Mandengue et al. (2015) reported a case in which an HIV-infected man was cured of disseminated histoplasmosis (Histoplasma capsulatum var duboisii) after treatment by highdose fluconazole (1,600 mg taken four times daily) for 2 months, combined with active antiretroviral therapy. The choice of fluconazole at this dosage was motivated by its availability as a generic and thus inexpensive medication, the patient's precarious status, and his critical clinical condition. At the end of the second month of treatment, the patient chose to stop the fluconazole, which he could no longer afford, while continuing the antiretroviral treatment, which was free. The clinical and laboratory improvement observed from the first week has continued to progress for more than 8 months after fluconazole treatment stopped. This single case needs - and deserves - to be confirmed in a series of patients. Nonetheless it makes it 253 possible to envision fluconazole as a low-cost and efficacious antifungal agent for the treatment of disseminated histoplasmosis in AIDS patients in sub-Saharan Africa. Kaplan et al. (2015) reported a patient with persistent breast and nipple thrush. Other therapies have failed, so he decided to treat her with a loading dose of 400 mg of oral fluconazole followed by 100 mg twice daily for at least 2 weeks. Available data regarding fluconazole use during breastfeeding are reassuring. Fluconazole is also used in the treatment of fungal diseases in infants and has a good safety profile. Therefore, there is no need to interrupt breastfeeding when a mother is treated with fluconazole. Manzoor et al. (2015) synthesised a molecularly imprinted polymer (MIP) capable of extracting fluconazole from its sample. The MIP was successfully prepared from methacrylic acid (functional monomer), ethyleneglycoldimethacrylate (crosslinker) and acetonitrile (porogenic solvent) in the presence of fluconazole as the template molecule through a non-covalent approach. The non-imprinted polymer (NIP) was prepared following the same synthetic scheme, but in the absence of the template. The data obtained from scanning electronic microscopy, infrared spectroscopy, thermogravimetric and nitrogen Brunauer-Emmett-Teller plot helped to elucidate the structural as well as the morphological characteristics of the MIP and NIP. The application of MIP as a sorbent was demonstrated by packing it in solid phase extraction cartridges to extract fluconazole from commercial capsule samples through an offline analytical procedure. The quantification of fluconazole was accomplished through UPLC-MS, which resulted in LOD≤1.63×10(-10) mM. Furthermore, a high percentage recovery of 91±10% (n=9) was obtained. The ability of the MIP for selective recognition of fluconazole was evaluated by comparison with the structural analogues, miconazole, tioconazole and secnidazole, resulting in percentage recoveries of 51, 35 and 32%, respectively. Mikamo et al. (2015) conducted a phase 3 study to evaluate the efficacy and safety of a single oral 150 mg dose of fluconazole in Japanese subjects with vulvovaginal candidiasis for regulatory submission. A total of 157 subjects received a single oral 150 mg dose of fluconazole. Candida species (104 strains) were identified by fungal culture from 102 subjects at baseline, including Candida albicans (100 strains). The efficacy rate for the therapeutic outcome (assessed based on a comprehensive evaluation of the clinical and mycological efficacy in each subject) was 74.7% (74/99) on Day 28 in the modified Intent-To-Treat (m-ITT) population. Concerning the clinical and mycological efficacy on Day 28 in the m-ITT population, the cure, cure or improvement, and eradication rates were 81.6%, 95.9%, and 85.9%, respectively. The most common treatment-related adverse events were diarrhea and nausea (1.9% for each). No clinically significant safety issues were reported. A single oral 150 mg dose of fluconazole demonstrated excellent therapeutic efficacy and was well tolerated in Japanese subjects with vulvovaginal candidiasis. Premachandra et al. (2015) reported that one spirocyclic piperazine derivative, which they have synthesized and named synazo-1, was found to enhance the effect of fluconazole with an EC50 value of 300 pM against a susceptible strain of C. albicans and going as low as 2 nM against some resistant strains. Synazo-1 exhibits true synergy with fluconazole, with an FIC index below 0.5 in the strains tested. Synazo-1 exhibited low toxicity in mammalian cells relative to the concentrations required for antifungal synergy. 254 Sinnollareddy et al. (2015a) described the influence of SLED-f on subcutaneous (SC) ISF concentrations of fluconazole and the implications for achieving pharmacokinetic/pharmacodynamic targets. Serial blood and ISF samples were collected at preand post-filter ports within the SLED-f circuit and subcutaneously inserted microdialysis probe, respectively. Fluconazole concentrations were measured using a validated chromatography method. The SC ISF-to-plasma partition coefficient of fluconazole in this patient was 0.91, indicating rapid equilibrium. SC ISF fluconazole concentrations consistently decreased after initiating SLED-f. The majority of the fluconazole was eliminated from the SC ISF as a result of redistribution. Considering the extensive tissue re-distribution of fluconazole and observed elimination from tissue compartments, higher doses may be required to treat deep-seated fungal infections. Sinnollareddy et al. (2015b) described the subcutaneous interstitial fluid (ISF) pharmacokinetics of fluconazole in critically ill patients with sepsis. This prospective observational study was conducted at two tertiary intensive care units in Australia. Serial fluconazole concentrations were measured over 24 h in plasma and subcutaneous ISF using microdialysis. The concentrations in plasma and microdialysate were measured using a validated high-performance liquid chromatography system with electrospray mass spectrometer detector method. Noncompartmental pharmacokinetic analysis was performed. Twelve critically ill patients with sepsis were enrolled. The mean in vivo fluconazole recovery rates ± standard deviation (SD) for microdialysis were 51.4% ± 16.1% with a mean (±SD) fluconazole ISF penetration ratio of 0.52 ± 0.30 (coefficient of variation, 58%). The median free plasma area under the concentration-time curve from 0 to 24 h (AUC0-24) was significantly higher than the median ISF AUC0-24 (340.4 versus 141.1 mg · h/liter; P = 0.004). There was no statistical difference in median fluconazole ISF penetration between patients receiving and not receiving vasopressors (median, 0.28 versus 0.78; P = 0.106). Both minimum and the maximum concentrations of drug in serum (Cmax and Cmin) showed a significant correlation with the fluconazole plasma exposure (Cmax, R(2) = 0.86, P < 0.0001; Cmin, R(2) = 0.75, P < 0.001). Our data suggest that fluconazole was distributed variably, but incompletely, from plasma into subcutaneous interstitial fluid in this cohort of critically ill patients with sepsis. Given the variability of fluconazole interstitial fluid exposures and lack of clinically identifiable factors by which to recognize patients with reduced distribution/exposure, we suggest higher than standard doses to ensure that drug exposure is adequate at the site of infection. Black et al. (2014) gave clinically normal koalas (n = 12) a single dose of 10 mg/kg fluconazole orally (p.o.; n = 6) or intravenously (i.v.; n = 6). Serial plasma samples were collected over 24 h, and fluconazole concentrations were determined using a validated HPLC assay. A noncompartmental pharmacokinetic analysis was performed. Following i.v. administration, median (range) plasma clearance (CL) and steady-state volume of distribution (Vss ) were 0.31 (0.11-0.55) L/h/kg and 0.92 (0.38-1.40) L/kg, respectively. The elimination half-life (t1/2 ) was much shorter than in many species (i.v.: median 2.25, range 0.98-6.51 h; p.o.: 4.69, range 2.47-8.01 h), and oral bioavailability was low and variable (median 0.53, range 0.20-0.97). Absorption rate-limited disposition was evident. Plasma protein binding was 39.5 ± 3.5%. Although fluconazolevolume of distribution (Varea ) displayed an allometric relationship with other mammals, CL and t1/2 did not. Allometrically scaled values were approximately sevenfold lower (CL) and sixfold higher (t1/2 ) than observed values, highlighting flaws 255 associated with this technique in physiologically distinct species. On the basis of fAUC/MIC pharmacodynamic targets, fluconazole is predicted to be ineffective against Cryptococcus gattii in the koala as a sole therapeutic agent administered at 10 mg/kg p.o. every 12 h. Krein et al. (2014) determined risk factors for prolonged anesthetic recovery time in horses that underwent general anesthesia for ocular surgery. 81 horses that underwent general anesthesia for ocular surgery between 2006 and 2013. Information recorded included the ocular procedure performed, concurrent fluconazole treatments, analgesic and anesthetic agents administered, procedure duration, use of sedation for recovery, and recovery time. Data were analyzed for associations between recovery time and other variables. 81 horses met inclusion criteria. In 72 horses, anesthesia was induced with ketamine and midazolam; 16 horses treated concurrently with fluconazole had significantly longer mean recovery time (109 minutes [95% confidence interval {CI}, 94 to 124 minutes]) than did 56 horses that were not treated with fluconazole (50 minutes [95% CI, 44 to 55 minutes]). In 9 horses anesthetized with a protocol that included ketamine but did not include midazolam, there was no difference between mean recovery time in horses that either received (59 minutes [95% CI, 36 to 81 minutes]; n = 5) or did not receive (42 minutes [95% CI, 16 to 68 minutes]; 4) fluconazole. Other variables identified as risk factors for prolonged recovery included duration of anesthesia and use of acepromazine for premedication. CONCLUSIONS :Fluconazole administration was associated with prolonged anesthetic recovery time in horses when ketamine and midazolam were used to induce anesthesia for ocular surgery. Duration of anesthesia and premedication with acepromazine were also identified as risk factors for prolonged recovery time. Liu et al. (2014) have conducted systematic structural modification, deconstruction, and reconstruction of the berberine core with the aim of lowering its cytotoxicity, investigating its pharmacophore, and ultimately, seeking novel synergistic agents to restore the effectiveness of fluconazoleagainst fluconazole-resistant Candida albicans. A structure-activity relationship study of 95 analogues led us to identify the novel scaffold of N-(2-(benzo[d][1,3]dioxol-5yl)ethyl)-2-(substituted phenyl)acetamides 7 a-l, which exhibited remarkable levels of in vitro synergistic antifungal activity. Compound 7 d (N-(2-(benzo[d][1,3]dioxol-5-yl)ethyl)-2-(2fluorophenyl)acetamide) significantly decreased the MIC₈₀ values of fluconazole from 128.0 μg mL⁻¹ to 0.5 μg mL⁻¹ against fluconazole-resistant C. albicans and exhibited much lower levels of cytotoxicity than berberine toward human umbilical vein endothelial cells. van der Elst et al. (2014) developed and clinically validate a method of analysis to determine fluconazole in oral fluid in pediatric patients. Twenty-one paired serum and oral fluid samples were obtained from 19 patients and were analyzed using a validated liquid chromatography-tandem mass spectrometry (LC-MS-MS) method after cross-validation between serum and oral fluid. The results were within accepted ranges for accuracy and precision, and samples were stable at room temperature for at least 17 days. A Pearson correlation test for the fluconazole concentrations in serum and oral fluid showed a correlation coefficient of 0.960 (P < 0.01). The mean oral fluid-to-serum concentration ratio was 0.99 (95% confidence interval [CI], 0.88 to 1.10) with Bland-Altman analysis. In conclusion, an oral fluid method of analysis was successfully developed and clinically validated for fluconazole in pediatric patients and can be a noninvasive, painless alternative to perform TDM of fluconazole when blood sampling is not possible or desirable. When patients receive prolonged courses of antifungal treatment and use fluconazole at home, this method of analysis can extend the possibilities of TDM for patients at home. 256 Han et al. (2013) investigated fluconazole PK in burn patients using a population approach and to recommend the optimal fluconazole regimen based upon the predicted therapeutic outcome. At steady state, blood samples for PK analysis were obtained from 60 burn patients receiving between 100 and ~400 mg fluconazole daily. A mixed-effect modeling was performed and the therapeutic outcome of antifungal therapy was predicted for 10,000 virtual patients using NONMEM (version 7.2). MIC values were sampled from the MIC distribution at the study site. An area under the free drug concentration-time curve (fAUC)/MIC measurement of >25 h was used as the criterion for therapeutic success. When the same dose was given, the plasma concentration of fluconazole was predicted to be lower in burn patients compared to the nonburn population because of the large PK parameter (clearance, volume of distribution) estimates and continuous renal replacement therapy (CRRT). This tendency was particularly predominant when the patients were within 30 postburn days. Based upon our findings, 400 mg/day fluconazole is recommended to obtain therapeutic successes in major burn patients. Han et al. (2013) investigated fluconazole PK in burn patients using a population approach and to recommend the optimal fluconazole regimen based upon the predicted therapeutic outcome. At steady state, blood samples for PK analysis were obtained from 60 burn patients receiving between 100 and ~400 mg fluconazole daily. A mixed-effect modeling was performed and the therapeutic outcome of antifungal therapy was predicted for 10,000 virtual patients using NONMEM (version 7.2). MIC values were sampled from the MIC distribution at the study site. An area under the free drug concentration-time curve (fAUC)/MIC measurement of >25 h was used as the criterion for therapeutic success. When the same dose was given, the plasma concentration of fluconazole was predicted to be lower in burn patients compared to the nonburn population because of the large PK parameter (clearance, volume of distribution) estimates and continuous renal replacement therapy (CRRT). This tendency was particularly predominant when the patients were within 30 postburn days. Based upon our findings, 400 mg/day fluconazole is recommended to obtain therapeutic successes in major burn patients. Sudan et al. (2013) determined pharmacokinetics and pharmacodynamics (PK-PD) of fluconazole in this setting. PK-PD relationships were estimated with 4 clinical isolates of Cryptococcus neoformans. MICs using Clinical and Laboratory Standards Institute (CLSI) methodology. A nonimmunosuppressed murine model of cryptococcal meningitis was used. Mice received two different doses of fluconazole(125 mg/kg of body weight/day and 250 mg/kg of body weight/day) orally for 9 days; a control group of mice was not given fluconazole. Fluconazole concentrations in plasma and in the cerebrum were determined using high-performance liquid chromatography (HPLC). The cryptococcal density in the brain was estimated using quantitative cultures. A mathematical model was fitted to the PK-PD data. The experimental results were extrapolated to humans (bridging study). The PK were linear. A dose-dependent decline in fungal burden was observed, with near-maximal activity evident with dosages of 250 mg/kg/day.. References 1. Alekha K. Dash1, William F. Elmquist2, in Analytical Profiles of Drug Substances and Excipients, 2001, Edited by Harry G. Brittain, ISBN: 978-0-12-260829-2 2. Black LA1, Krockenberger MB, Kimble B, Govendir M. Pharmacokinetics of fluconazole following intravenous and oral administration to koalas (Phascolarctos cinereus). J Vet Pharmacol Ther. 2014 Feb;37(1):90-8. 257 3. Bodley V, Powers D. Long-term treatment of a breastfeeding mother with fluconazole-resolved nipple pain caused by yeast: a case study. J Hum Lact. 1997;13(4):307–11. 4. Chetwynd EM, Ives TJ, Payne PM, Edens-Bartholomew N. Fluconazole for postpartum candidal mastitis and infant thrush. J Hum Lact. 2002;18(2):168–71 5. Egunsola O, Adefurin A, Fakis A, Jacqz-Aigrain E, Choonara I, Sammons H. Safety of fluconazole in paediatrics: a systematic review. Eur J Clin Pharmacol. 2013;69(6):1211–21. 6. Force RW. Fluconazole concentrations in breast milk. Pediatr Infect Dis J. 1995;14(3):235–6. 7. Gandra SC1, Nguyen S, Nazzal S, Alayoubi A, Jung R, Nesamony J. Thermoresponsive fluconazole gels for topical delivery: rheological and mechanical properties, in vitro drug release and anti-fungal efficacy. Pharm Dev Technol. 2015 Jan;20(1):41-9 8. Gharibian KN, Mueller BA. Fluconazole dosing predictions in critically-ill patients receiving prolonged intermittent renal replacement therapy: a Monte Carlo simulation approach. Clin Nephrol. 2016 Jul;86(7):43-50. 9. Govendir M1, Black LA1, Jobbins SE1, Kimble B1, Malik R2, Krockenberger MB1. Some pharmacokinetic indices of oral fluconazole administration to koalas (Phascolarctos cinereus) infected with cryptococcosis. J Vet Pharmacol Ther. 2016 Aug;39(4):412-5. 10. Gonzalez JM1,2, Rodriguez CA1, Zuluaga AF1, Agudelo M1,3, Vesga O1,3. Demonstration of Therapeutic Equivalence of Fluconazole Generic Products in the Neutropenic Mouse Model of Disseminated Candidiasis. PLoS One. 2015 Nov 4;10(11):e0141872. doi: 10.1371/journal.pone.0141872. eCollection 2015. 11. Han S1, Kim J, Yim H, Hur J, Song W, Lee J, Jeon S, Hong T, Woo H, Yim DS. Population pharmacokinetic analysis of fluconazole to predict therapeutic outcome in burn patients with Candida infection. Antimicrob Agents Chemother. 2013 Feb;57(2):1006-11. 12. Hashemi SM1, Badali H2, Irannejad H3, Shokrzadeh M4, Emami S5. Synthesis and biological evaluation of fluconazole analogs with triazole-modified scaffold as potent antifungal agents. Bioorg Med Chem. 2015 Apr 1;23(7):1481-91. 13. Jane E. Sykes, Mark G. Papich, in Canine and Feline Infectious Diseases, 2014 14. Kaplan YC, Koren G, Ito S, Bozzo P. Fluconazole use during breastfeeding. Can Fam Physician. 2015 Oct;61(10):875-6. 15. Kratzer A1, Kees F2, Dorn C3. Unbound fraction of fluconazole and linezolid in human plasma as determined by ultrafiltration: Impact of membrane type. J Chromatogr B Analyt Technol Biomed Life Sci. 2016 Dec 15;1039:74-78. 16. Krein SR1, Lindsey JC, Blaze CA, Wetmore LA. Evaluation of risk factors, including fluconazole administration, for prolonged anesthetic recovery times in horses undergoing general anesthesia for ocular surgery: 81 cases (2006-2013). J Am Vet Med Assoc. 2014 Mar 1;244(5):577-81. 17. Liao J1, Yang F, Zhang L, Chai X, Zhao Q, Yu S, Zou Y, Meng Q, Wu Q. Synthesis and biological evaluation of novel fluconazole analogues bearing 1,3,4-oxadiazole moiety as potent antifungal agents. Arch Pharm Res. 2015 Apr;38(4):470-9. 18. Liu H1, Wang L, Li Y, Liu J, An M, Zhu S, Cao Y, Jiang Z, Zhao M, Cai Z, Dai L, Ni T, Liu W, Chen S, Wei C, Zang C, Tian S, Yang J, Wu C, Zhang D, Liu H, Jiang Y. Structural optimization of berberine as a synergist to restore antifungal activity of fluconazoleagainst drugresistant Candida albicans. Chem Med Chem. 2014 Jan;9(1):207-16. 19. Mandengue Ebenye C1, Takuefou Mfangam B2, Nouédoui C2, Atangana PJ3. [Disseminated histoplasmosis treated by boluses of fluconazole]. Med Sante Trop. 2015 Jan-Mar;25(1):110-1. 258 20. Manzoor S1, Buffon R1, Rossi AV2. Molecularly imprinted solid phase extraction of fluconazole from pharmaceutical formulations. Talanta. 2015 Mar;134:1-7. 21. McEvoy, G.K. (ed.). American Hospital Formulary Service. AHFS Drug Information. American Society of Health-System Pharmacists, Bethesda, MD. 2006., p. 511 22. Mikamo H1, Matsumizu M2, Nakazuru Y3, Okayama A3, Nagashima M4. Efficacy and safety of a single oral 150 mg dose of fluconazole for the treatment of vulvovaginal candidiasis in Japan. J Infect Chemother. 2015 Jul;21(7):520-6. 23. Moorhead AM, Amir LH, O‘Brien PW, Wong S. A prospective study of fluconazole treatment for breast and nipple thrush. Breastfeed Rev. 2011;19(3):25–9. 24. Novelli V, Holzel H. Safety and tolerability of fluconazole in children. Antimicrob Agents Chemother. 1999;43(8):1955–60. 25. Premachandra ID1, Scott KA1, Shen C1, Wang F2, Lane S2, Liu H2, Van Vranken DL3. Potent Synergy between Spirocyclic Pyrrolidinoindolinones and Fluconazole against Candida albicans. hem Med Chem. 2015 Oct;10(10):1672-86. 26. Rençber S1, Karavana SY1, Yılmaz FF2, Eraç B2, Nenni M3, Özbal S4, Pekçetin Ç4, Gurer-Orhan H3, Hoşgör-Limoncu M2, Güneri P5, Ertan G1. Development, characterization, and in vivo assessment of mucoadhesive nanoparticles containing fluconazole for the local treatment of oral candidiasis. Int J Nanomedicine. 2016 Jun 10;11:2641-53. 27. Santos JR1, César IC2, Costa MC3, Ribeiro NQ3, Holanda RA3, Ramos LH3, Freitas GJ3, Paixão TA4, Pianetti GA2, Santos DA5. Pharmacokinetics/pharmacodynamic correlations of fluconazole in murine model of cryptococcosis. Eur J Pharm Sci. 2016 Sep 20;92:235-43. 28. Schilling CG, Seay RE, Larson TA, Meier KR. Excretion of fluconazole in human breast milk Pharmacotherapy. 1993;13(3):287. 29. Sharma R1, Garg T1, Goyal AK1, Rath G1. Development, optimization and evaluation of polymeric electrospun nanofiber: A tool for local delivery of fluconazole for management of vaginal candidiasis. Artif Cells Nanomed Biotechnol. 2016;44(2):524-31. 30. Shoham et al. (2017), in Infectious Diseases (Fourth Edition) Author(s):Jonathan Cohen, William G Powderly and Steven M. Opal ISBN: 978-0-7020-6285-8 31. Sing Mahal H1. Fluconazole-Induced Type 1 Kounis Syndrome. Am J Ther. 2016 MayJun;23(3):e961-2. 32. Sinnollareddy MG1, Roberts MS2, Lipman J3, Peake SL4, Roberts JA5. Influence of sustained low-efficiency diafiltration (SLED-f) on interstitial fluid concentrations of fluconazole in a critically ill patient: Use of microdialysis. Int J Antimicrob Agents. 2015 Jul;46(1):121-4. 33. Sinnollareddy MG1, Roberts MS1, Lipman J2, Lassig-Smith M3, Starr T3, Robertson T1, Peake SL4, Roberts JA5. In Vivo Microdialysis To Determine Subcutaneous Interstitial Fluid Penetration and Pharmacokinetics of Fluconazole in Intensive Care Unit Patients with Sepsis. Antimicrob Agents Chemother. 2015 Nov 23;60(2):827-32. 34. Sudan A1, Livermore J, Howard SJ, Al-Nakeeb Z, Sharp A, Goodwin J, Gregson L, Warn PA, Felton TW, Perfect JR, Harrison TS, Hope WW. Pharmacokinetics and pharmacodynamics of fluconazole for cryptococcal meningoencephalitis: implications for antifungal therapy and in vitro susceptibility breakpoints. Antimicrob Agents Chemother. 2013 Jun;57(6):2793-800. 35. van der Elst KC1, van Alst M2, Lub-de Hooge MN1, van Hateren K1, Kosterink JG3, Alffenaar JW4, Schölvinck EH2. Clinical validation of the analysis of fluconazole in oral fluid in hospitalized children. Antimicrob Agents Chemother. 2014 Nov;58(11):6742-6. 259 15. Flusilazole  Flusilazole is an organosilicon fungicide invented by DuPont, which is used to control fungal infections on a variety of fruit and vegetable crops. Chemical name(s)   IUPAC bis (4-fluorophenyl)(methyl)(1H-1,2,4-triazol-1-ylmethyl)silane CAS 1-[[bis(4-fluorophenyl)methylsilyl]methyl]-1H-1,2,4-triazole Synonyms DPXH6573 IN-H6573 Formula: C16H15F2N3Si Mode of action, Henry (1990)      Flusilazole is a potent inhibitor of Ustilago maydis sporidial growth (I50= 20 μg liter−1). Incorporation of[14C]acetate into ergosterol of growing sporidia is inhibited 50% by 0.5 μg liter−1of the fungicide. Inhibition of ergosterol biosynthesis is concomitant with the accumulation of the precursors eburicol, obtusifoliol and 14α-methylfecosterol. A novel cell-free assay has been developed to measure the 14α-demethylation of[3H]dihydrolanosterol. Flusilazole inhibits the cell-free demethylation with an I50of 15 μg liter−1. These data provide strong evidence that the mode of action of flusilazole is by inhibiting ergosterol biosynthesis through direct inhibition of the 14α-demethylation of ergosterol precursors. Toxicity:    The developmental toxicity of flusilazole was studied in CD-1 mice after oral administration.( Farag and Ibrahim, 2007 ) Marked maternal toxicity, growth retardation, and skeletal abnormalities in the mid- and high-dose groups. It seems likely that marked maternal toxicity contributed to the observed alterations in fetal growth retardation and skeletal development. The no-observed-effect level in the present study for maternal and developmental toxicity was 10 mg/kg/day. 261 Recent reports: Im et al. (2016) investigated method validations in addition to decline patterns of fluquinconazole and flusilazole in lettuce grown under greenhouse conditions at two different locations. Following the application of fluquinconazole and flusilazole at a dose rate of 20 mL/20 L water, lettuce samples were collected randomly for up to 7 days post-application, and simultaneously extracted with acetone, purified through solid-phase extraction, analyzed via gas chromatography with a nitrogen phosphorus detector, and confirmed through gas chromatography-mass spectrometry. The linearity was excellent, with determination coefficients (R(2) ) between 0.9999 and 1.0. The method was validated in triplicate at two different spiking 261 levels (0.2 and 1.0 mg/kg) with satisfactory recoveries between 75.7 and 97.9% and relative standard deviations of <9. The limit of quantification was 0.01 mg/kg. Both analytes declined very quickly, as can be seen from the short half-life time of <4 days. Statistical analysis revealed significant differences between residues at different days of sampling, except at 7 days postapplication (triple application). At that point, the decline patterns of fluquinconazole and flusilazole were independent of application rate, location, temperature and humidity. Ozakca and Silah (2013) evaluated the effects of the fungicide flusilazole on somatic cells of Allium cepa. For evaluation of cytogenetic effects, root meristem cells of A. cepa were treated with 10, 20, 30 and 45 ppm (EC50 concentration) for 24, 48 and 72 h. The mitotic index and different types of chromosomal abnormalities such as bridges, stickiness and laggards were determined in both control and test groups. Acridine orange/Ethidium bromide double staining and fluorescence microscope was used to determine the stability of chromosome structure. Data obtained from staining process indicated that ratio of necrotic cells significantly increased by the flusilazole presoaking. The RAPD-PCR method was used and the higher doses treated-group (45 ppm) was more distant to the control group compare with others Wang et al. (2013) studied dissipation dynamic and terminal residue of flusilazole in mandarin and soil, as well as residue distribution of flusilazole in mandarin, at three sites in China. Mandarin peel, mandarin pulp, whole mandarin, and soil samples were extracted by acetonitrile, cleaned up with dispersive solid-phase extraction, then analyzed by gas chromatography-mass spectrometry. The dissipation half-lives of flusilazole in mandarin and soil at all three experiment sites were 6.3-8.4 days and 5.5-13.4 days, respectively, with the exception of the soil dissipation at the Hunan site, which showed an increase-decrease process. Flusilazole residue levels in whole mandarin were all below 0.1 mg/kg on 14 days after the last application. Terminal residue study showed that flusilazole was mostly distributed in mandarin peel, which indicates minimal risk for eating mandarin pulp. These results could provide guidance for the proper and safe use of flusilazole on citrus fruits, and further our understanding of pesticide distribution in citrus fruits. van Dartel et al. (2011) designed the murine embryonic stem cell test (EST) to evaluate developmental toxicity based on compound-induced inhibition of embryonic stem cell (ESC) differentiation into cardiomyocytes. The addition of transcriptomic evaluation within the EST may result in enhanced predictability and improved characterization of the applicability domain, therefore improving usage of the EST for regulatory testing strategies. Transcriptomic analyses assessing factors critical for risk assessment (i.e. dose) are needed to determine the value of transcriptomic evaluation in the EST. Here, using the developmentally toxic compound, flusilazole, we investigated the effect of compound concentration on gene expression regulation and toxicity prediction in ESC differentiation cultures. Cultures were exposed for 24 h to multiple concentrations of flusilazole (0.54-54 μM) and RNA was isolated. In addition, we sampled control cultures 0, 24, and 48 h to evaluate the transcriptomic status of the cultures across differentiation. Transcriptomic profiling identified a higher sensitivity of developmentrelated processes as compared to cell division-related processes in flusilazole-exposed differentiation cultures. Furthermore, the sterol synthesis-related mode of action of flusilazole toxicity was detected. Principal component analysis using gene sets related to normal ESC differentiation was used to describe the dynamics of ESC differentiation, defined as the 'differentiation track'. The concentration-dependent effects on development were reflected in 262 the significance of deviation of flusilazole-exposed cultures from this transcriptomic-based differentiation track. Thus, the detection of developmental toxicity in EST using transcriptomics was shown to be compound concentration-dependent. This study provides further insight into the possible application of transcriptomics in the EST as an improved alternative model system for developmental toxicity testing. Yu et al. (2011) developed a simple, quick and reliable residue analytical method for flusilazole in apple and soil. The samples were extracted with acetonitrile and determined by liquid chromatography with UV detection. The LOQ of the method was 0.02 mg/kg. The dissipation dynamic and final residues of flusilazole in apple and soil were studied using field trial method. The results of residual dynamics experiment showed that after the apple was treated by flusilazole at treble of recommended high dosage (3.75 g/kg H(2)O), the half-life times of flusilazole in apple and soil were 4.23-7.77 days and 3.04-5.14 days, respectively. Residues of flusilazole in apple at harvest time were all below 0.05 mg/kg at both recommended high dosage and 1.5 times of recommended high dosage References: 1. Henry, M. J. (1990), Mode of action of the fungicide flusilazole in ustilago maydis. Pestic. Sci., 28: 35–42. doi:10.1002/ps.2780280106 2. Im SJ1, Rahman MM1, Abd El-Aty AM2,3, Kim SW1, Kabir H1, Farha W1, Lieu T1, Lee YJ1, Jung DI1, Choi JH1, Shin HC2, Im GJ4, Hong SM4, Shim JH1. Simultaneous detection of fluquinconazole and flusilazole in lettuce using gas chromatography with a nitrogen phosphorus detector: decline patterns at two different locations. Biomed Chromatogr. 2016 Jun;30(6):946-52 3. Ozakca DU1, Silah H2. Genotoxicity effects of Flusilazole on the somatic cells of Allium cepa. Pestic Biochem Physiol. 2013 Sep;107(1):38-43. 4. van Dartel DA1, Pennings JL, de la Fonteyne LJ, Brauers KJ, Claessen S, van Delft JH, Kleinjans JC, Piersma AH. Concentration-dependent gene expression responses to flusilazole in embryonic stem cell differentiation cultures. Toxicol Appl Pharmacol. 2011 Mar 1;251(2):110-8. 5. Wang C1, Qiu L, Zhao H, Wang K, Zhang H. Dissipation dynamic and residue distribution of flusilazole in mandarin. Environ Monit Assess. 2013 Nov;185(11):916976. 6. Yu S1, Qin D, Wu Q, Guo X, Han L, Jiang S. Residue and dissipation dynamics of flusilazole in apple and soil. Bull Environ Contam Toxicol. 2011 Mar;86(3):319-22. . 263 16. Flutriafol        Flutriafol is relatively broad-spectrum 1,2,4-triazole fungicide used for the control of fungal diseases on fruits, vegetables, and cereals by inhibiting the synthesis of ergosterol. CAS Name: ?-(2-fluorophenyl)-?-(4-fluorophenyl)-1H-1,2,4-triazole-1-ethanol Other names: pp450;VINCIT;IMPACT;r152450;PP 450 5;ATOUT(R);ALTOSUPER;IMPACT(R);CINCIT(R);FLUTRIAFOL Molecular Formula: C16H13 F2 N3O "ICI introduced flutriafol in 1981. Since its introduction the compound has attained an important position in the global fungicide market, where flutriafol products have proved effective in controlling a vast number of diseases affecting a wide range of crops. In April 2001, Cheminova acquired the global flutriafol business from Syngenta, including all of the rights, know-how, registrations, and trademarks for the product. Today, Cheminova sells the product throughout the world as a foliar application product for cereals and other arable crops, as a microgranule product for use in coffee and maize and as a seed treatment product for the control of major seedborne and soil-borne diseases in cereals. The foliar products are mainly marketed under the trade name Impact® whereas the seed treatment products are sold under the trade name Vincit The mode of action  Flutriafol is sterol-inhibiting, triazole fungicide Uses   Flutriafol is a systemic fungicide of the triazole class. Flutriafol has broad spectrum fungicidal activity and is used to control effectively cereal powdery mildew, cloud disease, leaf spot disease a nd rust disease. Toxicity   Flutriafol has a low toxicity to mammals, birds, and insects (see Appendix 5, this addendum). Flutriafol may be toxic to fish and aquatic invertebrates. 264 Brands Recent reports: de Oliveira et al. (2016) monitored flutriafol and pyraclostrobin residues in Brazilian green coffees. More than 10,000 samples were analyzed. The pesticides were extracted using the QuEChERS method and analyzed by LC-MS/MS. The validated method is fast, with 5 min runs, and efficient, as precision and accuracy showed RSD no greater than 5% and recoveries within the 88-119% range. LOQ for flutriafoland pyraclostrobin were 0.005 mg/kg. The results of the analyzed samples showed that the percentage of nonconformities regarding flutriafolincreased throughout the years, with over 1200 samples (11.8%). On the other hand, just 15 samples (0.15%) presented residues above 10 μg/kg for pyraclostrobin. Considering that flutriafol is a toxic and carcinogenic pesticide, as well as the increase in the number of irregularities throughout the years, it becomes important to implement public actions to assure consumer safety. Zhang et al. (2015a) investigated the enantioselective bioactivity, acute toxicity and stereoselective degradation of the chiral triazole fungicide flutriafol in vegetables were investigated for the first time using the (R)-, (S)- and rac-flutriafol. The order of the bioactivity 265 against five target pathogens (Rhizoctonia solani, Alternaria solani, Pyricularia grisea, Gibberella zeae, Botrytis cinerea) was found to be (R)-flutriafol>rac-flutriafol>(S)-flutriafol. The fungicidal activity of (R)-flutriafol was 1.49-6.23 times higher than that of (S)-flutriafol. The (R)flutriafol also showed 2.17-3.52 times higher acute toxicity to Eisenia fetida and Scenedesmus obliquus than (S)-flutriafol. The stereoselective degradation of flutriafol in tomato showed that the active (R)-flutriafol degraded faster, resulting in an enrichment of inactive (S)-form, and the half-lives were 9.23 d and 10.18 d, respectively. Inversely, the (S)-flutriafol, with a half-life of 4.76 d, was preferentially degraded in cucumber. In conclusion, the systemic assessments of the triazole fungicide flutriafol stereoisomers on the enantioselective bioactivity, acute toxicity and environmental behavior may have implications for better environmental and ecological risk assessment. Zhang et al. (2015b) studied the stereoselective dissipation of flutriafol and tebuconazole in grape. A simple and sensitive method for determination of flutriafol and tebuconazole enantiomers in grape was developed by high-performance liquid chromatography on a cellulose tris(3-chloro-4-methylphenylcarbamate) column. The limits of quantification for flutriafol and tebuconazole in grape were 0.033 and 0.043 mg kg(-1), respectively. The dissipations of flutriafol and tebuconazole stereoisomers in grape followed first-order kinetics (R (2) > 0.93). The stereoisomers of flutriafol and tebuconazole were enantioselectively degraded in grape, and tebuconazole was more enantioselective than flutriafol. The half-life of (-)-tebuconazole was 5.2 days and shorter than (+)-tebuconazole with half-life of 6.4 days. The (-)-flutriafol was also preferentially degraded in grape, the half-lives of which were 6.59 and 6.98 days for (-) and (+)-flutriafol, respectively. The enantiomeric ratio value of the two fungicides was nearly 1.0 at the 1st day and increased to 1.143 for flutriafol and 2.015 for tebuconazole at the 28th day. The stereoselective dissipations could provide a reference to fully evaluate the risks of two important chiral triazole fungicides. References: 1. de Oliveira LAB1, Pacheco HP2, Scherer R3. Flutriafol and pyraclostrobin residues in Brazilian green coffees. Food Chem. 2016 Jan 1;190:60-63. 2. Song Y1, Zou Z, Gong Y, Shan W, Li W, Han L. Dissipation and residues of flutriafol in wheat and soil under field conditions. Bull Environ Contam Toxicol. 2012 Sep;89(3):611-4. 3. Tao Y1, Dong F, Xu J, Liu X, Cheng Y, Liu N, Chen Z, Zheng Y. Green and sensitive supercritical fluid chromatographic-tandem mass spectrometric method for the separation and determination of flutriafol enantiomers in vegetables, fruits, and soil. J Agric Food Chem. 2014 Nov 26;62(47):11457-64. 4. Zhang Q1, Hua XD1, Shi HY1, Liu JS1, Tian MM1, Wang MH2. Enantioselective bioactivity, acute toxicity and dissipation in vegetables of the chiral triazole fungicide flutriafol. J Hazard Mater. 2015a Mar 2;284:65-72. 5. Zhang Q1, Hua X, Yang Y, Yin W, Tian M, Shi H, Wang M. Stereoselective degradation of flutriafol and tebuconazole in grape. Environ Sci Pollut Res Int. 2015b Mar;22(6):4350-8. 266 17. Flutrimazole   Flutrimazole (UR-4056) is a derivative of imidazole, synthesized by J. Uriach & Cía (S.A., Barcelona, Spain), Flutrimazole is a wide-spectrum antifungal drug. It is used for the topical treatment of superficial mycoses of the skin. Molar mass: 346.373 g/mol Chemical Names: Flutrimazole; 119006-77-8; Molecular Formula: C22H16F2N2      Flutrimazole is an imidazole derivate. Its antifungal activity has been demonstrated in in vivo and in vitro studies to be comparable to that of clotrimazole and higher than bifonazole. Flutrimazole is active against dermatophytes, filamentous fungi and yeasts. Flutrimazole exerts a fungistatic action based on the inhibition of fungal lanosterol 14αdemethylase. Flutrimazole shows anti-inflammatory properties that are similar to ketoconazole. Flutrimazole is available in different topical formulations, namely as dermal cream (1%), solution (1%), gel shampoo (1%) and, tablets (500 mg) for vaginal application, and site-release® cream. Generic Names  Flutrimazole (OS: BAN)  UR 4056 (IS: Uriach)  Flutrimazol (PH: Ph. Eur. 8)  Flutrimazole (PH: BP 2016, Ph. Eur. 8)  Flutrimazolum (PH: Ph. Eur. 8) 267 Brand Names  Flusporan Laboratorios Menarini, Spain  Funcenal Uriach-Aquilea, Spain  Gine Micetal Uriach-Aquilea, Spain  Micetal ABL Pharma, Peru; Biosintetica, Brazil; CSC, Bulgaria; CSC, Hungary; CSC Pharmaceuticals, Austria; Medicom, Czech Republic; Scharper, Italy; Uriach & Cia, Poland; Uriach Pharma, Georgia; Uriach Pharma, Slovakia; Vifor, Spain 268 Reports Yim et al. (2010) compared the antifungal effect and safety of fluconazole cream 0.5% and 1% with flutrimazole cream 1% in superficial mycosis. A total of 162 subjects selected to participate in this study were equally divided into three groups and assigned to be given fluconazole cream 0.5%, fluconazole cream 1%, and flutrimazole cream 1% in the ratio of 1 : 1. The primary index of drug efficacy was determined by complete mycological cure in which no fungus was detected on KOH smear test 4 weeks after application of fluconazole. The secondary index of efficacy was defined as complete mycological cure 4 weeks after the application of fluconazole, improvement of clinical symptoms and overall effectiveness assessed by the research staff. According to this study, on comparing the efficacy of cure of superficial dermatomycosis after 4 weeks of application, both fluconazole 0.5% and fluconazole 1% cream were found to be equally effective and non-inferior to flutrimazole 1% cream. Given the effectiveness and safety of the drug, both fluconazole 0.5% and 1% cream might be said to be optimal concentration in the treatment of superficial dermatomycosis. Rigopoulos et al. (2007) compared for the first time, the efficiency and safety of flutrimazole 1% shampoo versus ketoconazole 2% shampoo in the treatment of tinea versicolor. Study population consisted of 60 patients with pityriasis versicolor diagnosed clinically and through direct microscopy and culture. Patients were randomly assigned to two groups: one instructed to apply flutrimazole shampoo 1% and one instructed to apply ketoconazole shampoo 2% both on head and body for 14 days. Patients were re-evaluated 14 days after the end of treatment clinically and through direct microscopy and culture. Twenty-one of 26 patients (80.8%) in the ketoconazole and 22 of 29 patients (75.9%) in the flutrimazole group had both visual healing and negative mycological evaluation. Comparison of the response between the two groups with the Yates' corrected chi-square was found statistically not significant (chi(2) = 0.19, d.f. = 1, P = 0.91). None of the patients in the two groups reported any adverse effects. Fourteen (53%) patients in the ketoconazole group and 23 (79%) in the flutrimazole group assessed the shampoos as cosmetically acceptable regarding texture, smell and foam properties. Flutrimazole shampoo 1% appears to present efficacy comparable with ketoconazole 2% in the treatment of tinea versicolor. Pereda et al. (2003) compared the efficacy and tolerability of flutrimazole 1% powder vs. bifonazole 1% powder in treating tinea pedis. A multicentre, double blind, randomized, parallel and comparative study was conducted. Two hundred and twenty-two patients with clinically and mycologically confirmed tinea pedis were randomized to flutrimazole (n = 136) or bifonazole (n = 138) 1% powder applied twice daily for 4 weeks. The corresponding clinical cure rates were assessed at 2 and 4 weeks of treatment, and the global (clinical and mycological) cure rates were determined at the fourth week. Clinical cure rates were 83.5 and 82.4% for flutrimazole and 269 bifonazole, respectively (95% CI: -0.0806 to 0.1009). Global cure rates were observed in 65.3 and 70.1% of patients treated with flutrimazole and bifonazole, respectively (95% CI: -0.0828 to 0.1779). Three non serious adverse events at the application site--itching (one patient per group) and dishydrotic eczema (one patient treated with flutrimazole)--were recorded during the study. These results support that flutrimazol 1% powder applied twice daily for a duration of 4 weeks is highly effective in the treatment of tinea pedis, showing a similar therapeutic profile with that of bifonazole 1% powder. Del Palacio et al. (2000) demonstrated a double-blind randomized comparative phase II study of flutrimazole site-release vaginal cream (1, 2 and 4%) with placebo site-release vaginal cream in patients with acute vulvovaginal candidosis. Vaginitis was demonstrated by both positive findings on microscopic examination of vaginal smears and positive culture as well as by the presence of clinical signs and symptoms. The vaginal monodose treatment was inserted in the evening at bedtime using a vaginal applicator and, in addition, all four groups of patients received additional topical external cream for application to the vulva twice-daily for 7 days; the placebo group received a placebo cream and the active therapy groups all received a 2% flutrimazole cream. A total of 133 patients who were seen over a 10-month period were screened and randomized: five patients did not take the allocated medication, and four patients whose menstrual period began shortly after study entry were excluded from the study, leaving 124 patients who were randomly allocated to receive a monodose vaginal 1% cream (regimen A, 28 patients), a monodose vaginal 2% cream (regimen B, 32 patients), a monodose vaginal 4% cream (regimen C, 31 patients) or a monodose vaginal placebo cream (regimen D, 33 patients). At the assessment 9 days after the end of therapy the proportion of patients who were cured was 82% in group A, 87.4% in group B, 83.8% in group C and 63.5% in group D. Three patients (10.7%) in group A, four (12.5%) in group B, one (3.2%) in group C and 12 (36.36%) in group D did not respond to the treatment. One patient (3.5%) in group A, and two patients (6.4%) in group C terminated the treatment prematurely due to intolerance. There was a significant association between Candida glabrata and treatment failure (P < 0.04) and C. glabrata and carrier state (P = 0.01) in vagina (chi 2 test, P = 0.01) and vulvovagina (chi 2 test, P = 0.00001). At the assessment 4 weeks after the end of therapy the proportion of cured patients was 60.6% in group A, 78% in group B, 80.6% in group C and 48.4% in group D. Group D (placebo) versus group B (2%) and group C (4%) showed a significant difference (P = 0.01 and P = 0.007, respectively). Although there were no significant differences in clinical and mycological activity between the three active groups, group B (flutrimazole 2% site-release vaginal cream) was chosen for clinical use due to its tolerance profile. Seven patients (25%) in group A, three (9.3%) in group B, two (6.4%) in group C and five (15.1%) in group D relapsed 4 weeks after the end of therapy; the relapse rate was not significantly associated with positive culture results 9 days after treatment. There was a significant association between C. glabrata and the carrier state (P < 0.01). Alomar et al. (1995) compared the efficacy and tolerability of flutrimazole cream 1% with a reference drug, bifonazole, in the treatment of dermatomycoses, eligible for topical treatment exclusively. A multicentre, double-blind, randomized, parallel-group clinical trial was conducted. Patients with clinically and mycologically (KHO and/or culture) diagnosed fungal infection of the skin were included in this study and were randomized into two treatment groups: 1% flutrimazole or 1% bifonazole, applied to the affected area (target lesion) once a day. The principal criterion of efficacy, 'cure', was based on clinical and mycological assessment. Four hundred and forty-nine patients were included in the study (228 flutrimazole, 221 bifonazole). 'Intention-to-treat' analysis of the data showed a difference between the treatments in terms of the 271 rate of cure (clinical and mycological) after 4 weeks: 73% in the flutrimazole group and 65% in the bifonazole group (p = 0.05). From a safety point of view, flutrimazole and bifonazole were well tolerated, and the overall incidence of adverse effects (mainly mild local effects like irritation or burning sensation) was 5%. Del Palacio et al. (1995) compared with bifonazole 1% solution, applied once daily for 4 weeks, in 40 patients with culturally proven dermatophytosis or cutaneous candidosis. Forty patients with mycologically proven pityriasis versicolor were treated with once-daily application for 1 week. The four groups of patients and distribution of target lesions were similar, although in the flutrimazole group more patients had cutaneous candidosis (n = 8 versus n = 1). The distribution of the sum of clinical scores was also similar in both groups. At the end of therapy the proportion of patients with negative microscopy and culture was 85% in the flutrimazole group and 65% in the bifonazole group. There was a significant difference (P = 0.022) in terms of efficacy, since 80% of patients in the flutrimazole group versus 40% in the bifonazole group were judged to have received effective treatment. At the assessment 6 weeks after the end of therapy the percentages of flutrimazole- and bifonazole-treated patients with negative mycology were 75% and 65% respectively. There were two relapses (one in each group), which represents a 5% rate. Fifteen flutrimazole-treated patients (75%) compared with 12-bifonazole-treated patients (60%) had overall effective therapy. Two patients treated with bifonazole (10%) and one treated with flutrimazole (5%) had a premature termination due to adverse events attributable to the medication. References: 1. Alomar A, Videla S, Delgadillo J et al. Flutrimazole 1% dermal cream in the treatment of dermatomycoses: a multicentre, double-blind, randomized, comparative clinical trial with bifonazole 1% cream. Dermatology 1995; 190: 295–30 2. Binet O, Soto-Melo J, Delgadillo J et al. Flutrimazole 1% dermal cream in the treatment of dermatomycoses: a randomized, multicentre, double-blind, comparative clinical trial with 1% clotrimazole cream. Mycoses 1994; 37: 455–9. 3. Del Palacio A, Cuétara S, Izquierdo I et al. A double blind, randomised, comparative trial: flutrimazole 1% solution versus bifonazole 1% solution once daily in dermatomycoses. Mycoses 1995; 38: 395–403. 4. Del Palacio A, Sanz F, Sánchez-Alor et al. Double-blind randomized dose-finding study in acute vulvovaginal candidosis. Comparison of flutrimazole site-release® cream (1, 2 and 4%) with placebo site-release® vaginal cream. Mycoses 2000; 43: 355–65. 5. Pereda J1, Noguera X, Boncompte E, Algueró M, Izquierdo I. Efficacy of flutrimazole 1% powder in the treatment of tinea pedis. Mycoses. 2003 Apr;46(34):126-31. 6. Rigopoulos D1, Gregoriou S, Kontochristopoulos G, Ifantides A, Katsambas A. Flutrimazole shampoo 1% versus ketoconazole shampoo 2% in the treatment of pityriasis versicolor. A randomised double-blind comparative trial. Mycoses. 2007 May;50(3):1935. 7. Yim SM1, Ko JH, Lee YW, Kim HW, Lee JY, Kim NI, Kye YC, Park KC, Choi JH, Lee KH, Kim MN, Kim KJ, Ro YS, Ahn KJ. Study to compare the efficacy and safety of fluconazole cream with flutrimazole cream in the treatment of superficial mycosis: a multicentre, randomised, double-blind, phase III trial. Mycoses. 2010 Nov;53(6):522-9. 271 18. Fosfluconazole      Fosfluconazole is a water-soluble phosphate prodrug of fluconazole — a triazole antifungal drug used in the treatment and prevention of superficial and systemic fungal infections. Fosfluconazole was approved by Pharmaceuticals and Medicals Devices Agency of Japan (PMDA) on Oct 16, 2003. It was developed and marketed as Prodif® by Pfizer in Japan. Prodif® is available as solution for intravenous use, containing 100, 200 or 400 mg of free Fosfluconazole per vial. Prodif is recommended dose is 50 to 100 mg administered intravenously once daily for candidiasis. Another dose is 50 to 200 mg fluconazole once daily for cryptococcosis. Fosfluconazole is a water-soluble phosphate prodrug of fluconazole - a triazole antifungal drug. It is indicated for the treatment of candida and cryptococcus infections. Molar mass: 386.25 g/mol Chemical Formula: C13-H13-F2-N6-O4-P Chemical Names α,α-Bis(1,2,4-triazol-1-ylmetyl)-2,4-difluorophenylmetyl dihydrogenphosphate (JAN) 1-(2,4-Difluorophenyl)-2-(1H-1,2,4-triazol-1-yl)-1-[(1H-1,2,4-triazol-1-yl)metyl]etyl dihydrogen phosphate (BAN) 2-(2,4-difluorophenyl)-1,3-bis(1H-1,2,4-triazol-1-yl)propyl dihydrogen phosphate 2,4-difluoro-α,α-bis(1H-1,2,4-triazol-1-ylmetyl)benzyl alcohol, dihydrogen phosphate (ester) (WHO) Synonyms: 2-(2,4-Difluorophenyl)-1,3-bis(1H-1,2,4-triazol-1-yl)-2-propyl dihydrogen phosphate Chemical Family: Prodrug of fluconazole ; Synthetic class of compounds known as bis-triazoles 272 Spectrum of activity  Fosfluconazole, in vitro, is at least 25-fold less potent than FLCZ against single isolates of Candida species and Cryptococcus neoformans, and requires metabolic conversion to FLCZ for antifungal activity in vivo. \ Pharmacokinetics, Sobue et al., 2004      Fosfluconazole is plasma protein binding rate 77.7% ~ 93.8%. Cerebrospinal fluid concentration of 52% to 62% of plasma concentration, t1 / 2 1.5 ~ 2.5h, Less than 1% of the administered dose of fosfluconazole was excreted unchanged in the urine and the majority (85.6%) was eliminated in the urine as FLCZ. Two loading doses regimen led to earlier achievement of target steady state plasma concentrations (by day 3) compared with use of one or no loading dose (towards the end of the dosing period). Similar adverse event profiles were seen in all three treatment groups. Fosfluconazole did not accumulate after multiple dosing. Product Name: Fosfluconazole Solution for Injection   Prodif (fosfluconazole) injection formulations are available in Japan for the treatment of a range of systemic candidiasis and cryptococcal fungal infections, including respiratory, esophageal and urethral infections. There are three kinds of specifications packaging. Pharmacological effects of this product is fluconazole prodrug, good solubility, can reduce the infusion volume, reduce the Indications  Fosfluconazole is suitable for Candida, Cryptococcus true, respiratory, digestive, urinary tract fungal disease, peritonitis, meningitis. Toxicological Effects       Fosfluconazole is quickly and efficiently converted (hydrolyzed) in the body (and by all tested animal species) to fluconazole. The toxicities of the two materials can be expected to be similar. Long Term: Rare cases of serious liver damage and allergic reactions have been reported Repeat-dose studies in animals have shown a potential to cause adverse effects on the developing fetus. Known Clinical Effects: o There have been reports of multiple congenital abnormalities in infants whose mothers were being treated for 3 or more months with high dose (400-800mg/day) fluconazole. o Fluconazole is found in human breast milk at concentrations similar to plasma. Therefore, nursing mothers should limit exposure. Adverse effects reported in clinical trials include headache, parasthesia (tingling or itching), nausea, and diarrhea Generic Names 273    Fosfluconazole (OS: BAN, JAN) UK-292663 (IS) UNII-3JIJ299EWH (IS) Brand Name  Prodif Pfizer Japan, Japan References Hagiya and Kajioka (2013) reported the case of an 85-year-old woman presenting with right internal jugular vein candidal thrombophlebitis associated with central venous catheters (CTCVC). The infecting agent was Candida albicans, which caused recurrent candidemia five times in total. Micafungin (MCFG) alone was ineffective; however, the combination of MCFG 274 with fosfluconazole (F-FLCZ) successfully treated the patient without a need for any anticoagulant or surgical therapies. To the extent of our knowledge, this is the first report of CTCVC being successfully treated with a combination of F-FLCZ and MCFG. These new antifungal agents have better efficacy, tolerability and bioavailability; therefore, they can be useful alternatives to classical combination therapies such as amphotericin-B and 5fluorocytosine. Aoyama et al. (2012) characterized the pharmacokinetics of the antifungal fluconazole after the intravenous administration of the prodrug fosfluconazole or fluconazole in critically ill patients with serious systemic fungal infections, by population pharmacokinetic analysis using the nonmem software package. Clinical biochemical data including serum fluconazole levels were obtained from 57 patients treated in the intensive care unit along with two naïve pooled patients gleaned from previous reports. The pharmacokinetic model of fluconazole was estimated using a one-compartment model. The probability that the area under the concentration-time curve is higher than 800 μg h/mL was determined by simulation. It was assumed that all the administered fosfluconazole was converted to fluconazole with an estimated fosfluconazole-fluconazole conversion rate constant of 2·05/h. The significant covariates for clearance for fluconazole (CL) and volume of distribution for fluconazole (Vd) were resulted in creatinine clearance (CLcr) and body weight (BW), respectively, in the final pharmacokinetic model equations: CL (L/h) = 0·799 × [CLcr (mL/min)/92·7](0·685) and Vd (L) = 48·1 × [BW (kg)/65](1·40) , where the interpatient variabilities in CL and Vd and the intrapatient variability were 44·8%, 79·7% and 19·8%, respectively. On the basis of the results of the Monte Carlo simulation, the probabilities of target attainment were 60%, 26% and 11% for 400 mg/day administration as fluconazole equivalent at CLcr values of 40, 70 and 100 mL/min, respectively. Sawada et al. (2009) performed a randomized trial comparing micafungin (MCFG), a new antifungal agent, with fosfluconazole, a prodrug of fluconazole (FF) conventionally used as a prophylactic agent, for prophylaxis against IFI. Cefpirome was administered as prophylaxis against bacterial infection, and meropenem+minocycline as an empiric window therapy for febrile neutropenia. MCFG 2 mg/kg/day (max 100 mg/day) and FF 10 mg/kg/day (max 400 mg/day) were both safe and effective (event free ratio of IFI, MCFG 94.4% vs FF 94.3%) without significant difference. Thus, MCFG is safe and can be used for prophylaxis against IFI in children. Takahashi et al. (2009) conducted a retrospective case series study to evaluate the safety of fosfluconazole prophylaxis for preventing invasive fungal infection in VLBW infants with a central vascular access. Fosfluconazole was administered intravenously at a dose of 6 mg/kg everyday during which time a central venous catheter was placed. A total of 23 infants met the criteria for enrollment in our study. No cases of fungal infection were detected during the central venous catheter placement in the group. None of the infants had an elevated beta-D-glucan, and all of them were still alive at discharge. Regarding the liver and renal function, no statistically significant differences were observed before and at the end of fosfluconazole prophylaxis. The results of this study demonstrate that fosfluconazole prophylaxis in preventing invasive fungal infection was well tolerated by VLBW infants. This is a first report to describe antifungal prophylaxis using fosfluconazole for VLBW infants. Sobue et al. (2004) conducted a single blind, placebo-controlled, escalating single-dose, threeperiod crossover study using two subject cohorts to investigate the safety, tolerability, and pharmacokinetics in healthy male Japanese subjects after intravenous bolus injection 275 of fosfluconazole 50 to 2000 mg, a phosphate prodrug of fluconazole (FLCZ). Fosfluconazole was rapidly converted to FLCZ with only minor amounts excreted in the urine (less than 4% of the dose). Fosfluconazole had a volume of distribution at the higher doses, which was similar to the extracellular volume in man (0.2 L/kg) and was eliminated with a terminal half-life of 1.5 to 2.5 hours. There was apparent dose proportionality in FLCZ pharmacokinetics. C(max) and AUC of FLCZ appeared to increase proportionally with increasing doses of fosfluconazole. There were no apparent dose-dependent trends in t(max), t(1/2), or mean residence time (MRT) of FLCZ. Bolus injection of fosfluconazole was well tolerated at doses of up to 2000 mg in healthy Japanese subjects. References: 1. Aoyama T1, Hirata K, Hirata R, Yamazaki H, Yamamoto Y, Hayashi H, Matsumoto Y. Population pharmacokinetics of fluconazole after administration of fosfluconazole and fluconazole in critically ill patients. J Clin Pharm Ther. 2012 Jun;37(3):356-63 2. Hagiya H1, Kajioka H. Successful treatment of recurrent candidemia due to candidal thrombophlebitis associated with a central venous catheter using a combination of fosfluconazole and micafungin. Intern Med. 2013;52(18):2139-43. 3. Sobue S, Tan K, Layton G, Eve M, Sanderson JB. Pharmacokinetics of fosfluconazole and fluconazole following multiple intravenous administration of fosfluconazole in healthy male volunteers. British Journal of Clinical Pharmacology. 2004a;58(1):20-25. doi:10.1111/j.1365-2125.2004.02107.x. 4. Sobue S1, Sekiguchi K, Shimatani K, Tan K. Pharmacokinetics and safety of Fosfluconazole after single intravenous bolus injection in healthy male Japanese volunteers. J Clin Pharmacol. 2004a Mar;44(3):284-92. 5. Sobue S1, Tan K, Shaw L, Layton G, Hust R. Comparison of the pharmacokinetics of fosfluconazole and fluconazole after single intravenous administration of fosfluconazole in healthy Japanese and Caucasian volunteers. Eur J Clin Pharmacol. 2004b Jun;60(4):247-53. 6. Sawada A1, Sakata N, Higuchi B, Takeshita Y, Ishihara T, Sakata A, Kouroki M, Kondo O, Koyama M, Hirano S, Yasui M, Inoue M, Yoshioka A, Kawa K. [Comparison of micafungin and fosfluconazole as prophylaxis for invasive fungal infection during neutropenia in children undergoing chemotherapy and hematopoietic stem cell transplantation]. Rinsho Ketsueki. 2009 Dec;50(12):1692-9. 7. Takahashi D1, Nakamura T, Shigematsu R, Matsui M, Araki S, Kubo K, Sato H, Shirahata A. Fosfluconazole for antifungal prophylaxis in very low birth weight infants. Int J Pediatr. 2009;2009:274768. 276 19. Hexaconazole  Hexaconazole is an agricultural broad-spectrum systemic triazole fungicide used for the control of many fungi particularly Ascomycetes and Basidiomycetes. Chemical Names: Hexaconazole; 79983-71-4; ... Molecular Weight: 314.21 g/mol Molecular Formula: C14H17Cl2N3O     Hexaconazole controls Podosphaera leucotricha, Gymnosporangium juniperivirginianae and Venturia inaequalis on apples, Guignardia bidwellii and Uncinula necator on vines, Hemileia vastatrix on coffee and Cercospora spp. on peanuts, rusts, mildew and eyespot on wheat, fungal pests on bananas, peaches, vegetables, citrus and soft fruit. Hexaconazole controls powdery mildew on vine and apple, black rot and apple scab. Hexaconazole also inhibits Puccinia horiana on chrysanthemum and Sphaerothea pannosa on roses. Hexaconazole has been recommended as a fungicidal wood preservative. Mode of Action:    Hexaconazole inhibits ergosterol biosynthesis (steriod dimethylation inhibitor). Hexaconazole is ergosterol biosynthesis inhibitor thereby controlling growth and reproduction of plant fungal pathogens. Hexaconazole is a systemic fungicide with protective and curative action. Used for the control of many fungi, particularly Ascomycetes and Basidiomycetes. Environmental fate:     It has a short half life in soil and is rapidly degraded . It has an EPA classification for soil mobility that ranges from Ground water contamination Accumulation in milk and tissues. Readily excreted by mammals with no significant retention in organs or tissue. It has a high potential for bioaccumulation. 277 Ecotoxicology for hexaconazole, IUPAC, http://sitem.herts.ac.uk/aeru/iupac/Reports/382.htm Source/Quality Score/Other Property Bioconcentration factor Value Information BCF (l kg-1) 412 Q2 Estimated CT50 (days) Not available Mammals - Acute oral LD50 (mg kg-1) Mammals Short term dietary NOEL Interpretation Threshold for concern - 2189 P4 Rat Low (mg kg-1) 5 L3 Rat High (ppm diet) - - Birds - Acute LD50 (mg kg-1) > 4000 L3 Anas platyrhynchos Low Birds - Short term dietary (LC50/LD50) - - - Fish - Acute 96 hour LC50 (mg l-1) 3.4 L3 Oncorhynchus mykiss Moderate Fish - Chronic 21 day NOEC (mg l-1) - - - Aquatic invertebrates - Acute 48 hour EC50 (mg l-1) > 2.9 P4 Daphnia magna Moderate Aquatic invertebrates Chronic 21 day NOEC (mg l-1) - - - Aquatic crustaceans - Acute 96 hour LC50 (mg l-1) - - - Sediment dwelling organisms - Acute 96 hour LC50 (mg l-1) - - - Sediment dwelling organisms - Chronic 28 day NOEC, static, water (mg l-1) - - Sediment dwelling organisms - Chronic 28 day NOEC, sediment (mg kg-1) - - - Aquatic plants - Acute 7 day EC50, biomass (mg l-1) - - - Non-target plants - - - - - - 278 Algae - Acute 72 hour EC50, growth (mg l-1) > 1.7 K3 Unknown species Moderate Algae - Chronic 96 hour NOEC, growth (mg l-1) - - - Honeybees Contact acute 48 hour LD50 (μg bee1 ) - - - Oral acute 48 hour LD50 (μg bee-1) > 100 L3 Low Unknown mode acute 48 hour LD50 (μg bee1 ) - - - Earthworms - Acute 14 day LC50 (mg kg-1) 414 L3 Moderate Earthworms - Chronic 14 day NOEC, reproduction (mg kg-1) - - - Other soil macroorganisms e.g. Collembola LR50 / EC50 / NOEC / % Effect - - - Other arthropod (1) LR50 g ha-1 - - - % Effect Harmless Dose: 120 g ha-1 AA2 Typhlodromus pyri - Other arthropod (2) LR50 g ha-1 - - - % Effect Harmless Dose: 120 g ha-1 AA2 Chrysoperla carnea - 279 Human health and protection for hexaconazole Source/Quality Score/Other Property Value Information Interpretation Threshold of Toxicological Concern High (class III) - - Mammals - Acute oral LD50 (mg kg-1) 2189 P4 Rat Low Mammals - Dermal LD50 (mg kg-1 body weight) > 2000 L3 Rat - Mammals - Inhalation LC50 (mg l-1) 5.9 L3 Rat - (Cramer Class) Brands 281 Recent reports Ju et al. (2017) conducted a 3-month-long experiment using two typical paddy soils in China (red soil and black soil) to assess the effects of hexaconazole (0.6 (T1) and 6 (T10) mgkg-1 soil) on the overall microbial biomass, respiratory activity, bacterial abundance and community structure, and nitrogen transformations. Soil was sampled after 7, 15, 30, 60, and 90days of incubation. The half-lives of the two doses of hexaconazole varied from 122 to 135d in the black soil and from 270 to 845d in the red soil. Both dosages of hexaconazole did not affect NH+4-N content, N2-fixing bacterial populations, total bacterial diversity, and community structure, but transitorily decreased the populations of total bacteria in both soil types. In the black soil, T10 negatively affected microbial biomass carbon (MBC) and soil basal respiration (RB), but transitorily increased NO-3-N concentration and ammonia-oxidizing bacteria populations, while T1 had almost no effect on most of the indicators. As for red soil, both concentrations of fungicide significantly, but transitorily, inhibited MBC and RB, while only T10 had a relatively long stimulatory effect on NO-3-N concentration and ammonia-oxidizing archaea populations. This study showed that over application of hexaconazole is indeed harmful to soil microorganisms and may reduce soil quality and increase the risk of nitrogen loss in paddy soils. Li et al. (2016) investigated the functions of Hex-Cu in regulating growth and the response to salt stress in the seedlings of Triticum aestivum. Pretreated with 60μmolL(-1) Hex-Cu, the seedling plants got increased root/shoot ratio by 42.0%, and the contents of chlorophyll and soluble protein were also increased by 38.1% and 27.9%, respectively. Furthermore, Hex-Cu alleviated the growth inhibition caused by salt stress, enabled the seedlings to maintain a higher proline content and lower malondialdehyde accumulation. The functions of Hex-Cu in regulating the expression of proline synthetase (P5CS and P5CR) genes were investigated by quantitative real-time PCR (qPCR). Under 100mmolL(-1) NaCl stress, the expression of P5CS and P5CR in the seedlings by Hex-Cu pretreatment were significantly up-regulated. It attributed to the enhanced salt tolerance in plants. Zhang et al. (2016) constructed co-delivery NPs which could delivery two kinds of pesticides, which function was similar with pesticides combination formulation. The co-delivery NPs of validamycin and hexaconazole were prepared with the amphiphilic copolymer methoxy poly(ethylene glycol)- poly(lactide-co-glycolide) (mPEG-PLGA) used an improved double emulsion method. The chemical structure of mPEG-PLGA copolymer was confirmed using fourier transform infrared spectroscopy (FT-IR), and nuclear magnetic resonance spectroscopy (NMR). The co-delivery NPs all exhibited good size distribution and held sustained-release property. Dubey et al. (2015) evaluated the comparative effects of methyl parathion and hexaconazole on genotoxicity, oxidative stress, antioxidative defence system and photosynthetic pigments in barley (Hordeum vulgare L. variety karan-16). The seeds were exposed with three different concentrations, i.e. 0.05, 0.1 and 0.5 % for 6 h after three pre-soaking durations 7, 17 and 27 h which represents G1, S and G2 phases of the cell cycle, respectively. Ethyl methane sulphonate, a well-known mutagenic agent and double distilled water, was used as positive and negative controls, respectively. The results indicate significant decrease in mitotic index with increasing concentrations of pesticides, and the extent was higher in methyl parathion. Chromosomal aberrations were found more frequent in methyl parathion than hexaconazole as compared to 281 their respective controls. Treatment with the pesticides induced oxidative stress which was evident with higher contents of H2O2 and lipid peroxidation, and the increase was more prominent in methyl parathion. Contents of total phenolics were increased; however, soluble protein content showed a reverse trend. Among the enzymatic antioxidants, activities of superoxide dismutase and peroxidase were significantly up-regulated, and more increase was noticed in hexaconazole. Increments in total chlorophyll and carotenoid contents were observed up to 0.1 % but decreased at higher concentration (0.5 %), and the reductions were more prominent in methyl parathion than hexaconazole as compared to their respective controls. Maznah et al. (2015) treated 2 experimental plots with hexaconazole at the recommended dosage of 4.5 g a.i. palm(-1) (active ingredient) and at double the recommended dosage (9.0 g a.i. palm(-1)), whilst one plot was untreated as control. The residue of hexaconazole was detected in soil samples in the range of 2.74 to 0.78 and 7.13 to 1.66 mg kg(-1) at the recommended and double recommended dosage plots, respectively. An initial relatively rapid dissipation rate of hexaconazole residues occurred but reduced with time. The dissipation of hexaconazole in soil was described using first-order kinetics with the value of coefficient regression (r (2) > 0.8). The results indicated that hexaconazole has moderate persistence in the soil and the half-life was found to be 69.3 and 86.6 days in the recommended and double recommended dosage plot, respectively. The results obtained highlight that downward movement of hexaconazole was led by preferential flow as shown in image analysis. References: 1. Dubey P1, Mishra AK2, Singh AK1. Comparative analyses of genotoxicity, oxidative stress and antioxidative defence system under exposure of methyl parathion and hexaconazole in barley (Hordeum vulgare L.). Environ Sci Pollut Res Int. 2015 Dec;22(24):19848-59. 2. Ju C1, Xu J2, Wu X1, Dong F1, Liu X1, Tian C1, Zheng Y1. Effects of hexaconazole application on soil microbes community and nitrogen transformations in paddy soils. Sci Total Environ. 2017 Dec 31;609:655-663. 3. Li J1, Sun C1, Yu N1, Wang C1, Zhang T1, Bu H2. Hexaconazole-Cu complex improves the salt tolerance of Triticum aestivum seedlings. Pestic Biochem Physiol. 2016 Feb;127:90-4. 4. Maznah Z1, Halimah M2, Ismail S3, Idris AS4. Dissipation of the fungicide hexaconazole in oil palm plantation. Environ Sci Pollut Res Int. 2015 Dec;22(24):19648-57. 5. Zendegi-Shiraz A1, Sarafraz-Yazdi A1, Es'haghi Z2. Polyethylene glycol grafted flowerlike cupric nano oxide for the hollow-fiber solid-phase microextraction of hexaconazole, penconazole, and diniconazole in vegetable samples. J Sep Sci. 2016 Aug;39(16):313744. 6. Zhang J, Liu Y, Zhao C, Cao L, Huang Q, Wu Y. Enhanced Germicidal Efficacy by CoDelivery of Validamycin and Hexaconazole with Methoxy Poly(ethylene glycol)Poly(lactide-co-glycolide) Nanoparticles. J Nanosci Nanotechnol. 2016 Jan;16(1):152-9. 282 20. Isavuconazole      Isavuconazole (Cresemba [formerly BAL4815]; Astellas Pharma US, Inc., Northbrook, IL), administered as isavuconazonium (BAL8857), was approved by the U.S. Food and Drug Administration on March 8, 2015, for the treatment of invasive aspergillosis and invasive mucormycosis. Isavuconazole is a second-generation triazole and is the first antifungal specifically indicated for the treatment of invasive fungal infections caused by Mucormycetes (or Mucorales) or mucormycosis. Isavuconazole available in both oral and cyclodextrin-free intravenous formulations. Isavuconazole has a broad spectrum of activity including yeast, dimorphic fungi, and various molds, as well as a favorable adverse effect profile and less substantial drug-drug interactions than other triazoles. Isavuconazole is currently indicated for the treatment of invasive aspergillosis and invasive mucormycosis, and the agent is currently being investigated for an indication in the treatment of candidemia and invasive candidiasis. The chemical structures of isavuconazonium and isavuconazole.     Isavuconazole possesses a core structure very similar to that of voriconazole including single triazole and difluorobenzene groups. Isavuconazole has a thiazolyl-benzonitrile side chain . Isavuconazole possesses low solubility in water, Isavuconazonium is a highly water-soluble prodrug,. The addition of an aminocarboxyl moiety via formation of a triazolium salt greatly increases the solubility of isavuconazonium. Chemical structures of isavuconazonium and isavuconazole. Rybak et al., 2015 Mode of action Isavuconazole inhibits the synthesis of ergosterol, a key component of the fungal cell membrane, through the inhibition of cytochrome P-450 dependent enzyme lanosterol 14-alpha-demethylase. This enzyme is responsible for the conversion of lanosterol to ergosterol. An accumulation of 283 methylated sterol precursors and a depletion of ergosterol within the fungal cell membrane weakens the membrane structure and function. Mammalian cell demethylation is less sensitive to isavuconazole inhibition. Spectrum of Activity, Rybak et al., 2015 Yeasts  Isavuconazole exhibits a broad spectrum of activity against most yeast species when studied in vitro  Isavuconazole displays greater activity against most Candida species including Candida glabrata and Candida krusei, maintaining a 24-hour MIC for 90% of tested isolates (MIC90) of 0.5 mg/L or lower when using Clinical and Laboratory Standards Institute (CLSI) methodology and broth microdilution.[ Seifert et al., 2007, Verweij rt al., 2009, Howard et al., 2013, Pfaller etr al.,2013, Espinel-Ingroff et al., 2015] Isavuconazole showed potent activity against Candida albicans with a 24-hour MIC for 50% of tested isolates (MIC50) of 0.008 mg/L and MIC90 of 0.016 mg/L, considerably lower than the MIC values for other Candida species. o Rarely did a Candida isolate show an elevated isavuconazole MIC, with 0.7% of isolates having an MIC of 8 mg/L or greater (eight C. glabrata, two C. parapsilosis, one C. albicans).[Seifert et al., 2007, Pfaller etr al., 2013] o The MIC methodology set by the European Committee on Antimicrobial Susceptibility Testing (EUCAST) confirms the potent activity of isavuconazole against most Candida species (C. albicans MIC50 and MIC90 0.015 mg/L or lower; C. glabrata MIC50 0.125 and MIC90 2 mg/L; C. krusei MIC50 0.125 and MIC90 0.5 mg/L).[ Schmitt-Hoffmann et al., 2006] Isavuconazole activity extends to both Cryptococcus gattii and Cryptococcus neoformans (including C. neoformans var. grubiigenotype VNI and nongenotyped C. neoformans).[ Howard et al., 2013]   Moulds    Isavuconazole displayed potent antifungal activity against Aspergillus species, demonstrating an MIC50 ranging from 0.125–1 mg/L and an MIC90 ranging from 0.5–2 mg/L (highest MICs were observed with A. niger). Isavuconazole MIC50 values by EUCAST methodology range from 0.12–1 mg/L, whereas MIC90 values ranged from 0.5–4 mg/L. Isavuconazole also has been observed to have activity against Mucoralean fungi. Against Mucorales, the MIC50 of isavuconazole ranges from 1–4 mg/L, and the MIC90 ranges from 4–16 mg/L. Pharmacokinetics, Rybak et al., 2015  Administered intravenously as water-soluble isavuconazonium, plasma esterases rapidly catalyze the formation of active isavuconazole and the release of the inactive cleavage product.  Greater than 99% of intravenously administered prodrug is converted to isavuconazole. 284    Following intravenous administration of a single 200-mg dose of isavuconazonium (measured by the resulting amount of active isavuconazole), o the maximum serum concentration (Cmax) of the prodrug is reached prior to the end of infusion and is undetectable in most patients within 2 hours. o The Cmax of isavuconazole is ~2.5 mg/L and is reached at the end of the 1-hour infusion period. o The inactive cleavage product reaches a Cmax of less than 0.5 mg/L and is undetectable within 8 hours of administration. Following oral administration of isavuconazonium, o substantial conversion of the prodrug to its active state via hydrolysis in the gut lumen occurs. o Oral bioavailability approximates 98%, and Cmax (2–2.5 mg/L) is reached in 1–3 hours, o concentrations of the prodrug and its cleavage product are untraceable in serum. [ Andes et al., 1999, Schmitt-Hoffmann et al.,2008 ] Administration of oral isavuconazonium with food o results in an ~20% decrease in area under the concentration-time curve (AUC) while also blunting Cmax (50% reduction) and increasing the time to Cmax by more than 1.5 hours.  Isavuconazole is extensively (more than 99%) protein bound in serum. o Following an initial 2-hour distribution phase, isavuconazole displays an elimination half-life of ~80–130 hours. o A single 200-mg dose leads to detectable serum concentrations for longer than 14 days. Secondary to the protracted half-life, steady-state concentrations of isavuconazole are not achieved until approximately day 14 of once/day dosing. o The mean AUC and Cmax at steady state are 4- to 5-fold and 2- to 3-fold higher, respectively, than after the first dose.  Hepatic metabolism is the primary mode of elimination. CYP3A4 and CYP3A5 are the predominant enzymes involved in phase I metabolism, followed by modification by uridine diphosphate glucuronosyltransferase (UGT) and excretion in feces and bile. Less than 1% of isavuconazole is excreted unchanged in urine, and no renal dosage adjustments are necessary. o To assess the need for dose modification in the setting of hepatic impairment, a single dose of isavuconazonium was administered intravenously or orally to 16 subjects with mild hepatic dysfunction (Child-Pugh class A) or 16 subjects with moderate hepatic dysfunction (Child-Pugh class B), and pharmacokinetic parameters were compared with 16 healthy control subjects.[ Andes et al., 2003]  No appreciable difference in the seroconversion of isavuconazonium to the active isavuconazole was observed between groups. o Serum concentrations of isavuconazole were similar between groups until 8 hours after administration when significantly decreased clearance, 29% and 47% 285 reductions in the mild and moderate hepatic dysfunction groups, respectively, led to increased isavuconazole concentrations. o The mean half-life in the intravenous groups increased accordingly to 224 and 302 hours in patients with mild and moderate impairment, respectively, compared with 123 hours in healthy controls. o Total systemic exposure, measured as AUC from time zero extrapolated to infinity (AUC0–∞), was 85% higher with mild impairment and 159% higher with moderate impairment. o Pharmacokinetic changes varied between oral and intravenous administration but were generally similar, and the difference could not be distinguished from intersubject variability.  Although these data show an increase in isavuconazole exposures with mild or moderate hepatic dysfunction, due to the severity of invasive aspergillosis and invasive mucormycosis and a risk of diminished efficacy with lower doses, dosage adjustment is not currently recommended in these patient populations. No data are currently available in patients with severe (Child-Pugh class C) hepatic dysfunction. Pharmacodynamics Yeast  The pharmacodynamics of isavuconazole were examined in a neutropenic murine model of disseminated candidiasis.[ Lepak et al., 2013a] o A single fluconazole-susceptible (fluconazole and isavuconazole MICs of 0.25 and 0.004 mg/L, respectively) clinical isolate of C. albicans was initially used in a dose-fractionation experiment for determination of the PK-PD profile best predicting activity. o Isavuconazole was administered 2 hours postinfection in one of 20 different treatment regimens consisting of five possible total daily doses, each 2-fold greater than the last, and four dosing frequencies (once/day to 4 times/day). o Although no significant impact on fungal burden was observed with differing dosing frequencies, significant decreases in C. albicans CFUs were observed with increasing total daily doses. o In this model, the AUC:MIC was found to best correlate to the antifungal activity of isavuconazole, accounting for 84% of all variability in reduction of C. albicans CFUs.  Lepak et al. [2013a] assessed the magnitude of the PK-PD index target, measured as half maximal effect (EC50), for isavuconazole using five C. albicans, two C. glabrata, and one C. tropicalis clinical isolates. o In these experiments, isavuconazole was orally administered every 12 hours, with various total daily doses ranging from 40–640 mg/kg/24 hours. o The average fAUC:MIC corresponding to EC50 for C. albicans at 24 hours was 68. 286 o Intriguingly, a more than 16-fold lower average target (fAUC:MIC of 3.1) was observed for the three non-albicans isolates studied (p=0.04).  Overall, the PK-PD profile of isavuconazole is superimposable with those of preceding triazoles. Although the PK-PD magnitude measured for C. albicans at 24 hours (fAUC:MIC of 68) appears to be more than 2-fold higher than that of fluconazole or voriconazole, this discrepancy is potentially attributable to the highly protein-bound nature of isavuconazole (protein binding exceeding 99%) and the need to convert total drug area under the curve in these experiments. Moulds    The pharmacodynamics of isavuconazole using a neutropenic murine model of invasive pulmonary aspergillosis have also been assessed.[ Lepak et al., 2013b] o Nine clinical isolates of A. fumigatus, including six with known Erg11p mutations associated with decreased triazole susceptibility, and one laboratory isolate with a mutation in the gene coding for the target of the echinocandins (Fks1) were studied. A model previously shown to produce invasive pulmonary aspergillosis and mortality in 90–100% of untreated control mice was used by the investigators.[ Viljoen et al/, 2015] o Suspensions of Aspergillus conidia were instilled into the nares of sedated mice positioned to facilitate aspiration into the lungs. o Initiation of antifungal therapy followed 2 hours later. Isavuconazole was administered every 12 hours for a total of 7 days, with total daily doses ranging from 40–640 mg/kg/24 hours. o Following the completion of therapy, mice were killed, and lungs were processed for quantification of fungal burden. o Isavuconazole MICs ranged from 0.25–1 mg/L among A. fumigatus isolates with wild-type Erg11p and 0.125–8 mg/L among isolates known to harbor Erg11p mutations (posaconazole MICs ranged from 0.25–0.5 mg/L and 1–8 mg/L, respectively). o Increasing total daily doses of isavuconazole corresponded to decreased fungal burden in all 10 isolates of A. fumigatus studied, with the AUC:MIC accounting for 75% of all variability in response. o In experiments using isolates with wild-type Erg11p, an average maximal effect of a greater than 3-log10 reduction in CFU was observed compared with untreated controls. Activity was more variable among isolates with mutant Erg11p. The clinical dosage studied in phase III trials was chosen after careful consideration of the PK-PD of isavuconazole. Due to the severity of invasive mold infections, particularly in the immunocompromised patient populations most frequently involved, rapid attainment of therapeutic concentrations was deemed paramount. o The currently recommended loading strategy is isavuconazonium 200 mg administered every 8 hours for the first 6 doses, followed by 200 mg/day thereafter. o This regimen attains isavuconazole serum concentrations exceeding the MIC90 for Aspergillus and the MIC50 for Mucorales on day 1, and mean 287 isavuconazole trough concentrations between 2 and 3 mg/L are attained prior to the initiation of the 200 mg/day maintenance dose.[ Lepak et al., 2013b] Clinical Efficacy, Murrell et al., 2016 Phase II Trials  Viljoen et al. [2015] conducted a multicentre, double-blind non-inferiority phase II study examining the efficacy, safety and tolerability of isavuconazole in immunocompromised patients with oesophogeal candidiasis. o this study utilized different dosing strategies of isavuconazole, o The primary endpoint was clinical response at the end of therapy with secondary endpoints assessing overall therapeutic response and microbiologic response at end of therapy. o The causative pathogen in the study was nearly universally Candida albicans with isavuconazole demonstrating greater potency relative to fluconazole. o Isavuconazole in all dosing strategies was deemed to be non-inferior to fluconazole for the primary endpoint with >95% of patients in the isavuconazole treatment arms experiencing a successful outcome. o Interestingly, the microbiological response was inferior to fluconazole in one of the treatment arms; however, authors did not speculate on this finding.  Cornely et al. [2015] conducted an open-label multicentre phase II dose escalation study assessing safety and tolerability of prophylactic intravenous isavuconazole in a neutropenic patient population. o This study was an exploratory analysis and thus was not adequately powered to detect any meaningful differences; however, did examine safety, tolerability and efficacy outcomes associated with different prophylactic dosing strategies. o While 20 of 24 patients completed the study, 18 were considered to be treatment successes compared to 2 patients in a lower dose treatment arm experiencing treatment failure due to predefined possibility of fungal infection. o The authors concluded their findings supported the safety and tolerability of isavuconazole as prophylaxis in patients at high risk of fungal infection. o Larger clinical trials are needed to support the efficacy of isavuconazole as prophylaxis in this patient population. Phase III Trials  Two phase III trials were conducted prior to FDA approval of isavuconazole for invasive aspergillosis and mucormycosis.  The VITAL trial, was a Phase III, multicentre, open-label trial which examined the use of isavuconazole in patients with aspergillosis and renal impairment or with invasive fungal disease caused by rare moulds, yeasts or dimorphic fungi.[Marty et al., 2014] 288 o Patients received the standard loading dose of isavuconazole 200 mg intravenously or orally three times daily for 2 days followed by maintenance dosing of 200 mg daily. o Duration of therapy was up to 180 days which was defined as end of treatment (EOT). o An independent data review committee (DRC) categorized patients as having proven or probable invasive fungal disease as categorized by European Organization for the Research and Treatment of Cancer/Mycoses Study Group (EORTC/MSG) criteria. o The primary endpoint was overall response at EOT, based on DRC assessment of clinical, mycological and radiological criteria. o The key secondary endpoint was all-cause mortality which was assessed at days 42, 84, 120 and 180. Overall, 37 patients received isavuconazole for invasive mucormycosis with the success rate at EOT being 31.4%. o The authors concluded isavuconazole likely had similar mortality data to amphotericin B and posaconazole. o The preliminary findings of this trial in conjunction with a matched control analysis requested by the FDA resulted in approval of isavuconazole for treatment of invasive mucormycosis.  The SECURE trial, was a multinational, double-blind, randomized Phase III noninferiority study, which sought to assess the efficacy and safety of isavuconazole in patients with invasive aspergillosis and other filamentous fungi.[ Maertens et al., 2015] o Patients were randomized in a 1 : 1 ratio to receive isavuconazole 200 mg intravenously three times a day on days 1 and 2, then either intravenous or oral administration once daily at the discretion of the physician. o The voriconazole treatment arm received 6 mg/kg intravenously twice daily on day 1, 4 mg/kg intravenously twice daily on day 2, then 4 mg/kg intravenously twice daily or 200 mg orally twice daily from day 3 until treatment completion. o The primary efficacy endpoint of all-cause mortality was assessed from first dose of study drug up to day 42 in patients receiving at least one dose of study drug. o The primary outcome was assessed based on findings in the intention-to-treat (ITT) population using a 10% non-inferiority margin. o The secondary endpoint was overall response in the modified intention to treat (mITT) population as determined by the DRC. o The mITT group was defined as patients receiving at least one dose of study drug (ITT) with proven or probable invasive fungal disease. o Safety was defined as any patient, irrespective of treatment assignment, who received any study drug. o All-cause mortality for the ITT population was 19% for the isavuconazole treatment arm (48 patients) compared to 20% for the voriconazole treatment arm (52 patients), with an adjusted treatment difference of −1.0% (95% CI, −7.8 to 5.7), thus demonstrating non-inferiority. 289  The ACTIVE trial, a Phase III, double-blind randomized study, was recently completed which examined the safety and efficacy of isavuconazole in the treatment of candidaemia or other invasive Candida disease . o This study compared isavuconazole with caspofungin followed by voriconazole in 440 adult patients. o The primary outcome measures included overall treatment response at the end of intravenous therapy (caspofungin versus isavuconazole) in conjunction with resolution of signs and symptoms of infection and eradication of fungal pathogens as assessed by an independent DRC. o The key secondary endpoint assessed the success rate of isavuconazole versus the comparator regimen 2 weeks after the completion of therapy. o Preliminary data from Astellas indicated isavuconazole failed to meet noninferiority compared to caspofungin. Safety and Tolerability  Schmitt-Hoffman et al. [2006] demonstrated single dose tolerability of isavuconazole in healthy males at doses ranging from 100 to 400 mg orally and 50 to 200 mg intravenously. o No serious adverse events, electrocardiogram (ECG) abnormalities, significant laboratory changes or vital sign disturbances were reported. o Because of the small sample sizes, adverse events rates between the placebo group (n = 14), oral group (n = 15) and IV group (n = 18) were not reported.  The safety and tolerability of multiple doses of isavuconazole were assessed in healthy male subjects randomized to four safety cohorts (Cohort 1: 100 mg oral loading dose followed by 50 mg oral daily for 21 days; Cohort 2: 200 mg oral loading dose followed by 100 mg oral daily for 21 days; Cohort 3: 100 mg IV loading dose over 1-h followed by 50 mg IV daily for 14 days; Cohort 4: 200 mg IV loading dose over 1-h followed by 100 mg IV daily for 14 days) or placebo (oral and IV). Six patients were randomized to each safety cohort. o Of the 24 subjects receiving isavuconazole, 19 (79%) experienced adverse events. o Of the eight subjects receiving placebo, each reported at least one adverse event. o One common adverse event was rhinitis (25%) including the only reported severe adverse event; however, the severe rhinitis was not thought to be attributed to study drug. o One case of rhinitis was also reported in the placebo group. o Another commonly reported adverse event in the safety groups was headache (29%); however, 75% of placebo subjects also experienced headaches. o Additionally, one subject receiving oral isavuconazole experienced elevated liver function tests (mild) on day 14. The subject's AST and ALT returned to normal 3 days later while his gamma-glutamyltransferase (GGT) returned to normal at follow-up, presumably after finishing 21 days of isavuconazole.  Isavuconazole was compared to fluconazole in patients with uncomplicated oesophageal candidiasis. Patients either received isavuconazole as a 200 mg oral loading dose 291 followed by 50 mg PO daily; 400 mg oral loading dose/400 mg oral weekly; 400 mg oral loading dose/100 mg oral daily; or fluconazole 200 mg oral loading dose/100 mg oral daily [Viljoen et al., 2015]. o Adverse events were most common in the high-dose isavuconazole group (70.7%) compared with 55.0%, 45.0%, and 57.9% in the isavuconazole 50 mg daily, 400 mg weekly, and fluconazole groups, respectively. o The high-dose (400/100) isavuconazole group reported high rates of gastrointestinal adverse events (19.5%) including diarrhoea, nausea, vomiting and gastritis. o The high-dose isavuconazole group also experienced higher rates of infectious complications (41.5%) compared to the other groups. o Two severe treatment-related adverse events were attributed to isavuconazole, both in the high dose group. o One case of second-degree atrioventricular block was reported in a patient with an abnormal baseline ECG that led to treatment discontinuation. o Additionally, one patient with HIV experienced tuberculous pleurisy and died before antituberculosis treatment could be given.  Isavuconazole has also been studied as antifungal prophylaxis in 23 acute myeloid leukaemia (AML) patients receiving chemotherapy who were expected to have prolonged neutropenia. Patients received either low-dose or high-dose isavuconazole. Low dose consisted of three IV loading doses (400, 200, 200 mg) each given over 4-h at equal intervals on day 1 followed by additional two loading doses of 200 mg over 2-h on day 2. A 200 mg IV daily maintenance dose was then given until the EOT. High-dose isavuconazole consisted of double the low-dose regimen, including both the maintenance and loading doses. Cornely et al. [2015] o Isavuconazole was well tolerated in both the low- and high-dose cohorts, with minimal drug-related adverse events reported. No severe drug-related adverse events were reported. o Mild-moderate adverse events included hypotension (8.7%), vertigo (8.7%), headache (13.0%), rash (13%) and cough (8.7%) across both dosing cohorts without any higher incidence in the high-dose cohort.  Data provided to the FDA's Anti-Infective Drugs Advisory Committee suggest isavuconazole is well tolerated compared to voriconazole. According to this data, o study drug-related treatment emergent adverse events (TEAEs) occurred in 42.4% of subjects receiving isavuconazole (n = 257) 200 mg IV three times daily on days 1 and 2 followed by 200 mg IV or oral daily thereafter compared to 59.8% of subjects receiving voriconazole (n = 259) 6 mg/kg IV twice daily on day 1 followed by 4 mg/kg IV or oral twice daily thereafter for the treatment of suspected invasive aspergillosis. [FDA, 2015] o The most common drug-related TEAEs with isavuconazole were nausea (7.4%), vomiting (5.1%) and LFT elevations including GGT elevations (1.6 to 2.3%). o Hepatotoxicity (ALT or AST > 3 × ULN and total bilirubin > 2 × ULN) appeared to be less common in the isavuconazole arm (3.2%) compared to the voriconazole arm (3.9%). 291 o Infusion site reactions were more common with isavuconazole (4.3%) than voriconazole (1.5%) although none of these events were deemed serious or led to study drug discontinuation. Severe cutaneous reactions were rare in both groups (1.2% isavuconazole; 0.8% voriconazole). o Visual disturbances were more common in the voriconazole group (16.6%) than in the isavuconazole group (8.2%). o Notably, visual hallucinations were seen in 4.2% of patients receiving voriconazole compared to 1.2% of patients receiving isavuconazole. Overall, isavuconazole appears to be well tolerated with a toxicity profile similar to fluconazole.  Adverse event data from the SECURE trial revealed: o adverse events with isavuconazole to be less common compared to voriconazole, particularly with regard to hepatobiliary, dermatologic and ophthalmic adverse events at 42% and 60% respectively. o adverse event data from the mucormycosis subset of the VITAL trial revealed 35 TEAEs and 13 study drug-related TEAEs. o The most common reported adverse event was vomiting with other gastrointestinal adverse effects being the next most common.[Schmitt-Hoffman et al., 2006] Dosing and Administration, Murrell et al., 2016      Isavuconazole can be administered IV or oral capsule and can be given without regard to meals. The current package insert labelling refers to dosing in units of the prodrug. Coadministration of omeprazole has a minimal effect on isavuconazole bioavailability (7.6% increase in AUC). Therefore, medications that interfere with gastric pH are not expected to alter isavuconazole pharmacokinetics. Capsules of 50, 100, 200 and 400 mg strengths were used during clinical trials. Intravenous isavuconazole was used in clinical trials as isavuconazonium in strengths equivalent to 100 and 200 mg of isavuconazole. o It was provided as lyphilized powder due to moisture sensitivity. Once reconstituted with 5 mL sterile water for injection, it can be diluted into 250 mL of normal saline or 5% dextrose in water. o Because of its poor aqueous solubility, precipitates of isavuconazole can be seen as translucent to white particulate matter. o Therefore, IV isavuconazole should be administered through an in-line filter of 0.2 to 1.2 μm in size over an hour to avoid possible infusion-related reactions. It is imperative to understand the dosing of isavuconazole relative to isavuconazonium content in the lyophilized powder and capsule formulations. o The powder contains 372.6 mg of isavuconazonium corresponding to 200 mg of isavuconazole, 292 o whereas the capsule contains 186.3 mg of isavuconazonium corresponding to 100 mg of isavuconazole. o The current FDA approved dosing is 200 mg of IV or oral isavuconazole every 8 h for 6 doses followed by a 200 mg daily maintenance dose. o The maintenance dose should start 12 to 24 h at the conclusion of the loading dose. Tolerability of Isavuconazole, Shirley and Scott., 2016  Across the SECURE and VITAL trials (Sect. 4), 403 patients with invasive fungal disease received isavuconazole therapy, with 144 of these treated for >12 weeks and 52 treated for >6 months. o Isavuconazole was generally well tolerated in these trials. o The most commonly reported adverse events among isavuconazole recipients were nausea (26 %), vomiting (25 %), diarrhoea (22 %), headache (17 %), elevated liver chemistry tests (16 %), hypokalaemia (14 %), constipation (13 %), dyspnoea (12 %) and cough (12 %), suggesting that the tolerability profile of isavuconazole is generally consistent with those of other triazole antifungals. o Serious adverse events occurred in 55 % of patients across the two trials, although it should be noted that the trials were performed in populations of patients with significant underlying comorbidities. o Fourteen percent of patients permanently discontinued isavuconazole treatment because of an adverse event, most commonly confusional state (0.7 %), acute renal failure (0.7 %), increased blood bilirubin (0.5 %), convulsion (0.5 %), dyspnoea (0.5 %), epilepsy (0.5 %), respiratory failure (0.5 %) and vomiting (0.5 %).    In the active-controlled SECURE trial, treatment-emergent adverse events (TEAEs) were reported by 96 % of isavuconazole recipients and by 98 % of voriconazole recipients. The most commonly reported TEAEs in the trial were nausea (28 % of isavuconazole recipients vs. 30 % of voriconazole recipients), vomiting (25 vs. 28 %), diarrhoea (24 vs. 23 %), pyrexia (22 vs. 30 %) and hypokalaemia (18 vs. 22 %) [40]. When TEAEs were grouped by system organ class, similar proportions of isavuconazole and voriconazole recipients experienced adverse events for most categories, although a significantly lower proportion of isavuconazole recipients experienced skin or subcutaneous disorders (33 vs. 42 %; p = 0.037), eye disorders (15 vs. 27 %; p = 0.002) or hepatobiliary disorders (9 vs. 16 %; p = 0.016) (Fig. 1). The proportion of patients experiencing TEAEs considered by the investigator to be remotely, possibly or probably related to the study drug was significantly lower in the isavuconazole group than in the voriconazole group (42 vs. 60 %; p < 0.001) [40]. 293 Treatment-emergent adverse events in the phase III SECURE trial, grouped by system organ class [Maertens et al., 2016]. Adverse events shown are those occurring in ≥15 % of patients in either treatment group. *p < 0.05, **p < 0.01, Shirley and Scott., 2016 Place of Isavuconazole in the Management of Invasive Aspergillosis and Mucormycosis, Shirley and Scott., 2016  The latest (2016) Infectious Diseases Society of America guidelines recommend voriconazole for the primary treatment of invasive aspergillosis, with isavuconazole or liposomal amphotericin B recommended as alternatives. Given its more recent development and approval, isavuconazole was not considered in other currently available guidelines.  These guidelines recommend voriconazole as the gold standard for primary treatment, with liposomal amphotericin B, amphotericin B lipid complex, caspofungin, posaconazole (EU only) or itraconazole generally recommended as salvage therapy alternatives for refractory disease or for patients intolerant of primary treatment.  In the well-designed, phase III SECURE trial, isavuconazole was non-inferior to voriconazole in terms of efficacy for the primary treatment of suspected invasive mould disease caused by Aspergillus spp. or other filamentous fungi. Of note, the trial population included patients with disease caused by A. fumigatus and A. flavus (i.e. the most common Aspergillusspecies associated with invasive disease), as well as by A. niger and A. terreus (albeit with low patient numbers). Furthermore, isavuconazole appeared to have favourable tolerability compared with voriconazole, with fewer drug294          related TEAEs and fewer TEAEs associated with skin, eye and hepatobiliary disorders reported among isavuconazole-treated patients in the SECURE trial. In the single-arm, international, phase III VITAL trial, treatment success (i.e. a complete or partial response) was achieved by 31 % of isavuconazole-treated patients at end-of-treatment, with the success rate reaching 60 % when patients with stable disease were included. Supportive evidence for the efficacy of isavuconazole in the treatment of mucormycosis was provided by a matched case–control analysis which showed that mortality rates were similar between patients who received isavuconazole as primary treatment in the VITAL trial and contemporary amphotericin B-treated patients from a registry database. Despite the lack of a double-blind, randomized controlled trial in mucormycosis (difficult to perform given the relative rarity of the disease), and variability in isavuconazole‘s in vitro activity against different Mucorales isolates, when compared with historical data [5, 21, 51], the findings from the VITAL trial and the case–control analysis suggest that isavuconazole is efficacious in the treatment of mucormycosis. In addition to the evidence for its efficacy in invasive aspergillosis and mucormycosis, isavuconazole has several other attributes that suggest it may be a useful new agent in the treatment of these life-threatening diseases. Available in intravenous and oral formulations, it has excellent bioavailability, with the two formulations being interchangeable based on clinical need. Furthermore, the water-solubility of the prodrug obviates the need in the intravenous formulation for a vehicle molecule such as cyclodextrin which can be associated with nephrotoxicity. Indeed, isavuconazole has no dosage adjustment requirements based on renal impairment (including ESRD), nor for patients with mild or moderate hepatic impairment. Isavuconazole has low clearance and a long half-life that enables a once-daily maintenance dose regimen, and the oral formulation can be administered without regard to food. Isavuconazole has predictable and linear pharmacokinetics with no apparent requirement for therapeutic drug monitoring, and is generally well tolerated, with the most common adverse events being gastrointestinal disorders such as nausea, vomiting and diarrhoea. Isavuconazole is associated with several potential drug–drug interactions, although these appear to be fewer (or less pronounced) than those reported for other azoles such as voriconazole and posaconazole. A possible limitation of isavuconazole is the potential for cross-resistance with other azole antifungals, although the clinical significance of this is not yet clear. Another area where further investigation would be of value is regarding the effectiveness of isavuconazole in treating invasive fungal infections in sites such as the eye and central nervous system. Eighteen percent of patients the SECURE trial mITT population had disease in organs outside the lower respiratory tract (8 % with disease exclusively outside the lower respiratory tract), and available pharmacokinetic data (largely from animal studies) suggest that isavuconazole is widely distributed in tissues. However, further investigation into the effectiveness of isavuconazole in treating infections such as cerebral aspergillosis would be of interest. Lastly, the place of isavuconazole in the management of invasive aspergillosis and mucormycosis will likely also be influenced by pharmacoeconomic considerations 295 Isavuconazole Approval History  FDA approved: Yes (First approved March 6th, 2015)  Brand name: Cresemba, isavuconazole  Generic name: isavuconazonium  Dosage form: Capsules and Injection  Company: Astellas Pharma US, Inc.  Treatment for: Invasive Aspergillosis; Invasive Mucormycosis Recent reports Astvad et al. (2017) determined the in vitro activity of isavuconazole for 1677 Candida and 958 Aspergillus isolates from 2012 to 2014 with voriconazole as comparator. Aspergillus isolates were screened for resistance using azole-agar. Aspergillus isolates that screened positive and all Candida isolates underwent EUCAST broth microdilution testing. Isolates were categorized as wild-type (wt) or non-wt, adopting EUCAST epidemiological cut-off values (ECOFFs) (where available) or wt upper limits (wtULs; two two-fold dilutions above the MIC50). The CYP51A gene was sequenced for non-wt Aspergillus fumigatus isolates. Itraconazole and posaconazole MICs were determined for selected Aspergillus isolates with isavuconazole MIC ≥2 mg/L. Isavuconazole MIC50 (range) (mg/L) against Candida species were: Candida albicans: ≤0.03 (≤0.03 to >4), Candida dubliniensis: ≤0.03 (≤0.03), Candida glabrata: ≤0.03 (≤0.03-4), Candida krusei: 0.06 (≤0.03-0.5), Candida parapsilosis: ≤0.03 (≤0.03-0.06), Candida tropicalis: ≤0.03 (≤0.03 to >4), Saccharomyces cerevisiae (anamorph: Candida robusta): ≤0.03 (≤0.03-0.5). Nonwt isavuconazole/voriconazole MICs were found for C. albicans: 0.8/1.0%, C. dubliniensis: 0/1.8%, C. glabrata: 14.9/9.5%, C. krusei: 2.7/1.4%, C. parapsilosis: 1.7/1.8%, C. tropicalis: 14.3/19.1% and S. cerevisiae: 10.0/0%. IsavuconazoleMIC50 (range) (mg/L) against Aspergillus species were: A. fumigatus: 1 (≤0.125 to >16), Aspergillus niger: 2 (1-8), Aspergillus terreus: 1 (0.25-8), Aspergillus flavus: 1 (0.5-2), Aspergillus nidulans: ≤0.125 (≤0.125-0.25). Nonwt isavuconazole/voriconazole MICs were found for 13.7/15.2% A. fumigatus, 4.9/0% A. niger and 48.2/22.2% A. terreus. Desai et al. (2017) evaluated pharmacokinetic and pharmacodynamic interactions between the novel triazole antifungal agent isavuconazole and warfarin in healthy adults. Multiple doses of isavuconazole were administered as the oral prodrug, isavuconazonium sulfate (372 mg 3 times a day for 2 days loading dose, then 372 mg once daily thereafter; equivalent to isavuconazole 200 mg), in the presence and absence of single doses of oral warfarin sodium 20 mg. Coadministration with isavuconazole increased the mean area under the plasma concentration-time curves from time 0 to infinity of S- and R-warfarin by 11% and 20%, 296 respectively, but decreased the mean maximum plasma concentrations of S- and R-warfarin by 12% and 7%, respectively, relative to warfarin alone. Mean area under the international normalized ratio curve and maximum international normalized ratio were 4% lower in the presence vs absence of isavuconazole. Mean warfarin area under the prothrombin time curve and maximum prothrombin time were 3% lower in the presence vs absence of isavuconazole. There were no serious treatment-emergent adverse events (TEAEs), and no subjects discontinued the study due to TEAEs. All TEAEs were mild in intensity. These findings indicate that coadministration with isavuconazole has no clinically relevant effects on warfarin pharmacokinetics or pharmacodynamics. Gebremariam et al. (2017) evaluated in vitro susceptibility to isavuconazole of Mucorales using the CLSI M38-A2 method. Immunosuppressed mice were intratracheally infected with either Mucor circinelloides or R. delemar. Treatment with isavuconazole (orally), micafungin (intraperitoneally), a combination of both or LAmB (intravenously) was compared, with survival and tissue fungal burden serving as primary and secondary endpoints, respectively. Isavuconazole was as effective as LAmB in prolonging survival of mice infected with M. circinelloides. Against R. delemar-induced mucormycosis, all monotherapy treatments significantly improved survival of mice versus placebo without showing superiority over one another. However, LAmB was superior in lowering fungal burden in target organs. Although combination therapy of isavuconazole + micafungin did not enhance survival of mice over monotherapy, antagonism was not detected between the two drugs. It was concluded that Isavuconazole is effective in treating pulmonary murine mucormycosis due to Mucor. In addition, combination therapy of isavuconazole + micafungin does not demonstrate synergy and it is not antagonistic against Rhizopus-induced mucormycosis. Harrington et al. (2017) evaluated the costs and cost-effectiveness of isavuconazole vs. voriconazole for the first-line treatment of IA from the US hospital perspective. An economic model was developed to assess the costs and cost-effectiveness of isavuconazole vs. voriconazole in hospitalized patients with IA. The time horizon was the duration of hospitalization. Length of stay for the initial admission, incidence of readmission, clinical response, overall survival rates, and experience of adverse events (AEs) came from the SECURE trial. Unit costs were from the literature. Total costs per patient were estimated, composed of drug costs, costs of AEs, and costs of hospitalizations. Incremental costs per death avoided and per additional clinical responders were reported. Deterministic and probabilistic sensitivity analyses (DSA and PSA) were conducted. Base case analysis showed that isavuconazole was associated with a $7418 lower total cost per patient than voriconazole. In both incremental costs per death avoided and incremental costs per additional clinical responder, isavuconazole dominated voriconazole. Results were robust in sensitivity analysis. Isavuconazole was cost saving and dominant vs. voriconazole in most DSA. In PSA, isavuconazole was cost saving in 80.2% of the simulations and cost-effective in 82.0% of the simulations at the $50,000 willingness to pay threshold per additional outcome. Katragkou et al. (2017) used Bliss independence drug interaction analysis and time-kill assays to examine the in vitro interactions of isavuconazole with amphotericin B or micafungin, an echinocandin, against strains of Candida albicans, Candida parapsilosis, Candida glabrata, Candida tropicalis, and Candida krusei. The Bliss independence-based drug interactions modeling showed that the combination of isavuconazole and micafungin resulted in synergistic interactions against C. albicans, C. parapsilosis, and C. krusei. The degree of synergy ranged 297 from 1.8% to 16.7% (mean %ΔΕ value) with the highest synergy occurring against C. albicans (∑SYN% = 8.8%-110%). Time-kill assays showed that the isavuconazole-micafungin combination demonstrated concentration-depended synergy against C. albicans and C. parapsilosis. The combined interaction by Bliss analysis between isavuconazoleand amphotericin B was indifferent for C. albicans, C. parapsilosis, and C. tropicalis while for C. glabrata was antagonistic (-2% to -6%) and C. krusei synergistic (3.4% to 7%). The combination of isavuconazole-amphotericin B by time-kill assay was antagonistic against C. krusei and C. glabrata. Collectively, our findings demonstrate that combinations of isavuconazole and micafungin are synergistic against Candida spp., while those of isavuconazole and amphotericin B are indifferent in vitro. Keirns et al. (2017) assessed the effects of isavuconazole (active moiety of isavuconazonium sulfate) on cardiac ion channels in vitro and cardiac repolarization clinically in a phase I, randomized, double-blind study in healthy individuals who received isavuconazole (after 2-day loading dose), at therapeutic or supratherapeutic doses daily for 11 days, moxifloxacin (400 mg q.d.), or placebo. A post-hoc analysis of the phase III SECURE trial assessed effects on cardiac safety. L-type Ca2+ channels were most sensitive to inhibition by isavuconazole. The 50% inhibitory concentrations for ion channels were higher than maximum serum concentrations of nonprotein-bound isavuconazole in vivo. In the phase I study (n = 161), isavuconazole shortened the QT interval in a dose- and plasma concentration-related manner. There were no serious treatment-emergent adverse events; palpitations and tachycardia were observed in placebo and supratherapeutic isavuconazole groups; no cardiac safety signals were detected in the SECURE study (n = 257). Isavuconazole was associated with a shortened cardiac QT interval. Townsend et al. (2017) described the phase 1 trials that evaluated the metabolism of the novel triazole antifungal isavuconazole by cytochrome P450 3A4 (CYP3A4) and isavuconazole's effects on CYP3A4-mediated metabolism in healthy adults. Coadministration of oral isavuconazole (100 mg once daily) with oral rifampin (600 mg once daily; CYP3A4 inducer) decreased isavuconazole area under the concentration-time curve (AUCτ ) during a dosing interval by 90% and maximum concentration (Cmax ) by 75%. Conversely, coadministration of isavuconazole (200 mg single dose) with oral ketoconazole (200 mg twice daily; CYP3A4 inhibitor) increased isavuconazole AUC from time 0 to infinity (AUC0-∞ ) and Cmax by 422% and 9%, respectively. Isavuconazole was coadministered (200 mg 3 times daily for 2 days, then 200 mg once daily) with single doses of oral midazolam (3 mg; CYP3A4 substrate) or ethinyl estradiol/norethindrone (35 μg/1 mg; CYP3A4 substrate). Following coadministration, AUC0-∞ increased 103% for midazolam, 8% for ethinyl estradiol, and 16% for norethindrone; C max increased by 72%, 14%, and 6%, respectively. Most adverse events were mild to moderate in intensity; there were no deaths, and serious adverse events and adverse events leading to study discontinuation were rare. These results indicate that isavuconazole is a sensitive substrate and moderate inhibitor of CYP3A4 Maertens et al. (2016) performed the SECURE trial to assess efficacy and safety of isavuconazole versus voriconazole in patients with invasive mould disease.This was a phase 3, double-blind, global multicentre, comparative-group study. Patients with suspected invasive mould disease were randomised in a 1:1 ratio using an interactive voice-web response system, stratified by geographical region, allogeneic haemopoietic stem cell transplantation, and active malignant disease at baseline, to receive isavuconazonium sulfate 372 mg (prodrug; equivalent to 200 mg isavuconazole; intravenously three times a day on days 1 and 2, then either intravenously or orally once daily) or voriconazole (6 mg/kg intravenously twice daily on day 1, 4 mg/kg intravenously twice daily on day 2, then intravenously 4 mg/kg twice daily or orally 200 mg twice daily from day 3 onwards). We tested non-inferiority of the primary efficacy endpoint of 298 all-cause mortality from first dose of study drug to day 42 in patients who received at least one dose of the study drug (intention-to-treat [ITT] population) using a 10% non-inferiority margin. Safety was assessed in patients who received the first dose of study drug. This study is registered with ClinicalTrials.gov, number NCT00412893. 527 adult patients were randomly assigned (258 received study medication per group) between March 7, 2007, and March 28, 2013. All-cause mortality from first dose of study drug to day 42 for the ITT population was 19% with isavuconazole(48 patients) and 20% with voriconazole (52 patients), with an adjusted treatment difference of -1·0% (95% CI -7·8 to 5·7). Because the upper bound of the 95% CI (5·7%) did not exceed 10%, non-inferiority was shown. Most patients (247 [96%] receiving isavuconazole and 255 [98%] receiving voriconazole) had treatment-emergent adverse events (p=0·122); the most common were gastrointestinal disorders (174 [68%] vs 180 [69%]) and infections and infestations (152 [59%] vs 158 [61%]). Proportions of patients with treatmentemergent adverse events by system organ class were similar overall. However, isavuconazoletreated patients had a lower frequency of hepatobiliary disorders (23 [9%] vs 42 [16%]; p=0·016), eye disorders (39 [15%] vs 69 [27%]; p=0·002), and skin or subcutaneous tissue disorders (86 [33%] vs 110 [42%]; p=0·037). Drug-related adverse events were reported in 109 (42%) patients receiving isavuconazole and 155 (60%) receiving voriconazole (p<0·001). Isavuconazole was non-inferior to voriconazole for the primary treatment of suspected invasive mould disease. Isavuconazole was well tolerated compared with voriconazole, with fewer studydrug-related adverse events. These results support the use of isavuconazole for the primary treatment of patients with invasive mould disease. Marty et al. (2016) assessed the efficacy and safety of isavuconazole for treatment of mucormycosis and compared its efficacy with amphotericin B in a matched case-control analysis. mIn a single-arm open-label trial (VITAL study), adult patients (≥18 years) with invasive fungal disease caused by rare fungi, including mucormycosis, were recruited from 34 centres worldwide. Patients were given isavuconazole 200 mg (as its intravenous or oral watersoluble prodrug, isavuconazonium sulfate) three times daily for six doses, followed by 200 mg/day until invasive fungal disease resolution, failure, or for 180 days or more. The primary endpoint was independent data review committee-determined overall response-ie, complete or partial response (treatment success) or stable or progressive disease (treatment failure)-according to prespecified criteria. Mucormycosis cases treated with isavuconazole as primary treatment were matched with controls from the FungiScope Registry, recruited from 17 centres worldwide, who received primary amphotericin B-based treatment, and were analysed for day-42 all-cause mortality. VITAL is registered with ClinicalTrials.gov, number NCT00634049. FungiScope is registered with ClinicalTrials.gov, number NCT01731353. Murrel et al. (2016) reviewed the place in therapy of isavuconazole, the active metabolite of isavuconazonium sulfate, via a review of the available literature on drug chemistry, spectrum of activity, pharmacokinetic/pharmacodynamic profile and trials assessing clinical efficacy and safety. Relevant data, original research articles and reviews, were gathered primarily through the use of a PubMed database search. The search was conducted without date restrictions in order to collect both historical and recent data regarding isavuconazole. Isavuconazole is a triazole currently approved not only for use in invasive aspergillosis and mucormycosis but also has demonstrable activity against Candida species and other common fungal pathogens. This drug has features which make it more clinically appealing compared to other azoles with similar indications. In specific, isavuconazole does not require a cyclodextrin vehicle due to its water solubility, and at present, does not require therapeutic drug monitoring. Moreover, isavuconazole 299 has displayed improved safety and tolerability compared to voriconazole. Available data from Phase III clinical trials shows isavuconazole to be a possible therapeutic option to currently available therapies for which it is approved; however, clinical conclusions should be reserved until results have been published and more data from clinical use is reported. Shirley and Scott (2016) mentioned that Isavuconazole is a second-generation triazole with activity against a broad spectrum of clinically important fungi. Its water-soluble prodrug, isavuconazonium sulfate (Cresemba®), available in interchangeable intravenous and oral formulations, is approved in the USA and EU for the treatment of adults with invasive aspergillosis and mucormycosis. In international phase III clinical trials, isavuconazole was efficacious and generally well tolerated in the treatment of these life-threatening diseases. In the phase III SECURE trial, isavuconazole was non-inferior to voriconazole for the primary treatment of invasive mould disease (primarily aspergillosis) and was associated with fewer drug-related treatment-emergent adverse events (TEAEs) than voriconazole. In addition, the single-arm, phase III VITAL trial and a matched case-control analysis of isavuconazole- versus amphotericin B-treated patients provided evidence of the efficacy of isavuconazole in the treatment of mucormycosis. The most commonly reported TEAEs among isavuconazole recipients were gastrointestinal disorders such as nausea, vomiting and diarrhoea. Isavuconazole has several other attributes that make it a useful new treatment option for these invasive mould diseases, including predictable pharmacokinetics, excellent bioavailability, no food effect with the oral formulation, and its potential utility in renally impaired patients given the absence of cyclodextrin in the intravenous formulation. Wilson et al. (2016) mentioned that Isavuconazole, a second-generation triazole, was approved by the US Food and Drug Administration in March 2015 and the European Medicines Agency in July 2015 for the treatment of adults with invasive aspergillosis (IA) or mucormycosis. Similar to amphotericin B and posaconazole, isavuconazole exhibits a broad spectrum of in vitro activity against yeasts, dimorphic fungi, and molds. Isavuconazole is available in both oral and intravenous formulations, exhibits a favorable safety profile (notably the absence of QTc prolongation), and reduced drug-drug interactions (relative to voriconazole). Phase 3 studies have evaluated the efficacy of isavuconazole in the management of IA, mucormycosis, and invasive candidiasis. Based on the results of these studies, isavuconazole appears to be a viable treatment option for patients with IA as well as those patients with mucormycosis who are not able to tolerate or fail amphotericin B or posaconazole therapy. In contrast, evidence of isavuconazole for invasive candidiasis (relative to comparator agents such as echinocandins) is not as robust. Therefore, isavuconazole use for invasive candidiasis may initially be reserved as a step-down oral option in those patients who cannot receive other azoles due to tolerability or spectrum of activity limitations. Post-marketing surveillance of isavuconazole will be important to better understand the safety and efficacy of this agent, as well as to better define the need for isavuconazole serum concentration monitoring. Badali et al. (2015) determined the MICs of amphotericin B, fluconazole, itraconazole, voriconazole, posaconazole, isavuconazole, terbinafine and MECs of caspofungin and anidulafungin based on CLSI M38-A2. The resulting MIC90 s of all strains were, in increasing order, as follows: terbinafine (0.063 mg l(-1) ); posaconazole (1 mg l(-1) ); isavuconazole and anidulafungin (2 mg l(-1) ); itraconazole, voriconazole, amphotericin B, and caspofungin (4 mg l(-1) ) and fluconazole (>64 mg l(-1) ). These results confirm that terbinafine is an excellent 311 agent for treatment of dermatophytosis due to T. rubrum, T. mentagrophytes, T. verrucosum, T. schoenleinii and E. floccosum. In addition, the new azoles POS and ISA are potentially useful antifungals to treat dermatophytosis. However, the clinical effectiveness of these novel antifungals remains to be determined. Cornely et al. (2015) performed an open-label dose escalation study to assess the safety and pharmacokinetics of intravenous isavuconazole prophylaxis in patients with acute myeloid leukemia who had undergone chemotherapy and had preexisting/expected neutropenia. Twentyfour patients were enrolled, and 20 patients completed the study. The patients in the low-dose cohort (n = 11) received isavuconazole loading doses on day 1 (400/200/200 mg, 6 h apart) and day 2 (200/200 mg, 12 h apart), followed by once-daily maintenance dosing (200 mg) on days 3 to 28. The loading and maintenance doses were doubled in the high-dose cohort (n = 12). The mean ± standard deviation plasma isavuconazole areas under the concentration-time curves for the dosing period on day 7 were 60.1 ± 22.3 μg · h/ml and 113.1 ± 19.6 μg · h/ml for the patients in the low-dose and high-dose cohorts, respectively. The adverse events in five patients in the low-dose cohort and in eight patients in the high-dose cohort were considered to be drug related. Most were mild to moderate in severity, and the most common adverse events were headache and rash (n = 3 each). One patient in the high-dose cohort experienced a serious adverse event (unrelated to isavuconazole treatment), and two patients each in the low-dose and high-dose cohorts discontinued the study due to adverse events. Of the 20 patients who completed the study, 18 were classified as a treatment success. Miceli et al. (2015) mentioned that Isavuconazole is a new extended-spectrum triazole with activity against yeasts, molds, and dimorphic fungi. It is approved for the treatment of invasive aspergillosis and mucormycosis. Advantages of this triazole include the availability of a watersoluble intravenous formulation, excellent bioavailability of the oral formulation, and predictable pharmacokinetics in adults. A randomized, double-blind comparison clinical trial for treatment of invasive aspergillosis found that the efficacy of isavuconazole was noninferior to that of voriconazole. An open-label trial that studied primary as well as salvage therapy of invasive mucormycosis showed efficacy with isavuconazole that was similar to that reported for amphotericin B and posaconazole. In patients in these studies, as well as in normal volunteers, isavuconazole was well tolerated, appeared to have few serious adverse effects, and had fewer drug-drug interactions than those noted with voriconazole. As clinical experience increases, the role of this new triazole in the treatment of invasive fungal infections will be better defined. Pettit and Carver (2015) reviewed the pharmacology, chemistry, in vitro susceptibility, pharmacokinetics, clinical efficacy, safety, tolerability, dosage, and administration of isavuconazole, a triazole antifungal agent. Studies and reviews were identified through an English language MEDLINE search (1978 to March 2015) and from http://www.clinicaltrials.gov, Food and Drug Administration (FDA) briefing documents, program abstracts from international symposia, and the manufacturer's Web site. All published and unpublished trials, abstracts, in vitro and preclinical studies, and FDA briefing documents were reviewed. Isavuconazole has activity against a number of clinically important yeasts and molds, including Candida spp, Aspergillus spp, Cryptococcus neoformans, and Trichosporon spp and variable activity against the Mucorales. Isavuconazole, available for both oral and intravenous administration, is characterized by slow elimination allowing once-daily dosing, extensive tissue distribution, and high (>99%) protein binding. The most commonly reported adverse events, which are mild and limited in nature, include nausea, diarrhea, and elevated liver 311 function tests. Its drug interaction potential appears to be similar to other azole antifungals but less than those observed with voriconazole. Comparative trials are under way or have been recently completed for the treatment of candidemia, invasive candidiasis and aspergillosis, and rare mold infections. CONCLUSIONS: Isavuconazole has a broad spectrum of activity and favorable pharmacokinetic properties, providing an advantage over other currently available broad-spectrum azole antifungals and a clinically useful alternative to voriconazole for the treatment of invasive aspergillosis. It may also prove useful for the treatment of candidemia and invasive mold infections; however, these indications await the results of clinical trials. Rybak et al. (2015) mention ed that Isavuconazole, administered as the prodrug isavuconazonium, is the latest second-generation triazole antifungal to receive U.S. Food and Drug Administration approval. Approved for the treatment of both invasive aspergillosis and invasive mucormycosis, and currently under investigation for the treatment of candidemia and invasive candidiasis, isavuconazole may have therapeutic advantages over its predecessors. With clinically relevant antifungal potency against a broad range of yeasts, dimorphic fungi, and molds, isavuconazole has a spectrum of activity reminiscent of the polyene amphotericin B. Moreover, clinical experience thus far has revealed isavuconazole to be associated with fewer toxicities than voriconazole, even when administered without therapeutic drug monitoring. These characteristics, in an agent available in both a highly bioavailable oral and a β-cyclodextrin-free intravenous formulation, will likely make isavuconazole a welcome addition to the triazole class of antifungals. Viljoen et al. (2015) compared the efficacy and safety of three oral dosing regimens of isavuconazole with an oral fluconazole regimen in the primary treatment of uncomplicated esophageal candidiasis. The isavuconazole regimens were as follows: 200 mg on day 1 and then 50 mg once daily (arm A), 400 mg on day 1 and then 400 mg once-weekly (arm B), and 400 mg on day 1 and then 100 mg once daily (arm C). Patients in arm D received fluconazole at 200 mg on day 1 and then 100 mg once daily. The minimum treatment duration was 14 days. The primary endpoint was the rate of endoscopically confirmed clinical response at end of therapy. Safety and tolerability were also assessed. Efficacy was evaluated in 153 of 160 enrolled patients. Overall, 146 (95.4%) achieved endoscopically confirmed clinical success. Each of the isavuconazole regimens was shown to be not inferior to fluconazole, i.e., arm A versus D, -0.5% (95% confidence interval [CI] -10.0 to 9.4), arm B versus D, 3.5% (95% CI, -5.6 to 12.7), and arm C versus D, -0.2% (95% CI, -9.8 to 9.4). The frequency of adverse events was similar in arm A (n = 22; 55%), arm B (n = 18; 45%), and arm D (n = 22; 58%), but higher in arm C (n = 29; 71%). In summary, efficacy and safety of once-daily and once-weekly isavuconazole were comparable with once-daily fluconazole in the primary treatment of uncomplicated esophageal candidiasis. Castanheira et al. (2014) assessed the in vitro activity of isavuconazole and nine antifungal comparator agents using reference broth microdilution methods against 1,421 common and uncommon species of Candida from a 2012 global survey. Isolates were identified using CHROMagar, biochemical methods and sequencing of ITS and/or 28S regions. Candida spp. were classified as either susceptible or resistant and as wild type (WT) or non-WT using CLSI clinical breakpoints or epidemiological cutoff values, respectively, for the antifungal agents. Isolates included 1,421 organisms from 21 different species of Candida. Among Candida spp., resistance to all 10 tested antifungal agents was low (0.0-7.9 %). The vast majority of each species of Candida, with the exception of Candida glabrata, Candida krusei, and Candida 312 guilliermondii (modal MICs of 0.5 µg/ml), were inhibited by ≤0.12 µg/ml of isavuconazole (99.0 %; range 94.3 % [Candida tropicalis] to 100.0 % [Candida lusitaniae and Candida dubliniensis]). C. glabrata, C. krusei, and C. guilliermondii were largely inhibited by ≤1 µg/ml of isavuconazole (89.7, 96.9 and 92.8 %, respectively). Decreased susceptibility to isavuconazole was most prominent with C. glabrata where the modal MIC for isavuconazole was 0.5 µg/ml for those strains that were SDD to fluconazole or WT to voriconazole, and was 4 µg/ml for those that were either resistant or non-WT to fluconazole or voriconazole, respectively. In conclusion, these data document the activity of isavuconazole and generally the low resistance levels to the available antifungal agents in a large, contemporary (2012), global collection of molecularly characterized species of Candida. References 1. Andes D, van Ogtrop M. Characterization and quantitation of the pharmacodynamics of fluconazole in a neutropenic murine disseminated candidiasis infection model. Antimicrob Agents Chemother 1999;9:2116–20. 2. Andes D, Marchillo K, Stamstad T, Conklin R. In vivo pharmacokinetics and pharmacodynamics of a new triazole, voriconazole, in a murine candidiasis model. Antimicrob Agents Chemother 2003;10:3165–9. 3. Astvad KMT1, Hare RK1, Arendrup MC2. Evaluation of the in vitro activity of isavuconazole and comparator voriconazole against 2635 contemporary clinical Candida and Aspergillus isolates. Clin Microbiol Infect. 2017 Apr 1. pii: S1198-743X(17)30192-1. 4. Badali H1, Mohammadi R, Mashedi O, de Hoog GS, Meis JF. In vitro susceptibility patterns of clinically important Trichophyton and Epidermophyton species against nine antifungal drugs. Mycoses. 2015 May;58(5):303-7. 5. Castanheira M1, Messer SA, Rhomberg PR, Dietrich RR, Jones RN, Pfaller MA. Isavuconazole and nine comparator antifungal susceptibility profiles for common and uncommon Candida species collected in 2012: application of new CLSI clinical breakpoints and epidemiological cutoff values. Mycopathologia. 2014 Aug;178(1-2):1-9. 6. Cornely OA1, Böhme A2, Schmitt-Hoffmann A3, Ullmann AJ4. Safety and pharmacokinetics of isavuconazole as antifungal prophylaxis in acute myeloid leukemia patients with neutropenia: results of a phase 2, dose escalation study. Antimicrob Agents Chemother. 2015 Apr;59(4):2078-85. 7. Desai A1, Yamazaki T1, Dietz AJ2, Kowalski D1, Lademacher C1, Pearlman H1, Akhtar S1, Townsend R1. Pharmacokinetic and Pharmacodynamic Evaluation of the Drug-Drug Interaction Between Isavuconazole and Warfarin in Healthy Subjects. Clin Pharmacol Drug Dev. 2017 Jan;6(1):86-92. 8. Espinel-Ingroff A1, Chowdhary A, Gonzalez GM, Lass-Flörl C, Martin-Mazuelos E, Meis J, Peláez T, Pfaller MA, Turnidge J. Multicenter study of isavuconazole MIC distributions and epidemiological cutoff values for Aspergillus spp. for the CLSI M38-A2 broth microdilution method. Antimicrob Agents Chemother. 2013 Aug;57(8):3823-8. 9. Espinel-Ingroff A, Chowdhary A, Gonzalez GM, et al. 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Howard SJ, Lass-Florl C, Cuenca-Estrella M, Gomez-Lopez A, Arendrup MC. Determination of isavuconazole susceptibility of Aspergillus and Candida species by the EUCAST method. Antimicrob Agents Chemother 2013;11:5426–31. 14. Katragkou A1, McCarthy M1, Meletiadis J2, Hussain K1, Moradi PW1, Strauss GE1, Myint KL1, Zaw MH1, Kovanda LL3, Petraitiene R1, Roilides E4, Walsh TJ1,5,6, Petraitis V1. In vitro combination therapy with isavuconazole against Candida spp. Med Mycol. 2017 Feb 16. doi: 10.1093/mmy/myx006.\ 15. Keirns J1, Desai A1, Kowalski D1, Lademacher C1, Mujais S1, Parker B1, Schneidkraut MJ1, Townsend R1, Wojtkowski T1, Yamazaki T1, Yen M2, Kowey PR3,4. QT Interval Shortening With Isavuconazole: In Vitro and In Vivo Effects on Cardiac Repolarization. Clin Pharmacol Ther. 2017 Jun;101(6):782-790. 16. Kelly SL, Lamb DC, Kelly DE, et al. Resistance to fluconazole and cross-resistance to amphotericin B in Candida albicans from AIDS patients caused by defective sterol delta5,6desaturation. FEBS Lett 1997;1:80–2. 17. Kontoyiannis DP, Giladi M, Lee M, et al. A Phase 3, Randomized, Double-Blind, Non-Inferiority Trial to Evaluate Efficacy and Safety of Isavuconazole versus Voriconazole in Patients with Invasive Mold Disease (SECURE): Outcomes in Invasive Aspergillosis Patients. Conference proceedings, ID Week 2014. 18. Lepak AJ, Marchillo K, VanHecker J, Diekema D, Andes DR. Isavuconazole pharmacodynamic target determination for Candida species in an in vivo murine disseminated candidiasis model. Antimicrob Agents Chemother 2013a;11:5642–8. 19. Lepak AJ, Marchillo K, Vanhecker J, Andes DR. Isavuconazole (BAL4815) pharmacodynamic target determination in an in vivo murine model of invasive pulmonary aspergillosis against wildtype and cyp51 mutant isolates of Aspergillus fumigatus. 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Maertens JA1, Raad II2, Marr KA3, Patterson TF4, Kontoyiannis DP5, Cornely OA6, Bow EJ7, Rahav G8, Neofytos D9, Aoun M10, Baddley JW11, Giladi M12, Heinz WJ13, Herbrecht R14, Hope W15, Karthaus M16, Lee DG17, Lortholary O18, Morrison VA19, Oren I20, Selleslag D21, Shoham S22, Thompson GR 3rd23, Lee M24, Maher RM24, Schmitt-Hoffmann AH25, Zeiher B24, Ullmann AJ26. Isavuconazole versus voriconazole for primary treatment of invasive mould disease caused by Aspergillus and other filamentous fungi (SECURE): a phase 3, randomised-controlled, non-inferiority trial. Lancet. 2016 Feb 20;387:760-9. 314 24. Marty FM1, Ostrosky-Zeichner L2, Cornely OA3, Mullane KM4, Perfect JR5, Thompson GR 3rd6, Alangaden GJ7, Brown JM8, Fredricks DN9, Heinz WJ10, Herbrecht R11, Klimko N12, Klyasova G13, Maertens JA14, Melinkeri SR15, Oren I16, Pappas PG17, Ráčil Z18, Rahav G19, Santos R20, Schwartz S21, Vehreschild JJ22, Young JH23, Chetchotisakd 24 25 26 27 27 P , Jaruratanasirikul S , Kanj SS , Engelhardt M , Kaufhold A , Ito M28, Lee M28, Sasse C28, Maher RM28, Zeiher B28, Vehreschild MJGT22; VITAL and FungiScope Mucormycosis Investigators. Isavuconazole treatment for mucormycosis: a single-arm open-label trial and case-control analysis. Lancet Infect Dis. 2016 Jul;16(7):828-837 25. Murrell, D., Bossaer, J. B., Carico, R., Harirforoosh, S. and Cluck, D. (2017), Isavuconazonium sulfate: a triazole prodrug for invasive fungal infections. International Journal of Pharmacy Practice, 25: 18–30. doi: 10.1111/ijpp.12302 26. Pettit NN1, Carver PL2. Isavuconazole: A New Option for the Management of Invasive Fungal Infections. Ann Pharmacother. 2015 Jul;49(7):825-42. 27. Rybak JM1, Marx KR2, Nishimoto AT1, Rogers PD1. Isavuconazole: Pharmacology, Pharmacodynamics, and Current Clinical Experience with a New Triazole Antifungal Agent. Pharmacotherapy. 2015 Nov;35(11):1037-51. 28. Schmitt-Hoffmann A, Roos B, Heep M, et al. Single-ascending-dose pharmacokinetics and safety of the novel broad-spectrum antifungal triazole BAL4815 after intravenous infusions (50, 100, and 200 milligrams) and oral administrations (100, 200, and 400 milligrams) of its prodrug, BAL8557, in healthy volunteers. Antimicrob Agents Chemother 2006;1:279–85. 29. Schmitt-Hoffmann A, Roos B, Maares J, et al. Multiple-dose pharmacokinetics and safety of the new antifungal triazole BAL4815 after intravenous infusion and oral administration of its prodrug, BAL8557, in healthy volunteers. Antimicrob Agents Chemother 2006;1:286–93. 30. Seifert H, Aurbach U, Stefanik D, Cornely O. In vitro activities of isavuconazole and other antifungal agents against Candida bloodstream isolates. Antimicrob Agents Chemother 2007;5:1818–21. 31. Shirley M1, Scott LJ2. Isavuconazole: A Review in Invasive Aspergillosis and Mucormycosis. Drugs. 2016 Nov;76(17):1647-1657. 32. Thompson GR 3rd, Wiederhold NP. Isavuconazole: a comprehensive review of spectrum of activity of a new triazole. Mycopathologia 2010;5:291–313. 33. Townsend R1, Dietz A2, Hale C3, Akhtar S1, Kowalski D1, Lademacher C1, Lasseter K4, Pearlman H1, Rammelsberg D5, Schmitt-Hoffmann A6, Yamazaki T1, Desai A1. Pharmacokinetic Evaluation of CYP3A4-Mediated Drug-Drug Interactions of Isavuconazole With Rifampin, Ketoconazole, Midazolam, and Ethinyl Estradiol/Norethindrone in Healthy Adults. Clin Pharmacol Drug Dev. 2017 Jan;6(1):44-53. 34. Upton A, Kirby KA, Carpenter P, Boeckh M, Marr KA. Invasive aspergillosis following hematopoietic cell transplantation: outcomes and prognostic factors associated with mortality. Clin Infect Dis 2007;4:531–40. 35. Verweij PE, Gonzalez GM, Wiedrhold NP, et al. In vitro antifungal activity of isavuconazole against 345 mucorales isolates collected at study centers in eight countries. J Chemother 2009;3:272–81. 36. Viljoen J1, Azie N2, Schmitt-Hoffmann AH3, Ghannoum M4. A phase 2, randomized, doubleblind, multicenter trial to evaluate the safety and efficacy of three dosing regimens of isavuconazole compared with fluconazole in patients with uncomplicated esophageal candidiasis. Antimicrob Agents Chemother. 2015 Mar;59(3):1671-9. 37. Wilson DT1, Dimondi VP2, Johnson SW3, Jones TM4, Drew RH5. Role of isavuconazole in the treatment of invasive fungal infections. Ther Clin Risk Manag. 2016 Aug 3;12:1197-206. 315 21. Itraconazole Itraconazole is a broad-spectrum orally active triazole antifungal used for both prophylaxis and treatment of systemic fungal infections Chemocal properties Chemical Names: Itraconazole; Sporanox; Oriconazole; Itraconazolum, 84625-61-6; Itraconazole Molecular Weight: 705.641 g/mol Molecular Formula: C35H38Cl2N8O4 Pharmacology of Itraconazole, De Beule and Van Gestel, 2001 Mechanism of Action  Itraconazole inhibits the growth of fungi by interfering with the synthesis of ergosterol, a vital component of the fungal cell membrane. o Under normal circumstances, lanosterol, the precursor of ergosterol, undergoes a 14α-demethylation catalysed by fungal cytochrome P450 (CYP). o Itraconazole interacts with the substrate-binding site of fungal CYP and blocks this reaction. o As a result, lanosterol and other 14α-methyl sterols accumulate in the cell membrane instead of ergosterol. o This impairment of ergosterol synthesis leads to abnormalities in the fungal membrane permeability, membrane-bound enzyme activity and the coordination of chitin synthesis. 316 Distribution      Itraconazole is lipophilic and tightly bound to blood cells and plasma proteins, primarily albumin, leaving only 0.2% of the drug unbound. Itraconazole concentrations in most body fluids, including cerebrospinal fluid and eye fluid, are low in relation to the plasma concentration. Itraconazole concentrations within tissues are considerable, with a large apparent volume of distribution (approximately 11 L/kg). Itraconazole protein or tissue bound concentration is more clinically relevant than the free drug concentration. o Tissues such as kidney, liver, bone, stomach, spleen and muscle accumulate large concentrations of itraconazole. Itraconazole also accumulates in tissues that are prone to fungal infections, such as the skin, nails, lungs and female genital tract. o The extensive protein binding of itraconazole ensures that its concentration at the site of infection remains higher than the corresponding plasma concentration for several days. o Once equilibrium is established between the tissue and plasma, itraconazole is eliminated from the tissue in line with the usual half-life (t1 ⁄2 ). o Small doses of itraconazole given over short durations are therefore highly effective for the treatment of acute vaginal candidiasis. The pharmacokinetics of itraconazole in the skin are unique. o The major route of delivery is via the sebum, leading to itraconazole concentrations 5- to 10-fold higher than in plasma. o Soon after the start of therapy, itraconazole can be detected in the distal part of the nail through incorporation into both the matrix and the nail bed. o itraconazole is not distributed back to the plasma, but remains in the nail until it is shed through normal growth, Accordingly, antifungal therapy does not have to be given continuously. Elimination    Itraconazole is metabolised primarily in the liver by a large number of pathways to produce more than 30 metabolites. The major metabolite, hydroxy-itraconazole, reaches higher plasma concentrations than the parent compound and has in vitro antifungal activity similar to that of itraconazole. Because of the lack of renal metabolism, the dose of itraconazole does not need to be reduced in patients with renal failure and supplementation after dialysis is not necessary. 317    Elimination of itraconazole is biphasic, with a terminal t1 ⁄2 of approximately 20 to 24 hours after a single dose. At steady state, the terminal t1⁄2 increases to 30 hours, indicating that the itraconazole excretion mechanism is saturated at clinical doses Most metabolites are eliminated through the bile and urine but unmetabolised itraconazole is not detected in the urine. Only 3 to 18% of the dose is detected in the faeces. Drug Interactions    Itraconazole also inhibits this enzyme in humans, although with a much lower affinity. Itraconazole has the potential to modify the pharmacokinetics of drugs that are metabolised by this route, e.g. o the plasma concentration of cyclosporin, a drug that is often used in transplant patients, increases after administration of itraconazole. Itraconazole may enable particular concomitant medications to achieve the same therapeutic effects at lower doses as are attained at higher doses without itraconazole, with favourable cost implications. Capsule Formulation Absorption  Itraconazole absorption from the capsules is perfectly adequate in healthy volunteers and in patients with superficial fungal infections. o Itraconazole capsules on an empty stomach leads to reduced absorption and a decline in clinical response. o Itraconazole capsules shortly after a meal leads to optimal systemic availability. o Coadministration of an acidic beverage is an effective way to improve the bioavailability of itraconazole. o Patients with systemic fungal infections may be unable to tolerate solid-dose formulations and, even if they can, absorption may be reduced by low oral food intake, frequent vomiting or difficulty in swallowing the capsules.  Patients with upper gastrointestinal abnormalities, diminishes the absorption of itraconazole from the solid formulation. 318 Oral Solution The combination of itraconazole with cyclodextrin in the oral solution formulation has improved several aspects of the pharmacological profile of this antifungal agent. Absorption and Bioavailability  Itraconazole oral solution has an improved bioavailability compared with itraconazole capsules, which makes the oral solution ideal for the treatment of systemic fungal infections. o In a comparative study of itraconazole capsules 200mg and itraconazole oral solution 200mg in healthy volunteers, the bioavailability of the oral solution was up to 37% higher than that of the capsule, measured by the area under the plasma concentration-time curve (AUC) from 0 to 96 hours after the dose. o The maximum concentrations of itraconazole in plasma (Cmax), the time to reach Cmax (tmax) and the terminal t1 ⁄2 were similar for the capsules and the oral solution (Barone et al., 1998)  Reports showed that absorption of itraconazole oral solution is even better when taken without food, which is more appropriate for at-risk patients (Van de Velde et al., 1996). o After a single dose of the oral solution, the Cmax and AUC from 0 to 24 hours after the dose (AUC24h) for itraconazole and hydroxy-itraconazole were significantly higher under fasting conditions than under fed conditions, and the tmax was considerably shorter. o Consequently, the bioavailability of itraconazole was 30% higher under fasting than under fed conditions. o After rapid absorption from the stomach, high plasma concentrations are probably achieved by transient saturation of the first-pass effect. o After administration of itraconazole oral solution, absorption of cyclodextrin is negligible. Enzymes in the gut microflora, such as cyclodextrin transglycolase, convert the cyclodextrin ring into its constituent glucose molecules, which are then absorbed and metabolised by the liver. The osmotic activity of cyclodextrin in the gut, however, may cause patients to experience diarrhoea or other gastrointestinal symptoms. Distribution  High concentrations have been detected in saliva for about 8 hours after a single dose of itraconazole oral solution. o These data suggest local persistence and the potential for a topical effect of the oral solution on the buccal mucosa. 319 o Itraconazole oral solution is therefore appropriate for treating fungal infections of the mouth, including candidiasis and has shown high efficacy even in fluconazole-refractory disease. IV Formulation The IV formulation of itraconazole is also formed from a complex of itraconazole and cyclodextrin. Bioavailability  For the IV formulation, an alternative dosage schedule has been designed that allows steady state plasma concentrations to be achieved more rapidly than with the oral solution. o A 1-hour IV infusion of itraconazole 200mg twice daily for 2 days is sufficient to achieve an itraconazole concentration that exceeds a plasma concentration (Cmin) of 250 to 500 μg/L in healthy volunteers. o Once-daily administration at the same dose from day 3 onwards maintains the plasma concentration at the same steady-state level. o In patients with invasive pulmonary aspergillosis, 91% of the population achieved these plasma concentrations after 2 days of itraconazole IV administration (200mg twice daily). Elimination  After IV administration of itraconazole, cyclodextrin is rapidly eliminated by glomerular filtration, with little accumulation in the body.  Patients with impaired renal function or those receiving dialysis, therefore, may not be ideal candidates for high doses of IV itraconazole, although clinical evidence to support this is lacking. Pharmacodynamics of Itraconazole, Grant and Clissold, 1989  Itraconazole is active in vitro against a wide variety of fungi with a spectrum of activity which qualitatively resembles that of ketoconazole, the first oral azole to gain widespread acceptance.  This spectrum includes: o dermatophytes (e.g. Microsporum, Trichophyton and Epidermophytonspecies), o yeasts (e.g. Candida spp., Pityrosporum spp. and Cryptococcus neoformans), o dimorphic fungi (e.g. Histoplasma, Paracoccidioides brasiliensis, Blastomyces dermatitidisand Sporothrix schenckii), o various organisms which cause chromomycosis, and other fungi including Aspergillus fumigatus. Quantitatively itraconazole is more potent than ketoconazole, although in vitro results vary considerably depending on culture medium, inoculum size, conditions of incubation,  311   etc. Because of the variability of in vitro results these tests may not necessarily reflect in vivo efficacy. In in vivo models of superficial mycoses o itraconazole is effective orally and topically in treating dermatophytic infections. o Cutaneous candidiasis in guinea-pigs and vaginal candidiasis in the pseudoestrus rat were cured by itraconazole. o In guinea-pigs injected intravenously with Candida albicans, itraconazole improved the survival rate at a dosage of 0.63 mg/kg/day and prevented systemic disease at 5 mg/kg/day administered for 21 days. o While all control animals infected with Aspergillus fumigatus died, > 80% of guineapigs, including immunocompromised animals, treated with itraconazole 5 mg/kg/day survived and most were culture negative and free of organ necrosis. o Itraconazole 200mg daily sterilised the cardiac vegetations of rabbits infected with A. fumigatus and improved the survival rate of these animals in comparison to those treated with amphotericin B and/or 5-fluorocytosine. In in vivo models of cryptococcal meningitis itraconazole sterilised CSF cultures in the majority of animals. o Higher doses of itraconazole (40 mg/kg/ day) cured guinea-pigs with a disseminated infection of Sporothrix schenckii and Histoplasma capsulatum var. duboisii. o Itraconazole 200 mg/kg/day administered for 7 weeks effected parasitological cure in mice infected with a virulent inoculum of Trypanosoma cruzi. Therapeutic Use  Most clinical experience with itraconazole in superficial mycoses has been gained from non-comparative studies, particularly a few large multicentre trials and some dosefinding clinical trials. Overall, o itraconazole 100mg once daily has proven to be the optimal dosage in dermatophytoses, producing ⩾ 80% clinical and mycological response (cure or marked improvement) against tinea corporis, tinea cruris, tinea pedis and tinea manuum. o Itraconazole 50mg once daily elicited less consistent results, while there is some evidence that a higher dosage (200mg once daily) may permit shorter courses of treatment. o In very limited experience with the treatment of tinea capitis, itraconazole 100mg once daily produced an excellent therapeutic response, although therapy was more prolonged (3 to 7 weeks).  Compared with griseofulvin 500mg (ultramicronised) once daily itraconazole 100mg once daily was superior in terms of mycological clearance in patients with various tinea infections, and it  also produced a significantly better clinical response in patients with tinea corporis and tinea cruris. 311 o Studies in patients with pityriasis versicolor showed that, provided  the total dosage was ⩾ 1000mg, itraconazole cured more than 90% of patients and helped reduce the number of early relapses.  Itraconazole 200mg daily for 5 days was found to be as effective as selenium sulphide 2.5% shampoo but tended to be better tolerated.  Reduction in P. orbiculare colonisation during treatment with itraconazole 50 to 100mg daily was associated with clearing or marked improvement of lesions in a small number of patients with sebopsoriasis. o In women with acute vaginal candidiasis itraconazole maintained initial mycological clearance during a follow-up period of 4 weeks in at least 80% of patients provided a minimum total dosage of 400mg had been administered. For recalcitrant vaginal candidiasis o itraconazole 200mg once daily for 3 days produced the best results; symptoms such as leucorrhoea, pruritus, dysuria and dyspareunia were relieved in > 90% of cases. o Preliminary data indicate that one day‘s treatment with itraconazole (400mg in 2 divided doses) produced mycological cure in > 80% of women with acute infection and that a single 200mg dose on the first day of menses may provide effective prophylaxis in patients with chronic recurrent disease. o Itraconazole 100mg once daily has also proven useful in fungal diseases such as chronic mucocutaneous candidiasis and chromomycoses although, as expected, much longer durations of treatment have been necessary. Adverse Effects     Itraconazole is well tolerated by most patients, the most common side effects relating to gastrointestinal disturbances. The incidence of side effects increases with duration of treatment; administration for ⩾ 1 month results in an incidence of adverse effects of 17.7%, with a resulting dropout rate of 4.7%. Itraconazole appears to be devoid of effects on the pituitary-testicular-adrenal axis at the dosages used to date. Rarely, transient increases in liver enzymes have occurred; however, no cases of symptomatic liver dysfunction have been reported. Seven instances of hypokalaemia have been described. Dosage and Administration  The recommended itraconazole dosage for superficial fungal infections is 100mg once daily at mealtime for: o 15 days in patients with tinea corporis/cruris; o 30 days, tinea pedis/ manuum; 312     o 4 to 8 weeks, tinea capitis, o 3 to 6 months, onychomycoses. In pityriasis versicolor, vaginal candidiasis and fungal keratitis the recommended dosage is 200mg once daily for 5 days, 3 days, and 3 weeks, respectively. The initial dose in systemic mycoses is 200mg daily increased to 400mg daily in 1 or 2 divided doses when oral absorption is questionable and/or response is inadequate. Treatment length in systemic disease should be individualised by clinical and mycological response. It is recommended that treatment continue beyond an apparent mycological cure, although the length of this additional treatment has not been well defined. In children the recommended dose is 3 to 5 mg/kg/day. Itraconazole is contraindicated in pregnancy. Efficacy and safety of itraconazole  Agarwal et al. (2013) evaluated the efficacy and safety of itraconazole in cavitary pulmonary aspergillosis (CCPA). chronic o Consecutive patients of CCPA with presence of chronic pulmonary/systemic symptoms; and pulmonary cavities; and presence of Aspergillus (immunological or microbiological) were randomised to receive either supportive treatment alone or itraconazole 400 mg daily for 6 months plus supportive therapy. o Response was assessed clinically, radiologically and overall after 6 months therapy. A total of 31 patients (mean age, 37 years) were randomised to itraconazole (n = 17) or the control (n = 14) group. o The number of patients showing overall response was significantly higher in the itraconazole group (76.5%) vs. the control (35.7%) group (P = 0.02). o The numbers of patients demonstrating clinical or radiological response were also significantly higher in the itraconazole group (P = 0.016 and 0.01 respectively). o Adverse events were noted in eight patients in the itraconazole group, however, none was serious or led to discontinuation of the study drug. Itraconazole was found to be superior to standard supportive treatment alone in stabilising cases of CCPA. (clinicaltrials.gov; NCT01259336). Brand names Sporanox is a brand name of itraconazole, approved by the FDA in the following formulation(s): SPORANOX (itraconazole - capsule;oral)  Manufacturer: JANSSEN PHARMS Approval date: September 11, 1992 Strength(s): 100MG [RLD] [AB] 313 SPORANOX (itraconazole - injectable;injection)  Manufacturer: JANSSEN PHARMS Approval date: March 30, 1999 Strength(s): 10MG/ML SPORANOX (itraconazole - solution;oral)  Manufacturer: JANSSEN PHARMS Approval date: February 21, 1997 Strength(s): 10MG/ML [RLD] 314 Brand Names 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. Adco-Sporozole Al Pharm, South Africa Albisec (Itraconazole and Secnidazole) Procaps, Colombia; Unimed, Peru Aranox APT Pharma, Hong Kong Arozole Acapi, Egypt Assosept-S S.J.A., Greece Bevonazole Bevo, Greece Biospore Biosciences, India Brovicton Bros, Greece Canadiol Laboratorios Dr. Esteve, Spain Canditral Glenmark, India; Glenmark, Peru; Glenmark, Philippines; Glenmark, Singapore; Glenmark, Vietnam Chme Wecam, Taiwan Cladosol STADA, Estonia Deratil Help, Greece Efectra Chong Kun Dang, South Korea Etrel Pharmex, Greece; T.C.Christoforou, Cyprus Eurotracon Navana Pharmaceuticals, Vietnam Fansidol Alapis Pharma, Greece Flunol Farmanic Chemipharma, Greece; Pharma Q, Cyprus Fonginox Mediphar, Lebanon Forcanox Guardian Pharmatama, Indonesia Fungitraxx (veterinary use) Avimedical, Belgium; Regivet, United Kingdom Fungitrazol Ikapharmindo, Indonesia Fungofunal Salutas Pharma, Bulgaria Fungonazol Verisfield, Greece Fungosin Dollder, Venezuela Fungospor Verisfield, Greece Funit Nobel, Serbia; Nobel, Turkey Gitrasek (Itraconazole and 78. Itraconazol Helvepharm Helvepharm, Switzerland 79. Itraconazol Itracic Ciclum, Portugal 80. Itraconazol LPH Labormed Pharma, Romania 81. Itraconazol Mylan Mylan, Spain; Mylan, Netherlands; Mylan, Portugal 82. Itraconazol Normon Normon, Spain 83. Itraconazol PCH Pharmachemie, Netherlands 84. Itraconazol Ramos Ramos, Nicaragua 85. Itraconazol ratiopharm ratiopharm, Netherlands 86. Itraconazol Sandoz Sandoz, Austria; Sandoz, Switzerland; Sandoz, Netherlands; Sandoz, Portugal; Sandoz Farmaceutica, Spain 87. Itraconazol Sandoz G Sandoz, Switzerland 88. Itraconazol Slavia Slavia Pharm, Romania 89. Itraconazol Spirig Galderma Spirig, Switzerland 90 . Itraconazol Stada STADA, Spain; Stada Arzneimittel, Austria 90. Itraconazol STADA STADA, Netherlands; Stada Arzneimittel, Germany 91. Itraconazol Tarbis Tarbis, Spain 92. Itraconazol Tecnigen Tecnimede, Spain 93. Itraconazol Teva Teva, Netherlands 94. Itraconazol Tolife ToLife, Portugal 95. Itraconazol Unisens Universal Farma, Portugal 96. Itraconazol Universal Farma Universal Farma, Austria 97. Itraconazol-CT AbZ-Pharma, Germany 98. Itraconazole Actavis Actavis UK, United Kingdom 99. Itraconazole Beacon Beacon Pharmaceuticals, United Kingdom 100. Itraconazole EG Eurogenerics, Belgium 101. Itraconazole Focus Focus Pharmaceuticals, United Kingdom 102. Itraconazole Glenmark Glenmark, Malta 103. Itraconazole Kaken Kaken Seiyaku, Japan 315 151. Itrizole Janssen Pharmaceutical, Japan 152. Itrizole 1% Janssen Pharmaceutical, Japan 153. Itrokast Axxon, Poland 154. Itrol Suiphar, Colombia; Suiphar, Dominican Republic 155. Itzol Lapi Laboratories, Indonesia 156. Kanazol Slaviamed, Serbia 157. Konitra Kolon, South Korea 158. Kupitral Korea United Pharm, Vietnam Laverio Elpen, Greece 159. Lorenzol Rafarm, Greece 160. Mei Fu Lisheng, China 161. Mesmor Rafarm, Greece 162. Micogal Rompharm, Romania 163. Micoral Mediderm, Peru 164. Micotenk Biotenk, Argentina 165. Micronazol Hospital Line, Greece 166. Mycodrox D.A.S.T Biotech, Greece 167. Mycotrazol Galenium Pharmasia Laboratories, Indonesia 168. Mylan Itraconazole Mylan, South Africa 169. Neo-Candimyk Viofar, Greece 170. Niddazol PharmaCoDane, Denmark 171. Nitridazol HLB Pharma, Argentina 172. Nufatrac Nufarindo, Indonesia 173. Omicral IPR Beta Pharma, Hungary; Medico Uno, Romania; Medico Uno, Serbia 174. Onmel Merz, United States 175. Orungal Janssen, Hungary; Janssen, Romania; Janssen-Cilag, Bulgaria; Janssen-Cilag, Lithuania; JanssenCilag, Latvia; Janssen-Cilag, Poland 176. Panastat Panalab, Argentina 29. 30. 31. 32. 33. 34. 35. 36. 37. 38. 39. 40. 41. 42. 43. 44. 45. 46. 47. 48. 49. 50. 51. 52. 53. Secnidazole) Chinoin, Costa Rica; Chinoin, Dominican Republic; Chinoin, Guatemala; Chinoin, Mexico; Chinoin, Nicaragua; Chinoin, Panama Hanall Itraconazole Hanall Biopharma, South Korea Hitrazole Joongwae Shinyak, South Korea Hongoseril Isdin, Spain Icomein Everest, Taiwan Iconazol Shin Poong, South Korea Idranox Gap, Greece Igrazol Graha, Indonesia Ikonaz Farmal, Croatia (Hrvatska) Inox Hovid, Hong Kong; Hovid, Malaysia; Hovid, Philippines Inrozol Gabriel Health, Greece Ipozumax Temapharm, Poland Iranstad Stada-VN JV, Vietnam Isoflon Proel, Greece Isox Senosiain, Dominican Republic; Senosiain, Guatemala; Senosiain, Honduras; Senosiain, Mexico; Senosiain, Panama; Senosiain, El Salvador Itacona Korean Drug, South Korea Itaspor-Aversi Aversi, Georgia Itcona Medica Korea, South Korea Itcure XL, Vietnam Itodal Cormin, Ecuador; Laboratorio Chile, Chile Itorat Sawai Seiyaku, Japan Itra East West, India; MacroPhar, Thailand; Opalia, Tunisia; Square, Bangladesh Itrabene ratiopharm Arzneimittel, Austria Itrabest Finixfarm, Greece Itrac 100 D & M Pharma, Chile Itrac 3 Belupo, Croatia (Hrvatska); Cassara, Argentina 104. Itraconazole MEEK Kobayashi Kako, Japan 2.105. Itraconazole Mylan Mylan, Belgium 3.106. Itraconazole Nichi-iko Nichi-Iko Pharmaceutical, Japan 107. Itraconazole P & D P & D, Malta 108. Itraconazole Sandoz Sandoz, Belgium; Sandoz, Denmark; Sandoz, France; Sandoz, United Kingdom; Sandoz, Sweden 109. Itraconazole Teva Teva, Belgium; Teva Santé, France 110. Itraconazole-Premier Research Sandoz Sandoz, Poland 111. Itraconazol-Mepha Mepha Pharma, Switzerland 112. Itraconazolo Doc Generici DOC Generici, Italy 113. Itraconazolo EG EG, Italy 114. Itraconazolo Mylan Generics Mylan, Italy 115. Itraconazolo Sandoz GmbH Sandoz, Italy 116. Itraconazolo Teva Teva Italia, Italy 117. Itraconazol-ratiopharm ratiopharm, Germany; Teva, Hungary 118. Itraconbeta Betapharm, Germany 119. Itraconep ExtractumPharma, Serbia 120. Itraderm Dermapharm, Austria; Dermapharm, Switzerland; Dermapharm, Germany 121. Itrafung Siegfried, Ecuador 122. Itrafungex Utopia, Egypt 123. Itrafungol (veterinary use) Elanco, Germany; Elanco Animal Health, Austria; Elanco Animal Health, Ireland; Elanco Animal Health, Norway; Eli Lilly Benelux, Belgium; Lilly, United Kingdom; Lilly Nederland, Netherlands; Lilly Vet, France; Lilly-Elanco, Italy; Orion Pharma Animal Health, Sweden; Orion Pharma Eläinlääkkeet, Finland; Provet, Switzerland 124. Itragen Generics, Hungary 125. ItraGen Generics, Poland 126. Itragerm Isdin, Spain 127. Itrahexal 316 177. Petrazole Pharos, Indonesia 178. Pharmaniaga Itraconazole Pharmaniaga, Hong Kong 179. Pharmitrole Pharmaniaga, Vietnam 180. Prokanazol Liconsa, Slovakia; Pro.Med.CS, Czech Republic; PRO.MED.CS Baltic, Estonia 181. Prominox Alet Pharmaceuticals, Greece 182. Quali-Itrazole Quality Pharm, Hong Kong 183. Rixtal Biomep, Mexico 184. Salimidin LKM, Argentina 185. Sempera Janssen-Cilag, Germany 186. Sepia (Itraconazole and Secnidazole) Wermar, Mexico 187. Seritral Lakeside, Mexico 188. SIROS Janssen-Cilag, Germany 189. Spazol Siam Bheasach, Thailand 190. Sporacid Dexa Medica, Myanmar; Dexa Medica, Vietnam; Ferron, Indonesia 191. Sporadal Harsen, Indonesia 192. Sporal Janssen, Thailand; Janssen-Cilag, Malta; Janssen-Cilag, Vietnam; Janssen-Cilag Ltd, Myanmar 193. Sporanox Janssen, Australia; Janssen, Brazil; Janssen, Canada; Janssen, Chile; Janssen, Finland; Janssen, Hong Kong; Janssen, Ireland; Janssen, Iceland; Janssen, Lebanon; Janssen, Malaysia; Janssen, Norway; Janssen, New Zealand; Janssen, Philippines; Janssen, Sweden; Janssen, Singapore; Janssen, Taiwan; Janssen, South Africa; Janssen Cilag, Argentina; Janssen Pharma, United States; Janssen-Cilag, Belgium; JanssenCilag, Switzerland; Janssen-Cilag, Colombia; Janssen-Cilag, Czech Republic; Janssen-Cilag, Denmark; Janssen-Cilag, Ecuador; Janssen-Cilag, Egypt; JanssenCilag, France; Janssen-Cilag, United Kingdom; Janssen-Cilag, Greece; Janssen-Cilag, Israel; Janssen-Cilag, Italy; JanssenCilag, Malta; Janssen-Cilag, Oman; Janssen-Cilag, Portugal; Janssen-Cilag, Vietnam; JanssenCilag Pharma, Austria; Johnson & 54. Itracare 55. 56. 57. 58. 59. 60. 61. 62. 63. 64. 65. 66. 67. 68. 69. 70. 71. 72. 73. 74. 75. 76. Sandoz, Ecuador Itracim Acino, Georgia; Acino, Tunisia; Acino Pharma, Switzerland Itracol HEXAL Hexal, Germany Itracon GNP, Egypt; Kukje, South Korea; Med-One, Greece; Navana, Bangladesh; Unison, Hong Kong; Unison, Thailand; Unison Laboratories Co Ltd, Myanmar; Vianex, Greece Itraconal Polychronis, Greece Itraconazol Farmindustria, Peru; Iqfarma, Peru; LCG, Peru Itraconazol - 1 A Pharma 1 A Pharma, Germany Itraconazol AbZ AbZ-Pharma, Germany Itraconazol Actavis Actavis, Denmark; Actavis, Lithuania; Actavis, Latvia; Actavis, Malta; Actavis, Netherlands; Actavis, Portugal; Actavis Baltics Eesti, Estonia Itraconazol AL Aliud, Germany Itraconazol Alter Alter, Spain; Alter, Portugal Itraconazol Apotex Apotex, Belgium Itraconazol Arena Arena, Romania Itraconazol Aristo Aristo Pharma, Germany Itraconazol Aurobindo Aurobindo, Netherlands Itraconazol Axapharm Axapharm, Switzerland Itraconazol Bexal Bexal Farmaceutica, Spain Itraconazol CF Centrafarm, Netherlands Itraconazol Dermapharm Dermapharm, Netherlands Itraconazol dura Mylan dura, Germany Itraconazol Fungizol Liconsa, Bulgaria; Universal Farma, Portugal Itraconazol Generis Generis, Portugal Itraconazol Germed Germed, Portugal Hexal, Brazil 128. Itrakonazol Actavis Actavis, Sweden 129. Itrakonazol PharmaS PharmaS, Croatia (Hrvatska) 130. Itrakonazol Pliva Pliva, Croatia (Hrvatska) 131. Itrakonazol Sandoz Sandoz, Slovakia 132. Itrakonazol Slaviamed Slaviamed, Bosnia & Herzegowina 133. Itrakonazol STADA PharmaCoDane, Sweden 134. Itralfa Chrispa, Greece 135. Itramicol AC Farma, Peru 136. Itranazole Adipharm, Bulgaria 137. Itranol Liconsa, Israel 138. Itranols Olainfarm, Latvia 139. Itranox Adwia, Egypt 140. Itranstad STADA, Hong Kong 141. Itrapex Apex, Egypt 142. Itraproton Proton Pharma, Greece 143. Itrasec (Itraconazole and Secnidazole) Elipesa, Dominican Republic; Elipesa, El Salvador 144. Itrasix Sinensix Pharma, Thailand 145. Itraspor Difare, Ecuador; Janssen-Cilag, Turkey; Suan Farma S.A., Greece 146. Itraviron Farmedia, Greece 147. Itrax Axxon, Poland 148. Itraxyl Keymen, Turkey 149. Itrazol ADWYA, Tunisia; Biolabfarma, Brazil; Medrock, Peru; Saja, Lebanon; Saja Pharmaceuticals, Oman; Verisfield, Greece; Vertex, Russian Federation 150. Itrazole Hwang's, Taiwan; Millimed, Thailand; Mylan, New Zealand 1.77. 317 Johnson, Indonesia; Johnson & Johnson, India; Johnson & Johnson, Slovakia; Ortho Biotech, United States; Xian Janssen, China; Janssen-Cilag, Lithuania; Janssen-Cilag, Peru 194. Sporanox G Janssen-Cilag, Switzerland 195. Sporasec (Itraconazole and Secnidazole) Janssen-Cilag, Peru 196. Sporax Dexa Medica, Indonesia 197. Sporex Toprak, Turkey 198. Sporizole Target Pharma, Greece 199. Spornar Charoen Bhaesaj Lab, Thailand 200. Spozole Mithra, Belgium 201. Spyrocon Interbat, Indonesia 202. Sterginox Novopharm, Greece 203. Teramic Laboratorios Andromaco, Chile 204. Toracona Nichi-Iko Pharmaceutical, Japan 205. Trachon Bernofarm, Indonesia 206. Tracon Spimaco, Lebanon 207. Traconal Ache, Brazil 208. Tracor Pharmacore Laboratories, Indonesia 209. Tranizolo EG, Italy 210. Trazer SF Group, Italy 211. Triasporin Italfarmaco, Italy 212. Trioxal Polpharma, Poland 213. Trisporal Fisher Farma, Netherlands; Janssen, South Africa; Janssen Cilag, Netherlands 214. Unitrac Dankos, Malaysia; Dankos, Singapore; Kalbe, Indonesia 215. Yi Qi Kang Bei Te Pharm, China Recent reports Rifkin et al. (2017) determined pharmacokinetics of 0.01% and 0.001% itraconazole in the Panamanian golden frog. Frogs were bathed 10 min, euthanized, and skin, liver, and heart were collected at 0, 0.5, 1, 2, 4, 6, 8, 10, 12, 24, and 36 hr. Itraconazoleconcentrations were measured using high performance liquid chromatography, and the minimum inhibitory concentration (MIC) of itraconazole (0.032 μg/ml) for B. dendrobatidis was used to determine whether therapeutic concentrations were attained. Itraconazole was detected in all tissues at both concentrations, indicating systemic absorption. At the 0.01% itraconazole bath, itraconazole concentrations in all tissues exceeded the MIC at all time points, and the lack of decline until the end of the study at 36 hr precluded determining a disappearance half-life. With the 0.001% bath, itraconazole exceeded the MIC and declined with a disappearance half-life that markedly varied (14.1-1,244 min). This study augments the growing literature base on chytridiomycosis and seeks to aid in further experimental attempts to find the most-optimal treatment protocol for this disease. Boehm et al. (2016) fabricated Poly(glycolic acid) microneedle arrays using a drawing lithography process; these arrays were modified with a drug release agent and an antifungal agent by piezoelectric inkjet printing. Coatings containing poly(methyl vinyl ether-co-maleic anhydride), a water-soluble drug release layer, and itraconazole (an antifungal agent), were applied to the microneedles by piezoelectric inkjet printing. Microscopic evaluation of the microneedles indicated that the modified microneedles contained the piezoelectric inkjet printing-deposited agents and that the surface coatings were released in porcine skin. Energy dispersive x-ray spectrometry aided in confirmation that the piezoelectric inkjet printingdeposited agents were successfully applied to the desired target areas of the microneedle surface. Fourier transform infrared spectroscopy was used to confirm the presence of the component materials in the piezoelectric inkjet printing-deposited material. Itraconazole-modified microneedle arrays incubated with agar plates containing Candida albicans cultures showed zones of growth inhibition. Lee et al. (2016) developed Itraconazole (ITZ)-loaded microemulsion (ME) systems for intranasal (IN) delivery for the treatment of human rhinovirus serotype 1B (HRV1B) infection. ITZ was incorporated into the oil-in-water (o/w) ME formulation composed of benzyl alcohol (oil), Cremophor EL (surfactant), Solutol HS15 (cosurfactant), and water. The optimized composition of ME was determined by constructing pseudo-ternary phase diagram. ITZ ME formulation with about 150nm mean diameter and spherical shape was prepared and the solubility of ITZ in blank ME was markedly improved (up to 13.9mg/mL). The initial value of droplet size was maintained with four times dilution in the aqueous buffer and 72h incubation. Released amounts of drug from ME formulation were significantly enhanced compared to drug suspension group (p<0.05). Particularly, ITZ ME group displayed lower levels of inflammatory markers in the lung compared to ITZ suspension group after their IN administration in the HRV1B-infected mouse model (p<0.05). Developed ITZ ME formulation via IN route can be a promising candidate for the treatment of rhinovirus infection. Liang et al. (2016) described the pharmacokinetics and bioavailability of itraconazole (ITR) oral solution in healthy cats. The pharmacokinetics of ITR were studied in eight healthy, fasted cats after a single intravenous (IV) and oral (PO) administration at a dose of 5 mg/kg, in a two-period crossover design study. Blood was obtained at predetermined intervals for the determination of ITR concentrations with high-performance liquid chromatography. Pharmacokinetic 318 characterisation was performed by a non-compartmental method using WinNonlin. After IV administration, the major pharmacokinetic parameters were as follows (mean ± SD): terminal elimination half-life (T1/2λz ) 15.8 ± 1.88 h; area under the curve from time zero to infinity (AUC0-∞ ) 13.9 ± 3.17 h·μg/ml; total body clearance 0.37 ± 0.08 l/h/kg; apparent volume of distribution 8.51 ± 1.92 l/kg; mean residence time 20.6 ± 3.95 h. After PO administration, the principal pharmacokinetic parameters were as follows (mean ± SD): T1/2λz 15.6 ± 3.20 h; AUC0-∞ 7.94 ± 2.83 h·μg/ml; peak concentration 0.70 ± 0.14 μg/ml; time of peak 1.43 ± 0.53 h. The absolute bioavailability of ITR oral solution after oral administration was 52.1 ± 11.6%. Middleton et al. (2016) evaluated every other day dosing of 100 mg itraconazole capsule in healthy adult cats. Ten healthy adult cats received a 100 mg capsule of itraconazole orally every 48 h for 8 weeks. Peak and trough serum concentrations of itraconazole were measured weekly using high-performance liquid chromatography (HPLC). Physical examination, complete blood count (CBC), and chemistry profiles were performed weekly. The dosage regimen achieved average therapeutic trough concentrations (>0.5 μg/mL) within 3 weeks. The protocol yielded no adverse effects in 8 of the 10 study cats, with affected cats recovering fully with discontinuation of the drug and supportive care. At 8 weeks, an average peak concentration of 1.79 ± 0.952 μg/mL (95% CI: 0.996-2.588) and an average trough concentration of 0.761 ± 0.540 μg/mL (95% CI: 0.314-1.216) were achieved. Overall, a 100 mg every other day oral dosage regimen for itraconazole in cats yielded serum concentrations with minimal fluctuation and with careful monitoring may be considered for treatment of cats with systemic fungal disease. Srinivas et al. (2016) developed a simple unweighted linear regression model was developed to describe the relationship between Cmax versus AUC for fexofenadine, losartan, EXP3174, itraconazole and hydroxyitraconazole. The fold difference, defined as the quotient of the observed and predicted AUC values, were evaluated along with statistical comparison of the predicted versus observed values. The correlation between Cmax versus AUC was well established for all the five drugs with a correlation coefficient (r) ranging from 0.9130 to 0.9997. Majority of the predicted values for all the five drugs (77%) were contained within a narrow boundary of 0.75- to 1.5-fold difference. The r values for observed versus predicted AUC were 0.9653 (n = 145), 0.8342 (n = 76), 0.9524 (n = 88), 0.9339 (n = 89) and 0.9452 (n = 66) for fexofenadine, losartan, EXP3174, itraconazole and hydroxyitraconazole, respectively. CONCLUSIONS: Cmax versus AUC relationships were established for all drugs and were amenable for limited sampling strategy for AUC prediction. However, fexofenadine, EXP3174 and hydroxyitraconazole may be most relevant for AUC prediction by a single time concentration as judged by the various criteria applied in this study Stappaerts et al. (2016) studied the solubilizing capacity of 2-hydroxypropyl-β-cyclodextrin (HP-β-CD) for itraconazole in presence of selected bile salts and phosphatidylcholine. Despite the fact that these competing agents significantly lowered the solubility of itraconazole in presence of cyclodextrins, the addition of concentrated solutions of these bile constituents to a solution containing itraconazole solubilized by HP-β-CD did not result in precipitation, even at bile salt and phospholipid concentrations where itraconazoleprecipitation would be anticipated based on solubility studies. This phenomenon was further investigated in more dynamic conditions via in vitro transfer studies, mimicking the gastrointestinal transfer of HP-β-CD solutions saturated with itraconazole. Intestinal supersaturation upon transfer was observed for all conditions tested and a concentration dependent impact of bile salts and phospholipids on the precipitation behavior of itraconazole was demonstrated: high concentrations of bile salts and 319 phospholipids generated the highest degrees of supersaturation shortly after the transfer step but also resulted in stronger itraconazole precipitation at later time points. These findings demonstrate the possible impact of the variable intestinal fluid composition on the behavior of cyclodextrin containing formulations. Abuhelwa et al. (2015) developed a population pharmacokinetic model for itraconazole and the active metabolite hydroxyitraconazole, in particular, quantifying the effects of food and formulation on oral absorption. Plasma pharmacokinetic data were collected from seven phase I crossover trials comparing the SUBA-itraconazole and Sporanox formulations of itraconazole. First, a model of single-dose itraconazole data was developed, which was then extended to the multidose data. Covariate effects on itraconazole were then examined before extending the model to describe hydroxyitraconazole. The final itraconazole model was a 2-compartment model with oral absorption described by 4-transit compartments. Multidose kinetics was described by total effective daily dose- and time-dependent changes in clearance and bioavailability. Hydroxyitraconazole was best described by a 1-compartment model with mixed first-order and Michaelis-Menten elimination for the single-dose data and a time-dependent clearance for the multidose data. The relative bioavailability of SUBA-itraconazolecompared to that of Sporanox was 173% and was 21% less variable between subjects. Food resulted in a 27% reduction in bioavailability and 58% reduction in the transit absorption rate constant compared to that with the fasted state, irrespective of the formulation. This analysis presents the most extensive population pharmacokinetic model of itraconazole and hydroxyitraconazole in the literature performed in healthy subjects. The presented model can be used for simulating food effects on itraconazole exposure and for performing prestudy power analysis and sample size estimation, which are important aspects of clinical trial design of bioequivalence studies. Jaiswal et al. (2015) investigated the role of amphiphilic block copolymer-based polymeric micelles of itraconazole for the management of fungal keratitis to overcome the limitations of the conventional dosage form. The polymeric micelles were made using pluronics above critical micelle concentration. Itraconazole-loaded polymeric micelles prepared by rotary evaporation method were characterized and the optimized micellar formulation (M5) was selected on the basis of least micelle size (79.99 nm), maximum entrapment efficiency (91.32%±1.73%) and in vitro permeation (90.28%±0.31%) in 8h, that best fitted zero-order kinetics. M5 was developed as pH sensitive in situ gel and characterized for various parameters. The optimized in situ gel (F5) proved to be superior in its ex vivo transcorneal permeation when compared with Itral(®) eye drop and pure drug suspension, exhibiting 41.45%±0.87% permeation with zero-order kinetics (r(2)=0.994) across goat cornea. Transmission electron microscopy revealed spherical polymeric micelles entrapped in the gel matrix. A spectrum of tests revealed hydration capability, non-irritancy, and histologically safe gel formulation that had appropriate handling characteristics. Kumar et al. (2015) developed a microemulsion system of an antifungal agent, itraconazole for overcoming the shortcomings and adverse effects of currently used therapies. Following preformulation studies like solubility determination, component selection and pseudoternary phase diagram construction, a 3-factor D-optimal mixture design was used for optimizing a microemulsion having desirable formulation characteristics. The factors studied for sixteen experimental trials were percent contents (w/w) of water, oil and surfactant, whereas the responses investigated were globule size, transmittance, drug skin retention and drug skin permeation in 6h. Optimized microemulsion (OPT-ME) was incorporated in Carbopol based 321 hydrogel to improve topical applicability. Physical characterization of the formulations was performed using particle size analysis, transmission electron microscopy, texture analysis and rheology behavior. Ex vivo studies carried out in Wistar rat skin depicted that the optimized formulation enhanced drug skin retention and permeation in 6h in comparison to conventional cream and Capmul 908P oil solution of itraconazole. The in vivo evaluation of optimized formulation was performed using a standardized Tinea pedis model in Wistar rats and the results of the pharmacodynamic study, obtained in terms of physical manifestations, fungal-burden score, histopathological profiles and oxidative stress. Rapid remission of Tinea pedis from rats treated with OPT-ME formulation was observed in comparison to commercially available therapies (ketoconazole cream and oral itraconazole solution), thereby indicating the superiority of microemulsion hydrogel formulation over conventional approaches for treating superficial fungal infections. The formulation was stable for a period of twelve months under refrigeration and ambient temperature conditions. Mohanty et al. (2015) investigated the feasibility of entrapping water-insoluble drug itraconazole into solid lipid nanoparticles (SLNs) for topical ocular delivery. The drugloaded SLNs were prepared from stearic acid and palmitic acid using different concentrations of polyvinyl alcohol employed as emulsifier. SLNs were prepared by the melt-emulsion sonication and low temperature-solidification method and characterized for particle size, zeta potential, drug loading and drug entrapment efficiency. The mean particle size of SLNs prepared with stearic acid ranged from 139 to 199 nm, while the SLNs prepared with palmitic acid had particle size in the range of 126-160 nm. The SLNs were spherical in shape. Stearic acid-SLNs showed higher entrapment of drug compared with palmitic acid-SLNs. Differential scanning calorimetry (DSC) and X-ray diffraction measurements showed decrease in crystallinity of drug in the SLN formulations. The modified Franz-diffusion cell and freshly excised goat corneas were used to test drug corneal permeability. Permeation of itraconazole from stearic acid-SLNs was higher than that obtained with palmitic acid-SLNs. The SLNs showed clear zone of inhibition against Aspergillus flavus indicating antimicrobial efficacy of formulations. Moon et al. (2015) investigated the effects of rifampin and rifabutin on serum itraconazole levels in patients with chronic pulmonary aspergillosis. Serum itraconazole concentrations were significantly lower in patients who received itraconazole with rifampin (median, 0.1 μg/ml; P < 0.001) or rifabutin (median, 0.34 μg/ml; P < 0.001) than those receiving itraconazole alone (median, 5.92 μg/ml). Concomitant use of rifampin or rifabutin and itraconazole should be avoided in patients with chronic pulmonary spergillosis and coexisting mycobacterial infections. Pornputtapitak et al. (2015) formulated Itraconazole (ITZ) NanoClusters via milling (topdown process) or precipitation (bottom-up process) without using any excipients. Itraconazole formulations were prepared by milling 1 gram of micronized itraconazole in 300 mL of fluid. The suspension was collected at 0.5, 1, and 2 hours milling time. Milled ITZ was compared to ITZ prepared by anti-solvent precipitation and to the stock micronized itraconazole. The aerosolization performance of ITZ formulations was determined using an Andersen Cascade Impactor (ACI). The physicochemical properties and aerosol performance of different ITZ NanoClusters suggested an optimized wet milling was the preferred process compared to precipitation. ITZ NanoClusters prepared by wet milling showed better aerosol performance compared to micronized ITZ as received and ITZ NanoClusters prepared by precipitation. ITZ NanoClusters prepared by precipitation methods also showed an 321 amorphous state, while ITZ milled in 10% EtOH maintained the crystalline character of ITZ throughout a 2 hour milling time. CONCLUSIONS: The aerosol performance of milled ITZ NanoClusters was dramatically improved compared to micronized ITZ as received due to the difference of drug particle structures. ITZ NanoCluster formulations represent a potential engineered drug particle approach for inhalation therapy, providing effective aerosol properties and stability due to the crystalline state of the drug powders. Denolle et al. (2014) reported the case of a 68-year-old male patient with a well-controlled hypertension treated with irbesartan 150mg/day since 2007. He developed a pulmonary aspergillosis on post-tuberculosis cavitary lesions treated in July 2011 with itraconazole 200mg/day. Early 2012, his antihypertensive treatment had to be gradually increased to a quadritherapy and his blood pressure was at 157/78mmHg at home. Hypokalemia was observed on several occasions as well as edema of the lower limbs. Plasma renin and plasma and urine aldosterone concentrations on treatment not interfering with the renin angiotensin system were low, associated with normal serum and urine cortisol, ACTH, SDHA and DOC, BNP and creatinine concentrations. Plasma itraconazole values were much above the therapeutic range. Left ventricular ejection fraction was preserved. There were no adrenal or renal artery abnormalities at the CT scan. Three months after stopping itraconazole, hypokalemia and edema disappeared and blood pressure was normalized with less treatment. Plasma renin and aldosterone concentrations were normalized. He had a pulmonary lobectomy for his pulmonary aspergillosis. Itraconazole may induce a resistant hypertension with low renin. The mechanisms of this adverse effect of itraconazole remain unknown. De Smet et al. (2014) performed a study to increase the bioavailability of itraconazole (ITRA) using nanosized cocrystals prepared via wet milling of ITRA in combination with dicarboxylic acids. Wet milling was used in order to create a nanosuspension of ITRA in combination with dicarboxylic acids. After spray-drying and bead layering, solid state was characterized by MDSC, XRD, Raman and FT-IR. The release profiles and bioavailability of the nanococrystalline suspension, the spray-dried and bead layered formulation were evaluated. A monodisperse nanosuspension (549±51nm) of ITRA was developed using adipic acid and Tween®80. Solid state characterization indicated the formation of nanococrystals by hydrogen bounds between the triazole group of ITRA and the carboxyl group of adipic acid. A bioavailability study was performed in dogs. The faster drug release from the nanocrystal-based formulation was reflected in the in vivo results since Tmax of the formulations was obtained 3h after administration, while Tmax of the reference formulation was observed only 6h after administration. This fast release of ITRA was obtained by a dual concept: manufacturing of nanosized cocrystals of ITRA and adipic acid via wet milling. Formation of stable nanosized cocrystals via this approach seems a good alternative for amorphous systems to increase the solubility and obtain a fast drug release of BCS class II drugs. Kim et al. (2014) identified prognostic factors for the outcomes of empirical antifungal therapy, Three hundred seventy-six patients (median age of 48) who had neutropenic fever and who received intravenous (IV) itraconazole as an empirical antifungal therapy for 3 or more days were analyzed. The patients with possible or probable categories of invasive fungal disease (IFD) were enrolled. The overall success rate was 51.3% (196/376). Age >50 years, underlying lung disease (co-morbidity), poor performance status [Eastern Cooperative Oncology Group (ECOG) ≥2], radiologic evidence of IFD, longer duration of baseline neutropenic fever (≥4 days), no antifungal prophylaxis or prophylactic use of antifungal agents other than itraconazole, and high 322 tumor burden were associated with decreased success rate in univariate analysis. In multivariate analysis, age >50 years (p=0.009) and poor ECOG performance status (p=0.005) were significantly associated with poor outcomes of empirical antifungal therapy. Twenty-two patients (5.9%) discontinued itraconazole therapy due to toxicity. It was concluded that empirical antifungal therapy with IV itraconazole in immunocompromised patients is effective and safe. Additionally, age over 50 years and poor performance status were poor prognostic factors for the outcomes of empirical antifungal therapy with IV itraconazole. Kumar et al. (2014) formulated nano-amorphous spray-dried powders of itraconazole to enhance its oral bioavailability. A combination approach of solvent-antisolvent precipitation followed by spray drying was used. DoE studies were utilized to understand the critical processing parameters: antisolvent-to-solvent ratio, drug concentration and stabilizer concentration. Particle size was the critical quality attribute. Spray drying of the nanoprecipitated formulation was performed with several auxiliary excipients to obtain nano-sized amorphous powder formulations. PLM, DSC and PXRD were utilized to characterize the spraydried powders. In vitro dissolution and in vivo bioavailability studies of the nano-amorphous powders were performed. The particle size of the nano-formulations was dependent on the drug concentration. The smallest size precipitates were obtained with low drug concentration. All high molecular weight auxiliary excipients and mannitol containing formulations were unstable and crystallized during spray drying. Formulations containing disaccharides were amorphous and non-aggregating. In vitro dissolution testing and in vivo studies showed the superior performance of nano-amorphous formulations compared to melt-quench amorphous and crystalline itraconazole formulations. This study shows superior oral bioavailability of nanoamorphous powders compared to macro-amorphous powders. The nano-amorphous formulation showed similar bioavailability to the nano-crystalline formulation but with a faster absorption profile. Mawby et al. (2014) determined oral bioequivalence of generic and compounded itraconazole compared to original innovator (brand name) itraconazole in 9 healthy, adult research Beagle dogs. A randomized, 3-way, 3-period, crossover design with an 8-day washout period. After a 12-hour fast, each dog received 100 mg (average: 10.5 mg/kg) of either innovator itraconazole, an approved human generic capsule, or compounded itraconazole (compounded using a commercially available compounding vehicle) with a small meal. Plasma was collected at predetermined intervals for high pressure liquid chromatography analysis. Concentration data were analyzed using noncompartmental pharmacokinetics to determine area under the curve (AUC), peak concentration (C(MAX)), and terminal half-life. Bioequivalence tests compared generic and compounded itraconazole to the reference formulation. Average ratios of compounded and generic formulations to the reference formulation of itraconazole for AUC were 5.52% and 104.2%, respectively, and for C(MAX) were 4.14% and 86.34%, respectively. A test of bioequivalence using 2 one-sided tests and 90% confidence intervals did not meet bioequivalence criteria for either formulation. CONCLUSION AND CLINICAL IMPORTANCE: Neither generic nor compounded itraconazole is bioequivalent to the reference formulation in dogs. However, pharmacokinetic data for generic formulation were similar enough that therapeutic concentrations could be achieved. Compounded itraconazoleproduced such low plasma concentrations, it is unlikely to be effective; therefore, compounded itraconazole should not be used in dogs. 323 Pawar et al. (2014) mentioned that A drug should be available in accessible in disintegrated state before producing its therapeutic effect however; in current market more than 40%, drugs are poorly soluble in water. In view of their low aqueous solubility, those new chemical entities fail to reach market in spite of revealing potential pharmacodynamics activities. Poorly aqueous soluble drugs are connected with moderate drug absorption leading inevitably to insufficient and variable bioavailability. Consequently, different methodologies have been grasped for solubility and dissolution enhancement of poorly water-soluble drugs thus bioavailability. Solubility assumes a paramount part in attaining the desired plasma drug concentration. In this review article, different techniques like solid dispersion using hot stage extrusion, freeze-drying, spray drying, and hot melt extrusion also nano suspensions, dried emulsions were discussed for solubility and dissolution rate improvement of BCS class II antifungal drug Itraconazole. Amongst various method described in this review, solid dispersion was found to be most preferred technique by researcher as it provide ease in preparation and efficiency in terms of resolving the solubility and dissolution problems associated with Itraconazole. References 1. Abuhelwa AY1, Foster DJ2, Mudge S3, Hayes D3, Upton RN1. Population pharmacokinetic modeling of itraconazole and hydroxyitraconazole for oral SUBA-itraconazole and sporanox capsule formulations in healthy subjects in fed and fasted states. Antimicrob Agents Chemother. 2015 Sep;59(9):5681-96 2. Al-Nakeeb Z, Sudan A, Jeans AR, et al. Pharmacodynamics of Itraconazole against Aspergillus fumigatus in an In Vitro Model of the Human Alveolus: Perspectives on the Treatment of Triazole-Resistant Infection and Utility of Airway Administration. Antimicrobial Agents and Chemotherapy. 2012;56(8):4146-4153. doi:10.1128/AAC.00141-1. 2 3. Barone JA, Moskovitz BL, Guarnieri J, et al. Enhanced bioavailability of itraconazole in hydroxypropyl-β-cyclodextrin solution versus capsules in healthy volunteers. Antimicrob Agents Chemother 1998; 42: 1862–5 4. Boehm RD1, Jaipan P2, Skoog SA1, Stafslien S3, VanderWal L3, Narayan RJ4. Inkjet deposition of itraconazole onto poly(glycolic acid) microneedle arrays. Biointerphases. 2016 Mar 11;11(1):011008. 5. Denolle T1, Azizi M2, Massart C3, Zennaro MC4. [Itraconazole: a new drug-related cause of hypertension]. Ann Cardiol Angeiol (Paris). 2014 Jun;63(3):213-5. 6. De Smet L1, Saerens L2, De Beer T2, Carleer R3, Adriaensens P3, Van Bocxlaer J4, Vervaet C5, Remon JP1. Formulation of itraconazole nanococrystals and evaluation of their bioavailability in dogs. Eur J Pharm Biopharm. 2014 May;87(1):107-13. 7. Grant SM1, Clissold SP. Itraconazole. A review of its pharmacodynamic and pharmacokinetic properties, and therapeutic use in superficial and systemic mycoses. Drugs. 1989 Mar;37(3):31044. 8. Hagihara M1, Kasai H, Umemura T, Kato T, Hasegawa T, Mikamo H, Pharmacokinetic– pharmacodynamic study of itraconazole in patients with fungal infections in intensive care units. Journal of Infection and Chemotherapy. Volume 17, Issue 2, 2011, Pages 224-230 9. Jaiswal M1, Kumar M2, Pathak K1. Zero order delivery of itraconazole via polymeric micelles incorporated in situ ocular gel for the management of fungal keratitis. Colloids Surf B Biointerfaces. 2015 Jun 1;130:23-30 10. Jaywant N. Pawar*, Tarique M. Ali, Kailash K. Moravkar, Rahul K. Patole , Divakar R. Jaiswar and Purnima D. Amin. RECENT DEVELOPMENT AND ACHIEVEMENTS IN SOLUBILITY AND DISSOLUTION ENHANCEMENT OF ITRACONAZOLE: A REVIEW. IJPSR, 2014; Vol. 5(8): 3096-3106. 324 11. Karel De Beule and Jef Van Gestel .Pharmacology of Itraconazole. Drugs 2001; 61 Suppl. 1: 2737 Janssen Research Foundation, Beerse, Belgium 12. Kim JS1, Cheong JW, Shin HJ, Lee JW, Lee JH, Yang DH, Lee WS, Kim H, Park JS, Kim SH, Kim YS, Kwak JY, Chae YS, Park J, Do YR, Min YH. Clinical outcomes and prognostic factors of empirical antifungal therapy with itraconazole in the patients with hematological malignancies: a prospective multicenter observational study in Korea. Yonsei Med J. 2014 Jan;55(1):9-18. 13. Kumar N1, Shishu2. D-optimal experimental approach for designing topical microemulsion of itraconazole: Characterization and evaluation of antifungal efficacy against a tandardized Tinea pedis infection model in Wistar rats. Eur J Pharm Sci. 2015 Jan 25;67:97-112. 14. Kumar S1, Shen J1, Burgess DJ2. Nano-amorphous spray dried powder to improve oral bioavailability of itraconazole. J Control Release. 2014 Oct 28;192:95-102. 15. Lee JJ1, Shim A2, Jeong JY1, Lee SY1, Ko HJ3, Cho HJ4. Development of intranasal nanovehicles of itraconazole and their immunological activities for the therapy of rhinovirus infection. Colloids Surf B Biointerfaces. 2016 Jul 1;143:336-341. 16. Lestner J1, Hope WW. Itraconazole: an update on pharmacology and clinical use for treatment of invasive and allergic fungal infections. Expert Opin Drug Metab Toxicol. 2013 Jul;9(7):911-26. 17. Liang C1, Shan Q2, Zhong J1, Li W1, Zhang X1, Wang J3, Cao C1, Zeng Z4. Pharmacokinetics and bioavailability of itraconazole oral solution in cats. J Feline Med Surg. 2016 Apr;18(4):310-4. 18. Mawby DI1, Whittemore JC, Genger S, Papich MG. Bioequivalence of orally administered generic, compounded, and innovator-formulated itraconazole in healthy dogs. J Vet Intern Med. 2014 Jan-Feb;28(1):72-7. 19. Middleton SM1, Kubier A2, Dirikolu L1, Papich MG3, Mitchell MA1, Rubin SI1. Alternate-day dosing of itraconazole in healthy adult cats. J Vet Pharmacol Ther. 2016 Feb;39(1):27-31. 20. Mohanty B1, Majumdar DK, Mishra SK, Panda AK, Patnaik S. Development and characterization of itraconazole-loaded solid lipid nanoparticles for ocular delivery. Pharm Dev Technol. 2015 Jun;20(4):458-64. 21. Moon SM1, Park HY1, Jeong BH1, Jeon K1, Lee SY2, Koh WJ3. Effect of rifampin and rifabutin on serum itraconazole levels in patients with chronic pulmonary aspergillosis and coexisting nontuberculous mycobacterial infection. Antimicrob Agents Chemother. 2015 Jan;59(1):663-5. 22. Pornputtapitak W1,2, El-Gendy N1,3, Berkland C1,4. NanoCluster Itraconazole Formulations Provide a Potential Engineered Drug Particle Approach to Generate Effective Dry Powder Aerosols. J Aerosol Med Pulm Drug Deliv. 2015 Oct;28(5):341-52 23. Rifkin A, Visser M, Barrett K, Boothe D, Bronson E. THE PHARMACOKINETICS OF TOPICAL ITRACONAZOLE IN PANAMANIAN GOLDEN FROGS (ATELOPUS ZETEKI). J Zoo Wildl Med. 2017 Jun;48(2):344-351. 24. Srinivas NR1. Prediction of area under the curve for a p-glycoprotein, a CYP3A4 and a CYP2C9 substrate using a single time point strategy: assessment using fexofenadine, itraconazole and losartan and metabolites. Drug Dev Ind Pharm. 2016;42(6):945-57 25. Stappaerts J1, Augustijns P2. Displacement of itraconazole from cyclodextrin complexes in biorelevant media: In vitro evaluation of supersaturation and precipitation behavior. Int J Pharm. 2016 Sep 10;511(1):680-7. 26. Van de Velde VJS, Van Peer AP, Heykants JJP, et al. Effect of food on the pharmacokinetics of a new hydroxypropyl-beta-cyclodextrin formulation of itraconazole. Pharmacotherapy 1996; 16: 424–8 27. L. Willems, R. van der Geest and K. de Beule . Itraconazole oral solution and intravenous formulations: a review of pharmacokinetics and pharmacodynamics Journal of Clinical Pharmacy and Therapeutics (2001) 26, 159±169 325 22. Ketoconazole, Greenblatt and Greenblatt (2014) Ketoconazole was introduced in 1981 as the first in a series of azole antifungal agents, characterized structurally by at least one five-membered, nitrogen-containing ring. Chemical and physical data Solubility in various solvents Water 0.0866 mg/L (22oC); 13 mcg/ml (25oC); PVP K-30 20% solution ~ 2 mg/ml (25oC) DMSO dry ~ 20 mg/ml (22oC) Ethanol anhydrous (warm) ~ 20 mg/ml (45oC) Methanol ~ 5 mg/ml (22oC) Chloroform~ 10 mg/ml (22oC) MCT oil~ 0.02 mg/ml (22oC) Molar mass Formula 531.431 g/mol C26H28Cl2N4O4 Mechanism of Action     Ketoconazole usually is fungistatic in action, but may be fungicidal at high concentrations after prolonged incubation or against very susceptible organisms. ketoconazole presumably exerts its antifungal activity by altering and damaging cellular membranes, resulting in increased membrane permeability, secondary metabolic effects, and growth inhibition of fungal cells. Ketoconazole fungistatic activity may result from interference with ergosterol synthesis, probably via inhibition of C-14 demethylation of sterol intermediates (e.g., lanosterol). Ketoconazole fungicidal activity of ketoconazole at high concentrations may result from a direct physiochemical effect of the drug on the fungal cell membrane. 326 Antimicrobial action and microbial sensitivity.    Ketoconazole inhibits the growth of the dermatophytes: Trichophyton rubrum, T. mentagrophytes, T. tonsurans, Microsporum canis, M. audouini, M. gypseum and Epidermophyton floccosum; Ketoconazole inhibits the growth of the yeast:Candida albicans, C. tropicalis, Pityrosporum ovale and Pityrosporum orbiculare (M. furfur). Ketoconazole has activity against some Gram-positive bacteria and some antiprotozoal activity against Leishmania spp. Resistance to ketoconazole   The emergence of strains of Candida spp. resistant to ketoconazole has become increasingly important, particularly in immunocompromised patients receiving longterm prophylaxis with fluconazole. In addition to resistance in C. albicans, infections with C. dubliniensis, C. glabrata, and C. krusei, all of which may be less sensitive to ketoconazole than C. albicans, have been noted in these patients, and secondary resistance of C. glabrata has been reported during ketoconazole therapy. Pharmaceutical preparations and uses  Ketoconazole Shampoo o Ketoconazole 2% shampoo is a red-orange liquid for topical application, containing the broad spectrum synthetic antifungal agent ketoconazole in a concentration of 2% in an aqueous suspension. o Ketoconazole 2% shampoo also contains: coconut fatty acid diethanolamide, disodium monolauryl ether sulfosuccinate, F.D.&C. Red No. 40, hydrochloric acid, imidurea, laurdimonium hydrolyzed animal collagen, macrogol 120 methyl glucose dioleate, perfume bouquet, sodium chloride, sodium hydroxide, sodium lauryl ether sulfate, and purified water. o Ketoconazole 2% shampoo is used for the treatment of fungal infections, pityriasis versicolor and conditions like seborrheic dermatitis and dandruff. Shampoo controls flaking, scaling and itching, associated with dandruff.  Ketoconazole Cream o Ketoconazole Cream 2%, for topical administration only, contains the broadspectrum synthetic antifungal agent, ketoconazole 2%, formulated in an aqueous cream vehicle consisting of propylene glycol, stearyl and cetyl alcohols, sorbitan monostearate, polysorbate 60, isopropyl myristate, sodium sulfite anhydrous, polysorbate 80 and purified water o Ketoconazole Cream is used to treat fungal infections of the skin such as athlete's foot, jock itch, ringworm, and seborrhea (dry, flaking skin). 327  Ketoconazole Tablets o Ketoconazole, USP is a synthetic broad-spectrum antifungal agent. Each tablet, for oral administration, contains 200 mg ketoconazole, USP base. o Ketoconazole tablet also contains the following inactive ingredients: colloidal silicon dioxide, corn starch, lactose monohydrate, magnesium stearate, microcrystalline cellulose, and povidone. o Ketoconazole Tablets are not indicated for treatment of onychomycosis, cutaneous dermatophyte infections, or Candida infections. o Ketoconazole Tablets should be used only when other effective antifungal therapy is not available or tolerated and the potential benefits are considered to outweigh the potential risks. o Ketoconazole Tablets are indicated for the treatment of the following systemic fungal infections in patients who have failed or who are intolerant to other therapies: blastomycosis, coccidioidomycosis, histoplasmosis, chromomycosis, and paracoccidioidomycosis. Ketoconazole Tablets should not be used for fungal meningitis because it penetrates poorly into the cerebrospinal fluid.  Ketoconazole Foam o Ketoconazole Foam 2% is indicated for the topical treatment of seborrheic dermatitis in immunocompetent patients 12 years of age and older. o Ketoconazole Foam, 2% is used on the skin (topical) to treat a skin condition called seborrheic dermatitis in patients 12 years and older. Seborrheic dermatitis can cause areas of flaky skin (scales) on the scalp, face, ears, chest or upper back. Pharmacokinetics   Ketoconazole was not detected in plasma in 39 patients who who used 2% shampoo 410 times per week for 6 months, or in 33 patients who shampooed 2-3 times per week for 3-26 months ( mean: 16 months). Ketoconazole systemic absorption following topical application in healthy subjects practically absents and has not any notable clinical effect. Absorption     Ketoconazole is a weak dibasic agent and thus requires acidity for dissolution and absorption. Mean peak plasma concentrations of approximately 3.5 µg/mL are reached within 1 to 2 hours, following oral administration of a single 200 mg dose taken with a meal. Oral bioavailability is maximal when the tablets are taken with a meal. Absorption of tablets is reduced in subjects with reduced gastric acidity, such as subjects taking medications known as acid neutralizing medicines (e.g. aluminum hydroxide) and gastric acid secretion suppressors (e.g. H2-receptor antagonists, proton pump inhibitors) or subjects with achlorhydria caused by certain diseases 328 Distribution      In vitro, the plasma protein binding is about 99% mainly to the albumin fraction. Ketoconazole is widely distributed into tissues; however, only a negligible proportion reaches the cerebrospinal fluid. Metabolism Following absorption from the gastrointestinal tract, Ketoconazole is converted into several inactive metabolites. In vitro studies have shown that CYP3A4 is the major enzyme involved in the metabolism of ketoconazole. The major identified metabolic pathways are oxidation and degradation of the imidazole and piperazine rings, by hepatic microsomal enzymes. Elimination  Elimination from plasma is biphasic with a half-life of 2 hours during the first 10 hours and 8 hours thereafter. o Approximately 13% of the dose is excreted in the urine, of which 2 to 4% is unchanged drug. o The major route of excretion is through the bile into the intestinal tract with about 57% being excreted in the feces. Ketoconazole side effects        Ketoconazole most commonly reported side effects are reversible gastrointestinal disturbances such as nausea, vomiting, or abdominal discomfort, which occur in an estimated 3 to 10% of patients. Ketoconazole more serious adverse reactions (common with amphotericin B) occur in less than 1% of patients. Ketoconazole fungal resistance was considered to be uncommon except in HIV-positive populations—another advantage for the azoles over amphotericin B. ketoconazole became recognized as a potent inhibitor of human drug metabolism (specifically via CYP3A isoforms), beginning with reports around 1982 describing inhibition of cyclosporine clearance. Ketoconazole also inhibits a number of CYP enzymes involved in steroidogenesis, leading to reports of adrenal insufficiency in some clinical situations. Ketoconazole inhibition of testosterone synthesis via CYP3A inhibition probably explains the anti-androgen effects of ketoconazole, underlying reports of gynecomastia as an infrequent side effect, as well as the potential applicability of high-dose ketoconazole for treatment of hormone-refractory prostate cancer. Ketoconazole has also been reported as a pharmacologic treatment for Cushing disease because of its ability to inhibit adrenal steroidogenesis. Early Reports of Ketoconazole Hepatotoxicity 329  Within five years of the introduction of ketoconazole into clinical practice, the possibility of hepatotoxicity was widely recognized, as was the need for monitoring of liver function. Brand names/Manufacturer (179 brand names)                           ABBA (Medichrom - GREECE) AC-FA (Pharmasant - THAILAND) ACIDERM (Sanval - BRAZIL) ADCO-DERMED (Adcock Ingram - SOUTH AFRICA) ADENOSAN (Pharmanik - GREECE) AKORAZOL (Collins - MEXICO) ANTANAZOL (Shin Poong - SINGAPORE) APO-KETOCONAZOLE (APOTEX - CANADA) AQUARIUS (Demo - GREECE) ARCOLAN (Galderma - BRAZIL) ARCOLANE (Galderma - CHILE) BEATOCONAZOLE (Beacons - SINGAPORE) BELTOP (Janssen-Cilag - AUSTRIA) BETAZOL CORT (Delta - BRAZIL) BIOGEL (Prater - CHILE) BIOZORAL (Bioresearch - MEXICO) BOTADERM (Zekides - GREECE) CANDICORT (Ache - BRAZIL) CANDIDERM (Ache - BRAZIL) CANDORAL (Ache - BRAZIL) CAPEL (Ache - BRAZIL) CESOL (Cesam - PORTUGAL) CETOBETA (Bunker - BRAZIL) CETOCORT (Teuto - BRAZIL) CETOHEXAL (Hexal - BRAZIL) CETOMED (Cimed - BRAZIL)  CETONAX (Janssen-Cilag - BRAZIL) CETONEO (Neo Quimica - BRAZIL) CETONIL (Stiefel, Braz. - BRAZIL                 KESTOMICOL (Farmaco - MEXICO) KETAZOL (Shiwa – THAILAND, SOUTH AFRICA) KETAZON (Siam Bheasach - THAILAND) KETOCINE (Medicine Products – THAILAND) KETOCONAZOLE (MUTUAL PHARMACEUTICALS, TEVA, MYLAN, TARO, STADA - U.S.) KETOCONAZOLE-200 (PRO DOC LIMITEE CANADA) KETOCON (Cibran - BRAZIL) KETODERM (Janssen-Cilag – FRANCE, Taro CANADA) KETOFAR (Farcoral - MEXICO) KETOISDIN (Isdin - SPAIN) KETOLAN (Olan-Kemed - THAILAND) KETOMED (Medifive - THAILAND) KETOMICOL (Luper - BRAZIL) KETOMIZOL (Reuffer - MEXICO) 331                           CETOZAN (Royton - BRAZIL) CETOZOL (Cazi - BRAZIL) CEZOLIN (Remedina - GREECE) CHINTARAL (Chinta - THAILAND) CONAZOL (Liomont - MEXICO) CREMOSAN (Quimica y Farmacia - MEXICO) DAKTAGOLD (Janssen-Cilag – Australia, N. Z.) DAKTARIN GOLD (Johnson & Johnson UK) DANDRAZOL (Transdermal - UK) DANDRID (Sandoz - UK) DEZOR (Hoe - MALAYSIA) DEZORAL (Hoe - Singapore) DIAZON (thailand, singapore, hong kong) EBERSEPT (Bros - GREECE) EHLIFUNG (Ehlinger - MEXICO) EPROFIL (Andromaco - CHILE) ERGOMICON (Offenbach - MEXICO) EUROLAT (Euromex - MEXICO) FEMISAN (Grossman - MEXICO) FLUZORAL (Merck - HONG KONG) FRISOLAC (BA Farma - PORTUGAL) FRISOL (BA Farma, - PORTUGAL) FUNDAN (Ipex - SWEDEN) FUNGAMIZOL (Ofimex - MEXICO) FUNGAREST (Janssen-Cilag – SPAIN, CHILE) FUNGAZOL (Biolab – thailand, hong kong,)  KEZON (Osoth - THAILAND)                 MICOTICUM (Vita - SPAIN) MI-KE-SONS (Sons - MEXICO) MIKETOS (Chinoin - MEXICO) MIZORON (Milano - THAILAND) MYCELLA (Silom - THAILAND) MYCODIB (Diba - MEXICO) MYCOFEBRIN (Coup - GREECE) MYCORAL (T Man - THAILAND) MYCORAL (Kalbe - SINGAPORE) NASTIL (Best - MEXICO) NAZOLFARM (Continentales - MEXICO) NEO-EGMOL (Norma - GREECE) NIKORAZOL (Mavi - MEXICO) NINAZOL (TO-Chemicals - THAILAND) NIZALE (Janssen-Cilag - PORTUGAL) NIZCREME (Janssen-Cilag - SOUTH AFRICA)                               KETOMOUSSE (Mipharm - ITALY) KETONAN (Marjan - BRAZIL) KETONAZOL (Bunker - BRAZIL) KETONAZOLE (Polipharm - THAILAND) KETONE (Wayne - MEXICO) KETONIL (Grunenthal - CHILE) KETORAL (Community Pharmacy - THAILAND) KETOSIL (Silom - THAILAND) KETOSON (CCS - SWEDEN) KETOZAL (Pond's- THAILAND) KETOZOL (Mepha – SWITZERLAND, Christo – HONG KONG) KETOZOLE (DHA – SINGAPORE, HONG KONG) KEZORAL (Upha – MALAYSIA, Durascan DENMARK) KONADERM (ICN - MEXICO) KONATURIL (IQFA - MEXICO) KONAZIL (Sintofarma - BRAZIL) KONAZOL (PP Lab, TAHILAND) KPL (Fouchard - CHILE) LAMA (Pharmaland - THAILAND) LARRY (Unison – THAILAND, HONG KONG) LIZOVAG (Novag - MEXICO) LORNAZOL (Loren - MEXICO) LOZAN (Teuto - BRAZIL) LUPERZOL (Quimica y Farmacia – MEXICO MANOKETO (March - THAILAND) MASAROL (Masa - THAILAND) MICOGAL (Galen – MEXICO) MICONAN (Ativus - BRAZIL) MICORAL (Elofar - BRAZIL) MICOSER (Serral - MEXICO) 331                     NIZORAL (Janssen-Cilag – ITALY, UK, CANADA, IRELAND, GERMANY, NETHERLANDS, SOUTH AFRICA, SWITZERLAND, BELGIUM, AUSTRIA, DENMARK, PROTUGAL, BRAZIL, HONG KONG, MEXICO, ISRAEL, THAILAND, SINGAPORE, FINLAND, NEW ZEALAND, AUSTRALIA, MALAYSIA, HUNGARY, CZECH REPUBLIC, FRANCE, USA) NIZORAL A-D (MCNEIL CONSUMER PRODUCTS - U.S.) NIZORELLE (Janssen-Cilag - SOUTH AFRICA) NIZOVULES (Janssen-Cilag - SOUTH AFRICA) NIZSHAMPOO (Janssen-Cilag - SOUTH AFRICA) NORA (TNP - THAILAND) NORIDERM (EMS - BRAZIL) NORIZAL (EMS - BRAZIL) NORONAL (Ducto - BRAZIL) NOVACORT (Ache - BRAZIL) NOVO-KETOCONAZOLE (Novopharm CANADA) NOZORAL (Janssen-Cilag - AUSTRALIA) NU-KETOCON (Nu-Pharm - CANADA) ONOFIN-K (Rayere - MEXICO) OROZANOL (KRKA, CZECH REPUBLIC) PANFUNGOL (Esteve - SPAIN) PASALEN (Pharmaland - THAILAND) PRENALON (Degorts - MEXICO) PRISTINE (Xepa-Soul Pattinson, HONG KONG, SINGAPORE, MALAYSIA) PRISTINEX (Xepa-Soul Pattinson, HONG KONG, SINGAPORE, MALAYSIA) 332 Recent reports Cirello et al. (2017) investigated the metabolism of ketoconazole in rat, rabbit and human ocular S9 fractions. Metabolism in liver S9 fractions was also studied for a direct comparison. Eleven putative metabolites were identified in the in vitro incubations. Of these metabolites, six were present in rat ocular S9 whereas eight were present in rabbit and human ocular matrices. Metabolic pathways in rabbit and human ocular fractions suggested the formation of reactive intermediates in rabbit and human liver and ocular S9 incubations, which was confirmed with trapping studies. Herein, we report eight human ocular metabolites of ketoconazole for the first time. To the best of our knowledge, this is the first report of ocular metabolic pathways and ocular bioactivation of ketoconazole in preclinical species and human. Blass et al. (2016) identified a series of novel sulfonamide analogs of (2S,4R)-Ketoconazole that are potent inhibitors of these enzymes. In addition, selected members of this class of compounds have pharmacokinetic properties consistent with orally delivered drugs, making them well suited to further investigation as potential therapies for MetS. Fukami et al. (2016) identified the responsible enzyme(s) for KC hydrolysis in humans and to clarify their relevance to KC-induced toxicity. Kinetic analysis and inhibition studies using human liver microsomes (HLM) and recombinant enzymes revealed that human arylacetamide deacetylase (AADAC) is responsible for KC hydrolysis to form DAK, and confirmed that FMO3 is the enzyme responsible for DAK N-hydroxylation. In HLM, the clearance of KC hydrolysis occurred to the same extent as DAK N-hydroxylation, which indicates that both processes are not rate-limiting pathways. Cytotoxicity of KC and DAK was evaluated using HepaRG cells and human primary hepatocytes. Treatment of HepaRG cells with DAK for 24h showed cytotoxicity in a dose-dependent manner, whereas treatment with KC did not show due to the low expression 333 of AADAC. Overexpression of AADAC in HepaRG cells with an adenovirus expression system elicited the cytotoxicity of KC. Cytotoxicity of KC in human primary hepatocytes was attenuated by diisopropylfluorophosphate, an AADAC inhibitor. In conclusion, the present study demonstrated that human AADAC hydrolyzes KC to trigger hepatocellular toxicity. Liu et al. (2016) Ketoconazole has been widely used as a strong cytochrome P450 (CYP) 3A (CYP3A) inhibitor in drug-drug interaction (DDI) studies. However, the US Food and Drug Administration has recommended limiting the use of ketoconazole to cases in which no alternative therapies exist, and the European Medicines Agency has recommended the suspension of its marketing authorizations because of the potential for serious safety concerns. In this review, the Innovation and Quality in Pharmaceutical Development's Clinical Pharmacology Leadership Group (CPLG) provides a compelling rationale for the use of itraconazole as a replacement for ketoconazole in clinical DDI studies and provides recommendations on the best practices for the use of itraconazole in such studies. Various factors considered in the recommendations include the choice of itraconazole dosage form, administration in the fasted or fed state, the dose and duration of itraconazole administration, the timing of substrate and itraconazole coadministration, and measurement of itraconazole and metabolite plasma concentrations, among others. The CPLG's recommendations are based on careful review of available literature and internal industry experiences. Maniruzzaman et al. (2016) developed mucoadhesive oral strips using hot-melt extrusion as a continuous manufacturing process. Powder blends of ketoconazole, a water-insoluble drug either hydroxypropyl methylcellulose (HPMC) or soluplus (SOL), sorbitol (SRB) and magnesium aluminometasilicate (MAS) were extruded to manufacture thin strips with 0.5-mm thickness. The presence of the inorganic metasilicate facilitated smooth processing of the extruded strips as it worked as an absorbent directly impacting on the extensive mixing of the drug/excipients inside the extruder barrel. The use of MAS also favoured the rapid hydration, swelling and eventual disintegration of the strips. Differential scanning calorimetry and transmission X-ray diffraction analysis revealed the existence of the amorphous drug within the extruded strips. Scanning electron microscopy and energy dispersive X-ray undertaken on the formulations showed a homogeneous drug distribution within the extruded strips. CONCLUSION: The strips produced via continuous hot-melt extrusion processing showed significantly faster release of ketoconazolecompared to the bulk drug substance. Adachi et al. (2015) investigated the incorporation of a pH-modifier as a method to increase compound solubility and uses ketoconazole (KZ), which is weakly basic (pKa: 6.5), as a model compound. Organic acids are effective pH-modifiers and are generally used in pharmaceutical industries. We successfully obtained granules containing variable organic acids (KZ/acid granule) using a high-shear mixer. Dissolution tests of the KZ/acid granule resulted in highly enhanced solubility under non-sink conditions. Adding water-soluble acids, such as citric acid (CA) and tartaric acid, resulted in more than 8-fold higher dissolution at pH 6.0 compared to that of KZ only. The granules containing citric acid (KZ/CA granule) improved the dissolution of KZ after oral administration to rats under low gastric acid conditions, where the bioavailability of the KZ/CA granules at elevated gastric pH was comparable with that of KZ only at gastric acidic pH. The incorporation of organic acids would result in effective therapeutic outcomes independent of gastric pH in patients. In addition, higher bioavailability of KZ was observed after oral administration of KZ/CA granules under gastric acidic pH conditions than that of KZ alone. Thus, CA improved the dissolution and absorption rate of KZ after oral administration. 334 Gobbato et al (2015) evaluated the efficacy of a new antifungal imidazole, dapaconazole tosylate, in the treatment of Pityriasis versicolor (PV). Sixty patients with clinical and mycological diagnosis of PV were randomly assigned to receive either 1 g dapaconazole tosylate 2% cream or 1 g ketoconazole 2% cream. Treatments were applied once a day for 28 days. A dermatologist evaluated efficacy and safety daily, and weekly laboratorial tests were performed. The primary end point was a clinical and mycological cure of lesions after 28 days of treatment. The secondary end point was the time to clinical healing assessed by Kaplan-Meier analysis and Log-rank testing. Fifty-three patients adhered to protocol rules. Clinical and mycological cure was achieved in 84.6% (22/26) and 92.6% (25/27) of patients treated with ketoconazole and dapaconazole, respectively (difference [effect size] = 8.0%, Standard error of difference: 8.69%, 95% CI: -6.3 to 22.3%). Median time to healing was 23.5 and 21 days for ketoconazole and dapaconazole, respectively (p = 0.126). Adverse events occurred only in ketoconazole-treated patients (13%; 4/30). CONCLUSION: Dapaconazole tosylate is non-inferior to ketoconazole when used at a dose of 20 mg/day for 28 consecutive days for the treatment of PV. Dapaconazole also demonstrated a good safety profile. Gupta and Lyons (2015) mentioned that Ketoconazole was the first broad-spectrum oral antifungal agent available to treat systemic and superficial mycoses. Evidence of hepatotoxicity associated with its use emerged within the first few years of its approval. Growing evidence of serious side effects including endocrine dysregulation, several drug interactions, and death led to the review of oral ketoconazole in 2011.This article chronicles the use of oral ketoconazole from its introduction to its near replacement in medicine.Due to its hepatotoxic side effects, oral ketoconazole was withdrawn from the European and Australian markets in 2013. The United States imposed strict relabeling requirements and restrictions for prescription, with Canada issuing a risk communication echoing these concerns. Today, oral ketoconazole is only indicated for endemic mycoses, where alternatives are not available or feasible. Meanwhile, topical ketoconazole is effective, safe, and widely prescribed for superficial mycoses, particularly as the first-line treatment for tinea versicolor. Gupta et al. (2015) summarized 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. 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. Kakkar et al. (2015) prepared solid lipid nanoparticles (SLNs) comprising Compritol(®) 888 ATO and PEG 600 matrix, using hot high-pressure homogenization. Employing extensive characterization: TEM, NMR, DSC, XRD and FTIR, it is proposed that SLNs comprise of a polyethylene glycol (PEG) core into which KTZ is dissolved. PEG endows the lipid matrix with amorphousness and imperfections; rigidity; and, stability to aggregation, on storage and autoclaving. PEG is a simple, cost-effective and safe polymer with superior solubilizing and 335 surfactant-supporting properties. Without its inclusion KTZ could not be loaded into SLNs. It ensured high incorporation efficiency (70%) of KTZ; small size (126 nm); and, better permeation into the eye. Pharmacokinetic studies indicated 2.5 and 1.6 fold higher bioavailability (AUC) in aqueous and vitreous humor, respectively. Biocompatibility and in vitro (both in corneal and retinal cell lines) and in vivo (in rabbits) ocular safety is the other highlight of developed formulation. Greenblatt and Greenblatt (2014) mentioned that the azole antifungal agent ketoconazole has been available since 1981 for the treatment of fungal infections. In 2013, the American Food and Drug Administration and the European Medicines Agency issued warnings or prohibitions against the clinical use of oral ketoconazole due to the risk of liver injury which may lead to liver transplantation or death. From the available published evidence it is difficult to determine the actual incidence or prevalence of liver injury during clinical use of ketoconazoleas an antifungal. Hepatic injury, when it occurs, is generally evident as asymptomatic and reversible abnormalities of liver function tests. However, serious liver injury has been reported. Alternatives to ketoconazole (such as itraconazole, fluconazole, voriconazole, and terbinafine) are available, but improved safety with respect to liver injury risk is not clearly established. Hu et al. (2014) described a simple, rapid and sensitive ultra-performance liquid chromatography tandem mass spectrometry (UPLC-MS/MS) method for determination of ketoconazole (KTZ) in human plasma samples using carbamazepine as the internal standard (IS). Sample preparation was accomplished through one-step liquid-liquid extraction by ethyl acetate, and chromatographic separation was performed on an Acquity BEH C18 column (2.1 mm×50 mm, 1.7 μm) with gradient profile at a flow of 0.45 mL/min. Mass spectrometric analysis was performed using a QTrap5500 mass spectrometer coupled with an electro-spray ionization (ESI) source in the positive ion mode. The MRM transition of m/z 531.2→489.3 was used to quantify for KTZ. The linearity of this method was found to be within the concentration range of 5-15 000 ng/mL for KTZ in human plasma. Only 1.5 min was needed for an analytical run. Elbendary et al. (2013) recruited patients with AUR secondary to BPO but those with hepatic or renal impairment were excluded. Following urethral catheterization, the participants were randomized into two equal groups. The first group received tamsulosin (0.4 mg o.d.) and ketoconazole(200 mg t.d.s.) while the second one had tamsulosin and placebo. The drugs were maintained for 7 days and then the patients were put on trial without catheter (TWOC). The successful cases were assessed with peak flow rate (PFR) and the post-void residual urine volume (PVRV) was also estimated. 106 men with a mean age of 64.1±5.2 years and a mean prostate size of 61.6±14.6 g were included in the two groups. The received medications were well tolerated by all patients and none of them had discontinued the prescribed drugs. The incidence of the successful TWOC was significantly higher in the combined treatment group (77.35%) compared to the tamsulosin group (58.84%; P=0.01). Among those who had a successful TWOC, the PFR and the PVRV were also significantly better in the combined treatment group compared to the other one (P=0.001). 336 References 1. Adachi M1, Hinatsu Y2, Kusamori K2, Katsumi H2, Sakane T3, Nakatani M4, Wada K4, Yamamoto A2. Improved dissolution and absorption of ketoconazole in the presence of organic acids as pH-modifiers. Eur J Pharm Sci. 2015 Aug 30;76:225-30. 2. Blass BE1, Iyer P2, Abou-Gharbia M3, Childers WE3, Gordon JC3, Ramanjulu M3, Morton G3, Arumugam P2, Boruwa J2, Ellingboe J2, Mitra S2, Nimmareddy RR2, Paliwal S2, Rajasekhar J2, Shivakumar S2, Srivastava P2, Tangirala 2 2 2 RS , Venkataramanaiah K , Yanamandra M . Design, synthesis, and evaluation of (2S,4R)-Ketoconazole sulfonamide analogs as potential treatments for Metabolic Syndrome. Bioorg Med Chem Lett. 2016 Dec 1;26(23):5825-5829. Cirello AL1, Dumouchel JL1, Gunduz M1, Dunne CE2, Argikar UA3. In vitro ocular metabolism and bioactivation of ketoconazole in rat, rabbit and human. Drug Metab Pharmacokinet. 2017 Apr;32(2):121-126. 3. Elbendary M1, El-Gamal OM, Soliman MG, Tawfik A, Taha MR. Role of combined use of ketoconazole and tamsulosin in management of acute urinary retention due to benign prostatic obstruction (a randomized controlled trial). Prostate Cancer Prostatic Dis. 2013 Dec;16(4):362-6. 4. Fukami T1, Iida A2, Konishi K2, Nakajima M2. Human arylacetamide deacetylase hydrolyzes ketoconazole to trigger hepatocellular toxicity. Biochem Pharmacol. 2016 Sep 15;116:153-61 5. Gobbato AA1, Babadópulos T1, Gobbato CA1, Ilha Jde O2, Gagliano-Jucá T3, De Nucci G A randomized double-blind, non-inferiority Phase II trial, comparing dapaconazole tosylate 2% cream with ketoconazole 2% cream in the treatment of Pityriasis versicolor. Expert Opin Investig Drugs. 2015;24(11):1399-407. 6. Gupta AK1, Daigle D, Foley KA. Drug safety assessment of oral formulations of ketoconazole. Expert Opin Drug Saf. 2015 Feb;14(2):325-34. 7. Greenblatt HK1, Greenblatt DJ. Liver injury associated with ketoconazole: review of the published evidence. J Clin Pharmacol. 2014 Dec;54(12):1321-9. 8. Gupta AK1, Lyons DC2. The Rise and Fall of Oral Ketoconazole. J Cutan Med Surg. 2015 Jul-Aug;19(4):352-7. 9. Hu ML1, Xu M1, Ye Q2. Quantitative determination of ketoconazole by UPLC-MS/MS in human plasma and its application to pharmacokinetic study. Drug Res (Stuttg). 2014 Oct;64(10):548-52. 10. Kakkar S1, Karuppayil SM2, Raut JS1, Giansanti F3, Papucci L4, Schiavone N4, Kaur IP5. Lipid-polyethylene glycol based nano-ocular formulation of ketoconazole. Int J Pharm. 2015 Nov 10;495(1):276-89. 11. Liu L1, Bello A2, Dresser MJ1, Heald D3, Komjathy SF4, O'Mara E5, Rogge M6, Stoch SA7, Robertson SM8. Best practices for the use of itraconazole as a replacement for ketoconazole in drug-drug interaction studies. J Clin Pharmacol. 2016 Feb;56(2):14351. 12. Maniruzzaman M1, Farias S2, Slipper IJ2, Boateng JS2, Chowdhry BZ2, Nair A3, Douroumis D2. Development and optimization of ketoconazole oral strips by means of continuous hot-melt extrusion processing. J Pharm Pharmacol. 2016 Jul;68(7):890900. 337 23. Lanoconazole  In the late 1970s, Niwano et al found that introduction of an imidazole moiety onto a ketene dithioacetal structure increased its antifungal activity manifold.  Lanoconazole, the compound thus generated, has been shown to have activity against a variety of fungi, including yeast, dermatophytes, and dematiaceous fungi, and has significant fungicidal activity against Trichophyton spp.  Lanoconazole has also been shown that a sufficient amount of lanoconazole is retained in the skin for long periods after application.  Lanoconazole is a racemic mixture, and further studies revealed that its antifungal activity is attributed to the R-enantiomer, and the latter has at least two-fold more potent antifungal activity when compared with the racemic compound. Chemical Formula C14-H10-Cl-N3-S2 Chemical Name (±)-α-[(E]-4-(o-chlorophenyl)-1,3-ditiolan-2-ylidene]imidazole-1-acetonitrile (WHO) Pharmacodynamics/pharmacokinetic Tanuma et al., 2001    Lanoconazole possesses a broad antimycotic spectrum against pathogenic fungi. In comparison with other imidazole derivatives (e.g. clotrimazole, econazole, bifonazole, etc.), the inhibitory effects against the dermatophytes are extremely potent. The minimum inhibitory concentrations (MICs) against the dermophytes are below 0.04 µg ml−1, and are also fungicidal. MICs against T. mentagrophytes and T. rubrum have been reported as 0.004–0.031 µg. 338       In experimental animal models of tinea corporis and tinea pedis, evidence for quickly mycological eradication was obtained with lanoconazole Topical administration of lanoconazole in patients with common tinea pedis (interdigital type and vesicular type) is effective, reported beneficial effects of topical lanoconazole therapy for patients with hyperkeratotic type tinea pedis The resident time of lanoconazole in the horny layer is as long as 96 h, which is approximately 7 times longer than those of clotrimazole and bifonazole. Penetration, as well as the accumulation, in the horny layer are higher than those of other drugs According to the pharmacokinetic study on lanoconazole in the horny layer of the soles in patients with tinea pedis, the concentrations were 589 ± 315 µg/g and 477 ± 295 µg/g after 12 and 24 h of the application, respectively, which corresponds with 20 000 times the MIC Formulations    1% cream; 1% ointment; 1% solution Foreign Names     Lanoconazolum (Latin) Lanoconazol (German) Lanoconazole (French) Lanoconazol (Spanish) Generic Names  Lanoconazole (OS: JAN)  BRN 4819111 (IS)  Latoconazole (IS)  NND-318 (IS)  TJN-318 (IS) Brand Names  Astat 1% Maruho, Japan  Lanoconazole 1% Iwaki Iwaki Seiyaku, Japan 339 Recent reports Shokoohi et al. (2017) ]determined the in vitro activities of novel imidazoles in comparison with five antifungal drugs against clinical (n = 28) and environmental (n = 102) isolates of black mold and melanized yeast. Luliconazole and lanoconazole had the lowest geometric mean MICs, followed by efinaconazole against tested isolates in comparison with other drugs. Therefore, it appears that these new imidazoles drugs are promising candidates for treatment of infections due to melanized fungi and relatives. Abastabar et al. (2016) tested a collection of azole-susceptible (n = 141) and azole-resistant (n = 27) Aspergillus fumigatus isolates against seven antifungal drugs, including the new imidazoles lanoconazole and luliconazole. The luliconazole and lanoconazole MIC90 values for the azole-susceptible strains were 0.001 μg/ml and 0.008 μg/ml, and those for the azole-resistant strains were 0.016 μg/ml and 0.032 μg/ml. Baghi et al. (2016) compared in vitro susceptibilities of 100 clinical dermatophyte isolates belonging to five species from Iran toward lanoconazole and luliconazole with ten other antifungal agents including econazole, itraconazole, miconazole, fluconazole, griseofulvin, butenafine, terbinafine, caspofungin, anidulafungin and tolnaftate. MIC and MEC values were analyzed according to CLSI M38-A2 document. The isolates were previously identified to the species level using PCR-RFLP on ITS rDNA region. The range of luliconazole and lanoconazole minimum inhibitory concentrations (MICs) was 0.016-0.032 and 0.063-1 μg/ml, respectively for dermatophyte species. Luliconazole and lanoconazole revealed potent activity against all dermatophyte isolates. Anidulafungin, caspofungin, and luliconazole showed the best activity 341 with the lowest geometric mean 0.01, 0.016, and 0.018 μg/ml, respectively, followed by tolnaftate (0.06 μg/ml), terbinafine (0.07 μg/ml), itraconazole (0.183 μg/ml), butenafine (0.188 μg/ml), econazole (0.20 μg/ml), lanoconazole (0.24 μg/ml), griseofulvin (1.28 μg/ml), miconazole (2.34 μg/ml) and fluconazole (15.34 μg/ml). Uratsuji et al. (2015) investigated an anti-inflammatory activity of lanoconazole (LCZ), a topical antifungal agent, against in vitro and in vivo models of inflammation. The release of interleukin-8 (IL-8) from human epidermal keratinocytes stimulated by the addition of 100 μg ml(-1) β-glucan of Saccharomyces cerevisiae was significantly inhibited by LCZ at the concentration of 10(-5) mol l(-1). The release of interferon-γ and IL-2 from human peripheral blood mononuclear cells stimulated by the addition of 30 and 100 μg ml(-1) phytohemagglutinin was significantly inhibited by LCZ at the concentrations of 10(-7) and 10(-6) mol l(-1), respectively. The increase in the ear thickness induced by topical application of 0.01% 12-Otetradecanoyl phorbol-13-acetate and 1% 2,4,6-trinitrochlorobenzene (TNCB) after sensitisation with 3% TNCB were established as the mouse models of irritant and contact dermatitis, respectively. Application of 1% and 3% LCZ showed a significant anti-inflammatory activity against both the irritant and contact dermatitis models. These findings suggest that LCZ possesses an anti-inflammatory activity, which may be partially helpful in the treatment of dermatomycoses. References 1. Abastabar M1, Rahimi N2, Meis JF3,4, Aslani N2, Khodavaisy S5, Nabili M1, RezaeiMatehkolaei A6, Makimura K7, Badali H8,9. Potent Activities of Novel Imidazoles Lanoconazole and Luliconazole against a Collection of Azole-Resistant and -Susceptible Aspergillus fumigatus Strains. Antimicrob Agents Chemother. 2016 Oct 21;60(11):69166919. 2. Baghi N1, Shokohi T2, Badali H2, Makimura K3, Rezaei-Matehkolaei A4, Abdollahi M5, Didehdar M1, Haghani I2, Abastabar M6. In vitro activity of new azoles luliconazole and lanoconazole compared with ten other antifungal drugs against clinical dermatophyte isolates. Med Mycol. 2016 Oct 1;54(7):757-63 3. Shokoohi GR1, Badali H2, Mirhendi H3,4, Ansari S5, Rezaei-Matehkolaei A6, Ahmadi B7, Vaezi A2, Alshahni MM8, Makimura K8. In Vitro Activity of Luliconazole, Lanoconazole, and Efinaconazole Compared with Five Antifungal Drugs Against Melanized Fungi and Relatives. Antimicrob Agents Chemother. 2017 Aug 28. pii: AAC.00635-17. 4. H. Tanuma, M. Tanuma, M. Abe, H. Kum. Usefulness of Lanoconazole (Astat®) cream in the treatment of hyperkeratotic type tinea pedis. Comparative study of monotherapy and combination therapy with 10% Urea Ointment (Pastaron®). Mycoses Volume 44, Issue 5 July 2001 Pages 181–190 5. Uratsuji H1, Nakamura A, Yamada Y, Hashimoto K, Matsumoto T, Ikeda F, Ishii R. Anti-inflammatory activity of lanoconazole, a topical antifungal agent. Mycoses. 2015 Apr;58(4):197-202 341 24. Luliconazole       Luliconazole is an imidazole antifungal drug. Luliconazole 1% topical cream is indicated for the treatment of athlete's foot, jock itch, and ringworm caused by dermatophytes such as Trichophyton rubrum, Microsporum gypseum and Epidermophyton floccosum Luliconazole is an imidazole antifungal agent with a unique structure, as the imidazole moiety is incorporated into the ketene dithioacetate structure. Luliconazole is the R-enantiomer, and has more potent antifungal activity than lanoconazole, which is a racemic mixture. Brand Name: Luzu Luzu, Lulicon, LUL Generic Name: luliconazole . Molar mass: 354.28 g/mol Formula: C14H9Cl2N3S2 Chemical structure of luliconazole: (-)-(E)-[4-(2,4-dichlorophenyl)-1,3-dithiolan-2-ylidene]-1imidazolylacetonitrile. Mechanism of Action:  Although the exact mechanism of action against dermatophytes is unknown, luliconazole appears to inhibit ergosterol synthesis by inhibiting the enzyme lanosterol demethylase. o Inhibition of this enzyme‘s activity by azoles results in decreased amounts of ergosterol, a constituent of fungal cell membranes, and a corresponding accumulation of lanosterol. o This will lead to a disruption of normal fungal cell membrane permeability.  Luliconazole has a low binding affinity for keratin, the main component of the nail plate, thereby allowing the drug to be readily released from the nail plate's keratin matrix to cross into the nail bed.  Luliconazole potency is unaffected by keratin this is in contrast to many azoles, which have a significant reduction in potency in the presence of keratin. 342 Preclinical studies, Khanna and Bharti, 2014  Preclinical studies have demonstrated excellent activity against dermatophytes.  Further, in vitro/in vivo studies have also shown favorable activity against Candida albicans, Malassezia spp., and Aspergillus fumigatus.  Luliconazole, although belonging to the azole group, has strong fungicidal activity against Trichophyton spp., similar to that of terbinafine. o The strong clinical antifungal activity of luliconazole is possibly attributable to a combination of strong in vitro antifungal activity and favorable pharmacokinetic properties in the skin. Clinical trials, Khanna and Bharti, 2014  Clinical trials have demonstrated its superiority over placebo in dermatophytosis, and its antifungal activity to be at par or even better than that of terbinafine.  Application of luliconazole 1% cream once daily is effective even in short-term use (one week for tinea corporis/cruris and 2 weeks for tinea pedis).  A Phase I/IIa study has shown excellent local tolerability and a lack of systemic side effects with use of topical luliconazole solution for onychomycosis.  Luliconazole 1% cream was approved in Japan in 2005 for the treatment of tinea infections.  Luliconazole 1% cream has recently been approved by US Food and Drug Administration for the treatment of interdigital tinea pedis, tinea cruris, and tinea corporis.  Topical luliconazole has a favorable safety profile, with only mild application site reactions reported occasionally. Chemistry and pharmacokinetics, Khanna and Bharti, 2014  Luliconazole, also known as NND-502, is an imidazole anti-fungal first synthesized by Nihon Nohyaku Co Ltd (Osaka, Japan).  Luliconazole has a unique structure as the imidazole moiety is incorporated into the ketene dithioacetate structure.  Luliconazole is an optically related compound of lanoconazole, with a 2,4dichlorophenyl group on the ketene dithioacetal structure.  Luliconazole chemical structure of luliconazole, ie, (−)-(E)-[4-(2,4-dichlorophenyl)-1,3dithiolan-2-ylidene]-1-imidazolylacetonitrile.  luliconazole, being the active R-enantiomer, has more potent antifungal activity than lanoconazole.  Luliconazole has been reported to have strong in vitro antifungal activity against Trichophyton spp., C. albicans, and Aspergillus fumigatus. 343  Luliconazole 1% cream was approved in Japan in 2005 for the treatment of tinea infections,  Luliconazole 1% cream was approved in November 2013 by the US Food and Drug Administration for the treatment of interdigital tinea pedis, tinea cruris, and tinea corporis caused by the organisms T. rubrum and E. floccosum, in patients 18 years of age and older.  Luliconazole is indicated for once-daily application for one week in tinea corporis/cruris and for 2 weeks in tinea pedis. In June 2009, the 1% cream was approved for marketing in India. Pharmacodynamics  Luliconazole MIC against Trichophyton spp. has been shown to be 2–4 times lower than that of lanoconazole, and the lowest amongst a wide variety of drugs tested, including terbinafine, liranaftate, butenafine, amorolfine, ketoconazole, clotrimazole, neticonazole, miconazole, bifonazole, and sertaconazole.  Luliconazole MIC against Candida spp. has been reported to be higher than that against filamentous fungi; however, it is similar to lanoconazole and greater than that of bifonazole, terbinafine, and amorolfine.  Luliconazole MIC against C. albicans was higher than that of ketoconazole, clotrimazole, neticonazole, and miconazole.  Luliconazole has been shown to be many times more effective than lanoconazole and bifonazole in inhibiting 14α demethylase of C. albicans.  Luliconazole MIC was shown to be similar to that of flucytosine against the C. albicans IFO 1270 strain and 1–4 times lower than that of flucytosine against other strains of C. albicans; however, in vivo susceptibility of systemic infection with C. albicans strain IFO 1270 was much lower for oral luliconazole than for flucytosine.  Luliconazole was found to be 150 times less potent than flucytosine in controlling systemic C. albicans infection. The authors attributed this difference to the different pharmacokinetic properties of the two compounds. Good oral absorption, metabolic stability, and low protein binding in animals/humans possibly translated into lower in vitro activity of luliconazole despite its higher in vitro activity when compared with flucytosine. Safety and tolerability, Scher et al. (2014)  Luliconazole has been reported to be safe and well tolerated by human subjects in singleand repeated-application studies.  Skin irritation indices have been reported to be within the range specified for a safe product.  No toxicity issues have been reported in guinea pig model studies of tinea pedis induced with T. mentagrophytes. 344   Toxicokinetic analysis showed that luliconazole area under the curve (AUC) values in the high-dose (100 mg kg−1 day−1) minipig group were up to 1200-fold higher than human AUC value observed in the human PK study. the no observed adverse effect level for both systemic and local toxicity was 100 mg kg−1 day−1 following 39 weeks of daily dermal application of luliconazole solution, 10% to Gottingen Minipigs® . Brand names of Luliconazole 1 %W/W Name Manufacturer Form EMLUZ 20GM CREAM EMCURE OINTMENTS LICOZAC 15GM CREAM AJANTA PHARMA OINTMENTS LILITUF XL 30GM CREAM ALKEM OINTMENTS LUCEE 10GM CREAM TALENT INDIA OINTMENTS LULIFIN 10GM CREAM SUN OINTMENTS LULIFIN 10ML LOTION SUN CONTAINERS LULIFIN 20GM CREAM SUN OINTMENTS LULIBET 10GM CREAM INTAS OINTMENTS LULIBET 20GM CREAM INTAS OINTMENTS LULICAN 20GM CREAM GLENMARK OINTMENTS LULICAN 10ML LOTION GLENMARK CONTAINERS LULIBET 30GM CREAM INTAS OINTMENTS LULICAN 30GM CREAM GLENMARK OINTMENTS LULIZOL 20GM CREAM KLM LABORATORIES OINTMENTS LULICLIN 15GM CREAM CANIXA LIFE SCIENCES OINTMENTS LULICLIN 30GM CREAM CANIXA LIFE SCIENCES OINTMENTS LULIZOL 30GM CREAM KLM LABORATORIES OINTMENTS 345 Name Manufacturer Form LULIMAC 10GM CREAM MACLEODS OINTMENTS LULICAN 10GM CREAM GLENMARK OINTMENTS LULIZOL 10GM CREAM KLM LABORATORIES OINTMENTS 346 Recent reports Abastabar et al. (2016) tested a collection of azole-susceptible (n = 141) and azole-resistant (n = 27) Aspergillus fumigatus isolates against seven antifungal drugs, including the new imidazoles lanoconazole and luliconazole. The luliconazole and lanoconazole MIC90 values for the azole-susceptible strains were 0.001 μg/ml and 0.008 μg/ml, and those for the azole-resistant strains were 0.016 μg/ml and 0.032 μg/ml. Baghi et al. (2016) compared in vitro susceptibilities of 100 clinical dermatophyte isolates belonging to five species from Iran toward lanoconazole and luliconazole with ten other antifungal agents including econazole, itraconazole, miconazole, fluconazole, griseofulvin, butenafine, terbinafine, caspofungin, anidulafungin and tolnaftate. MIC and MEC values were analyzed according to CLSI M38-A2 document. The isolates were previously identified to the species level using PCR-RFLP on ITS rDNA region. The range of luliconazole and lanoconazole minimum inhibitory concentrations (MICs) was 0.016-0.032 and 0.063-1 μg/ml, respectively for dermatophyte species. Luliconazole and lanoconazole revealed potent activity against all dermatophyte isolates. Anidulafungin, caspofungin, and luliconazole showed the best activity with the lowest geometric mean 0.01, 0.016, and 0.018 μg/ml, respectively, followed by tolnaftate (0.06 μg/ml), terbinafine (0.07 μg/ml), itraconazole (0.183 μg/ml), butenafine (0.188 μg/ml), econazole (0.20 μg/ml), lanoconazole (0.24 μg/ml), griseofulvin (1.28 μg/ml), miconazole (2.34 μg/ml) and fluconazole (15.34 μg/ml). The current study demonstrated luliconazole and lanoconazole displayed excellent activity against all dermatophyte isolates, although the majority of dermatophyte isolates showed low susceptibility to griseofulvin and very low to miconazole, and fluconazole. 347 Gupta and Daigle (2016) mentioned that Luliconazole is a novel imidazole derivative, which has demonstrated in vitro efficacy against dermatophytes and Candida. The results from Phase III trials show that luliconazole 1% cream applied once daily for 2 weeks successfully resolved the clinical signs and symptoms as well as eradicated the pathologic fungi, which cause tinea pedis. A 1-week treatment with luliconazole 1% cream also produced favorable clinical and mycological results in clinical trials for tinea corporis and tinea cruris. Across trials, adverse events consisted mainly of localized reactions following application. The development of a new antifungal agent is timely due to mounting resistance among existing treatments. Because luliconazole requires a short duration of treatment, it may assist in reducing disease recurrence as a result of patient nonadherenc. Hasuko et al. (2016) studied LLCZ affinity to keratin powder prepared from healthy human nail and porcine hoof. The LLCZ adsorbed to keratin preparations was washed with phosphate buffer, and its concentration in the buffer supernatant was measured by HPLC. Antifungal titer of the supernatant was also biologically confirmed by disk diffusion assay. Adsorption rate of LLCZ was 80% or more, and LLCZ was gradually liberated into washing buffer. Cumulative liberation rate in 10 times repeated washing against initially adsorbed drug amount was 47.4% for keratin from human nail and was either 52.5% or 50.8% (depending on the LLCZ concentration) for keratin from porcine hoof. The supernatant showed antifungal potential to T. rubrum. These results indicate that LLCZ applied to the nail surface is fully adsorbed to nail keratin and gradually liberated from it. The nail keratin could function as drug reservoir to supply biologically active LLCZ to the nail tissue region of infection loci. The LLCZ delivered to the loci would exert its antifungal potential on tinea unguium. This study also suggests the versatility of porcine hoof powder as an alternative to human nail keratin preparation for nonclinical study. Koga et al. (2016) compared drug concentrations in the stratum corneum following daily application of luliconazole and terbinafine cream in a guinea pig tinea pedis model. Luliconazole 1% cream or terbinafine 1% cream were topically applied once daily to hind limbs of guinea pigs for 14 days. Drug concentration in stratum corneum of plantar skin was measured by HPLC-UV on days 1, 3, 7, 10, and 14. Separately, creams were applied daily for 5 days to the hind limbs of guinea pigs and skin drug release determined. In addition, drug retention in the stratum corneum was assessed by infecting guinea pigs with Trichophyton mentagrophytes, 14 and 21 days after a single application of luliconazole or terbinafine creams. Luliconazole stratum corneum concentrations were higher than those of terbinafine throughout the study. Concentrations of luliconazole and terbinafine were 71.6μg/g and 36.6μg/g, respectively, after a single application (P<.05), reaching steady state after 10 days. Cumulative release of luliconazole from the stratum corneum was 4.5 times greater than with terbinafine. Unlike terbinafine, no fungal invasion of the stratum corneum was seen 14 days post-treatment with luliconazole. CONCLUSIONS: Drug concentrations of luliconazole in the stratum corneum and subsequent release are greater than those achieved with terbinafine and may contribute to clinical efficacy. Luliconazole may also provide greater protection against disease recurrence. Shimamura et al. (2016) investigated luliconazole distribution and antifungal activity in nail plate. An in vitro permeation study which measured luliconazole concentration of sliced nail in the transverse direction after treatment of luliconazole nail solution was conducted to investigate 348 for concentration dependency and the influences of nail thickness and treatment duration. When 0.2, 1, 3, 5, and 7.5% luliconazole nail solutions were used, luliconazole was detected in the all the layers of nail and there was a concentration gradient from the dorsal side to deep nail layers. The luliconazole concentration was almost same after 14-day treatment with 5% luliconazole nail solution when using nails of different thicknesses. And we confirmed that concentration of luliconazole into the nail was increased depending on the treatment duration. In zone of inhibition test after 14-day treatment, 5% luliconazole nail solution showed statistically high formation rate of zones of inhibition compared to 8% ciclopirox nail lacquer. Above all, these data suggested that 5% luliconazole nail solution has the potential to show high therapeutic effect for onychomycosis. Shimamura et al. (2016b) evaluated luliconazole nail solution, originally generated formulation, for the topical treatment of onychomycosis by two infection models. First, a suspension of Trichophyton mentagrophytes was dropped onto the ventral layer of human nail plate and these nails were set in Franz diffusion cells. After 9-day culture, luliconazole nail solutions (1, 3, and 5%) were applied to the dorsal surface of the nails once a day for 7 days. After application, fungal viability was assessed by measuring the ATP contents of the samples. The dose-dependent efficacy was confirmed, with 3% and 5% luliconazole nail solutions producing significantly lower ATP levels at 7-day treatment. When 3% and 5% luliconazole nail solutions were evaluated in a rabbit model of onychomycosis, both concentrations completely inhibited the recovery of fungi on culture after 4-week treatment. We therefore think these results indicate that 5% luliconazole nail solution is sufficiently potent for treatment of onychomycosis. Gold and Olin (2015) summarized the in vitro data, animal studies and clinical trial data relating to the use of topical luliconazole cream 1% in the treatment of tinea pedis. Preclinical studies have demonstrated potent activity against dermatophytes. Luliconazole has strong fungicidal activity against Trichophyton spp., similar to that seen with terbinafine. Evidence from clinical trials in tinea pedis have shown once-daily application of luliconazole cream 1% for 14 days to be effective and well tolerated. Wakumoto-Nakashima et al. (2015) investigated scales from lesional skin of 12 patients with tinea pedis by scanning electron microscopy (SEM) and transmission electron microscopy (TEM) to gain an insight into the spatial and morphological changes of dermatophytes after application of a clinical dosage of topical luliconazole 1% cream (Lulicon® cream 1%). In all cases, Trichophyton rubrum was identified. The scales from the lesions collected before and after topical luliconazole application were fixed with glutaraldehyde and subjected to SEM and TEM. For SEM, fixed specimens were first placed in 1N-KOH and then post-fixed and observed. SEM showed a swollen appearance of fungal hyphae as an early change, and then shrinkage of them showing a flattened and twisted appearance as a later change. TEM showed cell wall alterations with initial development of and accumulation of a granular structure in the outermost layer and subsequent amorphous and electron-lucent change of the thickened inner part of the cell wall. This is the first report of dramatic morphological changes of T. rubrum before and after topical luliconazole application in vivo demonstrated by SEM and TEM. We hypothesize that luliconazole has double acting points, on the plasma membrane and cell wall, of dermatophyte hyphae. 349 References 1. Abastabar M1, Rahimi N2, Meis JF3,4, Aslani N2, Khodavaisy S5, Nabili M1, RezaeiMatehkolaei A6, Makimura K7, Badali H8,9. Potent Activities of Novel Imidazoles Lanoconazole and Luliconazole against a Collection of Azole-Resistant and -Susceptible Aspergillus fumigatus Strains. Antimicrob Agents Chemother. 2016 Oct 21;60(11):69166919 2. Baghi N1, Shokohi T2, Badali H2, Makimura K3, Rezaei-Matehkolaei A4, Abdollahi M5, Didehdar M1, Haghani I2, Abastabar M6. In vitro activity of new azoles luliconazole and lanoconazole compared with ten other antifungal drugs against clinical dermatophyte isolates. Med Mycol. 2016 Oct 1;54(7):757-63. 3. Gold MH1, Olin JT1. Once-daily luliconazole cream 1% for the treatment of interdigital tinea pedis. Expert Rev Anti Infect Ther. 2015;13(12):1433-40. 4. Gupta AK1, Daigle D2. A critical appraisal of once-daily topical luliconazole for the treatment of superficial fungal infections. Infect Drug Resist. 2016 Jan 18;9:1-6. 5. Hasuko M1, Toga T, Tsunemitsu T, Matsumoto T, Koga H, Hirano H, Tsuboi R. [Affinity of Luliconazole to Keratin Prepared from Healthy Human Nailand Porcine Hoof]. Med Mycol J. 2016;57(1):J7-12. 6. Koga H, Nanjoh Y, Toga T, Pillai R, Jo W, Tsuboi R. Luliconazole Retention in Stratum Corneum and Prevention of Fungal Infection in a Guinea Pig Tinea Pedis Model. J Drugs Dermatol. 2016 Jan;15(1):104-8 7. Khanna D1, Bharti S1. Luliconazole for the treatment of fungal infections: an evidencebased review. Core Evid. 2014 Sep 24;9:113-24. 8. Shimamura T1, Miyamae A, Arai M, Minemura A, Nozawa A, Kubota N. [Distribution of Luliconazole in Nail Plate by In Vitro Permeation and Efficacy by Zone of Inhibition Test after Treatment of Luliconazole Nail Solution]. Med Mycol J. 2016;57(1):J19-25. 9. Shimamura T1, Hasegawa N, Kubota N. [Antifungal Activity of Luliconazole Nail Solution on in vitro and in vivo Onychomycosis Model]. Med Mycol J. 2016b;57(1):J138. 10. Wakumoto-Nakashima K1, Yamada N2, Morino S3, Yamamoto O1. Novel in vivo observations on double acting points of luliconazole on Trichophyton rubrum: an ultrastructural study. Med Mycol. 2015 Nov;53(8):860-7. . 351 25. Metconazole         Metconazole is a triazole fungicide invented by Kureha that is highly effective against various fungal diseases in a broad range of crops Metconazole was first registered in France in 1994 as a cereal fungicide, and has now received registrations in more than 40 countries worldwide. Metconazole registration in Japan was achieved in 2006 for cereals and turf. Metconazole registration in Canada in 2015. Metconazole is currently used for crops including cereals, corn, rapeseed, soybean and turf, mainly in Europe and the Americas. Metconazole is highly effective against various fungal diseases in a wide range of crops including cereals, corn, rapeseed, soybean, turf, stone fruits Metconazole is widely recognized as a plant growth regulator (PGR) for increasing rapeseed yields. Metconazole is an agricultural fungicide, used mainly for foliar application o Wheat varieties: Fusarium blight, leaf rust, etc. o Rapeseed: Sclerotal disease, etc.; increasing yield o Corn: Rust, etc. Chemical name: Metconazole; 125116-23-6; CHEBI:81773; XWPZUHJBOLQNMN-UHFFFAOYSA-N; Cyclopentanol, 5-(4-chlorophenyl)methyl-2,2-dimethyl-1-(1H-1,2,4-triazol-1-ylmethyl)-; 5[(4-chlorophenyl)methyl]-2,2-dimethyl-1-(1,2,4-triazol-1-ylmethyl)cyclopentan-1-ol Molecular Formula‎: ‎C17H22ClN3O Molecular Weight‎: ‎319.833 g/mo Uses:   Metconazole is a systemic triazole fungicide proposed for control of Black Sigatoka disease (Mycosphaerella fijiensis) on bananas grown outside the United States (U.S.). Metconazole acts primarily as an inhibitor of ergosterol biosynthesis, and interferes with synthesis of fungal cell membranes. 351 Toxicology      Toxicology studies in laboratory animals describe potential health effects from varying levels of exposure to a chemical and identify the dose where no effects are observed. The health effects noted in animals occur at doses more than 100 times higher (and often much higher) than levels to which humans are normally exposed when pesticide products are used according to label directions. The technical grade active ingredient, metconazole, was moderately toxic to rats and highly toxic to mice when given as a single oral dose. It was of low acute dermal toxicity to rats and rabbits and of low inhalation toxicity to rats. It was moderately irritating to the eyes and non-irritating to the skin of rabbits. It was not a potential skin sensitizer to guinea pigs. The signal words, "DANGER – POISON" and "EYE IRRITANT" have been included on the label in light of these findings. The end-use product, Caramba Fungicide, was found to be of low oral, dermal and inhalation toxicity in rats. It was moderately irritating to the eyes and minimally irritating to the skin of rabbits and not a dermal sensitizer in guinea pigs. Brands: 352 26. Miconazole     Miconazole is a synthetic imidazole antifungal agent that has been used to treat superficial fungal infections since the early 1970s. Miconazole, when first released, was hoped it would replace amphotericin B as a parenteral antifungal agent. Miconazole was soon discovered, however, that not only it failed to offer the same efficacy as amphotericin B, but also possessed intrinsic toxicities after IV administration. Miconazole, most commonly, is used topically and intravaginally. Formula: C18H14Cl4N2O Molar mass: 416.127 g/mo Miconazole chemical structure Spectrum of activity   Miconazole is the only fungicidal azole that has a broad-spectrum antifungal activity against the most frequent Candida species in oropharyngeal candidiasis, including Candida albicans, C. tropicalis, C. glabrata, and C. krusei . Miconazole resistance in chronically treated patients is rarely reported. However, topical miconazole is used infrequently in patients with OC because of the requirement of multiple daily dosing . Mode of action Like other azole antifungals, miconazole exerts its effect by altering the fungal cell membrane. Miconazole inhibits ergosterol synthesis by interacting with 14a demethylase, a cytochrome P450 enzyme that is necessary for the conversion of lanosterol to ergosterol, an essential component of the membrane. Inhibition of ergosterol synthesis results in increased cellular permeability, causing leakage of cellular contents. Miconazole does not appear to have the same effect on human cholesterol synthesis. Indication for topical application in the treatment of tinea pedis (athlete‘s foot), tinea cruris, and tinea corporis caused by Trichophyton rubrum, Trichophyton mentagrophytes, and Epidermophyton floccosum, in the treatment of cutaneous candidiasis (moniliasis), and in the treatment of tinea versicolor. Miconazole, sold under the brand name Monistat among others, is an antifungal medication used 353 Pharmacokinetics Oral absorption of Miconazole (Nitrate) is found to be 20% . Volume of distribution is found to be 20 l/kg and plasma protien binding is 92 %. and metabolism is reported Hepatic. Renal Excretion accounts for 20 % and plasma half life is 24.1 hr. Pharmacodynamics      Miconazole is an anti-fungal medication related to fluconazole (Diflucan), ketoconazole (Nizoral), itraconazole (Sporanox), and clotrimazole (Lotrimin, Mycelex). Miconazole is used either on the skin or in the vagina for fungal infections. Miconazole was approved by the FDA in 1974. Miconazole prevents fungal organisms from producing vital substances required for growth and function. Miconazole is effective only for infections caused by fungal organisms. It will not work for bacterial or viral infections. Side Effects     The severe or irreversible adverse effects of Miconazole (Nitrate), which give rise to further complications include Cardiac arrhythmias, Hepatitis, Cardiac arrhythmias, Phlebitis, Pruritis, Arachnoiditis. Miconazole (Nitrate) produces potentially life-threatening effects which include Cardiac Arrest, Cardiac arrest, Anaphylaxis. which are responsible for the discontinuation of Miconazole (Nitrate) therapy. The signs and symptoms that are produced after the acute overdosage of Miconazole (Nitrate) include Vomiting, Diarrhea, Arrhythmias. The symptomatic adverse reactions produced by Miconazole (Nitrate) are more or less tolerable and if they become severe, they can be treated symptomatically, these include Drowsiness, Anorexia, Rashes, GI upset, Flushing, Nausea and vomiting, Local irritation. Single Ingredient Eye Oint: 2 %w/w, Oral Solutionn: 2 %w/w, Cream: 2 %, 20 mg, 2 %w/w, Gel: 2 %, 20 mg, 2 %w/w, 2 % w/w, Vag Cream: 2 %w/w, Powder: 2 %w/w, Generic Prescription Products, drugbank NAME Miconazole Nitrate DOSAGE Suppository STRENGTH 200 mg/1 354 ROUTE Vaginal LABELLER MARKETING START Actavis Pharma Company 2002-09-03 Brand names, .medindia.net/drug SNo Brand Name Combination Generics Manufacturers 1 3-D (Skin) Fluocinolone Acetonide, Miconazole Nitrate, Neomycin Dermocare Laboratories (Guj) Pvt Ltd 2 Agiclob NM Clobetasol Propionate, Miconazole Nitrate, Neomycin Agio Pharmaceuticals Limited 3 Atderm Fluocinolone, Gentamicin, Miconazole Nitrate Atoz Pharmaceuticals 4 Bakil Clobetasol Propionate 0.05% + Neomycin 0.5% + Miconazole 2% TNT 5 Beclomin Beclomethasone, Miconazole Nitrate Leben Laboratories Pvt Ltd 6 Beclona Miconazole, Beclomethasone Zota Healthcare Pvt Ltd (Sayona) 7 Bectiderm - M Miconazole, Clobetasol Prayas Pharmaceuticals 8 Betaderm (20 gm) Betamethasone, Miconazole Nitrate Dermocare Laboratories (Guj) Pvt Ltd 9 Betamil -M Miconazole, Betamethasone Merck (India) Ltd 10 Betanate M Clobetasol Propionate, Miconazole Nitrate Cosme Healthcare 11 Betnovate -M Betamethasone Valerate, Miconazole Nitrate Glaxo Smithkline Pharmaceuticals Ltd. 12 Betzee -M Miconazole, Betamethasone, Zinc Sulphate Apex Laboratories Limited 13 Butesone M Miconazole, Clobetasone 17-butyrate Gary Pharmaceuticals Pvt. Ltd. 14 Clobaderm -GM Clobetasol, Gentamicin, Miconazole Nitrate Intermed Pharma Pvt Ltd 15 Clobecos -GM Clobetasol Propionate, Gentamicin Sulphate, Miconazole Nitrate Symbiosis Labs (P) Ltd. 16 Cloberis -GM Clobetasol Propionate, Gentamicin Sulphate, Miconazole Nitrate Symbiosis Labs (P) Ltd. 17 Cloberuth -M Miconazole, Clobetasol Propionate, Clorocresol Rut Pharma 18 Clobesym -GM Clobetasol Propionate, Gentamicin Sulphate, Miconazole Nitrate Symbiosis Labs (P) Ltd. 19 Clobetazole -GM Miconazole, Clobetasol Propionate, Gentamicin Khandelwal Laboratories Pvt Ltd. 20 Clobetazole -GM (10 gm) Miconazole, Clobetasol Propionate, Gentamicin Khandelwal Laboratories Pvt Ltd. 21 Clobetazole -GM (25 gm) Miconazole, Clobetasol Propionate, Gentamicin Khandelwal Laboratories Pvt Ltd. 22 Clobid -GM Miconazole, Clobetasol Propionate, Gentamicin Merril Pharma Pvt. Ltd. 355 23 Cloburut -M Miconazole, Clobetasol Propionate, Clorocresol Rut Pharma 24 Cloderm -GM Miconazole, Clobetasol Propionate, Gentamicin Cipla Limited 25 Clodip GM Miconazole, Clobetasol Propionate, Gentamicin Sulphate Intra Labs India Pvt Ltd 26 Clomad ZM (10 gm) Clobetasol Propionate, Miconazole Nitrate, Neomycin Austro Labs 27 Clomax GM Clobetasol, Miconazole Nitrate, Neomycin Injecto Capta Pvt. Ltd. 28 Clonate - GM Miconazole, Clobetasol Propionate, Gentamicin Sulphate IP Gujarat Pharmalab Pvt. Ltd. 29 Clop -M Clobetasol Propionate, Miconazole Nitrate Zydus Cadila Healthcare Ltd. (Liva) 30 Clop -MG Clobetasol Propionate, Gentamicin Sulphate, Miconazole Nitrate Zydus Cadila Healthcare Ltd. (Liva) 31 Cloprobit GM Miconazole, Clobetasol Propionate, Gentamicin Agrawal Pharmaceuticals 32 Cloprobit -NM Miconazole, Clobetasol Propionate, Neomycin Agrawal Pharmaceuticals 33 Cloriv -M Clobetasol Propionate, Miconazole Nitrate East African (I) Remedies Pvt Ltd 34 Closar -GM Miconazole, Clobetasol Propionate, Gentamicin Sarmain Pharmaceuticals 35 Clotof -GM Miconazole, Clobetasol Propionate, Gentamicin Sulphate Osmed Formulations (P) Ltd. 36 Clotof M Miconazole, Clobetasol Propionate Osmed Formulations (P) Ltd. 37 Clovate -GM Miconazole, Clobetasol Propionate, Gentamicin Sulphate Dermocare Laboratories (Guj) Pvt Ltd 38 Coniderm -F Fluocinolone Acetonide, Miconazole Nitrate Ciens Laboratories 39 Cuticare Neomycin 0.5% + Miconazole 2% + Fluocinolide 0.01% DWD 40 Daktacort Gel Miconazole, Hydrocortisone Acetate Johnson & Johnson (Ethnor) 41 Daktarin -T Miconazole Nitrate, Triamcinolone Johnson & Johnson (Ethnor) 42 Dermotyl -M Clobetasol, Miconazole Nitrate Hetero Healthcare Ltd. 43 Drez -V Miconazole, Metronidazole Stedman Pharmaceuticals Pvt. Ltd. 44 E -Derm Fluocinolone, Gentamicin, Miconazole Nitrate Zota Healthcare Pvt Ltd (Marline Biocare) 45 Ecziclo -M Clobetasol, Miconazole Nitrate CFL Pharmaceuticals Ltd 356 46 Emclo -G Miconazole, Clobetasol Propionate, Gentamicin Emson Medichem Pvt. Ltd. 47 Enderm GM Clobetasol, Gentamicin, Miconazole Nitrate Leben Laboratories Pvt Ltd 48 Eugel F Miconazole, Fluocinolone Universal Pharmaceuticals Ltd 49 Eugel F (15 gm) Fluocinolone Acetonide, Miconazole Nitrate Universal Pharma 50 Eumosone - M Miconazole, Clobetasone 17-butyrate Glaxo Smithkline Pharmaceuticals Ltd. 51 Excel -M Miconazole, Clobetasol Propionate Ranbaxy Laboratories Ltd (Consumer Healthcare) 52 Exel -M Miconazole, Clobetasol Propionate Ranbaxy Laboratories Ltd (Consumer Healthcare) 53 Flucort -MZ Miconazole, Fluocinolone Glenmark Pharmaceuticals Ltd. (Milieus) 54 Flucort-MZ Fluocinolone Acetonide 0.01% + Mconazole 2% Glenmark (Milieus) 55 Flucreme -NM Fluocinolone, Miconazole Nitrate, Neomycin Concept Pharmaceuticals Ltd. 56 Fungiderm -F Miconazole, Fluocinolone Acetonide Dermocare Laboratories (Guj) Pvt Ltd 57 Fungifite Clobetasol Propionate, Miconazole Nitrate Neiss Labs Pvt. Ltd. 58 Fungiguard F Miconazole, Fluocinolone Gary Pharmaceuticals Pvt. Ltd. 59 Fungin -V Miconazole, Metronidazole Drakt Pharmaceutical Pvt. Ltd. (DPPL) 60 Fungitop -F Fluocinolone, Miconazole Nitrate Micro Labs Ltd (Gratia) 61 Kloryl -M Clobetasol Propionate, Miconazole Nitrate Unimarck Healthcare 62 Klosoft M Miconazole, Clobetasol Sandoz Pvt.Ltd 63 Ledercort -AF Miconazole, Triamcinolone Wyeth (I) Limited 64 Lobate -GM Miconazole, Clobetasol Propionate, Gentamicin Nicholas Piramal India Ltd. 65 Lobate -M Miconazole, Clobetasol Propionate Boots Piramal Healthcare Limited 66 Lobate-GM Clobetasol Propionate 0.05% + Neomycin Sulphate 0.5% + Miconazole 2% AHPL 67 Losweat Powder Chlorhexidine, Miconazole Nitrate Stedman Pharmaceuticals Pvt. Ltd. 68 Lupiderm -M Miconazole, Betamethasone Lupin Laboratories Ltd. 69 Metazole Miconazole, Mometasone, Nadifloxacin Captab Biotec 357 70 Micogel F Ointment Fluocinolone, Miconazole Nitrate Cipla Limited 71 Micolon Miconazole, Triamcinolone Johnson & Johnson (Ethnor) 72 Miconit C Miconazole, Clobetasol Propionate Woodrock Healthcare Pvt. Ltd. 73 Micoptic-Opticop (1%w/ v) Miconazole 1%w/v FDC 74 Microgram Miconazole, Clobetasone Butyrate, Gentamicin Sulphate Glenmark Pharmaceuticals Ltd. (Gracewell) 75 Mictop -F Fluocinolone, Miconazole Nitrate Ind-Swift Limited 76 MIF Miconazole, Fluocinolone Acron Pharmaceuticals 77 My -Zole-F Miconazole, Fluocinolone Gujarat Pharmalab Pvt. Ltd. 78 Mycorid -F Skin Miconazole, Fluocinolone Acetonide Klar Sehen Pvt. Limited 79 Rexgard (15 gm) Miconazole, Acetate Sandoz Pvt.Ltd 80 Rhobesole -M Miconazole, Clobetasol Cure Quick Remedies 81 Sebagard Miconazole, Cetrimide Royal Sapphire Remedies 82 Sensicort -BF Miconazole, Mometasone, Mupirocin Zuventus Health Care Ltd. (Zuvista) 83 Sensicort -F Miconazole, Mometasone Zuventus Health Care Ltd. (Zuvista) 84 Sensicort-BF Mometasone Fluorate 0.1% + Mupirocin 2% + Miconazole 2% Zuventus (Zuvista) 85 Sensicort-F Mometasone Fluorate 0.1% + Miconazole 2% Zuventus (Zuvista) 86 Sigmazol Miconazole, Fluocinolone Acetonide Svizera Healthcare (Inspira) 87 Sigmazol (10 gm) Miconazole, Fluocinolone Acetonide Svizera Healthcare (Inspira) 88 Solicort -GM Miconazole, Clobetasol Propionate, Gentamicin Sulphate Aurochem Labs (India) Pvt Ltd 89 Starbact -MF Fluocinolone, Miconazole Nitrate Invision Medi Sciences 90 Synadil -M Miconazole, Fluconazole Acetate Albatross Pharma 91 Tenovate M Miconazole, Clobetasol Propionate Glaxo Smithkline Pharmaceuticals Ltd. 92 Topisone -M Miconazole, Chlorocresol, Clobetasone Butyrate Dermocare Laboratories (Guj) Pvt Ltd 93 Triben MN Cream Fluocinolone Acetonide, Miconazole Nitrate, Neomycin Jenburkt Pharmaceuticals Ltd. 358 94 Tryderm Fluocinolone Acetonide IP, Miconazole Nitrate, Neomycin Universal Pharmaceuticals Ltd 95 Valbet Cream Betamethasone, Miconazole Nitrate, Neomycin Lupin Laboratories Ltd. 96 Varderm Fluocinolone, Gentamicin, Miconazole Nitrate Zota Healthcare Pvt. Ltd. 97 Winzole -F Miconazole, Fluocinolone Acetonide Intra Labs India Pvt Ltd 98 Zole -F Miconazole, Fluocinolone Ranbaxy Laboratories Ltd (Rexcel) 99 Zole -F (15 ml) Miconazole, Fluocinolone Acetonide Ranbaxy Laboratories Ltd (Rexcel) 100 Zole -F (5 gm) Fluocinolone, Miconazole Nitrate Ranbaxy Laboratories Ltd (Rexcel) 101 Zovate M Miconazole, Beclomethasone Glaxo Smithkline Pharmaceuticals Ltd. 359 Recent reports Gautam et al. (2017) ompounded miconazole and fluconazole separately in RECURA compounding cream, and they were tested at different time points (0, 7, 14, 28, 45, 60, 90, and 180 days) to determine the beyond-use date of those formulations. The beyond-use date testing of both formulations (10% miconazole in RECURA and 10% fluconazole in RECURA) proved them to be physically, chemically, and microbiologically stable under International Conference of Harmonisation controlled room temperature (25°C ± 2°C/60% RH ±5%) for at least 180 days from the date of compounding. Stability-indicating analytical method validation was completed for the simultaneous determination of miconazole and fluconazole in RECURA base using highperformance liquid chromatography coupled with photodiode array detector prior to the study Moriello et al. (2017) evaluated the antifungal efficacy of shampoo formulations of ketoconazole, miconazole or climbazole and accelerated hydrogen peroxide wash/rinse against Microsporum canis and Trichophyton species spores. Methods Lime sulfur (1:16)-treated 361 control, enilconazole (1:100)-treated control, accelerated hydrogen peroxide (AHP 7%) 1:20 and a 1:10 dilution of shampoo formulations of miconazole 2%, miconazole 2%/chlorhexidine gluconate 2-2.3%, ketoconazole 1%/chlorhexidine 2%, climbazole 0.5%/chlorhexidine 3% and sterile water-untreated control were tested in three experiments. In the first, a suspension of infective spores and hair/scale fragments was incubated with a 1:10, 1:5 and 1:1 dilution of spores to test solutions for 10 mins. In the second, toothbrushes containing infected cat hair in the bristles were soaked and agitated in test solutions for 10 mins, rinsed, dried and then fungal cultured (n = 12×). In the third, a 3 min contact time combined with an AHP rinse was tested (n = 10×). Good efficacy was defined as no growth. Results Water controls grew >300 colonyforming units/plate and all toothbrushes were culture-positive prior to testing. For the suspension tests, all test products showed good efficacy. Miconazole 2%, ketoconazole 1% and AHP showed good efficacy after a 10 min contact time. Good efficacy was achieved with a shorter contact time (3 mins) only if combined with an AHP rinse. Conclusions and relevance Lime sulfur and enilconazole continued to show good efficacy. In countries or situations where these products cannot be used, shampoos containing ketoconazole, miconazole or climbazole are alternative haircoat disinfectants, with a 10 min contact time or 3 mins if combined with an AHP rinse. Aljaeid and Hosny(2016) formulated and evaluate miconazole-loaded solid lipid nanoparticles (MN-SLNs) for oral administration to find an innovative way to alleviate the disadvantages associated with commercially available capsules. MN-SLNs were prepared by hot homogenization/ultrasonication. The solubility of miconazole in different solid lipids was measured. The effect of process variables, such as surfactant types, homogenization and ultrasonication times, and the charge-inducing agent on the particle size, zeta potential, and encapsulation efficiency were determined. Furthermore, in vitro drug release, antifungal activity against Candida albicans, and in vivo pharmacokinetics were studied in rabbits. The MN-SLN, consisting of 1.5% miconazole, 2% Precirol ATO5, 2.5% Cremophor RH40, 0.5% Lecinol, and 0.1% Dicetylphosphate, had an average diameter of 23 nm with a 90.2% entrapment efficiency. Furthermore, the formulation of MN-SLNs enhanced the antifungal activity compared with miconazole capsules. An in vivo pharmacokinetic study revealed that the bioavailability was enhanced by >2.5-fold. CONCLUSION: MN-SLN was more efficient in the treatment of candidiasis with enhanced oral bioavailability and could be a promising carrier for the oral delivery of miconazole. Birsan et al. (2016) developed original pharmaceutical formulation with miconazole nitrate, biomucoadhesive tablets, used in antifungal medication. The oral biomucoadhesive tablets with miconazole nitrate were developed by direct compression of the excipient mixture: carboxymethylcellulose sodium and lutrol 6000, excipients used for bioadhesivity, mannitol as a sugar substitute and aerosil as a lubricant. The main goal of the study is to determine the disintegration time and the swelling index of biomucoadhesive tablets with miconazole nitrate in order to estimate the time of contact with mucosa, respectively the prolongation of drug substance release. The swelling index was calculated depending on time in all the 5 formulations that included the carboxymethylcellulose sodium and Lutrol 6000 as matrix-forming, and the studied were time and association ratio between polymers. CONCLUSIONS: Analysing the results, we noticed that out of the four excipients we used, carboxymethylcellulose sodium had the higher influence on the swelling index and disintegration time. 361 Clark et al. (2016) determined minimum inhibitory concentrations (MICs) of combinations of chlorhexidine/miconazole and chlorhexidine/trisEDTA in vitro in a collection of Staphylococcus pseudintermedius (SP) from northern (NUK) and southeastern (SEUK) United Kingdom (UK) sources. MICs of chlorhexidine, miconazole, trisEDTA and combinations of chlorhexidine/miconazole (1:1) or chlorhexidine/trisEDTA (80:16:1 and 80:5:1) were determined for 196 canine SP isolates from NUK [49 meticillin-resistant (MRSP), 50 meticillinsusceptible (MSSP)] and fom SEUK (48 MRSP, 49 MSSP) using agar dilution. TrisEDTA alone did not inhibit growth. Chlorhexidine/miconazole MICs (median = 0.5 mg/L) were lower than those of either drug alone (P < 0.05) and lower than chlorhexidine/trisEDTA MICs (median = 1 mg/L; P < 0.0005) in each bacterial type and from both regions, except for miconazole in NUK MSSP. An additive interaction was noted between chlorhexidine and miconazole or trisEDTA (80:16:1 ratio) in 79 and 43 isolates, respectively, whereas antagonism between chlorhexidine and trisEDTA was noted for three isolates. NUK isolates were more susceptible than SEUK isolates (P < 0.05), except MRSP exposed to chlorhexidine and the chlorhexidine/trisEDTA (80:16:1) combination. CONCLUSIONS AND CLINICAL IMPORTANCE: These low MICs are likely to be exceeded by topical therapy. Evaluation of the mechanisms by which chlorhexidine combinations interact to reduce MICs is warranted, in view of increasing concerns of biocide tolerance in staphylococci. Davies et al. (2016) examined the photoactivity of the porphyrin-based photosensitizer, TMP1363, against biofilms of C. albicans, C. glabrata, C. tropicalis and C. parapsilosis, and the effect of the combined use of miconazole and aPDT. Biofilms of three American Type Culture Collection (ATCC) strains and four clinical isolates developed on poly(methyl methacrylate) (PMMA) disks, were incubated with miconazole, followed by treatment with TMP-1363 for 30 min at 37°C. The plates were exposed to broadband visible light at a distance of 10 cm to the plate, for 30 min (irradiance at the surface of the plate: 32.5 mW/cm2). The metabolic activity of the biofilms was measured by the XTT assay. ATCC strains and C. glabrata 7531/06 were not sensitive to TMP-aPDT, whereas the metabolic activities of the remaining three clinical isolates were reduced to 64.2 ± 5.5% of controls. Miconazole at 25 μg/ml decreased the viability of all strains except the ATTCC strain C. albicans MYA274; however its combination with aPDT was effective against this strain, suggesting a synergistic interaction. Effects of miconazole and aPDT on C. albicans MYA 2732, C. albicans 6122/06 were additive. With C. tropicalis and C. parapsilosis, the combined treatment had a higher, but not entirely additive, cytotoxic effect. The combined use of miconazole and TMP-aPDT is advantageous in the treatment of biofilms of a number of Candida species and strains, but not all. The molecular basis of this differential response is not known. Dimopoulou et al. (2016) evaluated the impact of salt and counterion identity on performance of solid immediate release dosage forms of miconazole and clopidogrel, respectively, in fasted upper gastrointestinal lumen using in-vitro methodologies. Two miconazole chemical forms (free base and nitrate salt) and three clopidogrel chemical forms (bisulfate, besylate and hydrochloride salts) were studied. Solubilities of miconazole forms were measured in simulated gastric fluids. Gastrointestinal transfer of the five chemical forms was evaluated by using a flow-through, three-compartmental set-up. Precipitation in duodenal compartment was evaluated by using solutions in gastric compartment. Solubilities in simulated gastric fluids, concentrations in duodenal compartment and solubilities in duodenal compartment indicated poorer performance of miconazole nitrate vs. miconazole free base in upper gastrointestinal lumen. In line with the low crystallization tendency of free base, duodenal precipitation of miconazole from a free base 362 solution was limited. Concentrations in duodenal compartment indicated that counterion identity does not affect the performance of clopidogrel; precipitation in duodenal compartment was extensive in all cases. CONCLUSIONS: Miconazole data indicate that salts may adversely affect performance of immediate release dosage forms of weak bases. In line with existing invivo data, clopidogrel data indicate that counterion identity is unimportant for the performance of clopidogrel salts in upper intestinal lumen. Firooz et al. (2016) presented an overview on novel nano-based formulation approaches employed to improve miconazole penetration through skin for the treatment of fungal infections. González-Calderón et al. (2016) synthesized seven miconazole analogs involving 1,4,5-tri and 1,5-disubstituted triazole moieties by azide-enolate 1,3-dipolar cycloaddition. The antifungal activity of these compounds was evaluated in vitro against four filamentous fungi, including Aspergillus fumigatus, Trichosporon cutaneum, Rhizopus oryzae, and Mucor hiemalis as well as three species of Candida spp. as yeast specimens. These pre-clinical studies suggest that compounds 4b, 4d and 7b can be considered as drug candidates for future complementary biological studies due to their good/excellent antifungal activities. Gupta and Kar (2016) aimed at formulation and evaluation of antifungal activity of miconazole nitrate (MN) vesicles vs C. albicans spp.<br /> Miconazole loaded vesicles were prepared by coacervation phase separation technique using nonionic surfactants and stabilizers. The antimycological activity of vesicles was performed using agar disc diffusion technique.<br /> The miconazole nitrate lipid vesicles F5A and F5B showed maximum activity with higher zones of inhibition ie, 13.95+1.54 mm and 13.64+0.65 mm, respectively, after 3 days (For all comparisons, <em>P</em>&lt;.05 was considered significant).<br /> CONCLUSION: The findings of this study suggest antifungal potential of a novel preparation of miconazole nitrate vesicles vs Candida albicans in the treatment of mycoses in dermatological practice. <br /><br /> <em> Maciel et al. (2016) compare the effect of oral miconazole gel to PDT combined with low-power laser (LPL) therapy in the treatment of denture stomatitis. Forty participants with clinical and microbiological diagnoses of type II denture stomatitis were randomly allocated to two treatment groups (PDT and miconazole gel), each with 20 individuals. The PDT group was submitted to one session of methylene blue-mediated PDT plus two sessions of low-laser therapy twice a week for 15 days. The miconazole group was submitted to the drug four times a day for 15 days. Forty percent of the patients achieved clinical and microbiological resolution of denture stomatitis after methylene blue-mediated photodynamic inactivation followed by low-laser therapy. The cure rate associated with miconazole was 80% (p < 0.05). Fifteen days after the end of treatment, the recurrence rate was 25% in patients treated with PDT combined with LPL therapy and 12.5% in patients treated with miconazole. CONCLUSION: Miconazole gel provides better results than a protocol combining methylene blue-mediated PDT and LPL therapy in the treatment of type II denture stomatitis. Murakami (2016) investigated the effect of terminating miconazole oral gel (MOG) treatment on the anticoagulant activity of warfarin by evaluating changes in international normalized ratio levels (INR).Data were collected from the medical records of 6 patients treated with warfarin and MOG. Following cessation of MOG treatment, increased INR and INR/dose levels were observed for an average of 15 days, showing that the anticoagulant activity of warfarin was 363 increased for ~ 2 weeks. CONCLUSIONS: Closer monitoring of INR levels for at least 2 weeks may be required upon withdrawal of MOG treatment in patients treated with warfarin. Pemberton (2016) evaluated the was analysed pharmacology literature, the medical literature and the 'yellow card' adverse drug reaction surveillance reports regarding possible interactions of nystatin and miconazole with warfarin. There is strong evidence to support the derangement of warfarin anticoagulation by miconazole oral gel in all areas of evidence studied. No postulated mechanism of interaction, no additional published reported cases and no supportive data from adverse drug reports were identified which would corroborate the case for a significant interaction between nystatin and warfarin. Ramos and Diogo (2016) determined the main kinetic features of the secondary relaxations and of the main (glass transition) relaxation, in particular their distribution of relaxation times. The dynamic fragility of the three glass formers was determined from DSC data (using two different procedures) and from TSDC data. According to our results voriconazole behaves as a relatively strong liquid, while miconazole is moderately fragile and itraconazole is a very fragile liquid. There are no studies in this area published in the literature relating to voriconazole. Also not available in the literature is a slow mobility study by dielectric relaxation spectroscopy in the amorphous miconazole. Apart from that, the results obtained are in reasonable agreement with published works using different experimental techniques. Torikai et al. (2016) elucidated the prophylactic effect of MCZ for the treatment of neonatal IP, and to establish a new prophylactic concept for this disease. In in vivo experiments, the effects of MCZ were examined histopathologically using a mouse model of intestinal ischemia. In in vitro experiments, the cytoprotective effect of MCZ against hypoxia was evaluated using Caco-2 intestinal cells, and its anti-inflammatory potential using a co-culture model of Caco-2 and HL60 cells. MCZ showed a tissue protective effect against intestinal ischemia. MCZ reduced high mobility group-box 1 (HMGB1) release in Caco-2 cells under hypoxic stress and attenuated the potential to activate co-cultured HL60 leukocytes with Caco-2 cells by suppressing interleukin-8 (IL-8). Yan et al. (2016) evaluated the efficacy and safety of miconazole nitrate mucoadhesive tablets in comparison with itraconazole capsules for OC treatment. The study was a randomized, openlabel, parallel-armed, multicenter clinical trial. Totally, 343 patients diagnosed with OC, who met the inclusion criteria, were randomly assigned to either a treatment group that received miconazole nitrate mucoadhesive tablets (10 mg) once daily or a control group that received itraconazole capsules (100 mg QD) for 2 weeks, and were followed up for 2 weeks. The clinical cure, improvement of clinical symptoms/signs, mycologic cure, and safety were evaluated. The mucoadhesive tablets (n = 171) did not show inferiority to itraconazole (n = 172) in the treatment of OC. At the end of the 14-day treatment, the clinical cure rates were 45.29% and 41.76% in the miconazole and itraconazole groups, respectively (P = 0.3472). At the end of the 14-day follow-up, the clinical cure rates were 51.18% and 41.76% in the miconazole and itraconazole groups, respectively (P = 0.0329). Adverse events occurred in 53 subjects (33 in the miconazole group and 20 in the itraconazole group). There was no statistical difference in the safety profile between miconazole and itraconazole (P = 0.0533). Thrombocytopenic purpura, although rare, occurred in one patient in the miconazole group and was considered a drugrelated, severe adverse event. CONCLUSION: Miconazole nitrate mucoadhesive tablets may be as effective as systemic itraconazole capsule for OC treatment. 364 Zhang et al. (2016) assessed the efficacy and safety of miconazole for treating oral candidiasis. Twelve electronic databases were searched for randomized controlled trials evaluating treatments for oral candidiasis and complemented by hand searching. The clinical and mycological outcomes, as well as adverse effects, were set as the primary outcome criteria. Seventeen trials were included in this review. Most studies were considered to have a high or moderate level of bias. Miconazole was more effective than nystatin for thrush. For HIV-infected patients, there was no significant difference in the efficacy between miconazole and other antifungals. For denture wearers, microwave therapy was significantly better than miconazole. No significant difference was found in the safety evaluation between miconazoleand other treatments. The relapse rate of miconazole oral gel may be lower than that of other formulations. References 1. Birsan M, Scutariu MM, Cojocaru I. Influence of carboxymethylcellulose sodium and lutrol on the swelling index and disintegration time of biomucoadhesive tablets with miconazolenitrate. Rev Med Chir Soc Med Nat Iasi. 2016 Apr-Jun;120(2):445-51. 2. Clark SM1, Loeffler A2, Schmidt VM3, Chang YM2, Wilson A2, Timofte D3, Bond R2. Interaction of chlorhexidine with trisEDTA or miconazole in vitro against canine meticillin-resistant and -susceptible Staphylococcus pseudintermedius isolates from two UK regions. Vet Dermatol. 2016 Oct;27(5):340-e84. 3. Davies A1,2, Gebremedhin S1, Yee M1, Padilla RJ2, Duzgunes N1, Konopka K1, DorockaBobkowska B3. Cationic porphyrin-mediated photodynamic inactivation of Candida biofilms and the effect of miconazole. J Physiol Pharmacol. 2016 Oct;67(5):777-783. 4. Dimopoulou M1, Mourouti CS1, Vertzoni M1, Symillides M1, Reppas C1. In-vitro evaluation of performance of solid immediate release dosage forms of weak bases in upper gastrointestinal lumen: experience with miconazole and clopidogrel salts. J Pharm Pharmacol. 2016 May;68(5):579-87. 5. Firooz A, Namdar R, Nafisi S1, Maibach HI2. Nano-Sized Technologies for Miconazole Skin Delivery. Curr Pharm Biotechnol. 2016;17(6):524-31. 6. Gautam P1, Light B, Purvis T. Stability of Two Antifungal Agents, Fluconazole and Miconazole, Compounded in HUMCO RECURA Topical Cream to Determine Beyond-Use Date. Int J Pharm Compd. 2017 Mar-Apr;21(2):154-159. 7. González-Calderón D1, Mejía-Dionicio MG2, Morales-Reza MA2, Ramírez-Villalva A2, Morales-Rodríguez M3, Jauregui-Rodríguez B3, Díaz-Torres E2, González-Romero C2, Fuentes-Benítes A4. Azide-enolate 1,3-dipolar cycloaddition in the synthesis of novel triazole-based miconazoleanalogues as promising antifungal agents. Eur J Med Chem. 2016 Apr 13;112:60-65. 8. Gupta A, Kar HK. Antimycotic Studies of Miconazole Nanovesicles Formulation vs Candida Strain. J Drugs Dermatol. 2016 Jun 1;15(6):734-7. 9. Maciel CM1, Piva MR1, Ribeiro MA1, de Santana Santos T2, Ribeiro CF1, Martins-Filho PR3. Methylene Blue-Mediated Photodynamic Inactivation Followed by Low-Laser Therapy versus Miconazole Gel in the Treatment of Denture Stomatitis. J Prosthodont. 2016 Jan;25(1):28-32. 365 10. Moriello KA1. In vitro efficacy of shampoos containing miconazole, ketoconazole, climbazole or accelerated hydrogen peroxide against Microsporum canis and Trichophyton species. J Feline Med Surg. 2017 Apr;19(4):370-374. 11. Murakami S, Tanaka A, Ido K, Tanaka M, Araki H. Prolonged effects of miconazole oral gel on warfarin anticoagulation even after treatment withdrawal. Int J Clin Pharmacol Ther. 2016 Jun;54(6):474-6. 12. Pemberton MN1. Nystatin and miconazole: pharmacological and clinical evidence regarding interactions with warfarin. Oral Dis. 2016 Nov;22(8):761-765. 13. Ramos JJ1, Diogo HP2. The slow relaxation dynamics in active pharmaceutical ingredients studied by DSC and TSDC: Voriconazole, miconazole and itraconazole. Int J Pharm. 2016 Mar 30;501(1-2):39-48. 14. Torikai M1, Ibara S2, Ieiri S3, Hamada T4, Noguchi H5, Sueyoshi K6, Fukuda T4, Abeyama K4. Prophylactic efficacy of enteral miconazole administration for neonatal intestinal perforation and its potential mechanism. Pediatr Surg Int. 2016 Oct;32(10):9537. 15. Yan Z1, Liu X1, Liu Y1, Han Y1, Lin M2, Wang W3, Guan X4, Zhu S5, Zhang H6, Wang Q7, Chou L8, Zhu X9, Hua H1. The Efficacy and Safety of Miconazole Nitrate Mucoadhesive Tablets versus Itraconazole Capsules in the Treatment of Oral Candidiasis: An Open-Label, Randomized, Multicenter Trial. PLoS One. 2016 Dec 15;11(12):e0167880. 16. Zhang LW1, Fu JY2, Hua H1, Yan ZM1. Efficacy and safety of miconazole for oral candidiasis: a systematic review and meta-analysis. Oral Dis. 2016 Apr;22(3):185-95. 17. Aljaeid BM1, Hosny KM2. Miconazole-loaded solid lipid nanoparticles: formulation and evaluation of a novel formula with high bioavailability and antifungal activity. Int J Nanomedicine. 2016 Jan 25;11:441-7. 27. Myclobutanil      Myclobutanil is a triazole chemical used as a fungicide. Myclobutanil is a steroid demethylation inhibitor, specifically inhibiting ergosterol biosynthesis. Ergosterol is a critical component of fungal cell membranes. Date of Approval: 01/06/2011 Expiration of Approval: 31/05/2021 Myclobutanil is the common name for the active ingredient in several fungicide products registered to Dow AgroSciences LLC, a wholly owned subsidiary of The Dow Chemical Company. Its mode of action is inhibition of the enzyme C14 demethylase which is involved in the synthesis of ergosterol, a component of fungal cellular membranes. Myclobutanil is used to control a broad spectrum of diseases in many perennial and annual crops, turf varieties, landscape ornamental plants, fruit trees, and vines.3 Chemical Names: MYCLOBUTANIL; Systhane; Formula: C15H17ClN4 366 Uses    Myclobutanil is used to control a diverse range of economically important plant pathogens including powdery mildews, dollar spot, summer patch, brown patch, rusts, and scab in a range of crops including established turf grasses, landscape ornamentals, greenhouse and nursery ornamentals, apple trees, stone fruit trees, almonds, strawberries, vegetables, soybeans and grape vines. Myclobutanil products are registered and authorized for use in all countries in which they are sold, including, but not limited to: Australia, Canada, India, New Zealand, South Africa, the European Union and the United States. Myclobutanil will systemically treat prevent and control; anthracnose red thread septoria leaf brown patch copper spot leaf spot crown rot melting out dollar spot blight smuts necrotic ring spot powdery mildew rusts scab dead spot fusarium patch snow mold take all patch zoysia large patch Health hazards, http://msdssearch.dow.com/PublishedLiteratureDOWCOM/dh_        Eye contact o Contact may cause moderate eye irritation and slight corneal injury. Skin contact o Brief contact is essentially nonirritating. o Prolonged contact is unlikely to result in absorption of harmful amounts. Inhalation o Prolonged excessive exposure to mist may cause irritation to the upper respiratory tract (nose and throat). Ingestion o This material has low toxicity if swallowed. o Swallowing small amounts incidental to normal handling operations is not likely to cause injury; o swallowing larger amounts may cause injury. Repeated exposure o In animal testing, effects have been reported on the adrenal gland, kidney, liver, testes, and thyroid. Birth defects/developmental effects o In animal testing, this material has been toxic to the fetus at doses that are nontoxic to the mother. Reproductive effects 367 o In animal testing, effects on reproduction have been seen only at doses that produced significant toxicity to the parent animals.   Myclobutanil is highly toxic to aquatic organisms on an acute basis (LC/EC50 between 0.1 and 1 mg/L in the most sensitive species tested). Myclobutanil is practically nontoxic to birds on a dietary basis (LC50>5000ppm), but is slightly toxic to birds on an acute basis (LD50 between 501 and 2000 mg/kg). Environmental Information    Myclobutanil is nonvolatile and has low mobility in soil. If released into a soil environment, it would remain in soil. If released into water, it would adsorb to suspended solids or sediment. Myclobutanil is not readily biodegradable, but will biodegrade slowly under environmental conditions. It would be removed by biological wastewater-treatment facilities as biosolids. Myclobutanil has a low bioconcentration potential (tendency to accumulate in the food chain) Brand Names                 CAS No. 88671-89-0 Myclobutanil Myclobutanil, technical α-Butyl-α-(4-chlorophenyl)-1H-1,2,4-triazole-1-propanenitrile 2-(4-Chlorophenyl)-2-(1H-1,2,4-triazol-1-ylmethyl) hexanenitrile EAGLE® 20EW Fungicide EAGLE WSP Turf and Ornamental Fungicide EAGLE 0.39% Granular Turf Fungicide MASALON® Fungicide MYCLOSS® Xtra Fungicide RALLY® 200EW Fungicide RALLY 40WSP Fungicide SYSTHANE® 125 Fungicide SYSTHANE 200EW Fungicide SYSTHANE 10WP Fungicide SYSTHANE 400WP Fungicide 368 Recent reports: Chen et al. (2016) mentioned that there are large amounts of toxicological data available regarding myclobutanil, but the adverse effects of myclobutanil on lizards has not been widely reported. In this study, treatment groups were orally administered a single-dose of myclobutanil (20mg/kg body weight (bw)). Subsequently, it was found that there were differences in myclobutanil levels between the different tissues and concentrations also changed with degradation time. The tissue concentrations of myclobutanil decreased in the order of: stomach > liver > lung > blood > testis > kidney > heart > brain. Based on our results, the liver and testis were considered to be the main target organs in lizards, indicating that the myclobutanil could induce potential hepatic and reproductive toxicity on lizards. Meanwhile, it was also demonstrated that the toxic effects of myclobutanil was different in different species, and the distribution of different pesticides in lizards were different. 369 Ju et al. (2016) conducted a 3-month-long experiment to ascertain the effects of different concentrations of myclobutanil (0.4 mg kg(-1) soil [T1]; 1.2 mg kg(-1) soil [T3]; and 4 mg kg(1) soil [T10]) on soil microbial biomass, respiration, and soil nitrogen transformations using two typical agricultural soils (Henan fluvo-aquic soil and Shanxi cinnamon soil). Soil was sampled after 7, 15, 30, 60, and 90 days of incubation to determine myclobutanil concentration and microbial parameters: soil basal respiration (RB), microbial biomass carbon (MBC) and nitrogen (MBN), NO(-)3-N and NH(+)4-N concentrations, and gene abundance of total bacteria, N2fixing bacteria, fungi, ammonia-oxidizing archaea (AOA), and ammonia-oxidizing bacteria (AOB). The half-lives of the different doses of myclobutanil varied from 20.3 to 69.3 d in the Henan soil and from 99 to 138.6 d in the Shanxi soil. In the Henan soil, the three treatments caused different degrees of short-term inhibition of RB and MBC, NH(+)4-N, and gene abundance of total bacteria, fungi, N2-fixing bacteria, AOA, and AOB, with the exception of a brief increase in NO(-)3-N content during the T10 treatment. The MBN (immobilized nitrogen) was not affected. In the Shanxi soil, MBC, the populations of total bacteria, fungi, and N2-fixing bacteria, and NH(+)4-N concentration were not significantly affected by myclobutanil. The RB and MBN were decreased transitorily in the T10 treatment. The NO(-)3-N concentrations and the abundance of both AOA and AOB were erratically stimulated by myclobutanil. Regardless of whether stimulation or suppression occurred, the effects of myclobutanil on the two soil types were short term. Stellavato et al. (2016) Myclobutanil is a conazole class fungicide widely used as an agrichemical. It is approved for use on fruit, vegetables and seed commodities in the EU and elsewhere to control fungi such as Ascomycetes, Fungi Imperfecti and, Basidiomycetes. Its widespread use has raised the issue of possible health risks for agrarian communities and the general population, which can be exposed to residues present in food and drinking water. The toxicities identified include adverse effects on liver and kidney and on the development of male reproductive organs. Since the liver is the first-line organ in the defense against xenobiotics, toxic effects on hepatic metabolism cause degeneration, necrosis, and tissue hypertrophy. Therefore, we investigated myclobutanil's effects on the human liver cell line HepG2. We found that myclobutanilincreases the amount of fatty acids in these hepatic cells, as evaluated with Oil Red O staining, and progressively reduces cell viability from 1ppm to 500ppm. Analysis of biomarkers such as Bcl-xL/Bak and Mcl-1/Bak confirmed activation of cell death pathways at low doses. Li et al. (2015) used tebuconazole and myclobutanil enantiomers to evaluate the occurrence of enantioselectivity in their acute toxicity to three non-target organisms (Scenedesmus obliquus, Daphnia magna, and Danio rerio). Significant differences were found: R-(-)-tebuconazole was about 1.4-5.9 times more toxic than S-(+)-tebuconazole; rac-myclobutanil was about 1.3-6.1 and 1.4-7.3 more toxic than (-)-myclobutanil and (+)-myclobutanil, respectively. Enantioselectivity was further investigated in terms of fungicide degradation in seven soil samples, which were selected to cover a broad range of soil properties. In aerobic or anaerobic soils, the S-(+)tebuconazole degraded faster than R-(-)-tebuconazole, and the enantioselectivity showed a correlation with soil organic carbon content. (+)-Myclobutanil was preferentially degraded than (-)-myclobutanil in aerobic soils, whereas both enantiomers degraded at similar rates in anaerobic soils. Apparent correlations of enantioselectivity with soil pH and soil texture were observed for myclobutanil under aerobic conditions. In addition, both fungicides were configurationally stable in soils, i.e., no enantiomerization was found. Enantioselectivity may be a common phenomenon in both aquatic toxicity and biodegradation of chiral triazole fungicides, 371 and this should be considered when assessing ecotoxicological risks of these compounds in the environment. Wang et al. (2015) investigated enantioselective metabolism and cytotoxicity in rat hepatocytes by chiral HPLC-MS/MS and the methyl tetrazolium (MTT) assay, respectively. Furthermore, tryptophan metabolism disturbance in rat hepatocytes after myclobutanil exposure was also evaluated by target metabolomics method. The half-life (t1/2) of (+)-myclobutanil was 10.66 h, whereas that for (-)-myclobutanil was 15.07 h. Such results indicated that the metabolic process of myclobutanil in rat hepatocytes was enantioselective with an enrichment of (-)-myclobutanil. For the cytotoxicity research, the calculated EC50 (12 h) values for rac-myclobutanil, (+)- and ()-myclobutanil were 123.65, 150.65 and 152.60 µM, respectively. The results of tryptophan metabolites profiling showed that the levels of kynurenine (KYN) and XA were both upregulated compared to the control, suggesting the activation effect of the KYN pathway by myclobutanil and its enantiomers which may provide an important insight into its toxicity mechanism. References: Chen L1, Li R2, Diao J2, Tian Z2, Di S1, Zhang W1, Cheng C1, Zhou Z3. Tissue distribution and toxicity effects of myclobutanil enantiomers in lizards (Eremias argus). Ecotoxicol Environ Saf. 2017 Nov;145:623-629. 1 2 1 1 1 1 2. Ju C , Xu J , Wu X , Dong F , Liu X , Zheng Y . Effects of myclobutanil on soil microbial biomass, respiration, and soil nitrogen transformations. Environ Pollut. 2016 Jan;208(Pt B):811-20. 1 1 1 1 1 2 3. Li Y , Dong F , Liu X , Xu J , Han Y , Zheng Y . Enantioselectivity in tebuconazole and myclobutanil non-target toxicity and degradation in soils. Chemosphere. 2015 Mar;122:145-153. 1. 4. Stellavato A1, Lamberti M2, Pirozzi AVA1, de Novellis F1, Schiraldi C1. Myclobutanil worsens nonalcoholic fatty liver disease: An in vitro study of toxicity and apoptosis on HepG2 cells. Toxicol Lett. 2016 Nov 16;262:100-104. 5. Wang Y1, Qiu J2, Zhu W1, Wang X1, Zhang P1, Wang D1, Zhou Z1. Enantioselective Metabolism and Interference on Tryptophan Metabolism of Myclobutanil in Rat Hepatocytes. Chirality. 2015 Sep;27(9):643-9. 371 28. Omoconazole     Omoconazole (CM 8282) is an antifungal imidazole derivative, developed as a topical antifungal agent by Siegfried AG (301). Omoconazole is evaluated for its effectiveness for treating dermatological fungal infections (Sochynsky and Hardcastle [ed.], Pharma Omoconazole In vitro, is comparable in activity to clotrimazole, econazole, isoconazole, ketoconazole, miconazole, and tioconazole against a panel of 55 clinical isolates of yeasts. Omoconazole was the second most active drug; tioconazole was the most active and ketoconazole was the least active in the agar dilution assay. Chemical Name Omoconazole; Omoconazol; Omoconazolum; Omoconazole [INN]; Omoconazol[INN-Spanish]; Omoconazolum [INN-Latin] (Z)-1-[2,4-Dichloro-β-[2-(p-chlorophenoxy)etoxy]-α-metylstyryl]imidazole Molecular Formula: C20H17Cl3N2O2 Generic Names  Omoconazole (OS: DCF)  CM 8282 (IS)  Omoconazole Nitrate (OS: USAN, JAN) Brand Names  Mikogal Biogal Pharmaceutical, Lithuania; Teva, Lithuania  Fongamil Alapis Pharma, Greece; Bailleul, Portugal  Fongamil Bailleul, France  Mikogal Teva, Hungary 372 1% Reports: Mosse et al. (1986) determined the omoconazole MICs against 55 recent clinical yeast isolates by agar dilution on pH 5.5-adjusted Sabouraud and casitone media. MIC 90% values showed that tioconazole was the most active product, followed by omoconazole and econazole, whereas ketoconazole was the least active compound under our experimental conditions. Itoyama et al. (1994) investigated the effects of various factors on in vitro antifungal activities of omoconazole nitrate (OMZ) with bifonazole (BFZ) as the reference drug using an agar dilution method and a broth dilution method. Composition of the culture medium significantly altered the activity as determined by minimum inhibitory concentration (MIC) of OMZ; OMZ exhibited a greater anti-Candida activity (smaller MIC values) on casitone agar (CA) than on Sabouraud dextrose agar (SDA). Anti-Candida activity of OMZ was the highest in pH 5 medium, but it was lowered by an increase of inoculum size, a prolongation of the incubation period and the addition of calf serum to the medium. Anti-Trichophyton activity of OMZ was not influenced with these factors except for the addition of calf serum. The activity of OMZ was fungicidal against Candida at pH 5.0 and against Trichophyton at pH 5.0 and 6.6. The geometric mean MIC of OMZ was lower than that of BFZ against C. albicans freshly-isolated on acid CA. Uchida et al. (1996) examined in vitro antifungal activities of omoconazole nitrate (OMZ), a novel antifungal imidazole antimycotic drug, against clinical isolates obtained from patients with cutaneous mycosis and its activity was compared with that of bifonazole (BFZ). The clinical isolates tested were 70 of dermatophytes including Trichophyton rubrum (47 isolates), T. mentagrophytes (22 isolates), Microsporum gypseum (1 isolate), and 27 isolates of Candida albicans. MIC values of OMZ to dermatophytes distributed in a range of < or = 0.04 to 0.63 microgram/ml were similar to those of BFZ (< or = 0.04 to 1.25 micrograms/ml). MIC values of OMZ to C. albicans were in a range of 0.16 to 2.5 micrograms/ml indicating that OMZ had more potent activities than BFZ (1.25 to 5 micrograms/ml). These results showed that in vitro 373 antifungal activities of OMZ against clinical isolates of dermatophytes and C. albicans were greater than or similar to those of BFZ. Hashiguchi et al. (1997) examined the clinically useful optimum dose of omoconazole nitrate, a topical antifungal agent, by analysing the percutaneous pharmacokinetics of the drug to assess its pharmacological activity in an in-vivo study. Creams containing omoconazole nitrate were prepared on a pilot basis. The therapeutic effect of the omoconazole nitrate creams was examined in an in-vivo pharmacological dermatophytosis infection model in guinea-pigs. Creams containing 0.25% or higher concentrations of omoconazole nitrate resulted in significant inhibition compared with no treatment and with vehicle-treated controls. In the mycological examination no growth of dermatophytes was observed for creams containing 1% or higher concentrations. In an in-vitro hairless mouse skin-permeability test a non-linear least squares program based on a fast inverse Laplace transform algorithm was used to calculate the partition and diffusion parameters of omoconazole nitrate in the stratum corneum and viable epidermis. The time-course of drug concentrations in the skin of the guinea-pig, estimated on the basis of these parameters, led to predictions that percutaneous drug concentrations on the guinea-pig would require 10 or more days to reach equilibrium in the skin; that drug concentrations in the corneum-viable epidermis border, where dermatophytes are considered to grow, would exceed the minimum effective concentration when 0.1% higher concentration creams were used; and that for binding to keratin drug concentrations would reach the practical minimum effective concentration when creams containing 0.5% or more omoconazole nitrate were used. These results show that partition and diffusion parameters obtained from in-vitro skin permeation studies can be used to predict in-vivo percutaneous pharmacokinetics and to estimate therapeutically effective concentrations. Itoyama et al. (1997a) investigated the therapeutic effects of topical omoconazole nitrate (OMZ) on Trichophyton mentagrophytes-infected guinea-pigs. Once-daily topical application of 0.25, 0.5, 1 or 2% OMZ cream preparation for 14 consecutive days, starting on the fifth day after infection, was therapeutically effective. The effectiveness appeared to increase with the concentration of the active preparation, and was nearly maximal at 1%. OMZ cream preparation (1% or 2%) was superior to 1% bifonazole cream preparation in improving local lesions and culture results. This result suggests that topical OMZ may be clinically useful in the treatment of patients with dermatophytosis and probably those with other superficial mycoses. Itoyama et al. (1997b) investigated the therapeutic efficacy of omoconazole nitrate in an experimental tinea pedis model produced by topical inoculation with Trichophyton mentagrophytes in guinea-pigs, which is pathologically similar to naturally infected tinea pedis in humans. Treatment with omoconazole nitrate cream was started on week 2 postinfection and continued for 3 or 4 weeks. Once-a-day application of 1% omoconazolenitrate to the site of infection exhibited an excellent therapeutic efficacy, and was superior to 1% bifonazole cream in culture result. This result suggests that omoconazole nitrate has a potential usefulness for the treatment of tinea pedis in humans. Nishiyama et al. (1997) studied the antifungal effects of an imidazoleantimycotic omoconazole nitrate (OMZ) on the morphology and ultrastructure of Candida albicans yeast cells using scanning and transmission electron microscopy. The treatment of growing Candida cultures with fungistatic doses (0.4 to 4 micrograms/ml) of OMZ produced the formation of a chain or cluster of cells. Thickening of the cell wall and accumulation of electrondense vesicles in the wall were clearly observed. Development of Golgi-like complex 374 membranous structures in the cytoplasm was the most prominent finding. The cytological alteration induced by exposure to a higher concentration (40 micrograms/ml) of the drug was characterized by disruption of the intracytoplasmic organelles. Our results confirm the strong antifungal activity of OMZ against fungal cells. References 1. Hashiguchi T1, Ryu A, Itoyama T, Uchida K, Yamaguchi H. Study of the effective dose of a topical antifungal agent, omoconazole nitrate, on the basis of percutaneous pharmacokinetics in guinea-pigs and mice. J Pharm Pharmacol. 1997 Aug;49(8):757-61. 2. Itoyama T1, Aoki Y, Hiratani T, Uchida K, Yamaguchi H. [Various factors influencing in vitro antifungal activities of omoconazole nitrate (OMZ), a new imidazole antimycotic]. Jpn J Antibiot. 1994 Jan;47(1):40-9. 3. Itoyama T1, Uchida K, Yamaguchi H. Therapeutic effects of omoconazole nitrate on guinea-pigs experimentally infected with Trichophyton mentagrophytes. J Antimicrob Chemother. 1997a Jun;39(6):825-7. 4. Itoyama T1, Uchida K, Yamaguchi H, Fujita S. Therapeutic effects of omoconazole nitrate on experimental tinea pedis, an intractable dermatophytosis, in guinea-pigs. J Antimicrob Chemother. 1997b Sep;40(3):441-4. 5. Mosse M, Alric MP, Berceaux M, Fourcine N, Salhi A. [Comparative study of the fungistatic activity in vitro of omoconazole and 6 other imidazoles against yeasts]. Pathol Biol (Paris). 1986 Jun;34(5 Pt 2):684-7. 6. Nishiyama Y1, Itoyama T, Yamaguchi H. Ultrastructural alterations of Candida albicans induced by a new imidazole antimycotic omoconazole nitrate. Microbiol Immunol. 1997;41(5):395-402. 7. Uchida K1, Itoyama T, Yamaguchi H. [In vitro antifungal activity of omoconazole nitrate, a novel imidazone antimycotic drug, against clinical isolates from patients with cutaneous mycosis]. Jpn J Antibiot. 1996 Aug;49(8):818-23. 375 29. Oxiconazole Oxiconazole is an antifungal medication typically administered in a cream or lotion to treat skin infections, such as athlete's foot, jock itch and ringworm. Molar mass: 429.126 g/mol Formula: C18H13Cl4N3O Pharmacodynamics   Oxiconazole is a broad-spectrum imidazole derivative whose antifungal activity is derived primarily from the inhibition of ergosterol biosynthesis, which is critical for cellular membrane integrity. Oxiconazole has fungicidal or fungistatic activity in vitro against a number of pathogenic fungi including the following dermatophytes, and yeasts: T. rubrum, T. mentagrophytes, T. tonsurans, T. violaceum, E. floccosum, M. canis, M. audouini, M. gypseum, C. albicans, and M. furfur. Mechanism of action     Oxiconazole inhibits ergosterol biosynthesis, which is required for cytoplasmic membrane integrity of fungi. Oxiconazole acts to destabilize the fungal cyctochrome P450 51 enzyme (also known as Lanosterol 14-alpha demethylase). This is vital in the cell membrance structure of the fungus. Its inhibition leads to cell lysis. Oxiconazole has also been shown in inhibit DNA synthesis and suppress intracellular concentrations of ATP. Like other imidazole antifungals, Oxiconazole can increase membrane permeability to zinc, augmenting its cytotoxicity. Generic Name : OXICONAZOLE 1. Oxistat is a brand name of oxiconazole topical, approved by the FDA in the following formulation(s): 376 OXISTAT (oxiconazole nitrate - cream;topical)  Manufacturer: FOUGERA PHARMS Approval date: December 30, 1988 Strength(s): EQ 1% BASE [RLD] [AB] OXISTAT (oxiconazole nitrate - lotion;topical)  Manufacturer: FOUGERA PHARMS Approval date: September 30, 1992 Strength(s): EQ 1% BASE [RLD] Oxiconazole nitrate cream;topical  Manufacturer: TARO Approval date: March 7, 2016 Strength(s): EQ 1% BASE [AB] Note: No generic formulation of the following product is available.  oxiconazole nitrate - lotion;topic 2. Brand Name : OXIFUN CRM Manufacturer/Marketer: Square Pharmaceuticals Ltd Composition: Oxiconazole 0.01 List of Oxifun substitutes (brand and generic names) Antimycolin (Taiwan) Antimycolin 10 mg/1 g x 5 g Apexazole 1% (Egypt) Fonx (France) Cream; Topical; Oxiconazole Nitrate 1% (Astellas) Powder; Topical; Oxiconazole Nitrate 1% (Astellas) Solution; Topical; Oxiconazole Nitrate 1% (Astellas) Fonx 1% (France) Gyno Oceral (Austria) Gyno-Liderman (Austria) Tablet; Vaginal; Oxiconazole Nitrate (Jacoby) Gyno-Myfungar (Switzerland) Liderman (Austria) Cream; Topical; Oxiconazole Nitrate (Jacoby) Solution; Topical; Oxiconazole Nitrate (Jacoby) Mifungar (Georgia) Myfungar (Czech Republic, Germany, Lithuania, Russian Federation, Slovakia) Cream; Topical; Oxiconazole Nitrate 1% (Klinge) Fonx (France) Cream; Topical; Oxiconazole Nitrate 1% (Astellas) Powder; Topical; Oxiconazole Nitrate 1% (Astellas) Solution; Topical; Oxiconazole Nitrate 1% (Astellas) Fonx 1% (France) Myfungar 30g - 1 Cream (Klinge) Oceral (Brazil, Switzerland, Turkey) Cream; Topical; Oxiconazole Nitrate 1% (Medika) Powder; Topical; Oxiconazole Nitrate 1% (Medika) Spray; Topical; Oxiconazole Nitrate 1% (Medika) Tablet; Vaginal; Oxiconazole Nitrate 600 mg (Medika) Oceral GB (Germany) Okiconale (Japan) Okiconale V (Japan) Okinazole (Japan) Okinazole 1% (Japan) Okinazole V (Japan) Oxiconazole (Czech Republic, Germany, Lithuania, Russian Federation, Slovakia) Oxistat 1% Cream 60 gm Oxistat 1% Lotion 30ml Bottle Oxistat 1% Cream 30 gm Tube Oxistat 1% Cream 15 gm Tube 1% cream Oxiconazole Cream Oxiconazole Lotion Oxicone (Taiwan) Oxicone 10 mg/1 g x 5 g Oxipelle (Brazil) Oxistat Topical Oxitrat (Brazil) Oxizole (Taiwan) Cream; Topical; Oxiconazole Nitrate 1% (Orthos) Lotion; Topical; 377 Oxiconazole Nitrate 1% (Orthos) Oxizole 10 mg/1 g x 15 g (Orthos) Oxizole cream 1 % (Orthos) Oxizole lotion 10 mg (Orthos) Salongo (Spain) Thioconazole Tinox 1% (Egypt) Oxiconazole Nitrate Cream1%  contains the antifungal active compound oxiconazole nitrate. This formulation is for topical dermatologic use only. 378     Chemically, oxiconazole nitrate is 2',4'-dichloro-2-imidazol-1-ylacetophenone (Z)-[0(2,4-dichlorobenzyl)oxime], mononitrate. The compound has the molecular formula C18H13ON3CI4•HNO3, a molecular weight of 492.15, and the following structural formula: Oxiconazole nitrate is a nearly white crystalline powder, soluble in methanol; sparingly soluble in ethanol, chloroform, and acetone; and very slightly soluble in water. Oxiconazole Nitrate Cream, 1% contains 10 mg of oxiconazole per gram of cream in a white to off-white cream base of cetyl alcohol, polysorbate 60, propylene glycol, purified water, stearyl alcohol, white petrolatum, and benzoic acid 0.2% as a preservative. Oxiconazole Nitrate Cream Pharmacokinetics  The penetration of oxiconazole nitrate into different layers of the skin was assessed using an in vitro permeation technique with human skin.  Five hours after application of 2.5 mg/cm2 of oxiconazole nitrate cream onto human skin, the concentration of oxiconazole nitrate was demonstrated to be 16.2 μmol in the epidermis, 3.64 μmol in the upper corium, and 1.29 μmol in the deeper corium. Systemic absorption of oxiconazole nitrate is low.  Using radiolabeled drug, less than 0.3% of the applied dose of oxiconazole nitrate was recovered in the urine of volunteer subjects up to 5 days after application of the cream formulation. Neither in vitro nor in vivo studies have been conducted to establish relative activity between the lotion and cream formulations. Microbiology   Oxiconazole nitrate is an imidazole derivative whose antifungal activity is derived primarily from the inhibition of ergosterol biosynthesis, which is critical for cellular membrane integrity. It has in vitro activity against a wide range of pathogenic fungi. Oxiconazole has been shown to be active against most strains of the following organisms both in vitro and in clinical infections o Epidermophyton floccosum Trichophyton mentagrophytes 379  Trichophyton rubrum Malassezia furfur Oxiconazole exhibits satisfactory in vitro minimum inhibitory concentrations (MICs) against most strains of the following organisms; o Candida albicans Microsporum audouini Microsporum canis Microsporum gypseum Trichophyton tonsurans Trichophyton violaceum Indications and Usage for Oxiconazole Nitrate Cream  Oxiconazole Nitrate Cream is indicated for the topical treatment of the following dermal infections: tinea pedis, tinea cruris, and tinea corporis due to Trichophyton rubrum, Trichophyton mentagrophytes, or Epidermophyton floccosum.  Oxiconazole Nitrate Cream is indicated for the topical treatment of tinea (pityriasis) versicolor due to Malassezia furfur Pharmacology, efficacy, and safety , Jegasothy and Pakes, 1991         Oxiconazole nitrate (1%) cream has also proved valuable in the once-daily treatment of tinea (pityriasis) versicolor. In vitro oxiconazole is highly effective against many dermatophytes, including Trichophyton rubrum, Trichophyton mentagrophytes, Trichophyton tonsurans, and Epidermophyton floccosum. Oxiconazole nitrate (1%) cream, after application to the skin, is rapidly absorbed into the stratum corneum, maximum concentrations often being attained within 100 minutes. Oxiconazole nitrate (1%) cream fungicidal concentrations are maintained in the epidermis, upper corium, and deeper corium for at least five hours, and levels exceeding the minimum inhibitory concentrations of susceptible fungi are present in the corneum, epidermis, upper corium, and the hair follicle for over 16 hours. Oxiconazole nitrate (1%) cream applied once daily for four weeks in the treatment of tinea pedis or for two weeks in the treatment of tinea corporis, tinea cruris, and tinea versicolor, has produced mycologic and clinical cures in at least 80% of patients. Oxiconazole nitrate (1%) cream, once-daily in plantar-type tinea pedis caused primarily by T rubrum, resulted in a mycologic cure in 76% of patients. The efficacy of once-daily and twice-daily regimens is similar. In comparative clinical trials of various types of dermatophytoses, oxiconazole was shown to be as effective as or more effective than miconazole, clotrimazole, and tolnaftate creams, and as effective as econazole and bifonazole creams. Tolerability of oxiconazole and the other antifungal creams was similar; in irritation studies oxiconazole was better tolerated than econazole. Oxiconazole cream exerts no detectable systemic effect since only a negligible amount is absorbed from the skin. 381  Once-daily use of oxiconazole cream could be valuable in patients with a history of noncompliance with multiple-daily regimens of other topical antifungal agents. Side effects Side effects include pruritus, burning, irritation, erythema, stinging and allergic contact dermatitis and folliculitis, fissuring, maceration rash and nodules. Contraindications Oxiconazole Nitrate Cream is contraindicated in individuals who have shown hypersensitivity to any of their components. Recent reports Özdemir et al. (2013) evaluated the ototoxicity of topical oxiconazole and boric acid in alcohol solutions.Fifty adult Wistar albino rats were divided into 5 groups consisting of 10 animals each. The right tympanic membranes were perforated, and baseline and posttreatment distortion product otoacoustic emission (DPOAE) measurements were performed. The solutions were applied through the external ear canal to the middle ear twice a day for 14 days. The rats in group I and group II received 0.1 mL of oxiconazole-containing solution drops and 4% boric acid in alcohol solution drops, respectively. Group III received gentamicin solution (40 mg/mL) (ototoxic control), group IV received saline solution, and group V was followed without any medication. The baseline DPOAE results of the right ears of all animals tested were normal. Animals in groups I, II, IV, and V showed no statistically significant change in the DPOAE amplitudes. The rats in the gentamicin group showed a significant decrease. CONCLUSION: This study demonstrates that topically used oxiconazole and boric acid in alcohol solutions to the middle ear appear to be safe on the inner ear of rats. The safety of these drugs has not yet been confirmed in humans. Caution should be taken when prescribing these drugs, especially to patients who had tympanic membrane perforation. Ear drops should be chosen more carefully in an external ear infection for patients with tympanic membrane perforation to avoid ototoxicity. References 1. Jegasothy BV1, Pakes GE. Oxiconazole nitrate: pharmacology, efficacy, and safety of a new imidazole antifungal agent. Clin Ther. 1991 Jan-Feb;13(1):126-41. 2. Özdemir S1, Tuncer Ü, Tarkan Ö, Akar F, Sürmelioğlu Ö. Effects of topical oxiconazole and boric acid in alcohol solutions to rat inner ears. Otolaryngol Head Neck Surg. 2013 Jun;148(6):1023-7. 381 30. Posaconazole  Posaconazole (Noxafil; Merck & Co, Inc., Whitehouse Station, NJ, USA) is a broadspectrum antifungal agent that is used both as antifungal prophylaxis and treatment against invasive fungal infections.  Posaconazole was the third extended-spectrum triazole to be approved for use against invasive fungal infections, following the availability of itraconazole and voriconazole.  Azole antifungals, which were discovered around 30 years ago, are currently the largest class of antifungal agents in clinical use. o Refinements to the azole class led to agents with a triazole at their core to enhance their specificity of binding to fungal P450 enzymes, and o The first-generation triazoles fluconazole and itraconazole have considerably improved the treatment of some serious fungal infections, such as candidiasis. o These earlier agents have limitations related to their spectrum of antifungal activity and their tolerability. So, there have been efforts to develop new triazoles that address these limitations, which have led to the regulatory approvals of voriconazole (Vfend; Pfizer), and posaconazole (Noxafil; Schering–Plough). Posaconazole was first produced as oral suspension, which has been proven to be effective in antifungal prophylaxis in adult and paediatric patients. A new posaconazole tablet formulation with absorption independent of the gastric conditions was approved by the FDA in 2013   Drug properties  Posaconazole is a triazole antifungal drug that is structurally similar to itraconazole.  Posaconazole has a broad spectrum of antifungal activity that includes causative agents of invasive fungal infections, such as Candida species and Aspergillus species . Chemical structure of Posaconazole  Posaconazole is designated chemically as 4-[4-[4-[4-[[ (3R,5R)-5-(2,4difluorophenyl)tetrahydro-5(1H-1,2,4-triazol-1-ylmethyl)-3-furanyl]methoxy]phenyl]-1piperazinyl]phenyl]-2-[(1S,2S)-1-ethyl-2hydroxypropyl]-2,4-dihydro-3H-1,2,4-triazol-3one  empirical formula of C37H42F2N8O4 The chemical structure 382  Posaconazole is a white powder with a low aqueous solubility. Mechanism of action  As a triazole antifungal agent, posaconazole exerts its antifungal activity through blockage of the cytochrome P-450 dependent enzyme, sterol 14α-demethylase, in fungi by binding to the heme cofactor located on the enzyme.  This leads to the inhibition of the synthesis of ergosterol, a key component of the fungal cell membrane, and accumulation of methylated sterol precursors.  This results in inhibition of fungal cell growth and ultimately, cell death. . Formulations of Posaconazole 1. Noxafil injection is available as a clear colorless to yellow, sterile liquid essentially free of foreign matter. o each vial contains  300 mg of posaconazole  6.68 g Betadex Sulfobutyl Ether Sodium (SBECD),  0.003 g edetate disodium,  hydrochloric acid and sodium hydroxide to adjust the pH to 2.6, and water for injection. 2. Noxafil delayed-release tablet is a yellow, coated, oblong tablet o Each delayed-release tablet contains  100 mg of posaconazole  the inactive ingredients:  hypromellose acetate succinate,  microcrystalline cellulose,  hydroxypropylcellulose,  silicon dioxide,  croscarmellose sodium,  magnesium stearate, and  Opadry® II Yellow (consists of the following ingredients: o polyvinyl alcohol partially hydrolyzed, o Macrogol/PEG 3350, o titanium dioxide, o talc, and o iron oxide yellow). 3. Noxafil oral suspension is a white, cherry-flavored immediate-release suspension o each vial contains:  40 mg of posaconazole per mL  the inactive ingredients: 383            polysorbate 80, simethicone, sodium benzoate, sodium citrate dihydrate, citric acid monohydrate, glycerin, xanthan gum, liquid glucose, titanium dioxide, artificial cherry flavor, and purified water.. Dosage Forms & Strengths  oral suspension 40mg/mL (105mL)  tablet, delayed-release 100mg  injectable solution 18mg/mL (300mg/vial) Posaconazole indications Posaconazole is indicated as a prophylactic treatment in patients at high risk of invasive fungal infections (IFI), such as those receiving remission-induction chemotherapy for acute myelogenous leukaemia (AML) or myelodysplastic syndromes (MDS) and hematopoietic stem cell transplant (HSCT) recipients undergoing high-dose immunosuppressive therapy for graftversus-host disease (GVHD). Mechanisms of action    Similar to all azole antifungal agents, posaconazole inhibits cytochrome P450 (CYP450)dependent lanosterol 14 alpha-demethylase (CYP51), which is an enzyme required for ergosterol synthesis and a major sterol component in the cell membrane of fungal cells. The inhibition of ergosterol synthesis by posaconazole leads to a depletion of ergosterol. The shortage of ergosterol weakens the stability of the fungal cell membrane, the transport of nutrients, and the synthesis of chitin.8 Furthermore, the inhibition of ergosterol synthesis causes the accumulation of toxic methylated ergosterol precursors, which leads to damage of the fungal cell membrane and increased permeability and inhibition of fungal cell growth. he mechanisms of resistance to azole antifungals arises either from mutations in the ERG11 gene encoding the target enzyme CYP51 or from the overexpression of efflux pumps. 384 Spectrum of activity. Soysal, 2015)  Posaconazole is active against all fungi with ergosterol in their cytoplasmic membrane. This drug exhibits organism-dependent fungicidal activity.  Posaconazole has fungistatic activity against most Candida spp. and fungicidal activity against Aspergillus spp. and Mucormycetes.  the breakpoint for posaconazole resistance in A. fumigatus, A. flavus, and A. terreus is >0.5 mg/L.  the EUCAST minimum inhibitory concentration (MIC) breakpoints for posaconazole susceptibility and resistance in C. albicans, C. tropicalis, and C. parapsilosisare #0.06 mg/L and >0.06 mg/L, respectively.  the posaconazole resistance rates for Candida species were found to be vary from 0.4% in C. parapsilosis strains to 5.6% in C. kruseistrains.14 Posaconazole has encouraging activity against Zygomycetes.  Posaconazole and itraconazole are the only available azoles that demonstrate activity against most Zygomycetes, itraconazole was significantly less active than posaconazole against all Zygomycetes species.  A comparative study found that posaconazole exhibited lower MICs against Zygomycetes isolates than voriconazole and itraconazole. However, the antifungal activity of posaconazole was lower than that of amphotericin B.  the MICs (means) of posaconazole were approximately 1.6-fold, 33-fold, and 47-fold lower than those of itraconazole, voriconazole, and fluconazole, respectively.  Zygomycetes species differ in their susceptibility to posaconazole: MICs have ranged from 0.25 to 8 µg/mL for Rhizopus species, from 0.125 to 8 µg/mL for Mucor species, from 0.03 to 0.25 µg/mL for A. corymbifera, and from 0.03 to 1 µg/mL for Cunninghamella spp.  The activity of posaconazole against the clinical isolates of Zygomycetes was lower than that of amphotericin B but higher than that of voriconazole, fluconazole, and itraconazole. Pharmacokinetics of posaconazole, Wiederhold (2016) Pharmacokinetics of posaconazole oral suspension  Posaconazole oral suspension was the only formulation that was available, when first approved for use in humans, and continued to be so for many years.  Posaconazole oral suspension was subjected to several studies, which reported that bloodstream concentrations were generally low, usually less than 700 ng/mL, or undetectable in many patients. 385     Significant interpatient variability with regard to posaconazole levels has been reported in clinical studies that evaluated the efficacy of oral suspension. Posaconazole bioavailability is negatively affected by the use of agents that raise gastric pH, such as proton pump inhibitors (PPI), histamine2-receptor antagonists (H2RA), and antacids; nausea and vomiting; and agents that promote gastrointestinal motility. A significant effect of food on the bioavailability of the oral suspension was observed. In healthy volunteers, a significant increase (300%) in the overall exposure to posaconazole, as measured by the area under the concentration curve (AUC) over a 72hour period, was observed when the oral suspension was administered with a high-fat meal as opposed to the fasted state.25 Similarly, a 168% increase in AUC was reported when the suspension was administered with a nonfat meal.  Thus, it was required that the oral suspension of posaconazole be taken multiple times per day, preferably with a high-fat meal, in order to obtain consistent bloodstream concentrations needed for prophylaxis or therapy. Pharmacokinetics of posaconazole delayed-release tablets and capsules  Posaconazole delayed-release tablets are now available as 100 mg tablets and approved for dosing as a 300 mg twice-daily load on the first day and 300 mg once-daily dose thereafter.  In the first part, subjects received a single dose of the posaconazole formulations after a 10-hour fast, while in the second part the formulations were administered during a standardized high-fat breakfast. Under both fed and fasted conditions, both posaconazole tablets and capsule formulations resulted in significantly higher exposures than the oral suspension.  The peak drug concentrations were also higher with the tablets and capsule formulations than with the oral suspension in the fasted condition, but were similar among all formulations when administered with food. Overall, the tablets and capsules also demonstrated less pharmacokinetic variability with smaller coefficients of variability for the peak and total exposures (~25% for each) compared to the oral suspension (45%– 60%).  Overall, the posaconazole tablets were well tolerated with 48% of the subjects reporting at least one treatment-emergent adverse effect, including 17% in the placebo group. The most commonly reported adverse effects were increases in liver function tests (24%), diarrhea (12%), and headache (2%). Although the increases in liver function tests were mild and without clinical sequelae, three subjects discontinued the therapy. Pharmacokinetics of posaconazole gastro-resistant posaconazole tablets    The once-daily, gastro-resistant posaconazole tablet combines the drug with a pHdependent polymer designed to inhibit the release of posaconazole until it reaches the small intestine where pH increases. Absorption from the small intestine maximizes systemic absorption and eliminates the need for food or multiple daily dosing to achieve adequate systemic exposure Single-and multiple-dose studies in healthy volunteers evaluated the pharmacokinetics and safety of the gastro-resistant posaconazole tablet (200 and 400 mg/ day). 386 o o o o o o o Results demonstrated that the tablet yields markedly higher mean drug exposures with less variability than the posaconazole suspension formulation under fasting conditions, and that drug exposure with the tablet is not substantially affected by food. Data from the multiple-dose study confirmed that the tablet could be administered once daily in clinical studies for the prophylaxis of IFD. The absorption of posaconazole gastro-resistant tablets is dose proportional. In healthy volunteers who received a single dose of posaconazole 300 mg, exposure was higher after a high-fat meal than under fasting conditions. However, posaconazole tablets may be taken with or without food. Posaconazole has a large volume of distribution, and the drug is highly protein bound ([98 %). Posaconazole is eliminated slowly, and after tablet administration, the mean halflife was 29 h with a mean apparent clearance ranging from 7.5–11 h. Renal clearance is a minor elimination pathway. Pharmacokinetics of posaconazole IV solution  Posaconazole 300 mg once daily led to adequate steadystate systemic exposure in a multicentre, phase 3 study in neutropenic AML/MDS patients or patients who had undergone HSCT (n = 237) Clinical efficiency, Wiederhold (2016)  The results from the Phase Ib and III clinical trials as well as the various single-center reports demonstrate that, indeed, the pharmacokinetics of posaconazole are significantly improved with the delayed-release tablet formulation.  Higher exposures with less variability were consistently demonstrated in these studies. In addition, the bioavailability of posaconazole with this formulation does not appear to be significantly affected by food or the concomitant use of medications that raise gastric pH or speed gastric motility.  Although the improved pharmacokinetics of posaconazole tablets is expected to improve clinical outcomes in patients, there are few clinical data at this time to support this.  The studies that have been conducted to date with the tablet have focused on the pharmacokinetics and safety of this formulation. While few breakthrough invasive fungal infections were observed in these reports, the studies were not designed to evaluate efficacy, either as prophylaxis or as treatment for invasive fungal infections. Tolerability of Posaconazole Posaconazole Oral Suspension  In a pooled analysis of 18 controlled studies in healthy volunteers and patients (n = 448) receiving posaconazole suspension 50–1,200 mg/day for up to 14 days, posaconazole was generally well tolerated.  The incidence of treatment-emergent adverse events was 57 % in posaconazole recipients and 63 % in placebo recipients and was unrelated to dosage.  The most common posaconazolerelated adverse events were headache (17 %), dry mouth (9 %) and dizziness (6 %). 387  Posaconazole treatment was associated with transient, mild to moderate elevations in liver enzymes and a low potential to prolong the corrected QT (QTc) interval Posaconazole tablets and the IV solution  In the phase 1b and 3 clinical trials in patients at risk of IFI, the tolerability profiles of posaconazole tablets and the IV solution were generally similar to that of the suspension, with no new safety concerns.  In a quartile analysis of phase 3 trial data on the posaconazole tablet (n = 186), o there was no evidence of an increase in the incidence of treatment-related adverse events with the higher posaconazole exposures associated with the tablet compared with the suspension. o The most common treatment-related adverse events during 28 days of treatment were gastrointestinal disorders, with nausea and diarrhoea occurring in 11 and 8 % of patients, respectively.  Once-daily IV posaconazole 300 mg administered via a central line (peripheral infusions were associated with thrombophlebitis [26]) was also generally well tolerated.  In the phase 3 trial, in which IV treatment was followed by the oral suspension (28 days‘ total treatment), the most common treatment-related adverse events were diarrhoea (8 % of patients), nausea (5 %) and rash (5 %) [24]. FDA-approved indications  Noxafil is indicated for prophylaxis of invasive Aspergillus and Candida infections in patient who are at high risk of developing these infections.  Noxafil oral suspension is indicated for the treatment of oropharyngeal candidiasis, including oropharyngeal candidiasis refractory to itraconazole and/or fluconazole Invasive Aspergillus & Candida Infections Oral suspension or delayed-release tablets are indicated for prophylaxis of invasive Aspergillus and Candida infections in patients who are at high risk of developing these infections due to being severely immunocompromised (eg, hematopoietic stem cell transplant recipients with GVHD, hematologic malignancies with prolonged neutropenia from chemotherapy)  Oral suspension: 200 mg (5 mL) PO TID  Tablet: 300 mg PO BID on Day 1, then 300 mg PO qDay  IV: 300 mg IV BID on Day 1, then 300 mg IV qDay (see IV preparation and administration) Duration of therapy is based on recovery from neutropenia or immunosuppression Oropharyngeal Candidiasis Oral suspension is indicated for oropharyngeal candidiasis 100 mg (2.5 mL) PO BID on Day 1, then 100 mg PO qDay for 13 days Refractory to itraconazole and/or fluconazole: 400 mg (10 mL) PO BID; duration based on severity of underlying disease and clinical response 388 Brand namex Noxafil (Australia, Austria, Belgium, Chile, Colombia, Croatia (Hrvatska), Czech Republic, Denmark, Finland, France, Germany, Hungary, Ireland, Israel, Italy, Latvia, Lithuania, Netherlands, New Zealand, Norway, Oman, Portugal, Romania, Russian Federation, Slovakia, Slovenia, South Africa, Spain, Sweden, Switzerland, Turkey, United Kingdom, United States) Suspension; Oral; Posaconazole 40 mg / ml (Merck Sharp & Dohme) Noxafil 40 mg/1 mL x 105 mL x 1's (Merck Sharp & Dohme) Noxafil 40 mg/1 mL x 105 mL (Merck Sharp & Dohme) 105 milliliter in 1 bottle, glass (Merck Sharp & Dohme) NOXAFIL 40 MG ORAL SUSPENSION 1 bottle / 105 ML oral suspension each (Merck Sharp & Dohme) $ 230.36 Noxafil oral susp 40 mg/mL 105 mL x 1's (Merck Sharp & Dohme) NOXAFIL oral susp 40 mg x 1 mL x 105ml (Merck Sharp & Dohme) $ 253.97 Noxafil suspension 40 mg/mL (Merck Sharp & Dohme) Noxafil Gastro-resistant tablet 100 mg (Merck Sharp & Dohme) Noxafil tablet, coated 100 mg/1 (Merck Sharp & Dohme) Noxafil solution 18 mg/mL (Merck Sharp & Dohme) Noxafil Oral suspension 40 mg/ml (Merck Sharp & Dohme) Noxafil 40mg Oral Suspension (Merck Sharp & Dohme) $ 230.36 Noxafil delayed-release tablet Noxafil Suspension NOXOFIL (India) 40 mg x 1 mL x 105ml (Fulford) NOXOFIL oral susp 40 mg x 1 mL x 105ml (Fulford) Posaconazole delayed-release tablet Posaconazole SP (Latvia, Lithuania) Suspension; Oral; Posaconazole 40 mg / ml Posaconazole Sp Oral suspension 40 mg/ml (Schering Plough Europe (EU)) Posaconazole Suspension Posanol (Canada) Suspension; Oral; Posaconazole 40 mg / ml Posanol 40 mg/1 mL x 105 mL Posanol suspension 40 mg (Merck Canada Inc (Canada)) Posanol tablet / delayed-release 100 mg (Merck Canada Inc (Canada)) Posanol solution 18 mg (Merck Canada Inc (Canada)) Spriafil (Mexico) Suspension; Oral; Posaconazole 40 mg ml http://www.ndrugs.com/?s=posaconazole 389 Recent reports: Belling et al. (2017) carried out a retrospective analysis to compare attainment of goal serum posaconazole steady state concentrations (Css) ≥ 700 ng/ml in patients with AML/MDS undergoing induction chemotherapy receiving PCZ-susp 600–800 mg per day (N = 118) versus PCZ-Tablet 300 mg twice daily for one day, followed by 300 mg daily (N = 64). Sixty-two patients (97%) in the PCZ-tab group compared to 20 patients (17%) in the PCZ-susp group achieved goal Css (P < 0.0001). Median posaconazole serum Css was 1,665 ng/ml (522– 3,830 mg/ml) in the PCZ-tab group versus 390 ng/ml (51–1,870 ng/ml) in the PCZ-susp group (P < 0.0001). There was no difference in hepatotoxicity, QTc prolongation, or breakthrough IFI. Patients receiving PCZ-tab were significantly more likely to achieve goal Css and demonstrated higher Css versus patients receiving PCZ-susp. Prospective studies are needed to assess the potential correlation of serum concentrations with efficacy and toxicity. Boglione-Kerrien et al. (2017) evaluated the safety profile, the pharmacokinetic variability, and the concentration–toxicity relationship of posaconazole tablets in patients with haematological malignancies. Sixty neutropenic patients treated with posaconazole tablets for prophylaxis of IFI were prospectively included in the study. Adverse drug reactions (ADR) were recorded and analyzed by the Regional Pharmacovigilance Centre to assess posaconazole implication. Blood 391 samples were drawn once a week and plasma trough concentrations (Cmin) were assayed by LC– MS/MS. The rates of ADR by quartile of Cmin were compared. Eighteen patients (30%) experienced at least one ADR attributed to posaconazole. Liver function test (LFT) abnormalities were encountered in 20% of patients and resulted in four (6.7%) treatment discontinuations. Posaconazole median (range) Cmin was 1.36 (< 0.1–3.44) µg/mL (inter-patient CV = 43.9%). During follow-up, 28.6% of patients had at least one concentration < 0.7 µg/mL, and 35.7% had at least one concentration > 2 µg/mL. Rates of ADR by quartile of Cmin were not different. Conclusions: Posaconazole was well tolerated; however, LFT abnormalities were frequent. ADR occurrence was not linked to posaconazole exposure. Because posaconazole concentrations were highly variable, TDM can be helpful to avoid underexposure to the drug and increase its efficacy in preventing IFI. Conversely, a large proportion of patients was overexposed and might have benefited of a dose reduction. Döring et al. (2017) published the first report on the use of posaconazole tablets in paediatric patients. This single-centre study included 63 paediatric patients with haemato-oncological malignancies who received posaconazole for antifungal prophylaxis after HSCT. They were analysed for efficacy, feasibility and the safety of posaconazole. Out of 63 patients, 31 received posaconazole oral suspension and 32 received posaconazole tablets up to 200 days after transplantation. Analyses of the posaconazole trough levels were determined. No possible, probable or proven invasive fungal infection was observed in either group. Posaconazole trough levels were significantly higher in the tablet group than in the suspension group at all analysed time points. Drug-related adverse events were similarly low in both groups. Conclusions Posaconazole tablets are effective in preventing invasive fungal infections in paediatric patients. As early as day 3 after starting posaconazole tablets, over 50% of the posaconazole trough levels were >500 ng/mL, while this was observed on day 14 after start with posaconazole suspension. The administration of posaconazole tablets was safe, effective and feasible as antifungal prophylaxis in paediatric patients after HSCT. Döring et al. (2017) analyzed trough concentrations of 33 pediatric patients with a median age of 8 years during 108 neutropenic episodes who received prophylactic posaconazole oral suspension. A total of 172 posaconazole trough levels were determined to median 438 ng/ml (range 111–2011 ng/ml; mean 468 ± 244 ng/ml). Age and gender had no influence on posaconazole plasma levels. Posaconazole was not discontinued due to adverse events in any of the patients. Only hepatic parameters significantly increased beyond the upper normal limit to median values of ALT of 87 U/l (P < .0001), and AST of 67 U/l (P < .0001). One patient with a median posaconazole trough concentration of 306 ng/ml experienced an invasive fungal infection. In conclusion, posaconazole was effective, safe and feasible in 33 pediatric patients with neutropenia ≥5 days after chemotherapy. Median posaconazole plasma concentrations were approximately 1.6-fold lower than the recommended plasma level of 700 ng/ml. Larger patient cohorts are needed to evaluate these findings. Liebenstein et al. (2017) carried out a study to determine if a switch to posaconazole tablets improved steady-state drug level attainment for invasive fungal infection prophylaxis in patients with acute myeloid leukemia. All adult inpatients with acute myeloid leukemia undergoing chemotherapy, who received posaconazole for invasive fungal infection prophylaxis between 2012 and 2015, were included. The primary outcome was proportion of patients with first 391 posaconazole level greater than 700 ng/mL. Secondary outcomes included proportion of patients with first posaconazole level greater than 1000 ng/mL, invasive fungal infection within 100 days, and adverse drug events. Forty patients received posaconazole tablets and 34 patients received suspension. Posaconazole levels were significantly higher at first measurement in patients receiving tablet than suspension (1296 ng/mL vs. 788 ng/mL, p < 0.01). Thirty-seven patients receiving tablets had a serum drug level greater than 700 ng/mL on first measurement versus 18 receiving suspension (p < 0.01). Patients receiving tablets were also more likely to have a serum drug level over 1000 ng/mL on first measurement (26 vs. 11, p < 0.01). Rates of invasive fungal infection and adverse events were not statistically different. Conclusions: Patients receiving posaconazole tablets attained significantly higher serum drug levels than those receiving suspension Cornely et al. (2016) reported a two-part (Phase 1B/3) study evaluated posaconazole tablet pharmacokinetics (PK) and safety. Patients with neutropenia following chemotherapy for haematological malignancy or recipients of allogeneic HSCT receiving prophylaxis or treatment for graft-versus-host disease received 300 mg posaconazole (as tablets) once daily (twice daily on day 1) for up to 28 days without regard to food intake. Weekly trough PK sampling was performed during therapy, and a subset of patients had sampling on days 1 and 8. Cminevaluable subjects received ≥6 days of dosing, and were compliant with specified sampling timepoints. Steady-state PK parameters, safety, clinical failure and survival to day 65 were assesse Two hundred and ten patients received 300 mg posaconazole (as tablets) once daily. Among Cmin-evaluable subjects (n = 186), steady-state mean Cmin was 1720 ng/mL (range = 210-9140). Steady-state Cmin was ≥700 ng/mL in 90% of subjects with 5% (10 of 186) <500 ng/mL and 5% (10 of 186) 500-700 ng/mL. Six (3%) patients had steady-state Cmin ≥3750 ng/mL. One patient (<1%) had an invasive fungal infection. The most common treatment-related adverse events were nausea (11%) and diarrhoea (8%). There was no increase in adverse event frequency with higher posaconazole exposure. CONCLUSIONS: In patients at high risk for invasive fungal disease, 300 mg posaconazole (as tablets) once daily was well tolerated and demonstrated a safety profile similar to that reported for posaconazole oral suspension: most patients (99%) achieved steady-state pCavg exposures >500 ng/mL and only one patient (<1%) had a pCavg <500 ng/mL. Farowski et al. (2016) showed that high intracellular concentrations of posaconazole do not significantly impact PMN and monocyte-derived macrophage function in vitro In particular, killing capacity and cytoskeletal features of PMN, such as migration, are not affected, indicating that these cells serve as vehicles for posaconazole to the site of infection. Moreover, since posaconazole as such slowed the germination of Aspergillus fumigatus conidia, infected neutrophils released less reactive oxygen species (ROS). Based on these findings, we propose that the delivery of posaconazole by neutrophils to the site of Aspergillus species infection warrants control of the pathogen and preservation of tissue integrity at the same time. Girmenia et al. (2016), in a prospective, multicenter study, evaluated the variability of PPCs in hematologic patients receiving PCZ-susp prophylaxis with the aim to define conditions at different risk of subtherapeutic PPCs. Overall, 103 acute leukemia (AL) patients submitted to intensive chemotherapy (115 courses) and 46 allogeneic stem cell transplant (allo-SCT) 392 recipients (47 courses) receiving PCZ-susp prophylaxis were considered. The adequacy of PPC pattern after the steady state (≥day 7 of treatment) in courses with two or more PPC measurements was defined as follows: inadequate pattern: PPC < 0.5 mcg/ml at least once; borderline pattern: PPC always ≥0.5mcg/ml but < 0.7 mcg/ml at least once; adequate pattern: PPC always ≥0.7 mcg/ml. The PPC pattern was evaluable in 83 and 37 AL and allo-SCT patients, respectively. It was adequate, borderline and inadequate in 63.9%, 14.5%, and 21.7% of courses, respectively, in AL, and in 62.2%, 10.8%, and 27.0% of courses, respectively, in alloSCT. In both groups, an inadequate PPC pattern was associated with the development of diarrhea. In absence of diarrhea, the probability of an inadequate PPC pattern was 11.9% in AL and 17.2% in allo-SCT patients. PCZ-susp might be used without stringent need of PPC monitoring in patients without diarrhea. Heinz et al. (2016) investigated 161 posaconazole serum concentrations in 27 pediatric patients after HSCT receiving 12 mg·kg BW(-1)·d(-1) posaconazolesuspension depending on age, gender, and intestinal graft-versus-host (iGvHD) disease, and the influence of posaconazole on cyclosporine A plasma concentrations. To improve the uptake of posaconazole, one patient cohort received higher fat nutrition with the drug administration. A comparison of the regular nutrition and higher-fat nutrition groups revealed the following values: 31 (27.4%) versus 8 (16.7%) < 500 ng/ml; 12 (10.6%) versus 7 (14.6%) 500-700 ng/ml; 8 (7.1%) versus 6 (12.5%) 700-1000 ng/ml; 51 (45.1%) versus 21 (43.8%) 1000-2000 ng/ml; and 11 (9.7%) versus 6 (12.5%) > 2000 ng/ml. The mean posaconazole concentrations in patients with regular nutrition was 1123 ± 811 ng/ml and with higher-fat nutrition was 1191 ± 673 ng/ml. Posaconazole levels in patients with iGvHD were significantly lower (P = 0.0003) than in patients without GvHD. The majority of samples showed a sufficient posaconazole concentration above 700 ng/ml. Posaconazole levels were slightly higher in patients with higher-fat nutrition and significantly lower in patients with iGvHD. Cyclosporine A levels were not significantly higher during posaconazole administration. Kim et al. (2016) evaluated the efficacy of posaconazole ST with either posaconazole oral suspension (SUS) or delayed-released tablet (TAB) in patients with IFI. A retrospective review of patients who received posaconazole ST for IFI at the University of Utah Health Sciences Center between December 2007 and March 2014 was conducted. A total of 14 episodes of posaconazole ST for proven (9 episodes) and probable (5 episodes) IFI were identified in 14 patients. The median age was 54 years and the majority of patients (64.3%) had underlying haematological diseases. PosaconazoleSUS and TAB were used in 11 episodes and 3 episodes respectively. The duration of posaconazole ST ranged from 28 to 370 days with a median of 65 days. Posaconazole ST with TAB achieved favourable serum posaconazole trough concentrations (median 1.4 μg mL-1 ) compared to posaconazole SUS (median 1.0 μg mL-1 ). The overall clinical success rate with posaconazole ST was 71.4% (10 of 14 episodes). One patient died of progression of IFI. Adverse events were noted in two patients. Posaconazole SUS or TAB may be used effectively for IFI ST. Park et al. (2016) analysed the impact of increasing the frequency of posaconazole administration on optimal plasma concentrations in adult patients with haematological malignancy. A total of 133 adult patients receiving chemotherapy for acute myeloid leukaemia or myelodysplastic syndrome who received posaconazole syrup 200 mg three times daily for fungal prophylaxis were enrolled in this study. Drug trough levels were measured 393 by liquid chromatography-tandem mass spectrometry. In 20.2% of patients (23/114) the steadystate concentration of posaconazole was suboptimal (<500 ng/mL) on Day 8. In these patients, the frequency of posaconazole administration was increased to 200 mg four times daily. On Day 15, the median posaconazole concentration was significantly increased from 368 ng/mL [interquartile range (IQR), 247-403 ng/mL] to 548 ng/mL (IQR, 424-887 ng/mL) (P = 0.0003). The median increase in posaconazoleconcentration was 251 ng/mL (IQR, 93-517 ng/mL). Among the patients with initially suboptimal levels, 79% achieved the optimal level unless the steady-state level was <200 ng/mL. This study shows that increasing the administration frequency of posaconazole syrup is effective for achieving optimal levels in patients with haematological malignancy undergoing chemotherapy. Petitcollin et al. (2016) modelled the inhibition of sirolimus clearance by posaconazole, and then simulated several dosage regimens of sirolimus taken together with posaconazole tablets. They were able to describe well the interaction, and found a value of IC50 of posaconazole towards sirolimus clearance of 0.68 μg/mL. The simulations showed that even a 80% decrease of the daily dose of sirolimus is unsuitable in many cases with trough concentrations of posaconazole of 2 μg/mL. A decrease of 40% of the dose with spacing administrations of 3 days may be considered. The clinicians and pharmacologists must be warned that the use of posaconazole tablets may result in an inhibition of CYP3A4 of greater magnitude than with the oral suspension. Thakuria et al. (2016) explored the pharmacokinetics of posaconazole oral suspension (POS) in the early perioperative period following lung transplantation in 26 patients. Organ recipients were scheduled to receive 400mg POS twice daily for 6 weeks as primary antifungal prophylaxis. Therapeutic drug monitoring (TDM) of serum posaconazole levels was performed in accordance with local clinical protocols. Bronchoalveolar lavage fluid (BALF) was sampled during routine bronchoscopies. Posaconazole levels were measured both in serum and BALF using mass spectrometry. Posaconazole levels were highly variable within lung transplant recipients during the perioperative period and did not achieve 'steady-state'. Serum posaconazole concentrations positively correlated with levels within the BALF (r=0.5527; P=0.0105). Of the 26 patients, 10 failed to complete the study for multiple reasons and so the trial was terminated early. Unlike study findings in stable recipients, serum posaconazolelevels rarely achieved steady-state in the perioperative period; however, they do reflect the concentrations within the airways of newly transplanted lungs. The role of POS as primary prophylaxis in the perioperative period is uncertain, but if used TDM may be helpful for determining attainment of therapeutic levels. Vanstraelen et al. (2016a) investigated. the impact of intestinal mucositis on posaconazole exposure A prospective pharmacokinetic study was performed including allogeneic HSCT patients receiving posaconazoleprophylaxis with the oral suspension or tablets. Steady state PPCs were determined using high-performance liquid chromatography-fluorescence detection at the day of transplantation (=day 0), day +7, and +14. Citrulline was measured using liquid chromatography-tandem mass spectrometry to evaluate severity of mucositis, at baseline (day -7 or -6), and at day 0, +7 and +14. Additionally, citrulline plasma concentrations and steady state trough PPCs were determined in hematological patients without HSCT or mucositis. Thirty-four HSCT patients received posaconazole oral suspension together with 25 cL of Coca 394 Cola, 6 HSCT patients received posaconazole tablets and 33 hematological patients not receiving HSCT received posaconazole oral suspension. The median (interquartile range) average PPC was 0.26 mg/L (0.17-0.43), 0.67 mg/L (0.27-1.38), and 1.08 mg/L (0.96-1.38), with suspension in HSCT patients, suspension in hematological patients and tablets in HSCT patients, respectively. A higher trough PPC was encountered with the oral suspension when citrulline plasma concentrations were above 10 μmol/L compared to values below 10 μmol/L (p < 0.001), whereas for tablets, average PPCs remained high with citrulline plasma concentrations below or above 10 μmol/L (p = 0.64). CONCLUSION: Posaconazole tablets should be preferred to suspension in HSCT patients immediately after transplantation to prevent insufficient plasma exposure due to intestinal mucositis. Vanstraelen et al. (2016b) investigated the pharmacokinetics of a newly introduced posaconazole dosing regimen based on the body surface area in pediatric hematologic patients. In this prospective pharmacokinetic study, 8 blood samples were taken during 1 dosing interval at steady state in children aged 13 years or younger with hematologic malignancy, who were treated prophylactically with posaconazole oral suspension at a dose of 120 mg/m 3 times daily. Posaconazole plasma concentrations were determined using high-performance liquid chromatography fluorescence detection. One hundred twelve samples were taken from 14 patients with a mean age of 6.7 ± 2.8 years. A median posaconazole daily dose of 100.0 mg (77.3-100.0) 3 times daily (tid), corresponding to a median of 117.9 mg/m (112.2-120.4) tid, resulted in mean trough posaconazole plasma concentrations of 0.85 ± 0.56 mg/L. Pharmacokinetic analysis revealed a clearance of 0.8 L/(h kg) (0.5-1.4). No invasive fungal infections or adverse events were encountered during treatment. CONCLUSIONS: Posaconazole is a promising antifungal agent to be used prophylactically in hematologic patients aged 13 years or younger. Administering posaconazole oral suspension in a dosage of 120 mg/m tid results in adequate posaconazole plasma exposure, without significant adverse events. Wiederhold (2016) mentioned that Posaconazole is a broad-spectrum triazole antifungal agent with potent activity against various pathogenic fungi, including yeast and moulds. Clinical studies have demonstrated that this agent is efficacious as prophylaxis against invasive fungal infections in patients at high risk, and may also be useful as salvage therapy against invasive aspergillosis and mucormycosis. However, the bioavailability of posaconazole following administration by oral suspension, which was the only formulation clinically available for many years, is highly variable and negatively influenced by several factors. Because of this, many patients had subtherapeutic or undetectable posaconazole levels when the oral suspension was used. To overcome this limitation, a delayed-release tablet was developed and is now available for clinical use. Hot-melt extrusion technology is used to combine a pH-sensitive polymer with posaconazole to produce a formulation that releases the drug in the elevated pH of the intestine where absorption occurs rather than in the low-pH environment of the stomach. This results in enhanced bioavailability and increased posaconazole exposure. Studies in healthy volunteers have demonstrated significantly higher and more consistent exposures with the tablet formulation compared to the oral suspension. In addition, pharmacokinetic parameters following administration of the tablets were not significantly affected by medications that raise gastric pH or increase gastric motility, and the tablets could also be administered without regard to food. Similar results have also been found in patients at high risk for invasive fungal infections who 395 have received posaconazole tablets. The tablet formulation also appears to be well tolerated to date, although data regarding clinical efficacy are needed. Chae et al. (2015) analyzed the relationship between posaconazole concentrations achieved with the oral suspension and the IFI occurrence with demographic and clinical covariates (mucositis, diarrhea, liver enzymes, co-medications, and food intake). One hundred twenty-two adult patients with AML/MDS undergoing remission induction chemotherapy were enrolled. They received posaconazole as prophylaxis and 557 posaconazole measurements were performed with a validated LC-MS/MS method. The median (range) posaconazole concentration (ng/ml) on days 2, 3, 7, 14, and 21 was 271 (43-493), 564 (101-1461), 713 (85-2186), 663 (851994), and 497 (43-1872), respectively. Thirteen patients (11%) developed proven (1/13), probable (2/13), and possible IFIs (10/13). A significant relationship existed between lower steady-state posaconazole concentrations and a higher breakthrough IFI incidence by binary logistic regression (P=0.0108). Posaconazole value of ≥ 338 ng/ml on day 3 predicted the achievement of ≥ 500 ng/ml at day 7 (sensitivity: 78.5%, specificity: 66.7%, AUC: 0.747). Food intake (P=0.0014) and proton pump inhibitor (P=0.0063) were significantly associated with higher and lower posaconazole concentrations, respectively. Cho et al. (2015) retrospectively reviewed data for all consecutive patients who received primary antifungal prophylaxis during remission induction chemotherapy in our acute myeloid leukemia/myelodysplastic syndrome cohort from December 2010 to November 2013. Patient characteristics and factors known as a risk of IFI were matched with propensity score analysis. We evaluated the medical cost according to the prophylactic antifungal agents (posaconazole vs fluconazole/itraconazole), the development of breakthrough IFIs, and survival status after propensity score matching in a 1:1 ratio. Of the 419 baseline patients, 100 patients in each group were analyzed after matching. A significant decrease was found in the development of breakthrough proven or probable IFIs (3.0% vs 14.0%; P = 0.009) and the rate of empirical antifungal therapy (EAFT) (12.0% vs 46.0%; P < 0.001) in the posaconazole group. Total inhospital medical costs per patient were not statistically different between posaconazole and fluconazole/itraconazole prophylaxis. However, the daily medical cost was lower for posaconazole prophylaxis, resulting in a total daily cost savings of $72 (₩79,458) per patient (P = 0.002). In the cases of breakthrough proven/probable IFIs, EAFT, and in-hospital deaths, the total medical costs per patient were significantly higher than in nonproven/probable IFIs, non-EAFT, and in-hospital survivors, as much as $7,916 (₩8,700,758), $4605 (₩5,062,529), and $11,134 (₩12,238,422), respectively. Costs for the antifungal agent used in targeted or empirical therapy were lower in the posaconazole group, resulting in a savings of $697 (₩766,347) per patient (P < 0.001). IMPLICATIONS: Posaconazole appears to be cost beneficial for primary antifungal prophylaxis in high-risk patients with hematologic malignancy, at a single center, in Korea. Cost-benefit is closely related with clinical outcomes, including breakthrough IFI development, EAFT, and survival status. Cho et al. (2015) evaluated the effectiveness of posaconazole PAP and identify characteristics of IFIs at a single centre in Korea. We retrospectively reviewed consecutive patients with AML/MDS undergoing remission induction chemotherapy between December 2010 and November 2013. Of the 424 patients, 140 received posaconazole and 284 received fluconazole 396 prophylaxis. The incidence of breakthrough proven/probable IFIs (15.5% vs. 2.9%, P < 0.001) and empirical antifungal treatment (EAFT) (45.8% vs. 12.9%, P < 0.001) decreased in the posaconazole group compared to the fluconazole group. In the posaconazole PAP group, two cases of breakthrough mucormycosis were noted among 13 proven/probable/possible IFI cases (15.4%). Overall and IFI-related mortality was 12.1% and 1.9% respectively. Fungus-free survival was significantly higher in the posaconazole group (74.7% vs. 87.1%, P = 0.028). Breakthrough IFIs and EAFT decreased significantly after posaconazole PAP. The benefit in fungus-free survival was noted with posaconazole PAP. Clinicians should be vigilant to identify non-Aspergillus IFIs with active diagnostic effort. Clark et al. (2015) mentioned that Posaconazole, a fluorinated triazole antifungal drug, is approved by the U.S. Food and Drug Administration (FDA) for (1) prophylaxis against Aspergillus and Candida infections in immunocompromised patients at high risk for these infections and (2) oropharyngeal candidiasis (OPC), including cases refractory to fluconazole and/or itraconazole. The European Medicines Agency (EMA) has approved posaconazole for (1) treatment of aspergillosis, fusariosis, chromoblastomycosis, and coccidioidomycosis in patients who are refractory to or intolerant of other azoles or amphotericin B; (2) first-line therapy for OPC for severe disease or in those unlikely to respond to topical therapy; and (3) prophylaxis of invasive fungal infections in high-risk hematologic patients and stem cell transplant recipients. In addition to approved indications, posaconazole has been used with success as salvage therapy for invasive mold infections and endemic mycoses in patients who are refractory to or intolerant of other antifungal agents, and as prophylaxis or salvage therapy in children, for whom indications are more limited owing to a paucity of data. Posaconazole has potent in vitro activity against a broad range of fungi and molds, including Aspergillus, Candida, Cryptococcus, filamentous fungi, and endemic mycoses including coccidioidomycosis, histoplasmosis, and blastomycosis. Importantly, posaconazole is much more active than other azoles against many Mucorales species and the combination of posaconazole with other antifungal agents may be synergistic. Hence, posaconazole is a potential candidate as a single or combination agent for difficult-totreat fungal infections. Posaconazole has an excellent safety profile; to date, serious side effects are rare, even with prolonged use. However, newer posaconazole formulations achieve higher blood levels and it remains to be seen whether this may lead to an increase in the rate of adverse effects. Currently, posaconazole is used predominantly for prophylaxis and salvage therapy of fungal infections in adults. Indications for use as initial therapy of fungal infections and for broader use in children will depend on the accrual of additional clinical dat Durani et al. (2015) compared achievement of therapeutic posaconazole levels in patients taking the delayed-release tablet to those taking the oral suspension. This retrospective cohort study included 93 patients initiated on posaconazole between 2012 and 2014 and had at least one serum posaconazolelevel measured. The primary measure was the proportion of patients achieving an initial therapeutic level (>700 ng/ml). An initial therapeutic posaconazole level was seen in 29 of 32 (91%) patients receiving tablets and 37 of 61 (61%) patients receiving suspension (P = 0.003). Among patients with a steady-state level measured 5 to 14 days after initiation, a therapeutic level was observed in 18 of 20 (90%) patients receiving tablets and 25 of 43 (58%) patients receiving suspension (P = 0.01). In these patients, the median posaconazole level of the tablet cohort (1655 ng/ml) was twice that of the suspension cohort (798 ng/ml) (P = 0.004). In this cohort study, the improved bioavailability of delayed397 release posaconazole tablets translates into a significantly higher proportion of patients achieving therapeutic serum levels than in the cohort receiving the oral suspension. Kersemaekers et al. (2015) evaluated the effect of food on the bioavailability of a new delayedrelease tablet formulation of posaconazole at the proposed clinical dose of 300 mg once daily in a randomized, open-label, single-dose, two-period crossover study with 18 healthy volunteers. When a single 300-mg dose of posaconazole in tablet form (3 tablets × 100 mg) was administered with a high-fat meal, the posaconazole area under the concentration-time curve from 0 to 72 h (AUC0-72) and maximum concentration in plasma (Cmax) increased 51% and 16%, respectively, compared to those after administration in the fasted state. The median time to Cmax (Tmax) shifted from 5 h in the fasted state to 6 h under fed conditions. No serious adverse events were reported, and no subject discontinued the study due to an adverse event. Six of the 18 subjects reported at least one clinical adverse event; all of these events were mild and short lasting. The results of this study demonstrate that a high-fat meal only modestly increases the mean posaconazole exposure (AUC), ∼1.5-fold, after administration of posaconazole tablets, in contrast to the 4-fold increase in AUC observed previously for a posaconazole oral suspension given with a high-fat meal. McKeage (2015) mentioned that Posaconazole (Noxafil(®)) is a triazole antifungal agent with an extended spectrum of antifungal activity. It is approved for the prophylaxis of invasive fungal infections in patients with neutropenia or in haematopoietic stem cell transplant recipients undergoing high-dose immunosuppressive therapy for graft-versus-host disease, and for the treatment of fungal infections. The efficacy and good tolerability of posaconazole oral suspension administered three or four times daily is well established. However, in order to overcome pharmacokinetic limitations associated with the suspension, a new gastro-resistant tablet and intravenous (IV) solution were developed. This article reviews the pharmacokinetic properties of the new posaconazole formulations and briefly summarizes efficacy data relating to the suspension. The pharmacokinetic advantages of the posaconazole gastro-resistant tablet compared with the suspension formulation include less interpatient variability, better systemic availability enabling once-daily administration, and absorption that is unaffected by changes in gastric pH or motility; in addition the tablets may be taken with or without food. The posaconazole tablet achieves higher and more consistent mean plasma concentrations than the suspension and, therefore, it is the preferred option to optimize efficacy in the prophylaxis or treatment of invasive fungal disease. The posaconazole IV solution provides an option for these same indications in patients who are unable to receive oral formulations. Mattiuzzi et al. (2015) recruited 20 adult patients for prospective, open label trial of posaconazole given as a prophylaxis in patients with newly diagnosed acute myeloid leukemia (AML) undergoing induction chemotherapy or first salvage therapy. The median age of all patients was 65 years and received prophylaxis for a median of 38 days (range: 5-42 days).Ten patients (50%) completed 42 days on posaconazoleprophylaxis. Median plasma posaconazole levels showed no statistical difference across gender, body surface area, patients developing IFI, and patients acquiring grade 3 or 4 elevation of liver enzymes. However, there was an overall trend for higher trough concentrations among patients with no IFI than those with IFI. Pharmacokinetics of posaconazole varies from patient to patient, and AML patients 398 receiving induction chemotherapy who never develop IFI tend to have higher plasma concentrations after oral administration of posaconazole. Molina et al. (2015) performed a prospective, randomized clinical trial to assess the efficacy and safety of posaconazole as compared with the efficacy and safety of benznidazole in adults with chronic Trypanosoma cruzi infection. We randomly assigned patients to receive posaconazole at a dose of 400 mg twice daily (high-dose posaconazole), posaconazole at a dose of 100 mg twice daily (low-dose posaconazole), or benznidazole at a dose of 150 mg twice daily; all the study drugs were administered for 60 days. We assessed antiparasitic activity by testing for the presence of T. cruzi DNA, using real-time polymerase-chain-reaction (rt-PCR) assays, during the treatment period and 10 months after the end of treatment. Posaconazole absorption was assessed on day 14. The intention-to-treat population included 78 patients. During the treatment period, all the patients tested negative for T. cruzi DNA on rt-PCR assay beyond day 14, except for 2 patients in the low-dose posaconazole group who tested positive on day 60. During the follow-up period, in the intention-to-treat analysis, 92% of the patients receiving lowdose posaconazole and 81% receiving high-dose posaconazole, as compared with 38% receiving benznidazole, tested positive for T. cruzi DNA on rt-PCR assay (P<0.01 for the comparison of the benznidazole group with either posaconazole group); in the per-protocol analysis, 90% of the patients receiving low-dose posaconazole and 80% of those receiving high-dose posaconazole, as compared with 6% receiving benznidazole, tested positive on rt-PCR assay (P<0.001 for the comparison of the benznidazole group with either posaconazole group). In the benznidazole group, treatment was discontinued in 5 patients because of severe cutaneous reactions; in the posaconazole groups, 4 patients had aminotransferase levels that were more than 3 times the upper limit of the normal range, but there were no discontinuations of treatment. References: 1. Belling M, Kanate AS, Shillingburg A, et al. Evaluation of Serum Posaconazole Concentrations in Patients with Hematological Malignancies Receiving Posaconazole Suspension Compared to the Delayed-Release Tablet Formulation. Leukemia Research and Treatment. 2017;2017:3460892. doi:10.1155/2017/3460892 2. Boglione-Kerrien, C. et al. Safety Study and Therapeutic Drug Monitoring of the Oral Tablet Formulation of Posaconazole in Patients With Haematological Malignancies J Cancer Res Clin Oncol. 2017 Sep 20.Chae H1, Cho SY2, Yu H3, Cha K4, Lee S1, Kim M5, Kim Y1, Kim YJ6, Kim HJ6, Lee DG7. Determination of posaconazole concentration with LC-MS/MS in adult patients with hematologic malignancy. Clin Chim Acta. 2015 Oct 23;450:220-6. 399 3. Cho SY1,2, Lee DG1,2,3, Choi SM1,2, Choi JK1,2, Lee HJ1,2, Kim SH1,2, Park SH1,2, Choi JH1,2, Yoo JH1,2, Kim YJ3, Kim HJ3, Min WS3. Posaconazole for primary antifungal prophylaxis in patients with acute myeloid leukaemia or myelodysplastic syndrome during remission induction chemotherapy: a single-centre retrospective study in Korea and clinical considerations. Mycoses. 2015 Sep;58(9):565-71. 4. Cho SY1, Lee DG2, Choi JK1, Lee HJ1, Kim SH1, Park SH1, Choi SM1, Choi JH1, Yoo JH1, Kim YJ3, Kim HJ3, Min WS3, Back H4, Kang S5, Lee EK6. Cost-benefit Analysis of Posaconazole Versus Fluconazole or Itraconazole as a Primary Antifungal Prophylaxis in High-risk Hematologic Patients: A Propensity Score-matched Analysis. Clin Ther. 2015 Sep;37(9):2019-27. 5. Clark NM1, Grim SA1, Lynch JP 3rd2. Posaconazole: Use in the Prophylaxis and Treatment of Fungal Infections. Semin Respir Crit Care Med. 2015 Oct;36(5):767-85. 6. Cornely OA, Maertens J, Winston DJ, et al. Posaconazole vs fluconazole or itraconazole prophylaxis in patients with neutropenia. N Engl J Med. 2007;356(4):348–359. 7. Cornely OA1, Duarte RF2, Haider S3, Chandrasekar P4, Helfgott D5, Jiménez JL6, Candoni A7, Raad I8, Laverdiere M9, Langston A10, Kartsonis N11, Van Iersel M12, Connelly N13, Waskin H13. Phase 3 pharmacokinetics and safety study of a posaconazole tablet formulation in patients at risk for invasive fungal disease. J Antimicrob Chemother. 2016 Mar;71(3):718-26. 8. Corrado Girmenia Luciana Annino Benedetta Mariotti Rosa FanciClara Minotti Antonio Spadea Alessandra Carotti Monica PiedimonteAnna Chierichini Elisabetta Cerchiara ... Show more. Posaconazole oral suspension primary prophylaxis in acute leukemia and allogeneic stem cell transplant patients: can it be used without measurement of plasma concentration? Medical Mycology, Volume 54, Issue 5, 1 July 2016, Pages 445– 458,https://doi.org/10.1093/mmy/myw001 9. Courtney R, Wexler D, Radwanski E, Lim J, Laughlin M. Effect of food on the relative bioavailability of two oral formulations of posaconazole in healthy adults. Br J Clin Pharmacol. 2004;57(2):218–222. 10. Döring, M., Karin Melanie Cabanillas Stanchi Hartwig KlinkerMelinda Eikemeier Judith Feucht Franziska BlaeschkeCarl-Philipp Schwarze Martin Ebinger Tobias FeuchtingerRupert Handgretinger. Posaconazole plasma concentrations in pediatric patients receiving antifungal prophylaxis during neutropenia. Medical Mycology, Volume 55, Issue 4, 1 June 2017, Pages 375– 11. Döring, M. et al. Efficacy, Safety and Feasibility of Antifungal Prophylaxis With Posaconazole Tablet in Paediatric Patients After Haematopoietic Stem Cell Transplantation J Cancer Res Clin Oncol 143 (7), 1281-1292. 2017 Mar 03.. 411 12. Döring M1, Cabanillas Stanchi KM2, Queudeville M2, Feucht J2, Blaeschke F3, Schlegel P2, Feuchtinger T3, Lang P2, Müller I4, Handgretinger R2, Heinz WJ Efficacy, safety and feasibility of antifungal prophylaxis with posaconazole tablet in paediatricpatients after haematopoietic stem cell transplantation. J Cancer Res Clin Oncol. 2017 Jul;143(7):1281-1292. 13. Durani U1, Tosh PK2, Barreto JN3, Estes LL3, Jannetto PJ4, Tande AJ5. Retrospective Comparison of Posaconazole Levels in Patients Taking the Delayed-Release Tablet versus the Oral Suspension. Antimicrob Agents Chemother. 2015 Aug;59(8):4914-8. 14. Farowski F1, Cornely OA2, Hartmann P3. High intracellular concentrations of posaconazole do not impact on functional capacities of human polymorphonuclear neutrophils and monocytederived macrophages in vitro. Antimicrob Agents Chemother. 2016 May 23;60(6):3533-9. 15. FDA labelling information [online], < http://www.fda.gov/cder/foi/label/2006/022003lbl.pdf > (2006). 16. Girmenia, C. et al. Med Mycol 54 (5), 445-458. 2016 Feb 11. Posaconazole Oral Suspension Primary Prophylaxis in Acute Leukemia and Allogeneic Stem Cell Transplant Patients: Can It Be Used Without Measurement of Plasma Concentration? 17. Heinz WJ1, Cabanillas Stanchi KM2, Klinker H1, Blume O2, Feucht J2, Hartmann U3, Feuchtinger T4, Lang P2, Handgretinger R2, Döring M5. Posaconazole plasma concentration in pediatric patients receiving antifungal prophylaxis after allogeneic hematopoietic stem cell transplantation. Med Mycol. 2016 Feb;54(2):128-37. 18. Kersemaekers WM1, Dogterom P1, Xu J1, Marcantonio EE2, de Greef R1, Waskin H1, van Iersel ML1. Effect of a high-fat meal on the pharmacokinetics of 300-milligram posaconazole in a solid oral tablet formulation. Antimicrob Agents Chemother. 2015;59(6):3385-9. 19. Kim JH1, Benefield RJ2,3, Ditolla K2,3. Utilization of posaconazole oral suspension or delayedreleased tablet salvage treatment for invasive fungal infection. Mycoses. 2016 Nov;59(11):726733. 20. Kraft WK, Chang PS, van Iersel ML, Waskin H, Krishna G, Kersemaekers WM. Posaconazole tablet pharmacokinetics: lack of effect of concomitant medications altering gastric pH and gastric motility in healthy subjects. Antimicrob Agents Chemother. 2014;58(7):4020–4025. 21. Krishna G, Ma L, Martinho M, O‘Mara E. Single-dose phase I study to evaluate the pharmacokinetics of posaconazole in new tablet and capsule formulations relative to oral suspension. Antimicrob Agents Chemother. 2012;56(8):4196–4201. 411 22. McKeage K1. Posaconazole: a review of the gastro-resistant tablet and intravenous solution in invasive fungal infections. Drugs. 2015 Mar;75(4):397-406. 23. Mattiuzzi G1, Yilmaz M2, Kantarjian H1, Borthakur G1, Konopleva M1, Jabbour E1, Brown Y1, Pierce S1, Cortes J3. Pharmacokinetics of posaconazole prophylaxis of patients with acute myeloid leukemia. J Infect Chemother. 2015 Sep;21(9):663-7. 24. Molina I1, Gómez i Prat J, Salvador F, Treviño B, Sulleiro E, Serre N, Pou D, Roure S, Cabezos J, Valerio L, Blanco-Grau A, Sánchez-Montalvá A, Vidal X, Pahissa A. Randomized trial of posaconazole and benznidazole for chronic Chagas' disease. N Engl J Med. 2014 May 15;370(20):1899-908. 25. Park WB1, Cho JY2, Park SI2, Kim EJ1, Yoon S2, Yoon SH2, Lee JO1, Koh Y1, Song KH1, Choe PG1, Yu KS2, Kim ES1, Bang SM1, Kim NJ1, Kim I1, Oh MD1, Kim HB3, Song SH4. Effectiveness of increasing the frequency of posaconazole syrup administration to achieve optimal plasma concentrations in patients with haematological malignancy. Int J Antimicrob Agents. 2016 Jul;48(1):106-10. 26. Petitcollin A1, Crochette R2, Tron C3, Verdier MC3, Boglione-Kerrien C4, Vigneau C2, Bellissant E3, Lemaitre F3. Increased inhibition of cytochrome P450 3A4 with the tablet formulation of posaconazole. Drug Metab Pharmacokinet. 2016 Oct;31(5):389-393. 27. Prattes, K., J2, Maertens J3, Lagrou K4, Schoemans H3, Peersman N4, Vermeersch P4,5, Theunissen K6, Mols R7, Augustijns P7, Annaert P7, Hoenigl M8,9,10, Spriet I11. Posaconazole plasma exposure correlated to intestinal mucositis in allogeneic stem cell transplant patients. Eur J Clin Pharmacol. 2016 Aug;72(8):953-63. 28. Seyedmousavi S1, Mouton JW1, Melchers WJ2, Verweij PE3.Posaconazole prophylaxis in experimental azole-resistant invasive pulmonary aspergillosis. Antimicrob Agents Chemother. 2015 Mar;59(3):1487-94. 29. Soysal A. Prevention of invasive fungal infections in immunocompromised patients: the role of delayed-release posaconazole. Infection and Drug Resistance. 2015;8:321-331. 30. Thakuria L1, Packwood K2, Firouzi A2, Rogers P2, Soresi S2, Habibi-Parker K2, Lyster H2, Zych B2, Garcia-Saez D2, Mohite P2, Patil N2, Sabashnikov A2, Capoccia M2, Chibvuri M2, Lamba H3, Tate H4, Carby M2, Simon A2, Leaver N2, Reed A2. A pharmacokinetic analysis of posaconazole oral suspension in the serum and alveolar compartment of lung transplant recipients. Int J Antimicrob Agents. 2016 Jan;47(1):69-76. 31. Tyler K Liebenstein, Kristin M Widmer, Michael J Fallon. Retrospective analysis of goal drug level attainment of posaconazole for invasive fungal infection prophylaxis in patients with acute myeloid leukemia pre- and post-switch to tablet formulation.J. Onchol. Pharm. Practice. First Published August 2, 2017 Research Article 32. Ullmann AJ, Lipton JH, Vesole DH, et al. Posaconazole or fluconazole for prophylaxis in severe graft-versus-host disease. N Engl J Med. 2007;356(4):335–347. 33. van der Elst KC1, Brouwers CH, van den Heuvel ER, van Wanrooy MJ, Uges DR, van der Werf TS, Kosterink JG, Span LF, Alffenaar JW. Subtherapeutic Posaconazole Exposure and Treatment Outcome in Patients With Invasive Fungal Disease. Ther Drug Monit. 2015 Dec;37(6):766-71. 34. Vanstraelen K1, Colita A, Bica AM, Mols R, Augustijns P, Peersman N, Vermeersch P, Annaert P, Spriet I. Pharmacokinetics of Posaconazole Oral Suspension in Children Dosed According to Body Surface Area. Pediatr Infect Dis J. 2016 Feb;35(2):183-8. 35. K Vanstraelen et al. Posaconazole Plasma Exposure Correlated to Intestinal Mucositis in Allogeneic Stem Cell Transplant Patients Eur J Clin Pharmacol 72 (8), 953-963.2016 Apr 11. 36. Wiederhold NP. Pharmacokinetics and safety of posaconazole delayed-release tablets for invasive fungal infections. Clinical Pharmacology : Advances and Applications. 2016;8:1-8. doi:10.2147/CPAA.S60933. 412 31. Propiconazole             Propiconazole is a triazole fungicide, also known as a DMI, or demethylation inhibiting fungicide. Other Names : 1-[ [2-(2,4-dichlorophenyl)-4-propyl-1,3-dioxolan-2-yl]methyl]-1,2,4-t Color : yellow to reddish brown Molecular Weight : 342.23 Appearance : Yellow to reddish brown viscous liquid, free from extraneous matter Formula: C15H17Cl2N3O2 Propiconazole should be applied at times of severe plant pressure. Common months to apply propiconazole are March, April, May, September, and October. These months are when plant diseases tend to break out. Propiconazole can be applied with spray equipment as a foliar spray or a soil treatment. Propiconazole applications should be made at 7-21 day intervals for best results. Propiconazole should be watered in after application to control soil born diseases Propiconazole can speed seedling establishment when applied at a rate of 1oz per 1,000 sq feet. It does this by promoting faster root development and top growth. Propiconazole can be used to treat for oak wilt, dutch elm disease, and other tree diseases through root flare applications. Mode of action  demethylation of C-14 during ergosterol biosynthesis, and leading to accumulation of C 14 methyl sterols. The biosynthesis of these ergosterols is critical to the formation of cell walls of fungi. Coverage Area  Each quart of Propiconazole will systemically treat up to 16,000 square feet of area for brown patch and other listed diseases. Time to Kill  Propiconazole should be reapplied at 7 to 21 day intervals for best control. It may take up to 2 months before complete control is achieved.  Propiconazole is toxic to fish. Do not apply directly to water or areas where runoff may occur. Do not allow animals to graze on treated areas. 413 Brands Recent reports: Dalhoff et al. (2016) investigated whether the toxicokinetic and toxicodynamic (TKTD) properties of the imidazole prochloraz and triazole propiconazole can explain their different 414 synergistic potential toward the freshwater macroinvertebrate Daphnia magna. Pulse exposure to external concentrations of propiconazole (1.4μM) and prochloraz (1.7μM) for 18h resulted in internal concentrations of 22.7 and 53.5μmolkg(-1)w.w. for propiconazole and prochloraz, respectively. This 2-fold difference in bioaccumulation corresponded very well with the observed 2.7-fold lower external EC50-estimate (7 days) for prochloraz compared to propiconazole. The estimated IC50 for the in vivo inhibition of cytochrome P450 (ECOD) activity, however, measured as transformation of 7-ethoxycoumarin into 7-hydroxycoumarin, was almost 500-fold higher for prochloraz (IC50: 0.011±0.002μM) compared to propiconazole (IC50: 4.9±0.06μM). When indirectly measuring the binding strength of the two azoles, daphnids exposed to propiconazole recovered roughly 80% of their ECOD activity compared to the control shortly after being moved to azole-free medium, indicating that propiconazole causes reversible inhibition of cytochrome P450. In contrast, the ECODactivity remained inhibited in the prochloraz-exposed daphnids for 12h following transfer to azole-free medium, which correlated with elimination of the measured internal prochloraz concentration (DT95≈13h). These results indicate that lethal toxicity of the azole fungicides is mainly driven by toxicokinetics through their hydrophobicities resulting in different internal concentrations. Their synergistic potential toward pyrethroid toxicity, on the other hand, is mainly governed by their toxicodynamic effects measured as the differences in IC50-values toward in vivo cytochrome P450 (ECOD) activity together with the proposed binding strength measured indirectly through the recovery of ECOD activity as a function of internal azole concentration. Edwards et al. (2016) studied in the current project. Canopy penetration was observed for both application types, however drift was associated only with the aerial application of these fungicides. Azoxystrobin and propiconazole persisted in the soil up to 301 d, with peak concentrations occurring approximately 30 d after application. The predominant mode of transport for these compounds was agricultural runoff water, with the majority of the fungicidal active ingredients leaving the target area during the first rain event following application. The timing of application in relation to the first rain event significantly affected the amount of loss that occurred, implying application practices should follow manufacturer recommended guidelines. Satapute and Kaliwal (2016) studied the role of plasmid in the degradation process by plasmid curing method. The PCZ acts as the sole carbon source and as energy substrate which can be utilized by the strain for its growth in Mineral salt medium and degraded 8.89 µg ml-1 of PCZ at 30 °C and pH 7 within 4 days. During the bioconversion process of PCZ, three metabolite were formed such as 1-(2,4-dichlorophenyl)-2-(1H-1,2,4-triazol-1-yl) ethanone, 1-[2-(4-chlorophenyl) ethyl]-1H-1,2,4-triazole and 1-ethyl-1H-1,2,4-triazole. The LD50 value of BBK_9 strain was determined with acridine orange which resulted in 40 µg ml-1 at cell density of 0.243 at 660 nm. Furthermore, plasmid curing was done using LD50 concentration and from that three plasmids got cured in the sixth generation. It was found that, cured strain was able to degrade 7.37 µg ml1 of PCZ, indicating the plasmid encoded gene were not responsible for the PCZ degradation. On the source of these outcomes, strain BBK_9 can be used as potential strain for bioremediation of contaminated sites. Sun et al. (2016) investigated sorption behavior of propiconazole (PROPI) by plant-residue derived biochars (PLABs) and animal waste-derived biochars (ANIBs) obtained at three heating treatment temperatures (HTTs) (300, 450 and 600 °C) (e.g., BCs300, BCs450, and BCs600) and 415 their corresponding de-ashed BCs450. PLABs belonged to high- or medium-C biochars and ANIBs were low-C biochars. Surface C concentrations of the tested biochars were generally higher than their corresponding bulk C. Surface polar groups were mainly composed of Ocontaining groups of minerals within biochars. The nonlinearity coefficients (n) of propiconazole (PROPI) sorption isotherms ranged from 0.23 to 0.64, which was significantly and negatively related to organic carbon (OC)-normalized CO2-surface area (CO2-SA/OC) of biochars. This correlation along with the positive relationship between CO2-SA/OC and aromaticity indicates that pore-filling in nanopores within aromatic C dominate nonlinear PROPI sorption. HTTs or C contents do not necessarily regulate PROPI sorption. Removal of minerals from BCs450 elevated PROPI sorption because minerals may exert certain influence on sorption via impacting spatial arrangement of polar groups and/or organic matter (OM)-mineral interactions. This study helps to better understand sorption behavior of PROPI to biochars and evaluate the potential role of biochar in water treatment systems. Tu et al. (2016) continuously exposed larvae of wild type or p53(-/-) mutant of medaka fish (Oryzias latipes) to propiconazole(2.5-250μg/L) for 3, 7, 14 or 28 days and assessed liver histopathology and/or the oxidative stress response and gene expression during exposure and throughout adulthood. Propiconazole dose-dependently induced reactive oxygen species (ROS) level, altered homeostasis of antioxidant superoxide dismutase, catalase and glutathione Stransferase and caused lipid and protein peroxidation during early life exposure in wild type medaka. Such exposure also significantly upregulated gene expression of the cytochrome P450 CYP1A, but marginally suppressed that of tumor suppressor p53 in adults. Furthermore, histopathology revealed that p53(-/-) mutant medaka with early life exposure to propiconazole showed increased incidence of hepatocarcionogensis, as compared to the p53(/-) control group and wild type strain. We demonstrated that propiconazole can initiate ROSmediated oxidative stress and induce hepatic tumorigenesis associated with CYP1A- and/or p53 mediated pathways with the use of wild type and p53(-/-) mutant of medaka fish. The toxic response of medaka to propiconazoleis compatible with that observed in rodents. References: 1. Dalhoff K1, Gottardi M2, Kretschmann A3, Cedergreen N2. What causes the difference in synergistic potentials of propiconazole and prochloraz toward pyrethroids in Daphnia magna? Aquat Toxicol. 2016 Mar;172:95-102. 2. Edwards PG1, Murphy TM1, Lydy MJ2. Fate and transport of agriculturally applied fungicidal compounds, azoxystrobin and propiconazole. Chemosphere. 2016 Mar;146:450-7. 3. Satapute P1, Kaliwal B. Biodegradation of propiconazole by newly isolated Burkholderia sp. strain BBK_9. Biotech. 2016 Jun;6(1):110. 4. Sun K1, Kang M2, Ro KS3, Libra JA4, Zhao Y2, Xing B5. Variation in sorption of propiconazole with biochars: The effect of temperature, mineral, molecular structure, and nano-porosity. Chemosphere. 2016 Jan;142:56-63. 5. Tu TY1, Hong CY1, Sasado T2, Kashiwada S3, Chen PJ4. Early life exposure to a rodent carcinogen propiconazole fungicide induces oxidative stress and hepatocarcinogenesis in medaka fish. Aquat Toxicol. 2016 Jan;170:52-61. 416 32. Prothioconazole    Prothioconazole is a broad-spectrum systemic fungicide for the control of Ascomycetes, Basidiomycetes and Deuteromycetes diseases in a variety of crops including barley, buckwheat, bushberry subgroup, low growing berry subgroup (except strawberry), canola, corn, crambe, cucurbit vegetables, dry shelled pea and bean crop subgroup, field mustard, Indian rapeseed, millet, oats, peanuts, rapeseed, rye, soybean, sugar beets, triticale, wheat conifer and hardwood nursery seeds and seedlings. Prothioconazole, 2-[(2&S)-2-(l-chlorocyclopropyl)-3-(2-chlorophenyl)-2hydroxypropyl]-2H-l,2,4-triazole-3(4H)-thione, Prothioconazole molecule was first described in US 5,789,430 and corresponding patent publications. Molecular Weight: 344.254 g/mol Molecular Formula: C14H15Cl2N3OS Mechanism of Action  Prothioconazole is a systemic demethylation inhibitor fungicide which belongs to the triazolinthione class of fungicides.  Prothioconazole acts against susceptible fungi through the inhibition of demethylation at position 14 of lanosterol or 24-methylene dihydroano-sterol, both of which are precursors of sterols in fungi; i.e., it works through disruption of ergosterol biosynthesis (Ergosterol, a precursor to Vitamin D2, is an important component of fungal cell walls). Absorption, Distribution and Excretion  Following single oral low dose administration, the absorption of prothioconazole in male rats was approximately 94% for the triazole label. o The absorption for the phenyl label was estimated to be approximately 90% at 48 hours based on extrapolation of the course of excretion for the triazolelabel at 48 hours. o Plasma radioactivity time-course data showed that absorption following single oral low dose administration was rapid, with peak plasma concentrations occurring between 0.33 and 0.66 hours post administration in males and females. 417 o Peak plasma concentrations following single oral high dose administration occurred between 0.66 and 1.00 hours post administration in males and females. o The absorption of the phenyl-labelled prothioconazole was slightly more rapid, with peak plasma concentrations occurring between 0.16 and 0.33 hours post administration of a single oral low dose in males, and at 0.16 hours post administration of a repeat oral low dose in males and females.  The primary route of excretion was via the feces. o Following single oral low dose administration (triazole label), total recovery was approximately 94-95% of the administered dose, with 10% (males) and 16% (females) of the administered dose eliminated in the urine, and 84% (males) and 78% (females) eliminated in the feces. Metabolism/Metabolites  Prothioconazole was extensively metabolized in the rat following oral administration. o Eighteen metabolites and the parent compound were identified in urine, feces and bile. o The biotransformation of prothioconazole consisted of three major reaction types including desulfuration, oxidative hydroxylation of the phenyl moiety and glucuronic acid conjugation. o Identification of the metabolites ranged from 26-63% of the administered dose  In plants, the major metabolite/degradate of prothioconazole is prothioconazole-desthio, which is significantly more toxic than prothioconazole. o Therefore, the residues of concern in plant commodities are both prothioconazole and its metabolite prothioconazole-desthio.  The residues of concern in edible ruminant tissues and milk are prothioconazole, and its desthio and 4-hydroxy metabolites and their conjugates. Brands containing prothioconazole 418 Recent reports: Lehoczki-Krsjak et al. (2015) studied the distribution of prothioconazole and tebuconazole between wheat ears and flag leaves following fungicide spraying with different nozzle types at flowering. On average, sideward-spraying Turbo TeeJet Duo nozzles resulted in 1.30 and 1.43 times higher prothioconazole-desthio and tebuconazole contents and Turbo FloodJet nozzles in 1.08 and 1.34 times higher prothioconazole-desthio and tebuconazole contents in wheat ears by comparison with those achieved with vertically-spraying XR TeeJet nozzles. In contrast, the vertically-spraying XR TeeJet nozzles resulted in 1.57 and 1.31 times higher prothioconazoledesthio and tebuconazole contents in the flag leaf blade. The degradation of the active ingredient (AI) depended on the year, the cultivar and the plant organ, but not on the spraying method. There was no clear relationship between the efficacy of a given nozzle type and the outcome of the FHB epidemic. CONCLUSIONS: The ear coverage and therefore the AI content have been improved with the two sideward-spraying nozzle types. There was no effective translocation of the AI content between the ears and flag leaf blades. Prothioconazole and tebuconazole proved to be highly effective in the management of FHB, but the FHB resistance of the cultivar was also decisive. Zhou et al. (2015) studied the toxicokinetics (TK) behavior and metabolism studies of prothioconazole (PTC) in male adult Sprague Dawley (SD) rats after a single oral administration. Serial blood and tissue samples were analyzed for their PTC content by highperformance liquid chromatography (HPLC) to obtain comprehensive time-course data for estimation of TK parameters. 3. PTC was rapidly but incompletely absorbed from the gastrointestinal tract of fasted adult rats. It was widely distributed in all parts of body, but demonstrated little tendency to accumulate. And PTC was excreted mainly in the form of parent compound. 4. The detection of PTC in brain and testis proved that further investigations are required to determine whether PTC could result in neurotoxicity and male reproductive toxicity. Parker et al. (2013) used Candida albicans CYP51 (CaCYP51) to investigate the in vitro activity of prothioconazole and to consider the use of such compounds in the medical arena. Treatment of C. albicans cells with prothioconazole, prothioconazole-desthio, and voriconazole resulted in CYP51 inhibition, as evidenced by the accumulation of 14α-methylated sterol substrates (lanosterol and eburicol) and the depletion of ergosterol. We then compared the inhibitor binding properties of prothioconazole, prothioconazole-desthio, and voriconazole with CaCYP51. We observed that prothioconazole-desthio and voriconazole bind noncompetitively to CaCYP51 in the expected manner of azole antifungals (with type II inhibitors binding to heme as the sixth ligand), while prothioconazole binds competitively and does not exhibit classic inhibitor binding spectra. Inhibition of CaCYP51 activity in a cell-free assay demonstrated that prothioconazole-desthio is active, whereas prothioconazole does not inhibit CYP51 activity. Extracts from C. albicans grown in the presence of prothioconazole were found to contain prothioconazole-desthio. We conclude that the antifungal action of prothioconazole can be attributed to prothioconazole-desthio. Parker et al. (2011) studied the mode of action prothioconazole. Treatment of wild-type M. graminicola (strain IPO323) with 5 μg of epoxiconazole, tebuconazole, triadimenol, 419 or prothioconazole ml(-1) resulted in inhibition of M. graminicola CYP51 (MgCYP51), as evidenced by the accumulation of 14α-methylated sterol substrates (lanosterol and eburicol) and the depletion of ergosterol in azole-treated cells. Successful expression of MgCYP51 in Escherichia coli enabled us to conduct spectrophotometric assays using purified 62-kDa MgCYP51 protein. Antifungal-binding studies revealed that epoxiconazole, tebuconazole, and triadimenol all bound tightly to MgCYP51, producing strong type II difference spectra (peak at 423 to 429 nm and trough at 406 to 409 nm) indicative of the formation of classical low-spin sixth-ligand complexes. Interaction of prothioconazole with MgCYP51 exhibited a novel spectrum with a peak and trough observed at 410 nm and 428 nm, respectively, indicating a different mechanism of inhibition. Prothioconazole bound to MgCYP51 with 840-fold less affinity than epoxiconazole and, unlike epoxiconazole, tebuconazole, and triadimenol, which are noncompetitive inhibitors, prothioconazole was found to be a competitive inhibitor of substrate binding. This represents the first study to validate the effect of prothioconazole on the sterol composition of M. graminicola and the first on the successful heterologous expression of active MgCYP51 protein. The binding affinity studies documented here provide novel insights into the interaction of MgCYP51 with DMIs, especially for the new triazolinethione derivative prothioconazole References: 1. Lehoczki-Krsjak S1, Varga M, Mesterházy Á. Distribution of prothioconazole and tebuconazole between wheat ears and flag leaves following fungicide spraying with different nozzle types at flowering. Pest Manag Sci. 2015 Jan;71(1):105-13. 2. Parker JE1, Warrilow AG, Cools HJ, Fraaije BA, Lucas JA, Rigdova K, Griffiths WJ, Kelly DE, Kelly SL. Prothioconazole and prothioconazole-desthio activities against Candida albicans sterol 14-α-demethylase. Appl Environ Microbiol. 2013 Mar;79(5):1639-45. 3. Parker JE1, Warrilow AG, Cools HJ, Martel CM, Nes WD, Fraaije BA, Lucas JA, Kelly DE, Kelly SL. Mechanism of binding of prothioconazole to Mycosphaerella graminicola CYP51 differs from that of other azole antifungals. Appl Environ Microbiol. 2011 Feb;77(4):1460-5. 4. Zhou F1, Dai L, Wei S, Cheng G, Li L. Toxicokinetics and tissue distribution of prothioconazole in male adult Sprague-Dawley rats following a single oral administration. Xenobiotica. 2015 May;45(5):450-5. 411 33. Ravuconazole      Ravuconazole is a broad-spectrum antifungal triazole originally discovered by Eisai Co., Ltd, Tokyo, for treatment of systemic fungal infections such as candidiasis, aspergillosis and cryptococcal meningitis. Eisai and Bristol-Myers Squibb signed a licensing agreement for ravuconazole in December 1996. And Bristol-Myers Squibb has conducted clinical development of ravuconazole. Eisai Co., Ltd. announced in 2004 a termination of the licensing agreement of the triazole-type anti-fungal agent (generic name: ravuconazole) with Bristol-Myers Squibb Eisai Co., Ltd proceeded with an independent development program for ravuconazole mainly in the U.S. Ravuconazole has a similar spectrum of activity to voriconazole, with an increased halflife. The chemical structure  The chemical structure of ravuconazole is similar to that of fluconazole and voriconazole.  The fluorinated pyrimidine ring of voriconazole is replaced by a thiazole ring bound to a cyano-phenyl group  Molecular Formula: C22H17F2N5OS Antifungal Agents Spectrum of activity, Yamaguchi, 2016      Ravuconazole shows a broad spectrum of activity against a wide range of fungi covering Candida spp., Trichosporon beigelii, C. neoformans and A. fumigatus. The MIC90 ranges from 0.025 to 0.39 mg/mL. Ravuconazole shows relatively higher levels of activity against three strains of Candida krusei, with MICs ranging from 0.05 to 0.39 mg/mL. Ravuconazole shows good activity against T. mentagrophytes, T. rubrum, M. gypseum and M. caniswith MICs ranging from 0.05 to 0.39 mg/mL. Ravuconazoleis about two- to four fold more potent than itraconazole and about 40-fold more active than fluconazole against yeasts. Ravuconazole and itraconazoleare inhibitory to most aspergilli, and against half of the isolates, the activity is fungicidal. 411      Ravuconazole and itraconazole are active, though not fungicidal, against most hyaline Hyphomycetes, dermatophytes, and the dematiaceous fungi and inactive against Sporothrix schenckii and zygomycetes. Ravuconazole maximum concentration in plasma and the area under the concentrationtime curve show good linearity over a range of doses from 2 to 40 mg/kg of body weight. Ravuconazole at a dose of 2.5 mg/kg delays mortality significantly compared with the control treatment. Ravuconazole also shows a substantial therapeutic effect against systemic cryptococcosis. Ravuconazole reduces the numbers of CFU in the lungs significantly compared with the numbers of CFU in the lungs of the controls. In an experimental model of oral candidiasis in rats, ravuconazole reduces the numbers of CFU in oral swabs significantly compared with the numbers of CFU in oral swabs from the controls and is more effective than itraconazole and as effective as fluconazole Pharmacokinetics, Yamaguchi, 2016 Experimental animals    Ravuconazole is well absorbed following oral administration, and its absorption is enhanced by food Penetration of absorbed ravuconazole into healthy rat tissues after oral administration of a single dose of 10 mg/kg of ravuconazole to female rats showed: o The mean elimination half-Life was16.9hr; o Throughout the 72 hr wash-out, drug concentrations in the lung were 4- to 20-fold higher than the corresponding blood concentra- tions; and（ o the ratio of plasma to lung levels of ravuconazole was superior to the published data of other azoles Following intravenous administration in normal catheterized rabbits which received single doses o Ravuconazole demonstrated linear plasma PK across the investigated dosage range（1.25-40 mg/kg） o Ravuconazole demonstrated non-linear PK at higher dosages, indicating saturable clearance and/or protein binding. o Ravuconazole displayed a long elimination half-life and achieved substantial plasma and tissue concentrations. Pharmacokinetics in human subjects  Consistent in animal studies, a limited number of Phase I and/or II clinical studies also showed that ravuconazole is readily absorbed after oral administration and has a long terminal half-life of 4-8 days, longer than other azoles（including itraconazole)  In an ascending oral dose study, single doses of ravuconazole（from 50 to 800 mg once daily）provided an approximately dose-proportional increase in plasma drug levels for doses of 50-400 mg, although a less than dose-proportional increase was noted for doses > 400 mg after 7 days of dosing in healthy subjects who had been in fasted state 412    A 2- to 4-fold increase in systemic bioavailability was observed when ravuconazole was coadministered with a high-fat meal When oral ravuconazole was given daily for 14 days in a multiple ascending dose study, a 10-fold accumulation was noted in accordance with the long drug half-life（4-8 days A long elimination half-life（76-202 hr）and high protein binding（98 %）were demonstrated in another Phase II trial Metabolism and safety profile  Ravuconazole is considered to be metabolized through the P450 enzymes although only limited information is available so far  Ravuconazole is similar to itraconazole, posaconazole, isavuconazole and albaconazole in that their degradation products are excreted in the feces,  Ravuconazole is different from fluconazole and voriconazole whose main elimination route is urine.  The study data are consistent with the potential for ravuconazole to both inhibit and induce CYP3A isozymes.  Ravuconazole looks to be a less potent inhibitor of the CYP3A enzyme than other triazole antifungals Adverse events  No toxicity was described in any animal studies reported thus far where ravuconazole was examined.  In healthy volunteers, ravuconazole was well tolerated in single doses up to 800 mg and at 400 mg/day for up to 14 days  All adverse events were mild or moderate and resolved prior to discharge and the most commonly reported side effect in each group was headache  In the double-blind study of safety and therapeutic efficacy of ravuconazole compared with those of fluconazole in patients with esophageal candidiasis, the most common drug-related adverse events occurring in the ravuconazole arm were: abdominal pain (8 %) ; diarrhea（6 %）; pruritus（6 %）; and rash（6 %）  There were no discontinuations related to laboratory abnormalities.  In the Phase II trial evaluating the efficacy, safety and PK of oral ravuconazole in the treatment of onychomycosis, adverse events were noted in 73 % of patients and < 3 % of patients discontinued medications because of adverse events, including dizziness, abnormal thinking, urinary incontinence, diarrhea and anemia  The most frequent severe adverse events recorded were headache and abdominal pain, although the incidence of these events was similar for patients treated with ravuconazole or placebo. No patient discontinued therapy because of laboratory abnormalities. 413 Recent reports Yamaguchi (2016) mentioned that Ravuconazole and its prodrugs are promising new drug candidates for oral therapy of onychomycosis, among which a water-soluble prodrug, monolysine phosphoester derivative (E1224 or BFE1224) is in the most advanced stage of clinical development; a Phase II dose-finding study has been successfully completed and Phase III comparative studies are in progress in Japan.This review aims to summarize our current status of knowledge and information on ravuconazole and its prodrugs, particularly BFE1224, as the potential oral treatment option for onychomycosis. It also summarize the clinical features of onychomycosis with particular stress on its etiology, epidemiology, and current therapeutic options and their limitations. Given its clinical usefulness, BFE1224 may become a valuable addition to the current armamentarium for the treatment of onychomycosis. Elizondo-Zertuchea et al. (2015) compared the efficacy of ravuconazole (RVC) and fluconazole (FLC) in the treatment of experimental C. albicans vaginitis. Forty isolates of C. albicans were screened for their in vitro susceptibility to RVC and FLC. A strain of C. albicans that was resistant to FLC (minimum inhibitory concentration [MIC] of >64 g/ml) was selected for the in vivo study. Treatment regimens for the murine vaginal infection model were (1) 1, 5, 414 10, and 20 mg/kg RVC once daily, (2) 20 mg/kg RVC twice daily, (3) 20 mg/kg FLC once daily, and (4) 20 mg/kg FLC twice daily. The geometric means of the MIC values at 48 h for all isolates tested were 0.05 and 0.5 g/ml for RVC and FLC, respectively. Regimens of either RVC or FLC at 20 mg/kg twice daily were more effective to reduce the load of FLC-resistant C. albicans than single dose administration. Conclusions: Complete eradication of C. albicans from the vagina was not observed with RVC or FLC treatment in the animal model, although RVC treatment showed a lower fungal concentration 14 days after drug administration. Ahmed et al. (2014) evaluated and compared the in vitro activity of ravuconazole against Madurella mycetomatis, the most common etiologic agent of eumycetoma, to that of ketoconazole and itraconazole. Ravuconazole showed excellent activity with MICs ranging between ≤0.002 and 0.031 µg/ml, which were significantly lower than the MICs reported for ketoconazole and itraconazole. On the basis of our findings, ravuconazole, could be an effective and affordable therapeutic option for the treatment of eumycetoma. Yamaguchi et al. (2014) compared the in vitro activity of ravuconazole (RVCZ) with those of itraconazole (ITCZ) and terbinafine (TBF) against 73 dermatophyte isolates and 18 Candida spp. isolates recovered from patients with dermatomycosis at 4 dermatological clinics in Japan in 2011. The dermatophyte isolates consisted of Trichophyton rubrum (n = 51), Trichophyton menfagrophyfes (n = 20: these strains were not identified by molecular phylogenetic analysis.), Trichophyton tonsurans (n = 1), and Microsporum canis (n = 1). The Candida spp. isolates comprised C. albicans (n = 11), C. parapsilosis (n = 5), C guilliermondii (n = 1), and C. pseudohaemulonii (n = 1). RVCZ was highly active against all dermatophytes and all Gandida spp.: the geometric mean (GM) MICs for T. rubrum and T. mentagrophytes were 0.035μg/mL and MICs for T fonsurans and M. canis were⩽0.03 μg/mL, and GM MICs for C. albicans and C. parapsilosis were⩽0.03μg/mL and MICs for C guilliermondii and C. pseudohaemulonii were 0.25 and⩽0.03μg/mL. respectively. Compared to RVCZ, ITCZ showed similar antidermatophytic and anti-Candida activities, while TBF had a slightly higher anti-dermatophytic but a markedly lower anti-Candida activity. These results suggest that RVCZ is a potential candidate systemic antifungal therapy against onychomycosis and other dermatomycoses that are refractory to topical antifungal therapy. References 1. Ahmed SA, Kloezen W, Duncanson F, et al. Madurella mycetomatis Is Highly Susceptible to Ravuconazole. Wanke B, ed. PLoS Neglected Tropical Diseases. 2014;8(6):e2942. doi:10.1371/journal.pntd.0002942. 2. Elizondo-Zertuchea, M. , Efrén Robledo-Leal , J. Gerardo González , Luis A. Cecenas , Gloria M. González . Efficacy of ravuconazole in a murine model of vaginitis by Candida albicans. Revista Iberoamericana de Micología Rev Iberoam Micol. 2015;32(1):30–33 3. Yamaguchi Hideyo. Potential of Ravuconazole and its Prodrugs as the New OralTherapeutics for Onychomycosis. Med Mycol J. 2016;57(4):E93-E11 415 34. Sertaconazole Medication Sertaconazole is an antifungal medication of the imidazole class. It is available as a cream to treat skin infections such as athlete's foot. It is also available in a vaginal tablet form. The most popular of these is Gyno-Dermofix. Wikipedia Molar mass: 437.77 g/mol CAS ID: 99592-32-2 Formula: C20H15Cl3N2OS Sertaconazole nitrate is designated chemically as (±)-1-[2,4-dichloro-ß-[(7-chlorobenzo[b]thien3-yl)methoxy]phenethyl]imidazole nitrate. It has a molecular weight of 500.8. The molecular formula is C20H15Cl3N2OS · HNO3, and the structural formula is as follows: Sertaconazole nitrate is a white or almost white powder. It is practically insoluble in water, soluble in methanol, sparingly soluble in alcohol and in methylene chloride. Mechanism of action, Wikipedia     Sertaconazole has several known mechanisms of action. Sertaconazole is fungistatic, fungicidal, antibacterial, antiinflammatory, antitrichomonal, and antipruritic. Like other imidazole antifungals, sertaconazole blocks the synthesis of ergosterol by inhibiting the 14α-demethylase enzyme. Ergosterol is a critical component of the fungal cell membrane. Inhibition of ergosterol synthesis prevents fungal cells from multiplying and impairs hyphae growth. Chemically, sertaconazole contains a benzothiophene ring which makes it unique from other imidazole antifungals. o A benzothiophene ring is a sulfur analogue of the indole ring found in the amino acid tryptophan. o Tryptophan is found in the fungal membrane in addition to lipids such as ergosterol. o The benzothiophene ring in sertaconazole mimics tryptophan and increases the drugs ability to form pores in the fungal cell membrane. o If the cell membrane is made sufficiently leaky by these pores the fungal cell will die from loss of ATP and other effects which can include calcium disregulation. o These pores are believed to open at about 10 minutes following topical application of sertaconazole. 416      One hour following topical application, approximately 90% of fungal cells die from lack of energy (due to ATP loss) and general loss of homeostasis. Sertaconazole is thought to be the only imidazole antifungal with this mechanism of action. Sertaconazole has also antiinflammatory and antipruritic action. It inhibits the release of proinflammatory cytokines from activated immune cells. It has been shown that sertaconazole activatates of the p38/COX2/PGE2 pathway. PGE2 can have a variety of important effects in the body including activation of the body's fever response. Sertaconazole also has antibacterial action. It is hypothesized that the mechanism of action again involves sertaconazole's ability to form pores by mimicking tryptophan. It has also been shown that sertaconazole can kill Trichomonas vaginalis in vitro. The exact mechanism of action is as yet unknown. Sertaconazole also appears to inhibit the dimorphic transformation of Candida albicans into pathogenic fungi. Indications and usage: sertaconazole nitrate Cream, 2%, is indicated for the topical treatment of interdigital tinea pedis in immunocompetent patients 12 years of age and older, caused by Trichophyton rubrum, Trichophyton mentagrophytes, and Epidermophyton floccosum. Generic Names 1. Sertaconazole (OS: BAN) 2. BRN 5385663 (IS) 3. FI-7045 (IS) 4. Sertaconazole Nitrate (OS: BANM) 5. FI 7056 (IS) 6. Sertaconazole (nitrate de) (PH: Ph. Eur. 8) 7. Sertaconazole Nitrate (PH: BP 2016) 8. Sertaconazole nitrate (PH: Ph. Eur. 8) 9. Sertaconazoli nitras (PH: Ph. Eur. 8) 10. Sertaconazolnitrat (PH: Ph. Eur. 8) Brand Names 1. Dermofix Ferrer, Lebanon 2. Dermofix 2% Ferrer, Malta; Ferring, Egypt; October Pharma, Egypt 3. Mykosert Pfleger, Germany 4. Onabet Glenmark, India 5. Onabet-V1 Glenmark, India 6. Sertakon Wockhardt, India 7. Velconazole 2% Al Esraa, Egypt 8. Zalain Adeka, Turkey; Excelsior, Taiwan; 13. Gine Zalain Ferrer Internacional, Spain 2.14. Ginedermofix Ferrer Internacional, Spain 15. Gynozalain Leti, Venezuela 16. Gyno-Zalain Ferrer, Peru; Pfizer, Brazil 17. Konzert Glenmark, Malaysia 18. Li Ling Qi Haishen Tongzhou Pharmaceutical, China 19. Micoderm Laboratorios Andromaco, Chile 20. Monazol Teva Santé, France; Théramex, Monaco 417 26. Sertacream Geymonat, Italy 4.27. Sertaderm 28. Teva Italia, Italy 29. Sertadie Geymonat, Italy 30. Sertagyn Teva Italia, Italy 31. Sertopic Ferrer-Azevedos, Portugal 32. Zalain Egis, Russian Federation; Excelsior, Taiwan; Ferrer, Bulgaria; Ferrer, China; Ferrer, Costa Rica; Ferrer, Dominican Republic; Ferrer, Guatemala; Ferrer, Hong Kong; Ferrer, Honduras; Ferrer, Nicaragua; Ferrer, Panama; Ferrer, El Ferrer, Georgia; Ferrer, Peru; Terramex, Georgia 9. Dermofix Azevedos, Portugal; Ferrer Internacional, Spain 10. Dermoseptic Ferrer Internacional, Spain 11. Ertaczo Ferrer Therapeutics, Mexico; Valeant, United States 1.12. Fuganol Galenica, Greece 21. Monazol 2% Teva Santé, France 22. Mykosert Pfleger, Germany 23. Onabet (Sertaconazole and Pyrithione Zinc) Glenmark, India 24. Onabet-B (Sertaconazole and Beclometasone) Glenmark, India 3.25. Sercos Adcock Ingram, India 418 Salvador; Ferrer, Thailand; Ferrer Internacional, Spain; Laboratorios Andromaco, Chile; Metro Pharma, Philippines; Robert Ferrer, Singapore; Trommsdorff, Germany 33. Zalaïn Trommsdorff, Germany 34. Zalain 2% Robert Ferrer, Singapore 35. Zalain Vaginal Ferrer, Hong Kong Recent reports Arpita et al. (2016) developed a topical formulation with control relase of drug, reducing the side effects associated with topical drug delivery and improve the efficacy of product with aid of microsponges. Cream containing microsponges loaded with sertaconazole nitrate were prepared by using quasi emulsion solvent diffusion with different proportions of the polymer (Ethyl cellulose). The developed microsponges were analyzed for particle size, production yield, entrapment efficiency and drug content. Scanning electron microscopic images of microsponges revealed that they are spherical in shape and contain pores. Pore structure analysis was done by using mercury intrusion porosimetry technique, which confirmed the porous nature of microsponges. Microsponges were then incorporated in to a 2% cream and evaluated for pH, drug content, spreadability, viscosity and in vitro drug release. The batch F6 was found to be optimal as it shown 70% controlled drug release in 9 hr that followed Higuchi model. Chatterjee et al. (2016) conducted a randomized, observer-blind, parallel group study (Clinical Trial Registry India [CTRI]/2014/09/005029) with adult patients of either sex presenting with localized lesions. The clinical diagnosis was confirmed by potassium hydroxide smear microscopy of skin scrapings. After baseline assessment of erythema, scaling, and pruritus, patients applied either of the two study drugs once daily for 2 weeks. If clinical cure was not seen at 2 weeks, but improvement was noted, application was continued for further 2 weeks. Patients deemed to be clinical failure at 2 weeks were switched to oral antifungals. Overall 88 patients on sertaconazole and 91 on terbinafine were analyzed. At 2 weeks, the clinical cure rates were comparable at 77.27% (95% confidence interval [CI]: 68.52%-86.03%) for sertaconazole and 73.63% (95% CI 64.57%-82.68%) for terbinafine (P = 0.606). Fourteen patients in either group improved and on further treatment showed complete healing by another 2 weeks. The final cure rate at 4 weeks was also comparable at 93.18% (95% CI 88.75%-97.62%) and 89.01% (95% CI 82.59%-95.44%), respectively (P = 0.914). At 2 weeks, 6 (6.82%) sertaconazole and 10 (10.99%) terbinafine recipients were considered as "clinical failure." Tolerability of both preparations was excellent. CONCLUSION: Despite the limitations of an observer-blind study without microbiological support, the results suggest that once-daily topical sertaconazole is as effective as terbinafine in localized tinea infections. Manian et al. (2016) formulated an anhydrous gel containing sertaconazole nitrate as a model drug and the amount of the drug in the skin was determined by in vitro tape stripping. The apparent diffusivity and partition coefficients were then calculated by a mathematical model describing the dermal absorption as passive diffusion through a pseudo-homogenous membrane. The skin irritation potential of the formulation was also assessed by using the in vitro Epiderm™ model. An estimation of the dermal absorption parameters allowed us to evaluate drug transport across the stratum corneum following topical application. The estimated concentration for the formulation was found to be higher than the MIC100 at the target site which suggested its potential efficacy for treating fungal infections. The skin irritation test showed the formulation to be non-irritating in nature. Thus, in vitro techniques can be used for laying the groundwork in developing efficient and non-toxic topical products 419 Sahoo et al. (2016) developed a topical microemulsion (ME)-based hydrogel to enhance permeation of an antifungal drug, sertaconazole (STZL) for effective eradication of cutaneous fungal infection. Pseudo-ternary phase diagrams were used to determine the existence of MEs region. ME formulations were prepared with oleic acid, Tween 80, propylene glycol (PG) and water. Carbopol 940 (0.75% w/w) was used for preparation of hydrogel of STZL microemulsion (HSM) and characterized. The in vitro and in vivo evaluation of prepared HSM and commercial cream of STZL were compared. The viscosity, average droplet size and pH of HSM were 154.23 ± 0.54 to 162.52 ± 0.21 Pas, 42.3-91.7 nm and 6.9-7.2, respectively. Permeation rate of STZL from optimized formulation (HSM-4), composed with oleic acid (8.75 % w/w), Tween 80 (33.35% w/w), PG (33.35% w/w) and water (24.55% w/w) was observed higher in compare with other HSMs and commercial cream. HSM-4 was stable, three times higher drug retention capacity in skin than commercial cream and did not caused any erythema or edema based on skin sensitivity study on rabbit. The average zone of inhibition of HSM-4 (23.54 ± 0.72 mm) was higher in compare with commercial cream (16.53 ± 0.63 mm) against Candida albicans. CONCLUSION: The results of study showed that ME played a major role in permeation enhancing and skin retention effect of HSM and the concentration of STZL used for cutaneous fungal infection could be decreased by using ME based hydrogel preparation. Ständer et al. (2016) carried out a prospective study on parallel-group, randomized, doubleblind, vehicle-controlled, multi-centre clinical trial to compare the efficacy of topical sertaconazole 2% cream with vehicle in reducing chronic pruritus in subjects with atopic dermatitis, and to assess its safety and local tolerability. A total of 70 subjects applied either of the 2 treatments twice daily for a period of 4 weeks on affected, itchy skin areas. Treatment efficacy was evaluated primarily considering the item itch intensity on a 5-point verbal rating scale. Insomnia, state of atopic dermatitis (Scoring Atopic Dermatitis; SCORAD), quality of life and therapy benefit were also assessed. No significant difference between active treatment and vehicle was found at any of the time-points for any of the investigated parameters. Under the experimental conditions of the study, sertaconazole 2% cream did not exert anti-pruritic effects that were better than vehicle in subjects with atopic dermatitis who had chronic pruritus. Trial registration ClinicalTrials.gov #NCT01792713. Pande et al. (2015) developed a topical formulation that releases the drug in controlled manner, reduce the side effects associated with topical drug delivery and improve product efficacy with aid of microsponges. Microsponges loaded with sertaconazole nitrate were prepared by using quasi emulsion solvent diffusion with five different proportions of the polymer (Eudragit RS 100). The developed microsponges were analyzed for particle size, production yield, entrapment efficiency and drug content. Scanning electron microscopic images of microsponges revealed that they are spherical in shape and contain pores. Pore structure analysis was done by using mercury intrusion porosimetry technique, which confirmed the porous nature of microsponges. Microsponges were then incorporated in to a 1% corbopol gel and evaluated for pH, drug content, texture profile analysis and in vitro drug release. The batch F IV was found to be optimal as it shown 69.38% controlled drug release in 8 h that followed Higuchi model. Sahoo et al. (2014) studied a microemulsion (ME) based hydrogel as a topical delivery of sertaconazole (STZL) for effective eradication of cutaneous fungal infection. The existence of microemulsion region was investigated in pseudo-ternary phase diagrams and various ME formulations were prepared using oleic acid, Tween 80, propylene glycol and water. Hydrogel of STZL microemulsions (HSM) were prepared in Carbopol 940 (0.75%, w/w) and characterized. 421 The prepared HSM and commercial cream of STZL were evaluated in vitro and ex vivo. The permeation rate of STZL from optimized formulation (HSM-4), composed with oleic acid (8.75%, w/w), tween 80 (33.35%, w/w), propylene glycol (33.35%, w/w) and water (24.55%, w/w) was observed higher in compare with other HSMs and commercial cream. HSM-4 was stable, had 3 times higher drug retention capacity in skin than commercial cream and did not caused any erythema or edema based on skin sensitivity study on rabbit. The average zone of inhibition of HSM-4 (23.54±0.72mm) was higher in compare with commercial cream (16.53±0.63mm) against Candida albicans which may be due to permeation enhancing effect of ME and skin retention effect of HSM. It is promising that the concentration of STZL used to treat cutaneous fungal infection could be decreased due to the high permeation and anti-fungal effect of STZL in HSM-4. Shivamurthy et al. (2014) compared the efficacy of topical antifungal agents, Sertaconazole and Clotrimazole in Tinea corporis patients. A total of 60(n=60) patients were included in the study. They were divided into two groups of 30 patients each. First group included patients treated with topical Sertaconazole as test drug whereas the second group constituted patients treated with topical Clotrimazole as standard drug. The patients were advised to apply the drug on affected area twice daily for three weeks. The parameters like erythema, scaling, itching, margins and size of the lesion and KOH mount were taken for the assessment of efficacy. This was an open labelled study and patients were followed up every week for three weeks. The total score included all grades in erythema, itching, scaling, margins and size of lesion and KOH mount. There was significant reduction in erythema (p<0.02) and highly significant reduction in scaling (p<0.001), itching (p<0.001) and margins of lesion (p<0.001) among Sertaconazole group. The mean difference and the standard deviation of total scores for Clotrimazole were 7.20 and 1.69 and for Sertaconazole group 8.80 and 1.52 respectively. The pvalue on application of students unpaired t- test was p<0.001 (Highly significant). CONCLUSION: From the present study, it can be concluded that topical Sertaconazole shows better improvement in the clinical parameters than topical Clotrimazole within a span of three weeks in the treatment of T corporis. Soliman et al. (2014) developed and characterized poly(ethylene glycol)-block-poly(εcaprolactone) (PEG-b-PCL) polymeric nanomicelles for the solubilization and enhancement of sertaconazole antifungal activity. Sertaconazole was incorporated into PEG-b- PCL polymeric nanomicelles by a co-solvent evaporation method and micelle size, drug loading capacity and drug release properties were determined. The antifungal properties of nanomicelle-loaded drug were evaluated in Fusarium miscanthi, Microsporum canis, and Trichophyton mentagrophytes isolated, respectively from fungal keratitis, ringworm, and tinea corporis. PEG-b-PCL formed nanomicelles in aqueous solution with a diameter ranging from 40-80 nm, depending on the polymer composition and level of drug loading. Drug loading properties of the nanomicelles were dependent on the PCL block molecular weight and drug/polymer weight feed ratio. Drug encapsulation efficiency of up to 85% was achieved and this resulted in more than 80-fold enhancement in sertaconazole aqueous solubility at polymer concentration of 0.2%. Drug release studies showed an initial burst release followed by sustained drug release for 72 hours. In vitro antimycotic studies showed that nanomicelle-incorporated sertaconazole inhibited fungal growth in a concentration dependent manner. Further, it was more effective than the free drug in inhibiting the growth of Fusarium miscanthi and Microsporum canis. These results confirm the 421 utility of PEG-b-PCL nanomicelles in enhancing the aqueous solubility and antifungal activity of sertaconazole or other similar antifungal drugs. Carrillo-Muñoz et al. (2013) mentioned that Sertaconazole is a useful antifungal agent against mycoses of the skin and mucosa, such as cutaneous, genital and oral candidiasis and tinea pedis. Its antifungal activity is due to inhibition of the ergosterol biosynthesis and disruption of the cell wall. At higher concentrations, sertaconazole is able to bind to nonsterol lipids of the fungal cell wall, increasing the permeability and the subsequent death of fungal cells. Fungistatic and fungicidal activities on Candida are dose-dependent. The antifungal spectrum of sertaconazole includes deramophytes, Candida, Cryptococcus, Malassezia and also Aspergillus, Scedosporium and Scopulariopsis. Sertaconazole also shows an antimicrobial activity against streptococci, staphylococci and protozoa (Trichomonas). In clinical trials including patients with vulvovaginal candidiasis, a single dose of sertaconazole produced a higher cure rate compared with other topical azoles such as econazole and clotrimazole, in shorter periods. Sertaconazole has shown an anti-inflammatory effect that is very useful for the relief of unpleasant symptoms. Goldust et al. (2013) compared efficiency of sertaconazole 2% cream vs. clotrimazole 1% cream for the treatment of seborrheic dermatitis. One hundred twenty eight patients suffering from SD were studied. Patients were randomly divided into two groups. Sixty four patients received local sertoconazole 2% cream and in control group 64 patients received clotrimazole 1% cream. They were recommended to use the cream twice a day for 4 weeks. At the beginning of referring and 2 and 4 weeks after first visit, the patients were examined by a dermatologist to assess improvement of clinical symptoms. The mean age of sertaconazole and clotrimazole group patients was 34.78+/-13.54 and 38.68+/-11.88, respectively. The highest level of satisfaction (87.6%) was observed 28 days after sertaconazole administration and in clotrimazole group it was 50%. Relapse of the disease one month after stopping treatment was not observed in groups treated with sertaconazole 2% cream and clotrimazole 1% cream. Saki et al. (2013) conducted a double-blind bilateral comparison study. Forty-five patients applied sertaconazole 2% cream twice daily on one side of the body and hydrocortisone 1% ointment twice daily on the opposite side for 1 month. The authors used a modified SCORAD score to assess the severity of the disease before and after therapy. There was no significant difference between the two drugs in decreasing erythema, swelling, crust, scratch marks, lichenification, xerosis and pruritus (p = 1, 1, 0.82, 0.625, 0.761, 0.125, 0.54, respectively). Sertaconazole was significantly better in decreasing the total score (p = 0.023). In terms of patients' overall idea about the drugs, sertaconazole was significantly superior to hydrocortisone (p = 0.023). CONCLUSION: The study showed that sertaconazole was significantly better in decreasing the total score of the disease and patients' ideas. There was no significant difference between the two drugs regarding each sign by itself. Sertaconazole could be a safe and efficient treatment in AD. References 1. Arpita Sharma*, Aashima Hooda and Hema Chaudhary Formulation and evaluation of topical microsponges of sertaconazole. World Journal of Pharmaceutical Research. Vol 5, Issue 11, 2016.1444-1461 422 2. Carrillo-Muñoz AJ1, Tur-Tur C, Giusiano G, Marcos-Arias C, Eraso E, Jauregizar N, Quindós G. Sertaconazole: an antifungal agent for the topical treatment of superficial candidiasis. Expert Rev Anti Infect Ther. 2013 Apr;11(4):347-58 3. Chatterjee D1, Ghosh SK2, Sen S3, Sarkar S4, Hazra A5, De R6. Efficacy and tolerability of topical sertaconazole versus topical terbinafine in localized dermatophytosis: A randomized, observer-blind, parallel group study. Indian J Pharmacol. 2016 NovDec;48(6):659-664. 4. Goldust M1, Rezaee E, Raghifar R. Treatment of seborrheic dermatitis: comparison of sertaconazole 2 % cream versus pimecrolimus 1 % cream. Ir J Med Sci. 2013 Dec;182(4):703-6. 5. Jerajani H1, Janaki C, Kumar S, Phiske M. Comparative assessment of the efficacy and safety of sertaconazole (2%) cream versus terbinafine cream (1%) versus luliconazole (1%) cream in patients with dermatophytoses: a pilot study. Indian J Dermatol. 2013 Jan;58(1):34-8. 6. Manian M1, Madrasi K2, Chaturvedula A3,4, Banga AK5. Investigation of the Dermal Absorption and Irritation Potential of Sertaconazole Nitrate Anhydrous Gel. Pharmaceutics. 2016 Jul 7;8(3). pii: E21 7. Pande VV1, Kadnor NA1, Kadam RN1, Upadhye SA1. Fabrication and Characterization of Sertaconazole Nitrate Microsponge as a Topical Drug Delivery System. Indian J Pharm Sci. 2015 Nov-Dec;77(6):675-80. 8. Sahoo S1, Pani NR1, Sahoo SK2. Effect of microemulsion in topical sertaconazole hydrogel: in vitro and in vivo study. doi: 10.3109/10717544.2014.914601. Epub 2014 May 20. 9. Sahoo S1, Pani NR2, Sahoo SK3. Microemulsion based topical hydrogel of sertaconazole: formulation, characterization and evaluation. Colloids Surf B Biointerfaces. 2014 Aug 1;120:193-9 10. Shivamurthy RP1, Reddy SG2, Kallappa R2, Somashekar SA2, Patil D2, Patil UN2. Comparison of topical anti- fungal agents sertaconazole and clotrimazole in the treatment of tinea corporis-an observational study. J Clin Diagn Res. 2014 Sep;8(9):HC09-12 11. Soliman GM1, Attia MA, Mohamed RA. Poly(ethylene glycol)-block-poly(εcaprolactone) nanomicelles for the solubilization and enhancement of antifungal activity of sertaconazole. Curr Drug Deliv. 2014;11(6):753-62. 12. Ständer S1, Metz M, Ramos F MH, Maurer M, Schoepke N, Tsianakas A, Zeidler C, Luger TA. Anti-pruritic Effect of Sertaconazole 2% Cream in Atopic Dermatitis Subjects: A Prospective, Randomized, Double-blind, Vehicle-controlled, Multi-centre Clinical Trial of Efficacy, Safety and Local Tolerability. Acta Derm Venereol. 2016 Aug 23;96(6):792-6. 13. Saki N1, Jowkar F, Alyaseen S. Comparison of sertaconazole 2% cream versus hydrocortisone 1% ointment in the treatment of atopic dermatitis. J Dermatolog Treat. 2013 Dec;24(6):447-9. 423 35. Sulconazole    Sulconazole is an imidazole derivative developed by Syntex Research as a topical antifungal agent for the treatment of dermatomycoses, pityriasis versicolor, and cutaneous candidiasis. Sulconazole is a broad-spectrum anti-fungal agent available as a topical cream and solution. Sulconazole nitrate, the active ingredient, is an imidazole derivative that inhibits the growth of common pathogenic dermatophytes making it an effective treatment for tinea cruris and tinea corporis infections. Molar mass: 397.749 g/mol Molecular Formula: C18H15Cl3N2S Brand names: Exelderm Drug class(es): topical antifungals Mode of action  Sulconazole inhibits macromolecular synthesis in the order ribonucleic acid > deoxyribonucleic acid > protein > mannan  Sulconazole RIF values for Candida species, Aspergillus species, and dermatophytes were 69, 71, and 12%, respectively. These values suggest that sulconazole is very active against dermatophytes, but only moderately active against Candida and Aspergillus species.  Sulconazole exerted direct physicochemical damage to C. parapsilosis at a concentration of 3.8 x10-5 M (16).  Sulconazole was fungicidal at a concentration of 2 x 10-5 M against early logarithmic phase of C. albicans, supporting the premise that sulconazole is capable of producing direct fungal cell membrane damage. 424 In vitro activity.  Sulconazole has broad-spectrum antifungal activity.  Sulconazole is active against dermatophytes and yeast-like fungi, including C. albicans, as well as gram-positive bacteria. Experimental in vivo activity.  Sulconazole, in a model of experimental trichophytosis in guinea pigs, was comparable to miconazole at a variety of dosage schedules and cream formulations.  Sulconazole, in other experimental guinea pig dermatophyte and mouse vaginal candidiasis models, sulconazole was comparable to miconazole  Sulconazole also penetrated full thickness skin 4 to 8 times more effectively than miconazole . Clinical studies.  Clinical trials of sulconazole have been limited to superficial fungal infections, i.e., tinea versicolor, and dermatophytoses. o In one such study, which was multicenter, double-blind, randomized, and parallel, 181 patients with tinea versicolor were treated with either 1.0% sulconazole or 2.0% miconazole applied twice daily for 3 weeks.  Mycological cures were obtained in 93 and 87% of the patients treated with sulconazole and miconazole, respectively.  Complete healing of lesions was observed in 89 and 82% of the patients, respectively.  No serious side effects were recorded with either compound. o In another comparative study, this time in 96 patients with either tinea pedis or tinea cruris/corporis, the same azoles were compared in the same dosage schedule. The compounds were administered twice a day for 3 weeks.  Sulconazole was comparable to miconazole in producing mycological cures and in the rate of relapse,  Sulconazole was superior to miconazole in producing fewer side effects. o An additional clinical study comparing sulconazole with miconazole in the treatment of dermatophytoses showed that  sulconazole was significantly superior to miconazole in providing a more rapid onset of clinical improvement, particularly in cases of tinea pedis. Indication Sulconazole solution 1.0% is indicated for the treatment of tinea cruris and tinea corporis caused by Trichophyton rubrum, Trichophyton mentagrophytes, Epidermophyton floccosum, and Microsporum canis; and for the treatment of tinea versicolor. Effectiveness has not been proven in tinea pedis (athlete‘s foot). 425 Pharmacodynamic Properties     Sulconazole possesses a broad spectrum of antifungal activity, inhibiting the growth of dermatophytes, yeasts and various filamentous and dimorphic fungi at concentrations below 5 mg/L in vitro. It has been shown that against representatives of pathogenic yeasts, dermatophytes and Aspergilli, the RIF values of sulconazole were broadly similar to those of other imidazoles. The fungicidal potency of sulconazole in vitro depends on its concentration and on the growth phase of the inoculum cells. Sulconazole has also demonstrated antibacterial activity in vitro, with MIC values below 12.5 mg/L, against several Staphylococcus species, Streptococcus faecalis and certain Grampositive anaerobes. Pharmacokinetic Properties About 12% of a topically administered (forearm) dose of sulconazole 1% cream was estimated to be percutaneously absorbed in humans. This value varied markedly in different animal species. Side Effects    Sulconazole has generally been very well tolerated in clinical trials. In the largest study, involving 323 patients, the overall incidence rate of adverse effects was 3.4%, with redness, irritation, contact dermatitis and pruritus being the most frequently reported. Few patients have withdrawn from sulconazole treatment due to side effects. Administration   Sulconazole 1% cream should be rubbed gently into the affected and surrounding skin area twice daily. To minimise the risk of reinfection treatment should continue for 3 weeks in Candida infections, tinea cruris, tinea corporis and pityriasis versicolor, and for 4 weeks in patients with tinea pedis. 426 Reports Aboul-Enein (2002) described The chiral resolution of (+/-)-econazole, (+/-)-miconazole and (+/-)-sulconazole on the columns containing different cellulose derivatives namely Chiralcel OD, OJ, OB, OK, OC and OF in normal phase mode. The mobile phase used was hexane-2-propanoldiethylamine (425:74:1, v/v/v). The flow rates of the mobile phase used were 0.50, 1.00 and 1.50 ml/min. The values of the separation factor (alpha) of the resolved enantiomers of econazole, miconazole and sulconazole on chiral phases were ranged from 1.07 to 2.50 while the values of resolution factor (R(s)) varied from 0.17 to 3.90. The chiral recognition mechanisms between the analytes and the chiral selectors are discussed. Aboul-Enein and Ali (2001) achieved resolution of the enantiomers of (+/-)-econazole, (+/-)miconazole, and (+/-)-sulconazole on different normal-phase chiral amylose columns, Chiralpak AD, AS, and AR. The mobile phase used was hexane-2-propanol-diethylamine, 400:99:1 (v/v). The flow rates of the mobile phase used were 0.50 and 1.00 mL min(-1). The alpha values for the resolved enantiomers of econazole, miconazole, and sulconazole on the chiral phases were in the range 1.63 to 1.04; the Rs values varied from 5.68 to 0.32. Gugnani et al. (1997) used 1% cream of sulconazole nitrate, an imidazole derivative, to treat 38 patients with diverse clinical types of dermatomycoses, including 16 cases of pityriasis versicolor, 14 of dermatophytosis (tinea pedis, tinea cruris, tinea corporis), two of balanoposthitis due to Candida albicans, another two of candidosis of the groin, one each of groin and foot infection due to Trichosporon beigelii and one case each of lesions of the hand and trunk caused by Petriellidium boydii and Scytalidium hyalinum respectively. A complete cure was achieved in 427 91% of patients, with resolution of the lesions in the majority within 2-4 weeks. There were only two relapses. Sulconazole is recommended as an effective drug for topical treatment of superficial fungal infections of the skin. Hercelin et al. (1993) reported that, after cutaneous application of radioactive solutions of Sulconazole nitrate in the hairless rat, the total absorption of the substance by the skin, estimated from the sum of the cumulative urinary and fecal excretions over 96 h, was 2.4% of the dose administered. The elimination reached a maximum between 6 and 24 h and was virtually complete after 96 h. The excretion was almost equally distributed between the urine and the feces, which corresponds to an intense elimination via the biliary tract. The quantities present in the stratum corneum, epidermis and dermis at the end of the period of contact constituted another estimation of the total absorption of the substance which confirmed the previous estimation (3.6% of the dose). The measurement of the concentrations of Sulconazole and its metabolites in the various layers of the skin revealed a high affinity of the substance for the stratum corneum, where it remained present in large quantities for more than 48 h. This affinity is due to the very intense lipophilia of the molecule. The concentrations in the other tissues were inversely proportional to the distance from the surface of the skin and were virtually nil in the circulating blood. These results suggest the absence of risk of systemic effects after cutaneous administration of Sulconazole and support the recommended therapeutic protocol in man (one administration per day). Akers et al. (1989) compared Sulconazole nitrate 1% cream applied twice daily with its vehicle in the treatment of 229 patients with chronic moccasin-type tinea pedis confirmed by positive results of a potassium hydroxide preparation. At admission in this randomized, double-blind, parallel multicenter trial, 131 patients had positive dermatophyte cultures; Trichophyton rubrum was identified in 121 (92%). After 4 weeks of treatment, patients were examined and, if necessary, were treated for an additional 2 weeks. Sulconazole cream was significantly more effective than the vehicle in the treatment of chronic T. rubrum tinea pedis; 57% of patients were cured by sulconazole, compared with 13% cured with the vehicle. Relapse rates, assessed 2 weeks after the end of treatment, were significantly lower in patients treated with sulconazole than in those receiving vehicle (27% vs 71%). The 103 patients with moccasintype tinea pedis whose cultures were not positive for T. rubrum achieved similar results. Tanenbaum et al. (1989) tested iSulconazole nitrate 1 percent cream, a new imidazole derivative, n 117 Colombian Army soldiers with tinea cruris/corporis under hot, humid conditions. The results of two clinical trials demonstrate that sulconazole applied once daily was as effective as clotrimazole applied twice daily. After three weeks of therapy 100 percent of the patients treated either once or twice daily with sulconazole showed negative findings on potassium hydroxide preparations and cultures from lesions. Although sulconazole was well tolerated and caused no adverse reactions, four of twenty-seven clotrimazole-treated patients showed reactions consisting of erosive primary irritation. Sulconazole nitrate 1 percent cream appears to be highly effective in the treatment of tinea cruris/corporis when applied once or twice daily and may be very useful in hot and humid conditions where contact irritation reactions occur more often. Franz and Lehman (1988) The percutaneous absorption of 1% sulconazole nitrate in a cream formulation containing 3H-labeled drug has been studied in seven human subjects. Two applications of 4.5 g each were made to 450 cm2 of abdominal skin at 0 and 12 h, and the site was washed at 24 h. The application site was subsequently washed at 24-h intervals for 3 428 consecutive days, and 6.7% of the dose was recovered in the urine and 2.0% in the feces following a 7-d collection period. Radioactivity was detectable in the plasma from 8-96 h, with a peak occurring at 24 h, and could also be recovered in the skin wash up to 96 h after application. Total percutaneous absorption of sulconazole was estimated to be 8.7-11.3% of the applied dose, considerably more than that previously reported for other imidazole drugs. References: 1. Aboul-Enein HY1, Ali I. Comparative study of the enantiomeric resolution of chiral antifungal drugs econazole, miconazole and sulconazole by HPLC on various cellulose chiral columns in normal phase mode. J Pharm Biomed Anal. 2002 Jan 15;27(3-4):441-6. 2. Aboul-Enein HY1, Ali I. Comparison of the chiral resolution of econazole, miconazole, and sulconazole by HPLC using normal-phase amylose CSPs. Fresenius J Anal Chem. 2001 Aug;370(7):951-5. 3. Akers WA1, Lane A, Lynfield Y, Greenberg J, Hall J, Mangan C, Tinker A. Sulconazole nitrate 1% cream in the treatment of chronic moccasin-type tinea pedis caused by Trichophyton rubrum. J Am Acad Dermatol. 1989 Oct;21(4 Pt 1):686-9. 4. Franz TJ1, Lehman P. Percutaneous absorption of sulconazole nitrate in humans. J Pharm Sci. 1988 Jun;77(6):489-91. 5. Gugnani HC1, Gugnani A, Malachy O. Sulconazole in the therapy of dermatomycoses in Nigeria. Mycoses. 1997 Sep;40(3-4):139-41. 6. Hercelin B1, Delaunay-Vantrou M, Alamichel F, Mazza M, Marty JP. Pharmacokinetics of cutaneous Sulconazole nitrate in the hairless rat: absorption, excretion, tissue concentrations. Eur J Drug Metab Pharmacokinet. 1993 Apr-Jun;18(2):149-54. 7. Tanenbaum L1, Taplin D, Lavelle C, Akers WA, Rosenberg MJ, Carmargo G. Sulconazole nitrate cream 1 percent for treating tinea cruris and corporis. Cutis. 1989 Oct;44(4):344-7. 429 36. Tebuconazole Tebuconazole is a triazole fungicide used agriculturally to treat plant pathogenic fungi. Though the U.S. Food and Drug Administration considers this fungicide to be safe for humans, it may still pose a risk. Formula: C16H22ClN3O Molar mass: 307.82 g/mol Density: 1.25 g/cm³ Melting point: 102.4 °C (216.3 °F; 375.5 K) Solubility in water: 0.032 g/L at 20 °C      Tebuconazole has been used successfully against Ustilago, Tilletia, Fusarium, Septoria, Pyrenophora, Cochliobolus, rusts and powdery mildew. Tebuconazole is effective against Mycosphaerella on bananas and Botrytis cinerea on grapes. Tebuconazole combats Pseudocercosporella herpotrichoides on wheat and barley, Onobasidium theobromae on cocoa, Cercosporida on peanuts, Sclerotium cepivorum of onion, Blumeriella jaapii on sour prunes, and Alternaria macrospora on cotton, and several diseases of oilseed rape. Tebucobazole is marketed as wood fungicide Preventol A8 Tebuconazole is recommended for the protection of other materials against Sclerophoma pityophila, Hylotrupes bajulus and Aspergillus niger. Formulations The following types of formulation have been registered for use internationally:        EW (emulsion, oil in water), EC (emulsifiable concentrate), FS (flowable concentrate for seed treatment), DS (powder for dry seed treatment), SC (suspension concentrate = flowable concentrate), WG (water-dispersible granule), WP (wettable powder) Products 431      Tebuconazole 95%TC Tebuconazole 80%WP Tebuconazole 25%EC Tebuconazole 12%FS Tebuconazole 6%FS Mode of Action and uses   Tebuconazole is a triazole sistemic fungicide with protective, curative, and eradicant action. Tebuconazole is rapidly absorbed into the vegetative parts of the plant, with translocation principally acropetally. Mammalian toxicology Oral Acute  oral LD50 for male rats 4000, female rats 1700, mice c. 3000 mg/kg. Skin and eye  Acute percutaneous LD50 for rats >5000 mg/kg. Non-irritating to skin; mild irritant to eyes (rabbits). Inhalation  LC50 (4 h) for rats 0.37 mg/l air (aerosol), >5.1 mg/l (dust). NOEL (2 y) for rats 300, dogs 100, mice 20 mg/kg diet. ADI (JMPR) 0.03 mg/kg b.w. Ecotoxicology       Birds Acute oral LD50 for male Japanese quail 4438, female Japanese quail 2912, bobwhite quail 1988 mg/kg b.w. Dietary LC50 (5 d) for mallard ducks >4816, bobwhite quail >5000 mg/kg feed. Fish LC50 (96 h) for rainbow trout 4.4, bluegill sunfish 5.7 mg/l (flow through). Daphnia LC50 (48 h) 4.2 mg/l (flow through). Algae ErC50 (96 h) for Scenedesmus subspicatus 4.01 mg/l (static). Other aquatic spp. No effect on Chironomus riparius at 0.1 mg/l (28 d). Bees LD50 (48 h) (oral) 175.8 mg/bee; (contact) 0.6 mg/bee. Worms Acute LC50 (14 d) for Eisenia foetida 1381 mg/kg dry soil. Environmental fate Animals  After three days, elimination was almost complete (>99%).  Tebuconazole was excreted with the urine and the faeces. Plants Metabolism 431    studies on wheat, grapes and peanuts show that tebuconazole is the major terminal residue. The metabolites detected were mainly triazole-containing compounds of no toxicological relevance. In plant tissue, a mean half-life of 12 days could be derived (cereals). Soil/Environment     The degradation of tebuconazole in soil was slow in laboratory studies. Under field conditions, the compound degraded much more rapidly, and did not accumulate in long-term studies (3-5 y). Since no residues could be detected in deeper soil layers of these and other studies, and adsorption/desorption studies indicated a low mobility in the soil, groundwater contamination through leaching can be excluded. In natural waters, hydrolysis and indirect photolysis occur; in a pond study, the compound dissipated from the water body with DT50 1-4 w. Low vapour pressure and strong adsorption result in low volatilisation into the air Brands 432 433 Recent reports: Álvarez-Martín et al. (2016) conducted a study under laboratory conditions to know the dissipation and bioavailability of the fungicides cymoxanil and tebuconazole over time in a vineyard soil amended with two rates of spent mushroom substrate (SMS) (5% and 50% (w/w)), selected to prevent the diffuse or point pollution of soil. The dissipation of cymoxanil was more rapid than that of tebuconazole in the different soils studied. The dissipation rate was higher in the amended soil than in the unamended one for both compounds, while no significant differences were observed between the amended soils in either case. An apparent dissipation occurred in the amended soil due to the formation of non-extractable residues. Bound residues increased with incubation time for tebuconazole, although a proportion of this fungicide was bioavailable after 303days. The major proportion of cymoxanil was tightly bound to the amended soil from the start, although an increasing fraction of bound fungicide was bioavailable for mineralization. Soil dehydrogenase activity was significantly affected by SMS application and incubation time; however, it was not significantly modified by fungicide application. The significance of this research suggests that SMS applied at a low or high rate to agricultural soil can be used to prevent both the diffuse or point pollution of soil through the formation of nonextractable residues, although more research is needed to discover the time that fungicides remain adsorbed into the soil decreasing either bioavailability (tebuconazole) or mineralization (cymoxanil) in SMS-amended soils. Díaz-Blancas et al. (2016) formulated Tebuconazole (TBZ) nanoemulsions (NEs) using a low energy method. TBZ composition directly affected the drop size and surface tension of the NE. Water fraction and the organic-to-surfactant-ratio (RO/S) were evaluated in the range of 1-90 and 1-10 wt %, respectively. The study was carried out with an organic phase (OP) consisting of an acetone/glycerol mixture containing TBZ at a concentration of 5.4 wt % and Tween 80 (TW80) as a nonionic and Agnique BL1754 (AG54) as a mixture of nonionic and anionic surfactants. The process involved a large dilution of a bicontinuous microemulsion (ME) into an aqueous phase (AP). Pseudo-ternary phase diagrams of the OP//TW80//AP and OP//AG54//AP systems at T = 25 °C were determined to map ME regions; these were in the range of 0.49-0.90, 0.01-0.23, and 0.07-0.49 of OP, AP, and surfactant, respectively. Optical microscope images helped confirm ME formation and system viscosity was measured in the range of 25-147 cP. NEs with drop sizes about 9 nm and 250 nm were achieved with TW80 and AG54, respectively. An innovative low-energy method was used to develop nanopesticide TBZ formulations based on nanoemulsion (NE) technology. The surface tension of the studied systems can be lowered 50% more than that of pure water. This study's proposed low-energy NE formulations may prove useful in sustainable agriculture. Jónsdóttir et al. (2016) developed a series of physiologically based toxicokinetic (PBTK) models for tebuconazole in four species, rat, rabbit, rhesus monkey, and human. The developed models were analyzed with respect to the application of the models in higher tier human risk assessment, and the prospect of using such models in risk assessment of cumulative and aggregate exposure is discussed. Relatively simple and biologically sound models were developed using available experimental data as parameters for describing the physiology of the species, as well as the absorption, distribution, metabolism, and elimination (ADME) of tebuconazole. The developed models were validated on in vivo half-life data for rabbit with good results, and on plasma and tissue concentration-time course data of tebuconazole after i.v. administration in rabbit. In most cases, the predicted concentration levels were seen to be within 434 a factor of 2 compared to the experimental data, which is the threshold set for the use of PBTK simulation results in risk assessment. An exception to this was seen for one of the target organs, namely, the liver, for which tebuconazole concentration was significantly underestimated, a trend also seen in model simulations for the liver after other nonoral exposure scenarios. Possible reasons for this are discussed in the article. Realistic dietary and dermal exposure scenarios were derived based on available exposure estimates, and the human version of the PBTK model was used to simulate the internal levels of tebuconazoleand metabolites in the human body for these scenarios. By a variant of the models where the R(-)- and S(+)-enantiomers were treated as two components in a binary mixture, it was illustrated that the inhibition between the two tebuconazole enantiomers did not affect the simulation results for these realistic exposure scenarios. The developed models have potential as an important tool in risk assessment. Lv et al. (2016) compared the removal of both pesticides by four commonly used wetland plants, Typha latifolia, Phragmites australis, Iris pseudacorus and Juncus effusus, and aimed to understand the removal mechanisms involved. The plants were individually exposed to an initial concentration of 10 mg/L in hydroponic solution. At the end of the 24-day study period, the tebuconazole removal efficiencies were relatively lower (25%-41%) than those for imazalil (46%-96%) for all plant species studied. The removal of imazalil and tebuconazole fit a firstorder kinetics model, with the exception of tebuconazole removal in solutions with I. pseudacorus. Changes in the enantiomeric fraction for imazalil and tebuconazole were detected in plant tissue but not in the hydroponic solutions; thus, the translocation and degradation processes were enantioselective in the plants. At the end of the study period, the accumulation of imazalil and tebuconazole in plant tissue was relatively low and constituted 2.8-14.4% of the total spiked pesticide in each vessel. Therefore, the studied plants were able to not only take up the pesticides but also metabolise them. Sancho et al. (2016) monitored the effect of the fungicide tebuconazole (0.41, 0.52, 0.71 and 1.14mg/L) on survival, reproduction and growth of Daphnia magna organisms using 14 and 21 days exposure tests. A third experiment was performed by exposing D. magna to the fungicide for 14 days followed by 7 days of recovery (14+7). In order to test fungicide effects on D. magna, parameters as survival, mean whole body length, mean total number of neonates per female, mean number of broods per female, mean brood size per female, time to first brood/reproduction and intrinsic rate of natural increase (r) were used. Reproduction was seriously affected by tebuconazole. All tebuconazole concentrations tested affected the number of broods per female and day to first brood. At 14-days test, number of neonates per female and body size decreased by concentrations of tebuconazole higher than 0.52mg/L, whereas at 21days test both parameters were affected at all the concentrations tested. Survival of the daphnids after 14 days fungicide exposure did not exhibited differences among experimental and control groups. In this experiment r value was reduced (in a 22%) when animals were exposed to concentrations of 0.71mg/L and 1.14mg/L. Survival of daphnids exposed during 21 days to 1.14mg/L declined, and the intrinsic rate of natural increase (r) decreased in a 30 % for tebuconazoleconcentrations higher than 0.41mg/L. Longevity of daphnids pre-exposed to tebuconazole for 14 days and 7 days in clean water did not show differences from control values and all of them survived the 21 days of the test. However, after 7 days in fungicide free medium animals were unable to restore control values for reproductive parameters and length. The maximum acceptable toxicant concentration (MATC) was calculated using the r values as parameter of evaluation. MATC estimations were 0.61mg/L and 0.46mg/L for 14 and 21 days, respectively. Results showed that the number of neonates per female was the highest sensitive 435 parameter to the effects of tebuconazole on D. magna. On the other hand, a recovery period of 7 days in a free toxicant medium would not be longer enough to reestablish normal reproduction parameters in pre-exposed tebuconazole daphnids. Zhou et al. (2016) showed that TEB could reduce cell viability, disturb normal cell cycle distribution and induce apoptosis of human placental trophoblast cell line HTR-8/SVneo (HTR8). Bcl-2 protein expression decreased and the level of Bax protein increased after TEB treatment in HTR-8 cells. The results demonstrated that this fungicide induced apoptosis of trophoblast cells via mitochondrial pathway. Importantly, we found that the invasive and migratory capacities of HTR-8 cells decreased significantly after TEB administration. TEB altered the expression of key regulatory genes involved in the modulation of trophoblast functions. Taken together, TEB suppressed human trophoblast invasion and migration through affecting the expression of protease, hormones, angiogenic factors, growth factors and cytokines. As the invasive and migratory abilities of trophoblast are essential for successful placentation and fetus development, our findings suggest a potential risk of triazole fungicides to human pregnancy. References: 1. Álvarez-Martín A1, Sánchez-Martín MJ1, Pose-Juan E1, Rodríguez-Cruz MS2. Effect of different rates of spent mushroom substrate on the dissipation and bioavailability of cymoxanil and tebuconazole in an agricultural soil. Sci Total Environ. 2016 Apr 15;550:495-503. 2. Díaz-Blancas V1, Medina DI2, Padilla-Ortega E3, Bortolini-Zavala R4, OlveraRomero M5, Luna-Bárcenas G6. Nanoemulsion Formulations of Fungicide Tebuconazole for Agricultural Applications. Molecules. 2016 Sep 26;21(10). pii: E1271. 3. Jónsdóttir SÓ1, Reffstrup TK1, Petersen A1, Nielsen E1. Physicologically Based Toxicokinetic Models of Tebuconazole and Application in Human Risk Assessment. Chem Res Toxicol. 2016 May 16;29(5):715-34. 4. Lv T1, Zhang Y2, Casas ME3, Carvalho PN4, Arias CA5, Bester K6, Brix H7. Phytoremediation of imazalil and tebuconazole by four emergent wetland plant species in hydroponic medium. Chemosphere. 2016 Apr;148:459-66. 5. Sancho E1, Villarroel MJ1, Ferrando MD2. Assessment of chronic effects of tebuconazole on survival, reproduction and growth of Daphnia magna after different exposure times. Ecotoxicol Environ Saf. 2016 Feb;124:10-17. 6. Zhou J1, Zhang J2, Li F3, Liu J4. Triazole fungicide tebuconazole disrupts human placental trophoblast cell functions. J Hazard Mater. 2016 May 5;308:294-302. 7. http://www.fao.org/fileadmin/templates/agphome/documents/Pests_Pesticides/JMPR/Eva luation94/tebucona.pdf 436 37. Terconazole Terconazole is an antifungal drug used to treat vaginal yeast infection. It comes as a lotion or a suppository and disrupts the biosynthesis of fats in a yeast cell. Wikipedia Molar mass: 532.462 g/mol Formula: C26H31Cl2N5O3 Mechanism of action    Terconazole exert its antifungal activity by disrupting normal fungal cell membrane permeability.. Terconazole inhibits ergosterol synthesis by inhibiting the 14-alpha-demethylase (lanosterol 14-alpha-demethylase), Depletion of ergosterol in fungal membrane disrupts the structure and many functions of fungal membrane leading to inhibition of fungal growth. Pharmacodynamics     Terconazole, a triazole ketal, is found to be highly active in vitro on a wide range of yeasts and mycelium-forming fungi. The in vitro activity depends largely on the medium used. In vitro it is a potent antifungal agent in preventing the morphogenetic transformation of the yeast into the (pseudo)mycelium form of Candida albicans. In vivo terconazole is highly active in topical treatment of various experimental models of dermatophytosis and candidosis. It also possesses moderate oral broad-spectrum activity. No side effects were observed (Van Cutsem et al., 1983). Clinical Pharmacology Absorption –  Following a single intravaginal application of a suppository containing 240 mg 14CTerconazole to healthy women, o approximately 70% (range: 64-76%) of Terconazole remains in the vaginal area during the suppository retention period (16 hours); o approximately 10% (range: 5-16%) of the administered radioactivity was absorbed systemically over 7 days. o Maximum plasma concentrations of Terconazole occur 5 to 10 hours after intravaginal application of the suppository. 437 o Systemic exposure to Terconazole is approximately proportional to the applied dose. o The rate and extent of absorption of Terconazole are similar in patients with vulvovaginal candidiasis (pregnant or non-pregnant) and healthy subjects. Distribution - Terconazole is highly protein bound (94.9%) in human plasma and the degree of binding is independent of drug concentration over the range of 0.01 to 5.0 mcg/mL. Metabolism - Systemically absorbed Terconazole is extensively metabolized (>95%). Elimination –  Across various studies in healthy women, o after single or multiple intravaginal administration of Terconazole,  the mean elimination half-life of unchanged Terconazole ranged from 6.4 to 8.5 hours. o Following a single intravaginal administration of a suppository containing 240 mg 14C-Terconazole to hysterectomized or tubal ligated women,  approximately 3 to 10% (mean ± SD: 5.7 ± 3.0%) of the administered radioactivity was eliminated in the urine and  approximately 2 to 6% (mean ± SD: 4.2 ± 1.6%) was eliminated in the feces during the 7-day collection period. Microbiology Activity in vitro - Terconazole exhibits antifungal activity in vitro against Candida albicans and other Candidaspecies. The MIC values of Terconazole against most Lactobacillus spp. typically found in the human vagina were ≥128 mcg/mL; therefore these beneficial bacteria are not affected by drug treatment. Indications and Usage for Terconazole Terconazole Vaginal Suppositories, 80 mg are indicated for the local treatment of vulvovaginal candidiasis (moniliasis). FDA Approval  April 7, 2004--Taro Pharmaceutical Industries Ltd. (Nasdaq: TARO) reported that its U.S. affiliate has received approval from the U.S. Food and Drug Administration ("FDA") for its Abbreviated New Drug Application ("ANDA") for terconazole vaginal cream, 0.8%.  Taro's terconazole vaginal cream, 0.8% is bioequivalent to Ortho-McNeil Pharmaceutical's Terazol(R) 3 Vaginal Cream 0.8%.  Terconazole cream is a prescription antifungal medication used for the local treatment of vulvovaginal candidiasis (yeast infections). TERAZOL® 7 (terconazole) Vaginal Cream 0.4% is a white to off-white, water washable cream for intravaginal administration containing 0.4% of the antifungal agent terconazole, 438 compounded in a cream base consisting of butylated hydroxyanisole, cetyl alcohol, isopropyl myristate, polysorbate 60, polysorbate 80, propylene glycol, stearyl alcohol, and purified water. TERAZOL® 3 (terconazole) Vaginal Cream 0.8% is a white to off-white, water washable cream for intravaginal administration containing 0.8% of the antifungal agent terconazole, compounded in a cream base consisting of butylated hydroxyanisole, cetyl alcohol, isopropyl myristate, polysorbate 60, polysorbate 80, propylene glycol, stearyl alcohol, and purified water. TERAZOL® 3 (terconazole) Vaginal Suppositories are white to off-white suppositories for intravaginal administration containing 80 mg of the antifungal agent terconazole, in triglycerides derived from coconut and/or palm kernel oil (a base of hydrogenated vegetable oils) and butylated hydroxyanisole. Prescription Products NAME Taro-terconazole Cream DOSAGE Cream STRENGTH ROUTE 0.4 % Vaginal LABELLER MARKETING START Taro Pharmaceuticals, Inc. 2004-09-21 Terazol 3 Suppository 80 mg/1 Vaginal Ortho Mc Neil Janssen 1988-06-27 Pharmaceutical Terazol 3 Cream 8 mg/g Vaginal A S Medication Solutions Terazol 3 Cream 8 mg/g Vaginal Ortho Mc Neil Janssen 1991-02-21 Pharmaceutical Terazol 3 Cream 8 mg/g Vaginal Janssen Pharmaceuticals 1991-02-21 Terazol 3 Suppository 80 mg/1 1991-02-21 Vaginal Janssen Pharmaceuticals 1988-05-24 Terazol 3 Vaginal Cream Cream 0.8% 0.8 % Vaginal Janssen Pharmaceuticals 1992-12-31 Terazol 3 Vaginal Ovules Insert 80mg 80 mg Vaginal Janssen Pharmaceuticals 1991-12-31 1987-12-31 Terazol 7 Cream 4 mg/g Vaginal Janssen Pharmaceuticals Terazol 7 Cream 4 mg/g Vaginal Ortho Mc Pharmaceuticals Neil 1988-06-27 Generic Prescription Products NAME DOSAGE Terconazole Cream MARKETING STRENGTH ROUTE LABELLER START 4 mg/g Vaginal E. Fougera & CO., A division of 2005-02-18 Fougera Pharmaceuticals Inc. Terconazole Cream 8 mg/g Vaginal Taro Pharmaceuticals U.S.A., Inc. 2004-04-06 Terconazole Cream 4 mg/g Vaginal Physicians Total Care, Inc. 2010-08-24 Terconazole Suppository 80 mg/1 Vaginal Perrigo New York Inc. 2006-08-28 Terconazole Suppository 80 mg/1 Vaginal Gw Pharmaceuticals Ltd. 2015-09-25 Terconazole Suppository 80 mg/1 Vaginal Taro Pharmaceuticals U.S.A., Inc. 2007-03-09 Terconazole Cream 4 mg/g Vaginal A S Medication Solutions 2005-01-19 Terconazole Cream 4 mg/g Vaginal Rebel Distributors 2005-01-19 Terconazole Cream 8 mg/g Vaginal Physicians Total Care, Inc. 2004-11-18 Terconazole Cream 8 mg/g Vaginal A S Medication Solutions 2004-04-06 439 441 Terconazole brand names Jean Bartek, in xPharm: The Comprehensive Pharmacology Reference, 2007 Fungistat; Ginconazol; Gyno-Fungistat; Gyno-Fungix; Gyno-Terazol (FM); Gyno-Terazol; Terazol (FM); Terazol; Tercospor; Terconazole; Piperazine,1-(4-((2-(2,4-dichlorphenyl)-2-(1H1,2,4-triazol-1-ylmethyl)-1,3-dioxalan-4-yl)methyl)-, cis-; 1 [4 [[2 (2,4 dichlorophenyl) 2 (1h 1,2,4 triazol 1 ylmethyl) 1,3 dioxolan 4 yl]methoxy]phenyl] 4 isopropylpiperazine; fungistat; r 42,470; r 42470; r42,470; r42470; terazol; tercospor; triaconazole Recent reports Abdelbary et al. (2016) encapsulated terconazole (TCZ), a water insoluble antifungal drug, into novel ultradeformable bilosomes (UBs) for achieving enhanced ocular delivery. In addition to the constituents of the conventional bilosomes; namely, Span 60, cholesterol, and the bile salts, UBs contain an edge activator which imparts extra elasticity to the vesicles and consequently hypothesized to result in improved corneal permeation. In this study, TCZ loaded UBs were prepared utilizing ethanol injection method according to 23 full factorial design. The investigation of the influence of different formulation variables on UBs properties and selection of the optimum formulation was done using Design-Expert® software. The selected UBs formulation (UB1; containing 10mg bile salt and 5mg Cremophor EL as an edge activator) showed nanosized spherical vesicles (273.15±2.90nm) and high entrapment efficiency percent (95.47±2.57%). Results also revealed that the optimum UBs formulation exhibited superior ex vivo drug flux through rabbit cornea when compared with conventional bilosomes, niosomes, and drug suspension. Furthermore, in vivo ocular tolerance and histopathological studies conducted using male albino rabbits proved the safety of the fabricated UBs after topical ocular application. Overall, the obtained results confirmed that UBs could be promising for ocular drug delivery. Elnaggar et al. (2016) investigated the relevance of novel lecithin-integrated liquid crystalline nano-organogels (LCGs) to improve physicochemical characteristics of Tr in order to enable its dermal application in skin candidiasis. Ternary phase diagram was constructed using lecithin/capryol 90/water to identify the region of liquid crystalline organogel. The selected organogel possessed promising physicochemical characteristics based on particle size, rheological behavior, pH, loading efficiency, and in vitro antifungal activity. Microstructure of the selected organogel was confirmed by polarized light microscopy and transmission electron microscopy. Ex vivo and in vivo skin permeation studies revealed a significant 4.7- and 2.7-fold increase in the permeability of Tr-loaded LCG when compared to conventional hydrogel. Moreover, acute irritation study indicated safety and compatibility of liquid crystalline organogel to the skin. The in vivo antifungal activity confirmed the superiority of LCG over the conventional hydrogel for the eradication of Candida infection. Overall, lecithin-based liquid crystalline organogel confirmed its potential as an interesting dermal nanocarrier for skin targeting purpose. Ting et al. (2015) compared the efficacy and safety of a 6-day course of a terconazole vaginal suppository (80 mg) with two doses of oral fluconazole (150 mg) for the treatment of severe 441 vulvovaginal candidiasis (SVVC). In this prospective, randomized case-control study, 140 consecutive patients with SVVC were enrolled at the Department of Obstetrics and Gynecology of Peking University Shenzhen Hospital from July 1, 2013, through June 31, 2014. Patients with SVVC, initially at a 1:1 ratio, were randomly assigned to receive treatment with either the terconazole vaginal suppository or oral fluconazole. The patients had follow-up visits at 7–14 days and 30–35 days following the last dose of therapy. The clinical cure rates in the terconazole group and the fluconazole group were, respectively, 81.0% (47/58) and 75.8% (50/66) at followup day 7–14 and 60.3% (35/58) and 56.1% (37/66) at day 30–35. The mycological cure rates in the two groups were, respectively, 79.3% (46/58) and 71.2% (47/66) at follow-up day 7–14 and 62.1% (36/58) and 53.0% (35/66) at day 30–35 (P> .05 for all). Local irritation was the primary adverse event associated with terconazole, whereas systemic side effects were associated with fluconazole; however, these effects were minimal. Li et al. (2015) compared the efficacy and safety of a 6-day course of a terconazole vaginal suppository (80 mg) with two doses of oral fluconazole (150 mg) for the treatment of severe vulvovaginal candidiasis (SVVC). In this prospective, randomized case-control study, 140 consecutive patients with SVVC were enrolled at the Department of Obstetrics and Gynecology of Peking University Shenzhen Hospital from July 1, 2013, through June 31, 2014. Patients with SVVC, initially at a 1:1 ratio, were randomly assigned to receive treatment with either the terconazole vaginal suppository or oral fluconazole. The patients had follow-up visits at 7-14 days and 30-35 days following the last dose of therapy. The clinical cure rates in the terconazole group and the fluconazole group were, respectively, 81.0% (47/58) and 75.8% (50/66) at follow-up day 7-14 and 60.3% (35/58) and 56.1% (37/66) at day 30-35. The mycological cure rates in the two groups were, respectively, 79.3% (46/58) and 71.2% (47/66) at follow-up day 7-14 and 62.1% (36/58) and 53.0% (35/66) at day 30-35 (P > .05 for all). Local irritation was the primary adverse event associated with terconazole, whereas systemic side effects were associated with fluconazole; however, these effects were minimal. This study demonstrated that a terconazolevaginal suppository (80 mg daily for 6 days) was as effective as two dose of oral fluconazole (150 mg) in the treatment of patients with SVVC; as such, terconazole could be a choice for therapy of this disorder. References 1. Abdelbary AA1, Abd-Elsalam WH1, Al-Mahallawi AM2. Fabrication of novel ultradeformable bilosomes for enhanced ocular delivery of terconazole: In vitro characterization, ex vivo permeation and in vivo safety assessment. Int J Pharm. 2016 Nov 20;513(1-2):688-696 2. Elnaggar YS1, Talaat SM2, Bahey-El-Din M3, Abdallah OY2. Novel lecithin-integrated liquid crystalline nanogels for enhanced cutaneous targeting of terconazole: development, in vitro and in vivo studies. Int J Nanomedicine. 2016 Oct 25;11:5531-5547. 3. Ting Li, Yuxia Zhu, Shangrong Fan, Xiaoping Liu, Huicong Xu, Yiheng Liang; A randomized clinical trial of the efficacy and safety of terconazole vaginal suppository versus oral fluconazole for treating severe vulvovaginal candidiasis, Medical Mycology, Volume 53, Issue 5, 1 June 2015, Pages 455–461, https://doi.org/10.1093/mmy/myv017 4. Li T1, Zhu Y1, Fan S2, Liu X3, Xu H3, Liang Y4. A randomized clinical trial of the efficacy and safety of terconazole vaginal suppository versus oral fluconazole for treating severe vulvovaginal candidiasis. Med Mycol. 2015 Jun;53(5):455-61. 442 38. Thiabendazole (Tiabendazole)   Thiabendazole [2-(4-thiazolyl)benzimidazole] is a systemic fungicide which translocates through the cuticle and across leaves. Thiabendazole, Originally, was developed as an anthelminthic for treating round worm infestations in humans and livestock. Chemical Names: Thiabendazole; 148-79-8; T... Molecular Formula: C10H7N3S Mode of action  Thiabendazole is a systemic fungicide with protective and curative activity. It inhibits mitosis by binding to tubuline and thus severely impairs fungal growth and development.  Thiabendazole forms a protective deposit on the treated surface of leaves, flowers, fruits and tubers. USAGE  Thiabendazole is used as a fungicide to control green mould, blue mould, and stem end rot on citrus fruits.  Thiabendazole controls Cercospora leaf spot on sugar beets; crown rot on bananas; blue mold rot, bully eye rot, and gray mold on apples and pears; black rot, scurf and foot rot on sweet potatoes; and to control Fusarium (dry rot) in potato storage.  Thiabendazole can be used on soybeans to reduce the severity of pod and stem blight such as anthracnose, brown spot, frogeye leaf spot and purple stain. Environmental fate .  Thiabendazole does not hydrolyze readily, nor is it metabolized in soil under aerobic or anaerobic conditions.  Thiabendazole is unlikely to contaminate ground water. Pharmacokinetics 443    In humans: approximately 87% of an administered oral dose was excreted in the urine (84% in the first 24 hours), 7% in the feces over the course of 5 days. Thus, humans appeared to absorb at least 87% of a single oral dose of thiabendazole. In rats, 70% of an absorbed oral dose was excreted in the urine, virtually all within 24 hours. The principal urinary metabolites (69-79%) were 5-hydroxythiabendazole as the sulfate and the glucuronide. Thiabendazole did not concentrate in the tissues of cattle, goats, pigs or sheep, and o virtually all of the administered doses were excreted in the first 24 hours, principally in the urine. o Peak plasma concentrations were found about 1 hour after treatment. o Only an average of 7% of the thiabendazole was excreted in the feces during the 5 day observation period. o Unaltered thiabendazole was not present in measurable levels in the urine. . Acute toxicity Thiabendazole concentrate (60% thiabendazole) have an oral LD50 in rats of 5 g/kg, and 7.4 g/kg in mice.  Thiabendazole 50% concentrate had an oral LD50 in rats of 13.5 g/kg.  Thiabendazole 25% wettable powder had an oral LD50 in rats of 12.62 g/kg, a dermal LD50 in rabbits greater than 4 g/kg, and an inhalation LC50 in rats greater than 145 mg/L.  Thiabendazole 1- day lowest observed effect level (LOEL) for clinical signs in humans was 25 mg/kg.  Thiabendazole 1-day no observed effect level (NOEL) for clinical signs and blood chemistry changes in humans was 3.3 mg/kg-day.  Thiabendizole did not cause dermal sensitization in the guinea pig, and it did not cause dermal irritation in rabbits. Subchronic Toxicity The principal target organs of thiabendazole in short term, repetitive dosing studies were the liver, the kidney, and the thyroid.  The 98-day oral gavage NOEL in rats for hepatotoxicity and changes in hematology was 25 mg/kg-day. In a 14 week dietary study, the NOEL for hepatotoxicity and thyrotoxicity in rats was 10 mg/kg-day. Chronic Toxicity/Oncogenicity The principal effects of chronic exposure to thiabendazole were thyroid toxicity, hepato/biliary toxicity, anemia and atrial thrombosis. 444 Brands Recent reports: Peris-Vicente et al. (2016) described micellar liquid chromatographic method to determine thiabendazole (TBZ) and o-phenylphenol in wastewater. The sample was directly injected without any additional treatment other filtration. The pesticides were resolved in <11 min, using a mobile phase of 0.10 M SDS-6% 1-pentanol buffered at pH 3 running through a C18 column at 1 mL/min. The detection was performed by fluorescence at 305/360 and 245/345 nm excitation/emission wavelengths for TBZ and o-phenylphenol, respectively. The method was validated following the directives of the Validation and Peer Review of U.S. Environmental Protection Agency Chemical Methods of Analysis guidelines in terms of selectivity, quantitation range (0.01-0.02 to 2 mg/L), detection limit (0.005-0.008 mg/L), trueness (92.1-104.2%), precision (<13.9%), robustness (<6.6%), and stability under storage conditions. The procedure was applied to the screening of TBZ and o-phenylphenol in wastewater samples from citrus packing plants, agricultural gutters, urban sewage, as well as in influent and effluent wastewater treatment plants. He et al. (2014) developed a rapid and simple method which combines a surface swab capture method and surface-enhanced Raman spectroscopy for recovery and quantitative detection of thiabendazole on apple surfaces. The whole apple surface was swabbed and the swab was vortexed in methanol releasing the pesticide. Silver dendrites were then added to bind the pesticide and used for enhancing the Raman signals. The recovery of the surface swab method was calculated to be 59.4-76.6% for intentionally contaminated apples at different levels (0.1, 445 0.3, 3, and 5 ppm, μg/g per weight). After considering the releasing factor (66.6%) from the swab, the final accuracy of the swab-SERS method was calculated to be between 89.2% and 115.4%. This swab-SERS method is simple, sensitive, rapid (∼10 min), and quantitative enough for QA/QC in plant procedure. This can be extended to detect other pesticides on raw agricultural produce like pears, carrots, and melons etc. Müller et al. (2014) investigated the possibility to detect and monitor the TBZ from the chemically treated bananas and citrus fruits available on Romanian market, using surface enhanced Raman spectroscopy (SERS) with a compact, portable, mini-Raman spectrometer. To assess the potential of the technique for fast, cheap and sensitive detection, we report the first complete vibrational characterization of the TBZ in a large pH and concentration range in conjunction with the density functional theory (DFT) calculations. From the relative intensity of the specific SERS bands as a function of concentration, we estimated a total amount of TZB as 78 mg/kg in citrus fruits, 13 times higher than the maximum allowed by current regulations, whereas in banana fruit the value was in the allowed limit. Zhang et al. (2014) mentioned that Thiabendazole in the substrates incurred from spraying and premixing was translocated to the pileus, stipe, and volva of selected mushrooms. The spraying on the substrates resulted in higher residues of thiabendazole in all three mushrooms than the premixing treatment. For premixing, in the five substrates, half-lives of thiabendazole were found to be 13.6 days for shimeji, 10.0 days for king oyster, 13.7 days for oyster, 19.1 days for sterilized substrate, and 8.4 days for nonsterilized substrate, respectively. For spraying, the longest and shortest half-lives were found to be 19.5 and 8.1 days for the nonsterilized and sterilized substrates, respectively. The residues of thiabendazole in three edible fungi were increased with the incubation days from 3 to 5 to 7. The residues of thiabendazole in king oyster were the highest among the three fungi while those in shimeji and oyster showed similar patterns References: 1. He L1, Chen T, Labuza TP. Recovery and quantitative detection of thiabendazole on apples using a surface swab capture method followed by surface-enhanced Raman spectroscopy. Food Chem. 2014 Apr 1;148:42-6. 2. Müller C1, David L, Chiş V, Pînzaru SC. Detection of thiabendazole applied on citrus fruits and bananas using surface enhanced Raman scattering. Food Chem. 2014 Feb 15;145:814-20. 3. Peris-Vicente J1, Roca-Genovés P2, Tayeb-Cherif K2, Esteve-Romero J2 . Development and validation of a method to determine thiabendazole and o-phenylphenol in wastewater using micellar liquid chromatography-fluorescence detection. Electrophoresis. 2016 Oct;37(19):2517-2521 4. Zhang Z1, Jiang W, Jian Q, Song W, Zheng Z, Ke C, Liu X. Thiabendazole uptake in shimeji, king oyster, and oyster mushrooms and its persistence in sterile and nonsterile substrates. J Agric Food Chem. 2014 Feb 12;62(6):1221-6. 446 39. Tioconazole Synonyms: Thioconazole  Tioconazole is an antifungal medication of the imidazole class used to treat infections caused by a fungus or yeast.  Tioconazole ointments serve to treat women's vaginal yeast infections. Molar mass: 387.711 g/mol Formula: C16H13Cl3N2OS Mode of action Tioconazole is an antifungal medication of the Imidazole class used to treat infections caused by a fungus or yeast. Tioconazole topical (skin) preparations are also available for ringworm, jock itch, athlete's foot, and tinea versicolor or "sun fungus". Tioconazole interacts with 14-alpha demethylase, a cytochrome P-450 enzyme that converts lanosterol to ergosterol, an essential component of the yeast membrane. In this way, tioconazole inhibits ergosterol synthesis, resulting in increased cellular permeability. Pharmacodynamics Tioconazole is a broad-spectrum imidazole antifungal agent that inhibits the growth of human pathogenic yeasts. Tioconazole exhibits fungicidal activity in vitro against Candida albicans, other species of the genus Candida, and against Torulopsis glabrata. Tioconazole prevents the growth and function of some fungal organisms by interfering with the production of substances needed to preserve the cell membrane. This drug is effective only for infections caused by fungal organisms. It will not work for bacterial or viral infections. Pharmacokinetics   Minimal systemic absorption of tioconazole has been demonstrated following the application of 2% vaginal cream, 6% vaginal ointment or a 300mg pessary to women with vaginal candidiasis, 1 or 2% dermal cream to the skin of patients, and 28% nail solution to the forearm skin of volunteers. Animal studies have confirmed minimal systemic exposure after l4C-tioconazole was applied dermally or intravaginally. 447 Toxicity Symptoms of overdose include erythema, stinging, blistering, peeling, edema, pruritus, urticaria, burning, and general irritation of the skin, and cramps.  Therapeutic Trials. Clissold and Heel, 2012  Tioconazole has been studied in relatively large numbers of patients with superficial fungal infections of the skin or vaginal candidiasis and in a smaller number of patients with superficial bacterial infections, onychomycosis or vaginal trichomoniasis.  Open studies in patients with superficial dermatophyte or yeast infections of the skin demonstrated that once or twice daily treatment with topical tioconazole 1% cream resulted in complete (clinical and mycological) cure rates of between 60 and 98% within 2 to 6 weeks.  One study showed that once daily administration was as effective as twice daily administration; if this is confirmed in a few additional trials it will be a worthwhile advantage, simplifying dosage regimens.  In comparative clinical trials in patients with fungal skin infections tioconazole cream was significantly superior to placebo cream and produced rates of cure equivalent to those of alternative imidazole antifungal drugs. Tioconazole cream   Brand Name: Gyne Cure, Trosyd Generic Name: tioconazole Tioconazole cream is applied to the skin to treat :      ringworm of the body (tinea corporis); ringworm of the foot (tinea pedis; athlete's foot); ringworm of the groin (tinea cruris; jock itch); tinea versicolor (sometimes called ``sun fungus''); and yeast infection of the skin (cutaneous candidiasis). Tioconazole-1 6.5 % Vaginal Ointment   Generic Name: tioconazole Brand Names: Monistat-1, Vagistat-1, Trosyd and Gyno-Trosyd Tioconazole-Vaginal Ointment is used to treat vaginal yeast infections. Tioconazole ointment reduces vaginal burning, itching, and discharge that may occur with this condition. 448 Recent reports Castro et al. (2016) performed identification and determination of chlorinated azoles in sludge using liquid chromatography quadrupole time-of-flight and triple quadrupole mass spectrometry platforms. Four antimycotic drugs (tioconazole, TCZ; sertaconazole, STZ; fenticonazole, FTZ and itraconazole, ITZ) and the fungicide imazalil (IMZ) are determined in sludge from sewage treatment plants (STPs) following a bottom-up analytical strategy. First, sludge extracts, obtained under different sample preparation conditions, were analyzed by liquid chromatography (LC) quadrupole time-of-flight (QTOF) mass spectrometry (MS). A non-target search strategy, combined with the use of the chlorine mass filter, permitted to detect several chlorinated pollutants including the above referred azoles, which either had not been previously reported (TCZ, STZ, FTZ and ITZ), or scarcely investigated (IMZ), in this environmental compartment. Then, the sample preparation procedure was validated using standards of these compounds and their sensitive and selective determination was performed by LC-MS/MS, based on a QqQ 449 system. Under final working conditions, quantitative extraction yields were attained with negligible changes in ionization efficiencies between sample extracts and standards; therefore, the above compounds were quantified against authentic standard solutions, with absolute recoveries in the range from 75 to 124%, achieving a limit of quantification of 2ngg-1. Analysis of sludge from 10 municipal STPs demonstrated the ubiquity of the identified chlorinated azoles with average concentrations from 31ngg-1, for IMZ, to more than 200ngg-1, for ITZ. Ribeiro et al. (2016) obtained solid formulations from polymeric nanocapsules and nanoemulsions containing tioconazole, a broad spectrum antifungal drug. Two dehydration methods were used: spray-drying and freeze drying, using lactose as adjuvant (10%, w/v). The liquid formulations had a mean particle size around 206 nm and 182 nm for nanocapsules and nanoemulsions, respectively, and an adequate polydispersity index. Tioconazole content was close to the theoretical amount (1.0 mg/mL). After drying, the content ranged between 98 and 102%with a mean nanometric size of the dried products after redispersion. Scanning electron microscopy showed that the particles are rounded, sphere-shaped for the dried products obtained by spray-drying, and shapeless and irregular shapes for those obtained by freeze-drying. In the microbiological evaluation, all dried products remained active against the yeast Candida albicans when compared to the original systems. The dried products obtained by spray-drying from nanocapsules presented better control of the tioconazole release when compared to the freezedrying products. Carrillo-Muñoz et al. (2015) studied the in vitro antifungal activity profile of amorolfine (AMR), bifonazole (BFZ), clotrimazole (CLZ), econazole (ECZ), fluconazole (FNZ), itraconazole (ITZ), ketoconazole (KTZ), miconazole (MNZ), oxiconazole (OXZ), tioconazole (TCZ) and terbinafine (TRB) against 26 clinical isolates of Scopulariopsis brevicaulis from patients with onychomycosis by means of an standardized microdilution method. Although this opportunistic filamentous fungi was reported as resistant to several broadspectrum antifungals agents, obtained data shows a better fungistatic in vitro activity of AMR, OXZ and TRB (0.08, 0.3, and 0.35 mg/L, respectively) in comparison to that of CLZ (0.47 mg/L), ECZ (1.48 mg/L), MNZ (1.56 mg/L, BFZ (2.8 mg/L), TCZ (3.33 mg/L), KTZ (3.73 mg/L). FNZ (178.47 mg/L) and ITZ (4.7 mg/L) showed a reduced in vitro antifungal activity against S. brevicaulis. Obtained MICs show the low in vitro antifungal susceptibility of S. brevicaulis to topical drugs for onychomycosis management, with exceptions (AMR, OZX and TRB). References 1. Carrillo-Muñoz AJ1, Tur-Tur C, Cárdenes D, Rojas F, Giusiano G. [In vitro antifungal susceptibility profile of Scopulariopsis brevicaulis isolated from onychomycosis]. Rev Esp Quimioter. 2015 Aug;28(4):210-3. 2. Castro G1, Roca M1, Rodríguez I2, Ramil M1, Cela R1. Identification and determination of chlorinated azoles in sludge using liquid chromatography quadrupole time-of-flight and triple quadrupole mass spectrometry platforms. J Chromatogr A. 2016 Dec 9;1476:69-76. 3. Ribeiro RF1, Motta MH2, Härter APG1, Flores FC1, Beck RCR3, Schaffazick SR1, de Bona da Silva C4. Spray-dried powders improve the controlled release of antifungal tioconazole-loaded polymeric nanocapsules compared to with lyophilized products. Mater Sci Eng C Mater Biol Appl. 2016 Feb;59:875-884 451 40. Voriconazole   Voriconazole (Vfend®, Pfizer) is a triazole antifungal medication used to treat serious fungal infections. Voriconazole is used to treat invasive fungal infections that are generally seen in patients who are immunocompromised. These include invasive candidiasis, invasive aspergillosis, and emerging fungal infections. History, Donnelly and De Pauw, 2004         Voriconazole was discovered in the late 1980s. The discovery process was started with the idea of developing an antifungal agent with a spectrum of activity beyond that of fluconazole. Like fluconazole, voriconazole belongs to the triazole class of drugs. It is relatively insoluble in water, so the intravenous formulation contains voriconazole in a sulphobutylether b-cyclodextrin (SBECD) solute to allow for parenteral administration. The clinical development programme included the largest-ever randomised controlled trial in the treatment of invasive aspergillosis. The findings of this trial demonstrated the significantly superior efficacy of a clinical regimen that starts with voriconazole, over standard therapy starting with amphotericin B deoxycholate. Pfizer brought the drug to market as Vfend. A generic version of the tablet form of voriconazole was introduced in the US in 2011 after Pfizer and Mylan settled litigation under the Hatch-Waxman Act; a generic version of the injectable form was introduced in 2012. In Europe patent protection expired in 2011 and pediatric administrative exclusivity expired in Europe in 2016. Chemical name: (AlphaR,betas)-alpha-(2,4-difluorophenyl)-5-fluoro-beta-methyl-alpha(1H-1,2,4-triazol-1ylmethyl)-4-pyrimidineethanol (R-(R*,s*))-alpha-(2,4-difluorophenyl)-5-fluoro-beta-methyl-alpha-(1H-1,2,4-triazol-1ylmethyl)-4-pyrimidineethanol Molar mass: 349.311 g/mol Formula: C16H14F3N5O 451 List of Voriconazole substitutes (brand and generic names): http://www.ndrugs.com Cantex (Cyprus) Fungior Fungior 200 mg Tablet (Lifecare Innovations Pvt. Ltd.) Fungivor (India) Fungivor 200 mg Tablet (Lifecare Innovations Pvt. Ltd.) $ 11.19 FUNGIVOR film-coated tab 200 mg x 4's (Lifecare Innovations Pvt. Ltd.) $ 44.76 Pinup (China) REXTRO REXTRO 200MG INJECTION 1 vial / 1 injection each (Dr Reddy's Laboratories Ltd) $ 29.20 REXTRO 200MG TABLET 1 strip / 4 tablets each (Dr Reddy's Laboratories Ltd) $ 65.20 REXTRO 50MG TABLET 1 strip / 4 tablets each (Dr Reddy's Laboratories Ltd) $ 13.92 Rextro 200mg Tablet (Dr Reddy's Laboratories Ltd) $ 16.30 Rextro 50mg Tablet (Dr Reddy's Laboratories Ltd) $ 3.48 Sandoz Voriconazole (Canada) Sandoz Voriconazole tablet 50 mg (Sandoz Canada Incorporated (Canada)) Sandoz Voriconazole tablet 200 mg (Sandoz Canada Incorporated (Canada)) Vedilozin (Netherlands) VERZ VERZ 200MG INJECTION 1 vial / 1 injection each (Dr Reddy's Laboratories Ltd) $ 29.45 VERZ 200MG TABLET 1 strip / 4 tablets each (Dr Reddy's Laboratories Ltd) $ 64.58 VERZ 50MG TABLET 1 strip / 4 tablets each (Dr Reddy's Laboratories Ltd) $ 13.79 Verz 200mg Tablet (Dr Reddy's Laboratories Ltd) $ 16.15 Verz 50mg Tablet (Dr Reddy's Laboratories Ltd) $ 3.45 Vfend (Argentina, Australia, Austria, Belgium, Belize, Brazil, Canada, Chile, China, Colombia, Costa Rica, Croatia (Hrvatska), Czech Republic, Denmark, El Salvador, Finland, France, Georgia, Germany, Guatemala, Honduras, Hong Kong, Hungary, Iceland, India, Indonesia, Ireland, Israel, Italy, Japan, Luxembourg, Malaysia, Mexico, Netherlands, New Zealand, Nicaragua, Norway, Panama, Peru, Poland, Portugal, Romania, Russian Federation, Serbia, Singapore, Slovakia, Slovenia, South Africa, Spain, Sweden, Switzerland, Taiwan, Tunisia, Turkey, United Kingdom, United States) Injectable; IV / Infusion; Voriconazole 200 mg (Pfizer Limited (Pharmacia India Pvt Ltd)) Tablet, Film-Coated; Oral; Voriconazole 200 mg (Pfizer Limited (Pharmacia India Pvt Ltd)) Tablet, FilmCoated; Oral; Voriconazole 50 mg (Pfizer Limited (Pharmacia India Pvt Ltd)) Tablet; Oral; Voriconazole 200 mg (Pfizer Limited (Pharmacia India Pvt Ltd)) Tablet; Oral; Voriconazole 50 mg (Pfizer Limited (Pharmacia India Pvt Ltd)) VFEND 50 mg x 10's (Pfizer Limited (Pharmacia India Pvt Ltd)) VFEND 200 mg x 10's (Pfizer Limited (Pharmacia India Pvt Ltd)) $ 411.97 VFEND 40 mg/1 mL x 100 mL x 1's (Pfizer Limited (Pharmacia India Pvt Ltd)) VFEND / vial 200 mg x 1's (Pfizer Limited (Pharmacia India Pvt Ltd)) VFEND 50 mg x 2 x 10's (Pfizer Limited (Pharmacia India Pvt Ltd)) VFEND 200 mg x 1's (Pfizer Limited (Pharmacia India Pvt Ltd)) $ 140.07 VFEND 50 mg x 30's (Pfizer Limited (Pharmacia India Pvt Ltd)) VFEND 200 mg x 30's (Pfizer Limited (Pharmacia India Pvt Ltd)) 200 mg x 1's (Pfizer Limited (Pharmacia India Pvt Ltd)) $ 95.59 50 mg x 10's (Pfizer Limited (Pharmacia India Pvt Ltd)) $ 71.61 200 mg x 10's (Pfizer Limited (Pharmacia India Pvt Ltd)) $ 281.10 20 milliliter in 1 vial, single-use (Pfizer Limited (Pharmacia India Pvt Ltd)) 75 milliliter in 1 bottle (Pfizer Limited (Pharmacia India Pvt Ltd)) 30 tablet in 1 bottle (Pfizer Limited (Pharmacia India Pvt Ltd)) VFEND 50 mg x 14's (Pfizer Limited (Pharmacia India Pvt Ltd)) VFEND 200 mg x 14's (Pfizer Limited (Pharmacia India Pvt Ltd)) Vfend 200 mg x 28's (Pfizer Limited (Pharmacia India Pvt Ltd)) $ 886.27 Vfend 200 mg x 30 ml x 1's (Pfizer Limited (Pharmacia India Pvt Ltd)) $ 121.41 Vfend 40 mg/1 mL x 70 mL (Pfizer Limited (Pharmacia India Pvt Ltd)) Vfend 50 mg Tablet (Pfizer Limited (Pharmacia India Pvt Ltd)) $ 0.68 Vfend 200 mg Tablet (Pfizer Limited (Pharmacia India Pvt Ltd)) $ 2.69 VFEND 200 MG INJECTION 1 vial / 2 ML injection each (Pfizer Limited (Pharmacia India Pvt Ltd)) $ 95.59 VFEND 200 MG TABLET 1 strip / 7 tablets each (Pfizer Limited (Pharmacia India Pvt Ltd)) $ 202.67 VFEND 200 MG TABLET 1 strip / 10 tablets each (Pfizer Limited (Pharmacia India Pvt Ltd)) $ 281.10 VFEND 50 MG TABLET 1 strip / 7 tablets each (Pfizer Limited (Pharmacia India Pvt Ltd)) $ 49.17 Vfend FC tab 200 mg 10's (Pfizer Limited (Pharmacia India Pvt Ltd)) Vfend FC tab 50 mg 10's (Pfizer Limited (Pharmacia India Pvt Ltd)) Vfend oral susp 40 mg/mL 70 mL x 1's (Pfizer Limited (Pharmacia India Pvt Ltd)) VFEND FC tab 200 mg 30's (Pfizer Limited (Pharmacia India Pvt Ltd)) VFEND FC tab 50 mg 30's (Pfizer Limited (Pharmacia India Pvt Ltd)) VFEND inj 200 mg 1's (Pfizer Limited (Pharmacia India Pvt Ltd)) VFEND FC tab 452 200 mg 28's (Pfizer Limited (Pharmacia India Pvt Ltd)) $ 959.05 VFEND tab 50 mg x 10's (Pfizer Limited (Pharmacia India Pvt Ltd)) $ 71.61 VFEND tab 200 mg x 10's (Pfizer Limited (Pharmacia India Pvt Ltd)) $ 281.10 VFEND tab 200 mg x 7's (Pfizer Limited (Pharmacia India Pvt Ltd)) $ 202.67 VFEND infusion 200 mg / vial 1's (Pfizer Limited (Pharmacia India Pvt Ltd)) Vfend tablet 200 mg (Pfizer Limited (Pharmacia India Pvt Ltd)) Vfend Tablet 50 mg (Pfizer Limited (Pharmacia India Pvt Ltd)) Vfend tablet, film coated 200 mg/1 (Pfizer Limited (Pharmacia India Pvt Ltd)) Vfend tablet, film coated 50 mg/1 (Pfizer Limited (Pharmacia India Pvt Ltd)) Vfend 200mg Injection (Pfizer Limited (Pharmacia India Pvt Ltd)) $ 47.80 Vfend D.A.C. (Iceland) Vfend I.V. Vfend Injection Vfend Oral Vfend Suspension Vfend Tablets VFEND 特福康 (Hongkong) VFEND film-coated tab 200 mg 14's (Pfizer) VFEND film-coated tab 50 mg 14's (Pfizer)‎ Vfend®‎ VFENDВ®‎ Vhope‎ (India)‎ VHOPE‎ 200MG‎ TABLET‎ 1‎ strip‎ /‎ 4‎ tablets‎ each‎ (Torrent) $ 52.91 VHOPE tab 200 mg x 4's (Torrent) $ 55.56 Vhope 200mg Tablet (Torrent) $ 13.23 Vodask (Netherlands) Volric (Poland) VONAZ (India) 50 mg x 4's (United Biotech) 200 mg x 4's (United Biotech) 200 mg x 1's (United Biotech) VONAZ 200 MG TABLET 1 strip / 4 tablets each (United Biotech) $ 50.00 VONAZ 200MG INJECTION 1 vial / 1 injection each (United Biotech) $ 41.25 VONAZ 50MG TABLET 1 strip / 4 tablets each (United Biotech) $ 49.76 VONAZ tab 50 mg x 4's (United Biotech) VONAZ tab 200 mg x 4's (United Biotech) $ 12.50 Vonaz 50mg Tablet (United Biotech) $ 12.44 VONFUNG NDD VONFUNG NDD INJECTION 1 vial / 1 injection each (Biocon) $ 42.33 Voramol (Netherlands) VORAZE (India) 200 mg x 4's (Natco Pharma Ltd) $ 54.13 200 mg x 1's (Natco Pharma Ltd) $ 40.92 Voraze 200 mg Injection (Natco Pharma Ltd) $ 0.03 VORAZE 200 MG INJECTION 1 vial / 1 ML injection each (Natco Pharma Ltd) $ 42.13 VORAZE 200 MG TABLET 1 strip / 4 tablets each (Natco Pharma Ltd) $ 54.13 VORAZE 50 MG TABLET 1 strip / 4 tablets each (Natco Pharma Ltd) $ 51.90 VORAZE film-coated tab 200 mg x 4's (Natco Pharma Ltd) $ 54.13 Voraze 200mg Injection (Natco Pharma Ltd) $ 42.13 Voraze 200mg Tablet (Natco Pharma Ltd) $ 13.53 Voraze 50mg Tablet (Natco Pharma Ltd) $ 12.98 Vorcum (Venezuela) Voriconazol Voriconazol 200 mg Tablet (Ranbaxy Laboratories Ltd.,) $ 6.75 Voriconazol Actavis (Switzerland) Voriconazol AET (Netherlands) Voriconazol Betapharm (Netherlands) Voriconazol CF (Netherlands) Voriconazol Fresenius Kabi (Netherlands) Voriconazol Genthon (Netherlands) Voriconazol Hexal (Netherlands) Voriconazol Mylan (Netherlands) Voriconazol Orion (Netherlands) Voriconazol Pfizer (Netherlands, Switzerland) Voriconazol Pharmathen (Netherlands) Voriconazol Polpharma (Poland) Voriconazol ratiopharm (Austria, Netherlands) Voriconazol Sandoz (Netherlands, Switzerland) Voriconazol Stada (Netherlands) Voriconazol Synthon (Netherlands) Voriconazol Teva (Netherlands) Voriconazol Tiefenbacher (Netherlands) Voriconazol Zentiva (Switzerland) Voriconazol-Mepha (Switzerland) Voriconazole Accord (Poland) Voriconazole Accord Film-coated tablet 50 mg (Accord Healthcare Ltd (EU)) Voriconazole Accord Film-coated tablet 200 mg (Accord Healthcare Ltd (EU)) Voriconazole Farmaprojects (Netherlands) Voriconazole Glenmark (Poland) Voriconazole Greenstone (United States) Voriconazole Matrix (United States) Voriconazole Mylan (Poland) Voriconazole Sandoz (United States) Voriconazole Stada (Poland) Voriconazole Suspension Voriconazole Synthon (Bulgaria) Voriconazole Tablets Voriconazole Teva (United States) Voriconazole Tiefenbacher (Poland) Voriconazole Zentiva (Poland) Voricostad (Netherlands, Poland) VORIER VORIER 200MG INJECTION 1 vial / 1 ML injection each (Zydus Cadila) $ 40.66 VORIER 200MG TABLET 1 strip / 4 tablets each (Zydus Cadila) $ 53.82 VORIER tab 200 mg x 4's (Zydus Cadila) $ 56.51 Vorier 200mg Tablet (Zydus Cadila) $ 13.45 Vorifast Vorifast 200mg Tablet (Galcare Pharmaceutical Pvt Ltd) $ 3.16 VORIFIT VORIFIT 200MG TABLET 1 strip / 4 tablets each (Intas Pharmaceuticals Ltd) $ 54.95 Vorikonazol PharmaS (Croatia (Hrvatska)) Vorikonazol Pliva (Croatia (Hrvatska)) Vorikonazol Sandoz (Croatia (Hrvatska), Slovenia) VORIMED VORIMED 200MG TABLET 1 strip / 4 tablets each (United Biotech) $ 50.00 VORIMED tab 200 mg x 4's (United Biotech) VORINEON VORINEON 200MG INJECTION 1 vial / 1 ML injection each (Neon Laboratories Ltd) $ 41.11 VORITEK (India) 200 mg x 4's (Cipla) $ 45.71 200 mg x 1's (Cipla) VORITEK 200 MG TABLET 453 1 strip / 4 tablets each (Cipla) $ 48.00 VORITEK 200MG INJECTION 1 vial / 30 ML injection each (Cipla) $ 46.10 VORITEK 50 MG TABLET 1 strip / 10 tablets each (Cipla) $ 29.00 VORITEK film-coated tab 50 mg x 10's (Cipla) $ 30.16 VORITEK film-coated tab 200 mg x 10's (Cipla) $ 114.29 VORITEK film-coated tab 200 mg x 4's (Cipla) $ 45.71 Voritek 200mg Injection (Cipla) $ 1.81 Voritek 200mg Tablet (Cipla) $ 13.20 Voritek 50mg Tablet (Cipla) $ 2.90 VORITOP (India) 50 mg x 4's (Intas) 200 mg x 4's (Intas) VORITOP film-coated tab 50 mg x 4's (Intas) VORITOP film-coated tab 200 mg x 4's (Intas) VORITROL (India) 200 mg x 1's (Lupin Laboratories Ltd.) $ 51.50 Voritrol 200 mg Tablet (Lupin Laboratories Ltd.) $ 13.89 VORITROL 200 MG INJECTION 1 vial / 10 ML injection each (Lupin Laboratories Ltd.) $ 28.77 VORITROL 200 MG TABLET 1 strip / 4 tablets each (Lupin Laboratories Ltd.) $ 31.37 VORITROL tab 50 mg x 4's (Lupin Laboratories Ltd.) $ 13.89 VORITROL tab 200 mg x 4's (Lupin Laboratories Ltd.) $ 60.10 Voritrol 200mg Injection (Lupin Laboratories Ltd.) $ 2.88 Voritrol 200mg Tablet (Lupin Laboratories Ltd.) $ 7.84 Voritrol Inj Voritrol Inj 200 mg Injection (Lupin Laboratories Ltd.) $ 0.05 VORITROP (India) 200 mg x 1's (Intas) $ 43.65 VORITROP 200MG INJECTION 1 vial / 1 injection each (Intas) $ 28.77 VORITROP 200MG TABLET 1 strip / 4 tablets each (Intas) $ 78.73 VORITROP 200MG TABLET 1 strip / 10 tablets each (Intas) $ 128.53 Voritrop 200mg Injection (Intas) $ 28.77 Voritrop 200mg Tablet (Intas) $ 19.68 VORITROP TAB (India) 50 mg x 10's (Intas) $ 31.43 200 mg x 4's (Intas) $ 50.16 VORITROP TAB film-coated tab 50 mg x 10's (Intas) $ 31.43 VORITROP TAB film-coated tab 200 mg x 4's (Intas) $ 50.16 VORIZ (India) 200 mg x 1's (Celon Labs) $ 39.52 200 mg x 4's (Celon Labs) $ 54.29 Voriz 200 mg Injection (Celon Labs) $ 0.03 VORIZ tab 200 mg x 4's (Celon Labs) $ 54.29 Voriz Tab Voriz Tab 200 mg Tablet (Celon Labs) $ 13.57 VORIZEF (India) 200 mg x 1's (Sun) VORIZEF 200MG TABLET 1 strip / 4 tablets each (Sun) $ 54.89 Vorizef 200mg Tablet (Sun) $ 13.72 Vorizef 200mg Injection (Sun) $ 39.18 VORIZEF LYOPHILISED VORIZEF LYOPHILISED 200MG INJECTION 1 vial / 1 injection each (Sun Pharma Laboratories Ltd) $ 39.18 VORIZOL (India) 200 mg x 4's (Natco) $ 50.79 VORIZOL tab 200 mg x 4's (Natco) $ 50.79 Vorizol 200mg Injection (Natco) $ 18.37 Vorizol 200mg Tablet (Natco) $ 14.40 VORIZOL (SUN) VORIZOL 200 MG TABLET 1 strip / 10 tablets each (Sun Pharma Laboratories Ltd) $ 119.05 VORIZOL 50 MG TABLET 1 strip / 4 tablets each (Sun Pharma Laboratories Ltd) $ 36.71 VORIZOL(NATCO) VORIZOL 200 MG INJECTION 1 vial / 2 ML injection each (Natco Pharma Ltd) $ 36.73 VORIZOL 200 MG TABLET 1 strip / 4 tablets each (Natco Pharma Ltd) $ 57.59 VORIZOL 50 MG TABLET 1 strip / 10 tablets each (Natco Pharma Ltd) $ 34.92 Vornal (Croatia (Hrvatska)) VORZU (India) 200 mg x 1 vial x 1's (Ranbaxy Laboratories Ltd.,) $ 37.41 Vorzu 200 mg Tablet (Ranbaxy Laboratories Ltd.,) $ 0.01 VORZU 200MG INJECTION 1 vial / 1 injection each (Ranbaxy Laboratories Ltd.,) $ 37.10 Vorzu 200mg Injection (Ranbaxy Laboratories Ltd.,) $ 37.10 Vosicaz (India) VOSICAZ 200MG INJECTION 1 vial / 10 ML injection each (Glenmark (Critica)) $ 39.72 VOSICAZ 200MG TABLET 1 strip / 4 tablets each (Glenmark (Critica)) $ 47.62 VOSICAZ film-coated tab 200 mg x 4's (Glenmark (Critica)) $ 47.62 Vosicaz 200mg Injection (Glenmark (Critica)) $ 3.97 Vosicaz 200mg Tablet (Glenmark (Critica)) More: Dosage forms. drugbank FORM Injection, powder, for solution ROUTE Intravenous STRENGTH 200 mg Injection, powder, for solution Intravenous 10 mg/mL Injection, powder, lyophilized, for solution Intravenous 10 mg/mL Powder, for solution Intravenous 200 mg Powder, for suspension Oral 3g Powder, for suspension Oral 40 mg/mL Suspension Oral 40 mg/mL 454 FORM ROUTE Tablet Oral STRENGTH 200 mg Tablet Oral 50 mg Tablet Oral 200 mg/1 455 Mechanism of action   Voriconazole selectively inhibits the fungal cytochrome P450-dependent enzyme 14asterol demethylase, thereby interrupting an essential step in ergosterol biosynthesis The drug is about 250-fold more active against the fungal demethylase enzyme than against mammalian P450- dependent steroid hormone biosynthesis. Spectrum of activity     Voriconazole exhibits broad-spectrum activity at concentrations of ≤ 1 mg ⁄ L against the more common fungal pathogens such as Candida spp. (including fluconazole-resistant C. krusei) Voriconazole is fungicidal to Aspergillus spp. as well as to Scedosporium and Fusarium spp. and certain other moulds. Voriconazole also exhibits good activity against less-common clinical isolates, including Acremonium, Alternaria, Bipolaris, Cladophialophora, Curvularia and Chrysosporium spp. , as well as the dimorphic fungi Histoplasma capsulatum, Blastomyces dermatitidis and Coccidioides immitis. Voriconazole has little activity against Sporothrix schenckii and the zygomycetes, such as Mucor, Rhizopus and Absidia spp Pharmacokinetics (PK) of voriconazole, Kadam and Van Den Anker (2016)    Several studies showed a large inter-individual variability on the pharmacokinetics (PK) of voriconazole between children and adults. High PK variability results in either lack of efficacy owing to the underexposure or toxicity because of the overexposure in many patients treated with clinical recommended doses. Various factors have been associated with a large variability in voriconazole exposure following standard dose administration in adults and children. List of the factors affecting the PK of voriconazole Factor Effect on voriconazole PK CYP2C19 genotype ↓ Exposure in CYP2C19*17 genotype patients CYP inducers ↓ Voriconazole exposure ↑ Exposure in CYP2C19*2 and *3 genotype patients 456 Factor Effect on voriconazole PK Co-administration with potent CYP inducers is contraindicated CYP inhibitors ↑ Voriconazole exposure Co-administration with potent CYP inhibitor fluconazole is contraindicated Voriconazole dose ↓ Clearance and ↑ elimination half-life with ↑ voriconazole doses owing to saturation of metabolism Food ↓ Bioavailability when administered with food Oral voriconazole should be administered in a fasted state Body weight ↓ Voriconazole exposure with ↑ body weight in children Voriconazole IV dose should be administered based on a patient‘s body weight ↓ Bioavailability and ↑ clearance in children Age Children need a higher body weight normalized dose as compared with adults Hepatic impairment      ↑ Voriconazole exposure in patients with mild or moderate hepatic impairment ↓ Maintenance dose by 50 % in patients with hepatic impairment Voriconazole can be administered by both intravenous (IV) and oral routes. Oral bioavailability of voriconazole is >90 % Voriconazole is not affected by gastric pH, but it decreases when administered with food. Voriconazole high bioavailability following oral administration allows for an easy switch between oral and intravenous formulations when needed. Following oral administration in the fasting state, voriconazole is rapidly and almost completely absorbed with a mean time to peak plasma concentration of around 1.5 h. The peak plasma concentration and the area under the plasma concentration–time curve (AUC) increase non-linearly with the dose. However, the bioavailability does not change with voriconazole dose, indicating that the decrease in elimination and not the saturation of first-pass metabolism with increasing dose is the contributing factor for non-linear PK . Voriconazole has moderate plasma protein binding (58 %) and a large volume of distribution (~150 L), suggesting extensive tissue distribution. Voriconazole is able to cross the blood–brain and blood–retinal barriers and is therefore recommended for the treatment of central nervous system and ocular fungal infections. 457        Voriconazole is eliminated mainly via hepatic metabolism with less than 2 % of the dose excreted unchanged in the urine. Voriconazole is eliminated mainly via hepatic metabolism with CYP2C19 as the major isoform and CYP3A4 as the minor isoform involved in its metabolism. In the absence of a major metabolic pathway, the minor metabolic pathway becomes the leading pathway for elimination. Voriconazole major metabolite N-oxide accounts for 72 % of all circulating metabolites in the plasma and has no antifungal activity. In vitro studies showed that CYP2C19, CYP3A4, and to a lesser extent CYP2C9 contribute to the oxidative metabolism of voriconazole in human liver microsomes. In vivo studies have indicated that CYP2C19 is the major CYP isoform involved in the metabolism of voriconazole. Non-linear PK owing to the saturation of voriconazole metabolism at higher doses results in a dose-dependent prolongation of terminal elimination half-life. Voriconazole kinetics varies significantly between children and adults. o Children up to ∼12 years of age require higher body weight normalized doses of voriconazole than do adults to attain the similar plasma concentrations. o A dosage of 7 mg/kg every 12 h is currently recommended in children to achieve plasma exposures comparable to those in an adult receiving 4 mg/kg every 12 h. o One possible reason for a higher body weight normalized voriconazole dose for children is higher CYP2C19 metabolic activity in children as compared with adults. Drug Interactions, Kadam and Van Den Anker (2016)  Drug interaction studies conducted during the clinical development of voriconazole showed that the potent CYP inducers significantly reduce the voriconazole exposure, therefore, co-administration of a potent CYP inducer with voriconazole is contraindicated. o Voriconazole exposure is significantly reduced by co-administration of potent CYP inducers such as rifampin, rifabutin, efavirenz, ritonavir, carbamazepine, long-acting barbiturates, and St. John‘s Wort. o Co-administration of CYP inhibitors such as omeprazole, cimetidine, ranitidine, ethinyl estradiol, and erythromycin results in an increase in voriconazole exposure but does not warrant clinical dose adjustments. o Concomitant administration of fluconazole, a potent CYP inhibitor, results in a significant increase in voriconazole exposure.  Therefore, co-administration of voriconazole and fluconazole at any dose is not recommended and close monitoring of voriconazole-related adverse events is required if voriconazole is administered, especially within 24 h of the last dose of fluconazole. 458 o Active drug transporters such as P-gp, organic anion-transporting polypeptides, and breast cancer resistant protein (BCRP), play an important role in drug–drug interactions. PK/PD of Voriconazole in adult and pediatric patients, Kadam and Van Den Anker (2016) Voriconazole efficacy  PK/PD analysis of voriconazole in a murine candidiasis model demonstrated that the treatment efficacy is strongly correlated with the AUC/MFC ratios followed by the percentage of time voriconazole concentration remained above the MFC (T > MFC).  Numerous clinical studies in both adults and children showed optimal antifungal activity, when voriconazole trough concentrations are maintained between 1.0 and 5.5 µg/mL. o Low voriconazole plasma concentrations (<1.0 µg/mL) are associated with treatment failure, o high plasma concentrations (>5.5 µg/mL) are associated with toxicities in both adult and pediatric patients. Retrospective analysis of voriconazole plasma concentrations and efficacy data from 46 pediatric patients showed a strong association between voriconazole trough >1 µg/mL and survival. o Each plasma trough concentration <1 µg/mL is associated with a 2.6-fold increased risk to death. o TDM in 29 pediatric cancer patients with invasive aspergillosis showed that the voriconazole trough concentration <1 µg/mL is more frequently observed in patients with treatment failure (42.1 % in failure vs. 19.7 % in success) .  Voriconazole adverse reactions The most frequently reported adverse events (all causalities) in the therapeutic trials were visual disturbances, fever, rash, vomiting, nausea, diarrhea, headache, sepsis, peripheral edema, abdominal pain, and respiratory disorder. The treatment-related adverse events which most often led to discontinuation of voriconazole therapy were elevated liver function tests, rash, and visual disturbances Voriconazole toxicity  Voriconazole toxicity is associated with voriconazole plasma concentrations. o Higher voriconazole concentrations (trough concentrations >5.5 µg/mL) are associated with an increased risk of adverse drug events such as ocular toxicity, neurological toxicity, and hepatotoxicity. 459 o Voriconazole visual toxicity is also associated with plasma trough concentrations.  Incidences of ocular toxicity increase from 10 % for plasma concentrations of <3 µg/mL to 40 % for voriconazole plasma concentrations >9 µg/mL.  Retrospective analysis of clinical study data from ten clinical trials showed that there is 4.7 % increase in odds of developing visual toxicity with every increase of 1 µg/mL in voriconazole plasma concentrations Current Dosing Regimen, Kadam and Van Den Anker (2016)       Current recommended dosing regimens in adults, teenagers older than 14 years of age, and teenagers aged between 12 and 14 years of age weighing ≥50 kg is 6 mg/kg IV or 400 mg orally every 12 h for the first 24 h as a loading dose followed by 4 mg/kg IV or 200 mg orally every 12 h, as maintenance doses. If patient response is inadequate, oral maintenance dose may be increased from 200 to 300 mg every 12 h. For children aged 2 to <12 years and teenagers aged 12–14 years weighing <50 kg, the voriconazole recommended dose is 9 mg/kg IV for every 12 h for the first 24 h (loading dose) and 8 mg/kg IV twice a day as maintenance doses. The dosing regimen of voriconazole treatment for children <2 years of age varied from 2.5 to 12 mg/kg twice daily based on clinical assessments. Voriconazole tablets or oral suspension should not be given after a meal and there should be at least a 1-h gap between dosing and the meal. Voriconazole has poor water solubility; thus, intravenous voriconazole is complexed to a cyclodextrin molecule to increase aqueous solubility Voriconazole IV administration is not recommended in patients with moderate to severe renal impairment (creatinine clearance <50 mL/min) Therapeutic drug monitoring (TDM)  Voriconazole meets the criteria of a narrow therapeutic index because its trough therapeutic target concentrations only range from 1 to 5 µg/mL.  Voriconazole trough concentrations outside this range are associated with either lack of efficacy or toxicity.  Voriconazole plasma concentrations are unpredictable because of the non-linear PK with wide intra- and inter-individual variability. In addition, dynamic physiological changes in neonates and infants further complicate the PK of voriconazole in this patient population.  TDM in voriconazole treatment showed successful outcomes in the management of IFI in pediatric and adult patients.  Recently published guidelines by the Infectious Disease Society of America for the treatment of IA using voriconazole support the use of TDM.  Success of TDM depends on the quality of analytical methods used for the measurement of drug concentrations in a clinical time frame.  High oral bioavailability of voriconazole in adults allows for easy switching between oral and IV formulations when clinically indicated. However, children exhibit 461  significantly reduced bioavailability (50 %) as compared with adults (90 %). Thus, switching from IV to oral dosing in pediatric patients would expose them to suboptimal voriconazole concentrations. According to European recommendations, a fixed 200-mg oral dose should be given twice daily in all children aged 2–12 years, irrespective of age or weight Recent reports Nitin et al. (2017) fabricated 0.5% w/w voriconazole transdermal spray for fungal infection. The transdermal spray was generated by using a film forming polymers like Eudragit RLPO and ethyl cellulose (1:2 ratios) along with eutectic camphor: menthol (1:1) mixture used as a penetration enhancer. The formulation optimized by constrained 32 factorial design. Regression analysis and response surface methodology were used to optimize the effect of polymers and formulate checkpoint batch based on overlay plots. The transdermal spray was subjected to evaluate parameters related to formulation and containers. The concentration of Eudragit RLPO and ethyl cellulose was showed influence on viscosity as well as t50. Diffusion study was showed 75% of voriconazole transport with 65.8 μgcm−2 h−1 fluxes. Penetration enhancers‘ had shown an increase in 1.68 fold of the penetration of voriconazole through the formulation. The study was concluded that fabricated film forming voriconazole transdermal spray formulations penetrate to the deep layer of the skin and was feasible to treat the dermatological fungal infection. This delivery platform is opened a wide range of treatment of fungal infection as compared to conventional formulations. Pana et al. (2017) evaluated the safety of AFP with voriconazole (VRC) in pediatric hematology/oncology patients. A retrospective study of VRC AFP in children with malignancies hospitalized in all 7 Greek pediatric hematology/oncology centers during 2008 to 2012 was conducted. Patients' demographics, outcome, and adverse event (AE) data were recorded. Four hundred twenty-nine VRC AFP courses in 249 patients (median age 6 y, 55% boys) were studied. The most common underlying diseases were acute lymphoblastic leukemia (51%), non Hodgkin lymphoma (8.6%), and acute myeloid leukemia (7.7%). The median number of VRC courses per patient was 1.7, whereas the median VRC dose was 7 mg/kg (range, 5 to 7 mg/kg) every 12 hours. During the last 2 weeks before AFP, 51% of the patients had received corticosteroids, 43% suffered from severe neutropenia, and 17.3% from mucositis. The median duration of VRC AFP was 17 days (range, 1 to 31 d). A single breakthrough fungemia due to Candida glabrata was recorded. Only 1 patient died due to the underlying disease. The most common AEs reported in 70/429 (16.3%) courses with >=1 AE were elevated liver enzymes (50%), hypokalemia (24.3%), and ophthalmological disorders (14.3%). The median time of AE onset was 5 days (range, 1 to 21 d). Among 70 AEs reported, 38.5%, 48.4%, and 12.8% were of grade I, II, and III, respectively. Conclusions: VRC prophylaxis in pediatric hematology/oncology patients appears to be well tolerated. Barajas et al. (2016) described the frequency and clinical presentation of patients presenting with pain and fluoride excess among allogeneic HSCT patients taking voriconazole, to identify when a plasma fluoride concentration was measured with respect to voriconazole initiation and onset of pain, and to describe the outcomes of patients with fluoride excess in the setting of HSCT. A retrospective review was conducted of all adult allogeneic HSCT patients 461 receiving voriconazole at Mayo Clinic in Rochester, Minnesota, between January 1, 2009 and July 31, 2012. Of 242 patients included, 32 had plasma fluoride measured to explore the etiology of musculoskeletal pain. In 31 patients with fluoride measurement while on voriconazole, 29 (93.5%) had elevated levels. The median plasma fluoride was 11.1 μmol/L (range, 2.4 to 24.7). The median duration of voriconazole was 163 days (range, 2 to 1327). The median time to fluoride measurement was 128 days after voriconazole initiation (range, 28 to 692). At 1 year after the start of voriconazoleafter HSCT, 15.3% of patients had developed pain associated with voriconazole use and 35.7% developed pain while on voriconazole after 2 years. Of the patients with an elevated fluoride level, 22 discontinued voriconazole; pain resolved or improved in 15, stabilized in 3, and worsened in 4 patients. Ten patients continued voriconazole; pain resolved or improved in 7, was attributable to alternative causes in 2, and undefined in 1. Serum creatinine, estimated glomerular filtration rate, alkaline phosphatase, and voriconazole concentration did not predict for fluoride excess and associated pain. Periostitis due to fluoride excess is a common adverse effect of voriconazole that should be considered in patients presenting with pain and is often reversible after drug discontinuation. Alternative antifungal agents with a lower risk for fluoride excess should be considered in patients receiving voriconazole who develop fluoride excess and pain. Chuwongwattana et al. (2016) investigated the association of genetic variants of CYP2C19 (CYP2C19*2, CYP2C19*3 and CYP2C19*17 alleles) and voriconazole trough plasma concentrations in Thai patients with invasive fungal infection. A total of 285 samples from patients with invasive fungal infection and treated with voriconazole were prospectively enrolled. At steady state, trough voriconazole concentrations were measured using tandem mass spectrophotometry and high performance liquid chromatography. The genetic variants in the CYP2C19 gene were genotyped for CYP2C19*2 (G681A), CYP2C19*3 (G636A) and CYP2C19*17 (C-806T) on plasma voriconazole level. VoriconazoleCtrough levels were positively associated with CYP2C19*3. The median Ctrough level for patients with the 636GA genotype (2.109, IQR 1.054-4.166 μg/ml) was statistically significantly higher than those with the 636GG genotype (1.596, IQR 0.755-2.980 μg/ml), P = 0.046. The patients with a poor metabolizer (PM; CYP2C19*2/*2, *2/*3) had voriconazole Ctrough level of 1.900 (IQR, 1.1303.673 μg/ml). This was statistically significantly higher than that seen with the extensive metabolizer phenotype (1.470; IQR, 0.632-2.720 μg/ml), P = 0.039. An association between CYP2C19 variant alleles and high voriconazole plasma level was identified. Therefore, determining the CYP2C19 genotype before initiation of voriconazole treatment may be useful in optimizing the dosing regimen in Thai patients with invasive fungal infections. Jin et al. (2016) determined the optimum trough concentration of voriconazole and evaluate its relationship with efficacy and safety. MEDLINE, EMBASE, ClinicalTrials.gov, the Cochrane Library and three Chinese literature databases were searched. Observational studies that compared clinical outcomes below and above the trough concentration cut-off value were included. We set the trough concentration cut-off value for efficacy as 0.5, 1.0, 1.5, 2.0 and 3.0 mg/L and for safety as 3.0, 4.0, 5.0, 5.5 and 6.0 mg/L. The efficacy outcomes were invasive fungal infection-related mortality, all-cause mortality, rate of successful treatment and rate of prophylaxis failure. The safety outcomes included incidents of hepatotoxicity, neurotoxicity and visual disorders. A total of 21 studies involving 1158 patients were included. Compared with voriconazole trough concentrations of >0.5 mg/L, levels of <0.5 mg/L significantly decreased the rate of treatment success (risk ratio = 0.46, 95% CI 0.29-0.74). The incidence of hepatotoxicity was significantly increased with trough concentrations >3.0, >4.0, >5.5 and >6.0 462 mg/L. The incidence of neurotoxicity was significantly increased with trough concentrations >4.0 and >5.5 mg/L. CONCLUSIONS: A voriconazole level of 0.5 mg/L should be considered the lower threshold associated with efficacy. A trough concentration >3.0 mg/L is associated with increased hepatotoxicity, particularly for the Asian population, and >4.0 mg/L is associated with increased neurotoxicity. Kadam and Van Den Anker (2016) mentioned that Voriconazole is a potent antifungal agent used for the treatment of invasive fungal infections caused by Aspergillus and Candida species in adult and pediatric patients. Voriconazole has a narrow therapeutic index and a large intra- and inter-individual pharmacokinetics (PK) variability. Several factors including non-linear PK, age, body weight, cytochrome P450 2C19 genotype, concomitant drugs, liver function, and food are responsible for the large variability in voriconazole PK. A combination of a narrow therapeutic index with a large PK variability results in treatment failure in many patients at clinically recommended doses. There is an urgent need to establish an optimal dosing regimen for pediatric patients <2 years of age because of a lack of recommended dosing guidelines and high (>60 %) treatment failure rates. Therapeutic drug monitoring is commonly used in clinical practice to optimize the voriconazole dosing regimens in pediatric patients, but it is associated with several practical limitations. Implementation of a PK model-guided individualized dose selection will help in reducing the PK variability and will improve therapeutic outcomes. In this review, they have summarized the covariates influencing the PK of voriconazole in adult and pediatric patients, emphasizing that the clearance of voriconazole is significantly different between adult and pediatric patients owing to developmental changes in the major clearance pathways. Moreover, we have provided the limitations of the current dosing regimens and have proposed a new dosing method using a PK model-guided dose individualization of voriconazole in pediatric patients. Luong et al. (2016) searched bibliographic databases for studies on voriconazole serum concentrations and clinical outcomes. We compared success outcomes between patients with therapeutic and subtherapeutic voriconazole serum concentrations, and toxicity outcomes between patients with and without supratherapeutic serum concentrations. Twenty-four studies were analysed. Pooled analysis for efficacy endpoint demonstrated that patients with therapeutic voriconazoleserum concentrations (1.0-2.2 mg/L) were more likely to have successful outcomes compared with those with subtherapeutic voriconazoleserum concentrations (OR 2.30; 95% CI 1.39-3.81). A therapeutic threshold of 1.0 mg/L was most predictive of successful outcome (OR 1.94; 95% CI 1.04-3.62). Patients with therapeutic concentrations did not have better survival rates. Pooled analysis for toxicity endpoint demonstrated that patients with supratherapeutic voriconazole serum concentrations (4.0-6.0 mg/L) were at increased risk of toxicity (OR 4.17; 95% CI 2.08-8.36). A supratherapeutic threshold of 6.0 mg/L was most predictive of toxicity (OR 4.60; 95% CI 1.49-14.16). CONCLUSIONS: Patients with therapeutic voriconazole serum concentrations were twice as likely to achieve successful outcomes. The likelihood of toxicity associated with supratherapeutic voriconazole serum concentrations was 4-fold that of therapeutic concentrations. Our findings suggest that the use of voriconazole TDM to aim for serum concentrations between 1.0 and 6.0 mg/L during therapy may be warranted to optimize clinical success and minimize toxicity. Maertens et al. (2016) carried out a phase 3, double-blind, global multicentre, comparativegroup study. Patients with suspected invasive mould disease were randomised in a 1:1 ratio using an interactive voice-web response system, stratified by geographical region, allogeneic 463 haemopoietic stem cell transplantation, and active malignant disease at baseline, to receive isavuconazonium sulfate 372 mg (prodrug; equivalent to 200 mg isavuconazole; intravenously three times a day on days 1 and 2, then either intravenously or orally once daily) or voriconazole (6 mg/kg intravenously twice daily on day 1, 4 mg/kg intravenously twice daily on day 2, then intravenously 4 mg/kg twice daily or orally 200 mg twice daily from day 3 onwards). We tested non-inferiority of the primary efficacy endpoint of all-cause mortality from first dose of study drug to day 42 in patients who received at least one dose of the study drug (intention-to-treat [ITT] population) using a 10% non-inferiority margin. Safety was assessed in patients who received the first dose of study drug. This study is registered with ClinicalTrials.gov, number NCT00412893. Sebaaly et al. (2016) presented results of a study of the relationship among voriconazole dosages, serum concentrations, adverse effects, and clinical outcomes are presented. A retrospective chart review was conducted that included all patients who had at least one voriconazole concentration drawn between July 1, 2009, and August 15, 2014, at a single academic medical center. The primary outcome was the proportion of patients with initial voriconazole concentrations in the target range. Forty-seven of 88 patients (53%) had an initial voriconazole concentration within the target range, 27% (24 of 88) of patients had a concentration above the range, and 19% (17 of 88) had a concentration below the range. Sixtyseven percent of patients with above-target concentrations had adverse effects. Voriconazole was discontinued in 9% of patients, and dosages were reduced in 11% of patients because of adverse effects. Voriconazole for treatment versus prophylaxis was analyzed in a subgroup, as was obesity and nonobesity. Twenty-four percent of patients died during their hospital admission, and 14% were not discharged on voriconazole therapy. The within-target group had the highest proportion of patients discharged on voriconazole and the lowest proportion of deaths. CONCLUSION: A retrospective study in one institution revealed that the first measured voriconazole concentration was within the target range in 53% of patients and that dosage was modified in only 51% of patients whose concentration was outside of that range. The majority of patients with above-target concentrations had an adverse effect, and this result was particularly common in patients with a body mass index of ≥35 kg/m(2). Smith et al. (2016) reported for the first time a method for the measurement of voriconazole in serum samples using gas chromatography mass spectrometry (GC-MS). Protein precipitation with methanol was used to extract the antifungal that was derivatized with BSTFA (SigmaAldrich, St. Louis, MO) and analyzed by GC-MS. Linearity, sensitivity, precision, accuracy, and drug interferences were evaluated for this assay. Our method was linear up to 10 μg/ml of voriconazole. The LOQ was determined to be 0.4 μg/ml. CV for between-day precision was <12%. Correlation with an established LC-MS/MS yielded a R2 of 0.96. Tested drugs did not result in >10% error in measurement. Vishkautsan et al. (2016) determined pharmacokinetics and adverse effects after voriconazole administration to cats and identify an oral dose of voriconazole for cats that maintains plasma drug concentrations within a safe and effective range. 6 healthy cats. Voriconazole (1 mg/kg, IV) was administered to each cat (phase 1). Serial plasma voriconazole concentrations were measured for 24 hours after administration. Voriconazole suspension or tablets were administered orally at 4, 5, or 6 mg/kg (phase 2). Plasma voriconazoleconcentrations were measured for 24 hours after administration. Pharmacokinetics of tablet and suspension preparations was compared. Finally, an induction 464 dose of 25 mg/cat (4.1 to 5.4 mg/kg, tablet formulation), PO, was administered followed by 12.5 mg/cat (2.05 to 2.7 mg/kg), PO, every 48 hours for 14 days (phase 3). Plasma voriconazole concentration was measured on days 2, 4, 8, and 15. Voriconazole half-life after IV administration was approximately 12 hours. Maximal plasma concentration was reached within 60 minutes after oral administration. A dose of 4 mg/kg resulted in plasma concentrations within the target range (1 to 4 μg/mL). Adverse effects included hypersalivation and miosis. During long-term administration, plasma concentrations remained in the target range but increased, which suggested drug accumulation. CONCLUSIONS AND CLINICAL RELEVANCE: Voriconazole had excellent oral bioavailability and a long half-life in cats. Oral administration of a dose of 12.5 mg/cat every 72 hours should be investigated. Miosis occurred when plasma concentrations reached the high end of the target range. Therefore, therapeutic drug monitoring should be considered to minimize adverse effects Chawla et al. (2015) assessed the correlation of voriconazole levels with CYP2C19 genotype in patients on voriconazoletherapy. Plasma voriconazole estimation was done in seventy-two patients on standard weight based voriconazole therapy by High Performance Liquid Chromatography (HPLC) while genotype assessment for the CYP2C19*2 and *3 was done by PCR-RFLP and *17 by ARMS-PCR. Statistical analysis and genotype-phenotype correlation was done by comparing the drug levels with the CYP2C19 genotype.CYP2C19 polymorphisms influence voriconazole metabolism. A wide variability is seen in plasma levels with only 51% attaining therapeutic levels. The allele frequency of *2, *3 and *17 variant were found to be 33.3, 0.7 and 18% respectively. The drug levels in carriers of *2 allele (poor metabolizers) was twofold higher than that in extensive metabolizers. However, the influence of *2 allele was compromised in presence of *17 allele and patients had low voriconazolelevels. In addition to the genotype, co-medication and clinical condition remarkably influenced voriconazole concentration. CONCLUSION: Plasma voriconazole levels are influenced by CYP2C19 variants, drug interactions and clinical condition of the patient. Genotype assessment at initiation of therapy followed by drug monitoring would help optimizing therapeutic efficacy and minimizing toxicity. Chung et al. (2015) compared the pharmacokinetic and tolerability profiles of SYP-1018 with those of Vfend(®), the marketed formulation of voriconazole. The effect of CYP2C19 polymorphism on the voriconazole pharmacokinetics was also evaluated. An open-label, twotreatment, two-period, two-sequence crossover study was conducted in 52 healthy male volunteers, who randomly received a single intravenous infusion of either of the two voriconazole formulations at 200 mg. Blood samples were collected up to 24 hours after drug administration for pharmacokinetic analysis. The plasma concentrations of voriconazole were determined using liquid chromatography with tandem mass spectrometry, and the pharmacokinetic parameters were estimated using a noncompartmental method. CYP2C19 genotype was identified in 51 subjects. The geometric mean ratio (90% confidence interval) of SYP-1018 to Vfend(®) was 0.99 (0.93-1.04) for the maximum plasma concentrations (Cmax) and 0.97 (0.92-1.01) for the area under the concentration-time curve (AUC) from dosing to the last quantifiable concentration (AUClast). Nineteen homozygous extensive metabolizers (EMs, *1/*1), 19 intermediate metabolizers (IMs, *1/*2 or *1/*3), and ten poor metabolizers (PMs, *2/*2, *2/*3, or *3/*3) were identified, and the pharmacokinetic comparability between SYP-1018 and Vfend(®) was also noted when analyzed separately by genotype. The systemic exposure to voriconazole was greatest in the PM group, followed by the IM, and then the EM groups. Furthermore, the intrasubject variability for Cmax and AUClast 465 was greater in IMs and PMs than in EMs. No serious adverse event occurred, and both treatments were well tolerated. CONCLUSION: SYP-1018 had comparable pharmacokinetic and tolerability profiles to Vfend(®) after a single intravenous infusion. CYP2C19 genotype affected not only the pharmacokinetics of voriconazole, but its intrasubject variability. SYP-1018 can be further developed as a clinically effective alternative to Vfend(®). Elewa et al. (2015) summarized and evaluated evidence from the primary literature that assessed TDM outcomes for voriconazole as well as evaluated the association between CYP2C19 polymorphism and the clinical outcomes of voriconazole. Findings showed associations for both efficacy and safety outcomes with measurement of drug concentrations, yet exact targets or thresholds remain unclear. As such, TDM should be reserved for those patients not responding to therapy with voriconazole or those experiencing adverse drug reactions. Future studies should attempt to further define these populations within controlled settings. Studies that evaluated the effect of CYP2C19 genetic polymorphism on clinical outcomes found no significant relationship between CYP2C19 genotype and hepatotoxicity. These negative findings may be due to lack of power, use of phenotypes not well-defined, and the presence of other interacting factors that may impact voriconazole pharmacokinetics. Future well-designed studies are warranted to confirm these findings. He et al. (2015) evaluated the influence of genetic polymorphisms in CYP3A4, CYP3A5, and CYP2C9 on the plasma concentrations of voriconazole. The study cohort comprised 158 patients with IFIs in whom 22 single-nucleotide polymorphisms (SNPs) in CYP3A4, CYP3A5, and CYP2C9 were genotyped using the Sequenom MassARRAY RS1000 system, and voriconazole plasma concentrations were measured by high-performance liquid chromatography (HPLC). 40, 91, and 27 patients presented with low (<1 mg/L), normal (1-4 mg/L), and high (>4 mg/L) plasma voriconazole concentrations, respectively. Correlation analysis between polymorphisms and the plasma voriconazoleconcentration revealed an association between the presence of the rs4646437 T allele and a higher plasma voriconazole concentration [p = 0.033, odds ratio (OR) = 2.832, 95% confidence interval (CI) = 1.086-7.384]. This study has identified a new SNP related to the metabolism of voriconazole, potentially providing novel insight into the influence of CYP3A4 on the pharmacokinetics of this antifungal agent. Hyatt et al. (2015) described 18 probable and 6 suspected cases of voriconazoletoxicity in six penguin species from nine institutions: 12 African penguins (Spheniscus demersus), 5 Humboldt penguins (Spheniscus humboldti), 3 Magellanic penguins (Spheniscus magellanicus), 2 gentoo penguins (Pygoscelis papua papua), 1 macaroni penguin (Eudyptes chrysolophus), and 1 emperor penguin (Aptenodytes forsteri). Observed clinical signs of toxicity included anorexia, lethargy, weakness, ataxia, paresis, apparent vision changes, seizure-like activity, and generalized seizures. Similar signs of toxicity have also been reported in humans, in whom voriconazole therapeutic plasma concentration for Aspergillus spp. infections is 2-6 μg/ml. Plasma voriconazoleconcentrations were measured in 18 samples from penguins showing clinical signs suggestive of voriconazole toxicity. The concentrations ranged from 8.12 to 64.17 μg/ml, with penguins having plasma concentrations above 30 μg/ml exhibiting moderate to severe neurologic signs, including ataxia, paresis, and seizures. These concentrations were well above those known to result in central nervous system toxicity, including encephalopathy, in humans. This case series highlights the importance of species-specific dosing of voriconazole in penguins and plasma therapeutic drug monitoring. Further investigation, including 466 pharmacokinetic studies, is warranted. The authors determining voriconazole dosages for use in penguin species. recommend caution in Kang et al. (2015) performed a retrospective study of 61 children with hemato-oncologic diseases or solid organ transplantation who were administered voriconazole for invasive fungal infections. Of the 61 patients, 31 (50.8%) were in the therapeutic drug monitoring (TDM) group, and 30 (49.2%) were in the non-TDM group. At 12 weeks, treatment failure rate in the non-TDM group was higher than the TDM group (78.6% versus 40.0%, p = 0.038). Drug discontinuation due to adverse events was less frequent in the TDM group than the non-TDM group (26.0% versus 92.3%, p = 0.001). Children required higher dosages to maintain drug levels within the targeted therapeutic range: an average of 8.3 mg/kg/dose in patients <12 years old and 6.9 mg/kg/dose for those ≥12 years old. Treatment failure rates were higher in patients whose voriconazole levels remained below 1.0 mg/L for more than 50% of their treatment duration than those above 1.0 mg/L (71.4% vs. 9.1% after 12 weeks, p = 0.013). Serial monitoring of voriconazole levels in children is important for improving treatment response and preventing unnecessary drug discontinuation. Higher dosages are needed in children to reach therapeutic range. Malani et al. (2015) mentioned that Voriconazole is an important agent in the antifungal armamentarium. It is the treatment of choice for invasive aspergillosis, other hyaline molds, and many brown-black molds. It is also effective for infections caused by Candida species, including those that are fluconazole resistant, and for infections caused by the endemic mycoses, including those that occur in the central nervous system. It has the advantage of being available in both an intravenous and an oral formulation that is well absorbed. Drawbacks to the use of voriconazole are that it has unpredictable, nonlinear pharmacokinetics with extensive interpatient and intrapatient variation in serum levels. Some of the adverse effects seen with voriconazole are related to high serum concentrations, and, as a result, therapeutic drug monitoring is essential when using this agent. Drug-drug interactions are common, and possible interactions must be sought before voriconazole is prescribed. With prolonged use, newly described adverse effects, including periostitis, alopecia, and development of skin cancers, have been noted. Mori et al. (2015) investigated the pharmacokinetics, safety, and tolerability of voriconazole following intravenous-to-oral switch regimens used with immunocompromised Japanese pediatric subjects (age 2 to <15 years) at high risk for systemic fungal infection. Twenty-one patients received intravenous-to-oral switch regimens based on a recent population pharmacokinetic modeling; they were given 9 mg/kg of body weight followed by 8 mg/kg of intravenous (i.v.) voriconazole every 12 h (q12h), and 9 mg/kg (maximum, 350 mg) of oral voriconazoleq12h (for patients age 2 to <12 or 12 to <15 years and <50 kg) or 6 mg/kg followed by 4 mg/kg of i.v. voriconazole q12h and 200 mg of oral voriconazole q12h (for patients age 12 to <15 years and ≥50 kg). The steady-state area under the curve over the 12-h dosing interval (AUC0-12,ss) was calculated using the noncompartmental method and compared with the predicted exposures in Western pediatric subjects based on the abovementioned modeling. The geometric mean (coefficient of variation) AUC0-12,ss values for the intravenous and oral regimens were 51.1 μg · h/ml (68%) and 45.8 μg·h/ml (90%), respectively; there was a high correlation between AUC0-12,ss and trough concentration. Although the average exposures were higher in the Japanese patients than those in the Western pediatric subjects, the overall voriconazoleexposures were comparable between these two groups due to large 467 interindividual variability. The exposures in the 2 cytochrome P450 2C19 poor metabolizers were among the highest. Voriconazole was well tolerated. The most common treatment-related adverse events were photophobia and abnormal hepatic function. These recommended doses derived from the modeling appear to be appropriate for Japanese pediatric patients, showing no additional safety risks compared to those with adult patients. (This study has been registered at ClinicalTrials.gov under registration no. NCT01383993.). Muto et al. (2015) conducted a population pharmacokinetic (PK) analysis to characterize the voriconazole pharmacokinetic profiles in immunocompromised Japanese pediatric subjects and to compare them to those in immunocompromised non-Japanese pediatric subjects. A previously developed two-compartment pharmacokinetic model with first-order absorption and mixed linear and nonlinear elimination adequately described the voriconazole intravenous and oral data from Japanese pediatric subjects with few modifications. Bayesian priors were applied to this analysis by using the NONMEM routine NWPRI, which allowed priors for the fixedeffect parameter vector and variance matrix of the random-effect parameters to be a normal distribution and an inverse Wishart distribution, respectively. Large intersubject variabilities in oral bioavailability and voriconazole exposure were observed in these pediatric subjects. The mean oral bioavailability estimated in Japanese pediatric subjects was 73% (range, 17% to 99%), which is consistent with the reported estimates of 64% in the previous model and less than what was originally estimated for healthy adults-96%. Voriconazole exposures in Japanese pediatric subjects were generally comparable to those in non-Japanese pediatric subjects receiving the same dosing regimens, given the large intersubject variability. Consistent with the previous findings, the CYP2C19 genotyping status did not have a clinically relevant effect on voriconazoleexposure in Japanese pediatric subjects, although it was identified as a covariate in the model to help explain the intersubject variability in voriconazole exposure. The CYP2C19 genotyping status alone does not warrant dose adjustment of voriconazole. No other factors besides age and weight were identified to explain the PK variability of voriconazole. Niece et al. (2015) examined the effects of five PPIs (rabeprazole, pantoprazole, lansoprazole, omeprazole, and esomeprazole) on voriconazole concentrations using four sets of human liver microsomes (HLMs) of different CYP450 phenotypes. Overall, the use of voriconazole in combination with any PPI led to a significantly higher voriconazole yield compared to that achieved with voriconazole alone in both pooled HLMs (77% versus 59%; P < 0.001) and individual HLMs (86% versus 76%; P < 0.001). The mean percent change in the voriconazole yield from that at the baseline after PPI exposure in pooled microsomes ranged from 22% with pantoprazole to 51% with esomeprazole. Future studies are warranted to confirm whether and how the deliberate coadministration of voriconazole and PPIs can be used to boost voriconazole levels in patients with difficult-to-treat fungal infections. Ona and Oh (2015) determined the photochemistry and photobiology of voriconazole and its major hepatic metabolite, voriconazole N-oxide. Voriconazole and voriconazole N-oxide were spectrophotometrically monitored following various doses of UVB. Cultured human keratinocytes were treated with parental drugs or with their UVB photoproducts, and survival following UVA irradiation was measured by thiazolyl blue metabolism. Reactive oxygen species (ROS) and 8-oxoguanine were monitored by fluorescence microscopy. Voriconazole and voriconazole N-oxide have varying UVB absorption but do not acutely sensitize cultured human keratinocytes following UVB exposure. However, sustained UVB exposures produced notable dose- and solvent-dependent changes in the absorption spectra 468 of voriconazole N-oxide, which in aqueous solution acquires a prominent UVA absorption band, suggesting formation of a discrete photoproduct. Neither the parental drugs nor their photoproducts sensitized cells to UVB although all but voriconazole N-oxide were moderately toxic to cells in the dark. Notably, both voriconazole N-oxide and its UVB photoproduct, but not voriconazole or its photoproduct, additionally sensitized cells to UVA by greater than threefold relative to controls in association with UVA-induced ROS and 8-oxoguanine levels. CONCLUSIONS: Voriconazole N-oxide and its UVB-photoproduct act as UVA-sensitizers that generate ROS and that produce oxidative DNA damage. These results suggest a mechanism for the phototoxicity and photocarcinogenicity observed with voriconazole treatment. Raad et al. (2015) compared the efficacy and safety of caspofungin, voriconazole or the combination as primary and salvage therapy in patients with IA. The study included 181 patients with haematological malignancies and IA who received primary or salvage therapy with caspofungin, voriconazole or the combination. In total, 138 patients who received treatment for ≥7 days were analysed; 86 underwent primary antifungal therapy (15 with caspofungin, 38 with voriconazole and 33 with both). Among the salvage therapy patients, 17 received caspofungin, 24 received voriconazole and 35 received both. In the primary therapy group, no difference in therapy response was found, but caspofungin was associated with higher IA mortality rates. A multivariate competing risk analysis of primary antifungal therapy revealed that voriconazole was independently associated with lower IA-associated mortality rates than caspofungin (hazard ratio=0.2, 95% confidence interval 0.06-0.96; P=0.04). In the salvage therapy group, the three treatment groups had similar responses and IA-associated mortality rates. The combination of voriconazole and caspofungin did not result in better outcomes compared with voriconazole alone, as primary or salvage therapy, in haematological malignancy patients. However, voriconazole was associated with a lower Aspergillus-associated mortality rate compared with caspofungin monotherapy. Sobolewska et al. (2015) asseseds the cytotoxic properties of voriconazole and sulfobutyletherβ-cyclodextrin (SBECD) on cultured primary human corneal epithelial cells. Human corneal epithelial cells were cultured and exposed to various concentrations of SBECD (0.016-32 mg/ml) and voriconazole (0.001-2 mg/ml). Cellular cytotoxicity of SBECD and voriconazole on human corneal epithelial cells was evaluated using the 3-[4,5-dimethylthiazol-2-yl]-2,5diphenyltetrazolium bromide test and the LIVE/DEAD Viability/Cytotoxicity Assay with fluorescence microscopy analysis. Cell damage was assessed with phase-contrast microscopy after 24 h of exposure to SBECD and voriconazole. The cytotoxicity tests and the morphological characteristic demonstrated the dose-dependent toxic effect of SBECD and voriconazole on human corneal epithelial cells. No corneal epithelial cytotoxicity was observed below the concentration of 0.08 and 0.025 mg/ml after 24-hour exposure to SBECD and voriconazole, respectively. CONCLUSIONS: The results of the study reveal the dose-dependent cytotoxic effect of SBECD and voriconazole on cultured human corneal epithelial cells. Therefore, voriconazole eye drops should be used cautiously in the treatment of fungal corneal ulcers. Vanstraelen et al. (2015) compared the pharmacokinetics of voriconazole in saliva with the pharmacokinetics of unbound and total voriconazole in plasma in order to clinically validate saliva as an alternative to plasma in voriconazole TDM. In this pharmacokinetic study, paired plasma and saliva samples were taken at steady state in adult haematology and pneumology patients treated with voriconazole. Unbound and bound plasma voriconazole concentrations were 469 separated using high-throughput equilibrium dialysis. Voriconazole concentrations were determined with liquid chromatography-tandem mass spectrometry. Pharmacokinetic parameters were calculated using log-linear regression. Sixty-three paired samples were obtained from ten patients (seven haematology and three pneumology patients). Pearson's correlation coefficients (R values) for saliva versus unbound and total plasma voriconazole concentrations showed a very strong correlation, with values of 0.970 (p < 0.001) and 0.891 (p < 0.001), respectively. Linear mixed modelling revealed strong agreement between voriconazole concentrations in saliva and unbound plasma voriconazole concentrations, with a mean bias of -0.03 (95 % confidence interval -0.14 to 0.09; p = 0.60). For total concentrations below 10 mg/L, the mean ratio of saliva to total plasma voriconazole concentrations was 0.51 ± 0.08 (n = 63), which did not differ significantly (p = 0.76) from the unbound fraction of voriconazole in plasma of 0.49 ± 0.03 (n = 36). CONCLUSIONS: Saliva can serve as a reliable alternative to plasma in voriconazole TDM, and it can easily be implemented in clinical practice. Wang et al. (2015) assessed the pharmacokinetic and pharmacodynamic (PK/PD) properties of voriconazole and to investigate the relationship between PK/PD parameters and the efficacy of a fixed-dose oral regimen in the treatment of invasive fungal infections (IFIs). Fifteen hospitalized patients with proven IFIs who were treated with oral voriconazole for at least 2 weeks. PK/PD properties of voriconazole were investigated using a noncompartmental analysis in 15 patients. Marked interpatient variation in voriconazole pharmacokinetic properties was noted including peak plasma concentrations (median 2.31 mg/L, range 1.06-4.01 mg/L), 12-hour area under the plasma concentration-time curve (AUCτ ) (median 21.18 hr mg/L, range 7.7142.07 hr mg/L), ratio of the unbound drug AUC over 24 hours (fAUC24 ) divided by the minimum inhibitory concentration (fAUC24 :MIC; median 62.61, range 6.48-415.30), and the free trough plasma concentration (Cmin ) divided by the MIC (fCmin :MIC; median 1.81, range 0.46-15.52). There was a good correlation between voriconazole Cmin and AUCτ (R(2) = 0.805). Voriconazole therapy was effective in 66.7% of patients (10/15). No significant difference was observed with regard to successful clinical response between the patients with a fAUC24 :MIC and fCmin :MIC values higher than 25 and higher than 1 (10/12 vs 10/13, respectively; χ(2) = 1.61, p=0.688). CONCLUSION: There is substantial interpatient variability in the PK/PD properties of voriconazole. fAUC24 :MIC values higher than 25 and fCmin :MIC values higher than 1 may predict clinical response in patients with IFIs. Designing an optimal dosage regimen based on individual PK/PD properties will improve the efficacy in patients with IFIs. Yamada et al. (2015) evaluated metabolic saturation of voriconazole based on the trough plasma concentrations of voriconazole and its major metabolite N-oxide according to CYP2C19 genotypes in 58 Japanese patients receiving voriconazole (median dose; 200 mg twice daily) for prophylaxis or treatment. Predose trough plasma concentrations of voriconazole and N-oxide were monitored on day 5 d or later after initiation of voriconazole treatment. Large interindividual variations in trough plasma concentrations of voriconazole and N-oxide were observed. Dose-normalized trough plasma concentrations of voriconazole were strongly correlated with its absolute trough concentrations, and the straight regression line between them intersected close to the origin of the coordinates. No significant correlation was observed between the trough plasma concentrations of voriconazole and N-oxide. The inverse value of the metabolic ratio of N-oxide to voriconazolewas strongly correlated with the absolute trough voriconazole concentrations. No significant differences in the trough plasma concentrations of voriconazole and N-oxide or the metabolic ratio of N-oxide 471 to voriconazole between the CYP2C19 genotypes were observed. Saturated metabolism of voriconazole N-oxidation rather than CYP2C19 genotypes contributed to the nonlinear pharmacokinetics. The metabolic process converting voriconazole to N-oxide was saturated at the clinical dose. Dolton et al. (2014) investigated the population pharmacokinetics of voriconazole in adults, including the effect of CYP2C19 genotype and drug-drug interactions. Non-linear mixed effects modelling (NONMEM) was undertaken of six voriconazole studies in healthy volunteers and patients. Dosing simulations to examine influential covariate effects and voriconazole target attainment (2-5 mg/L) stratified by CYP2C19 phenotype were performed. They analysed 3352 voriconazole concentration measurements from 240 participants. A two-compartment pharmacokinetic model with first-order oral absorption with lag time and Michaelis-Menten elimination best described voriconazole pharmacokinetics. Participants with one or more CYP2C19 loss-of-function (LoF) alleles had a 41.2% lower Vmax for voriconazole. Coadministration of phenytoin or rifampicin, St John's wort or glucocorticoids significantly increased voriconazole elimination. Among patients receiving 200 mg of voriconazoletwice daily, predicted trough concentrations on day 7 were <2 mg/L for oral and intravenous regimens for 72% and 63% of patients without CYP2C19 LoF alleles, respectively, with 49% and 35% below this threshold with 300 mg twice daily dosing. Conversely, these regimens resulted in 29%, 39%, 57% and 77% of patients with CYP2C19 LoF alleles with voriconazole trough concentrations ≥5 mg/L. CONCLUSIONS: Current dosing regimens for voriconazole result in subtherapeutic exposure in many patients without CYP2C19 LoF alleles, suggesting the need for higher doses, whereas these regimens result in supratherapeutic exposure in a high proportion of patients with reduced CYP2C19 activity. These findings support the essential role of therapeutic drug monitoring in ensuring efficacious and safe voriconazole exposure. Liu and Mould (2014) assessed the pharmacokinetics (PK) of voriconazole and anidulafungin in patients with invasive aspergillosis (IA) in comparison with other populations, sparse PK data were obtained for 305 adults from a prospective phase 3 study comparing voriconazole and anidulafungin in combination versus voriconazole monotherapy (voriconazole, 6 mg/kg intravenously [IV] every 12 h [q12h] for 24 h followed by 4 mg/kg IV q12h, switched to 300 mg orally q12h as appropriate; with placebo or anidulafungin IV, a 200-mg loading dose followed by 100 mg q24h). Voriconazole PK was described by a two-compartment model with first-order absorption and mixed linear and time-dependent nonlinear (Michaelis-Menten) elimination; anidulafungin PK was described by a two-compartment model with first-order elimination. For voriconazole, the normal inverse Wishart prior approach was implemented to stabilize the model. Compared to previous models, no new covariates were identified for voriconazole or anidulafungin. PK parameter estimates of voriconazole and anidulafungin are in agreement with those reported previously except for voriconazole clearance (the nonlinear clearance component became minimal). At a 4-mg/kg IV dose, voriconazoleexposure tended to increase slightly as age, weight, or body mass index increased, but the difference was not considered clinically relevant. Estimated voriconazole exposures in IA patients at 4 mg/kg IV were higher than those reported for healthy adults (e.g., the average area under the curve over a 12-hour dosing interval [AUC0-12] at steady state was 46% higher); while it is not definitive, age and concomitant medications may impact this difference. Estimated anidulafungin exposures in IA patients were comparable to those reported for the general patient population. This study was approved by the 471 appropriate institutional review boards or ethics committees and registered on ClinicalTrials.gov (NCT00531479). Owusu et al. (2014) mentioned that, since its approval by the U.S. Food and Drug Administration in 2002, voriconazole has become a key component in the successful treatment of many invasive fungal infections including the most common, aspergillosis and candidiasis. Despite voriconazole's widespread use, optimizing its treatment in an individual can be challenging due to significant interpatient variability in plasma concentrations of the drug. Variability is due to nonlinear pharmacokinetics and the influence of patient characteristics such as age, sex, weight, liver disease, and genetic polymorphisms in the cytochrome P450 2C19 gene (CYP2C19) encoding for the CYP2C19 enzyme, the primary enzyme responsible for metabolism of voriconazole. CYP2C19 polymorphisms account for the largest portion of variability in voriconazole exposure, posing significant difficulty to clinicians in targeting therapeutic concentrations. In this review, we discuss the role of CYP2C19 polymorphisms and their influence on voriconazole's pharmacokinetics, adverse effects, and clinical efficacy. Wang et al. (2014) determined an optimum voriconazole target concentration, to study the influence of CYP2C19 gene status on metabolism of voriconazole and to identify a doseadjustment strategy for voriconazole according to CYP2C19 polymorphism in patients with invasive fungal infections. A total of 328 voriconazole trough plasma concentrations (C(min)) were collected and monitored from 144 patients. Information on efficacy and safety was obtained. Voriconazole therapy was effective in 81.9% of patients (118/144), and 12.5% (18/144) exhibited signs of hepatotoxicity. The relationships between voriconazole C(min) and clinical response and hepatotoxicity were explored using logistic regression, and a target clinical C(min) range of 1.5-4 mg/L was identified. Values of voriconazole C(min) and the ratio of C(min) to concentration of voriconazole-N-oxide (C(min)/C(N)) of poor metabolisers (PMs) were significantly higher than extensive metabolisers and intermediate metabolisers. Modelbased simulations showed that PM patients could be safely and effectively treated with 200 mg twice daily orally or intravenously, and non-PM patients with 300 mg twice daily orally or 200mg twice daily intravenously. References 1. Barajas MR1, McCullough KB2, Merten JA3, Dierkhising RA4, Bartoo GT2, Hashmi SK5, Hogan WJ5, Litzow MR5, Patnaik MM5, Wilson JW6, Wolf RC2, Wermers RA7. Correlation of Pain and Fluoride Concentration in Allogeneic Hematopoietic Stem Cell Transplant Recipients on Voriconazole. Biol Blood Marrow Transplant. 2016 Mar;22(3):579-83. 2. Chawla PK1, Nanday SR2, Dherai AJ1,2, Soman R3, Lokhande RV2, Naik PR2, Ashavaid TF4,5. Correlation of CYP2C19 genotype with plasma voriconazole levels: a preliminary retrospective study in Indians. Int J Clin Pharm. 2015 Oct;37(5):925-30. 3. Chung H1, Lee H2, Han HK1, An H1, Lim KS3, Lee YJ4, Cho JY1, Yoon SH1, Jang IJ1, Yu KS1. 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The Clinical Significance of Voriconazole Therapeutic Drug Monitoring in Children With Invasive Fungal Infections. Pediatr Hematol Oncol. 2015;32(8):557-67. 12. Lat A, Thompson GR. Update on the optimal use of voriconazole for invasive fungal infections. Infection and drug resistance. 2011;4:43-53. doi:10.2147/IDR.S12714. 13. Liu P1, Mould DR2. Population pharmacokinetic analysis of voriconazole and anidulafungin in adult patients with invasive aspergillosis. Antimicrob Agents Chemother. 2014 Aug;58(8):471826. 14. Luong ML1, Al-Dabbagh M2, Groll AH3, Racil Z4, Nannya Y5, Mitsani D6, Husain S7. Utility of voriconazole therapeutic drug monitoring: a meta-analysis. J Antimicrob Chemother. 2016 Jul;71(7):1786-99. 15. Maertens JA1, Raad II2, Marr KA3, Patterson TF4, Kontoyiannis DP5, Cornely OA6, Bow EJ7, Rahav G8, Neofytos D9, Aoun M10, Baddley JW11, Giladi M12, Heinz WJ13, Herbrecht R14, Hope W15, Karthaus M16, Lee DG17, Lortholary O18, Morrison VA19, Oren I20, Selleslag D21, Shoham S22, Thompson GR 3rd23, Lee M24, Maher RM24, Schmitt-Hoffmann AH25, Zeiher B24, Ullmann AJ26. Isavuconazole versus voriconazole for primary treatment of invasive mould disease caused by Aspergillus and other filamentous fungi (SECURE): a phase 3, randomisedcontrolled, non-inferiority trial. Lancet. 2016 Feb 20;387(10020):760-9 16. Malani AN1, Kerr LE2, Kauffman CA3. Voriconazole: How to Use This Antifungal Agent and What to Expect. Semin Respir Crit Care Med. 2015 Oct;36(5):786-95. 17. Mori M1, Kobayashi R2, Kato K3, Maeda N4, Fukushima K5, Goto H6, Inoue M7, Muto C8, Okayama A9, Watanabe K10, Liu P11. Pharmacokinetics and safety of voriconazole intravenous-to-oral switch regimens in immunocompromised Japanese pediatric patients. Antimicrob Agents Chemother. 2015 Feb;59(2):1004-13. 18. Muto C1, Shoji S2, Tomono Y2, Liu P3. Population pharmacokinetic analysis of voriconazole from a pharmacokinetic study with immunocompromised Japanese pediatric subjects. Antimicrob Agents Chemother. 2015;59(6):3216-23. 19. Niece KL1, Boyd NK2, Akers KS3. In vitro study of the variable effects of proton pump inhibitors on voriconazole. Antimicrob Agents Chemother. 2015 Sep;59(9):5548-54. 20. Nitin Merubhai Mori Priya Patel Navin R. Sheth Lalji V.Rathod Kalpesh ChhotalalAshara. Fabrication and characterization of film-forming voriconazole transdermal spray for the treatment of fungal infection. Bulletin of Faculty of Pharmacy, Cairo University Volume 55, Issue 1, June 2017, Pages 41-51 473 21. Ona K1,2, Oh DH1,2. Voriconazole N-oxide and its ultraviolet B photoproduct sensitize keratinocytes to ultraviolet A. Br J Dermatol. 2015 Sep;173(3):751-9. 22. Owusu Obeng A1, Egelund EF, Alsultan A, Peloquin CA, Johnson JA. CYP2C19 polymorphisms and therapeutic drug monitoring of voriconazole: are we ready for clinical implementation of pharmacogenomics? Pharmacotherapy. 2014 Jul;34(7):703-18 23. Pana, Zoi Dorothea,; Kourti, Maria; Vikelouda, Katerina; Vlahou, Antonia; Katzilakis, Nikolaos; Papageorgiou, Maria; Doganis, Dimitrios; Petrikkos, Loizos MD, PhD; Paisiou, Anna; Koliouskas, Dimitrios; Kattamis, Antonios; Stiakaki, Eftichia; Chatzistilianou, Maria; VasilatouKosmidis, Helen; Polychronopoulou, Sophia; Grafakos, Stelios; Roilides, Emmanuel. Voriconazole Antifungal Prophylaxis in Children With Malignancies: A Nationwide Study. Journal of Pediatric Hematology/Oncology: Post Author Corrections: August 14, 2017 24. Raad II1, Zakhem AE2, Helou GE2, Jiang Y2, Kontoyiannis DP2, Hachem R2. Clinical experience of the use of voriconazole, caspofungin or the combination in primary and salvage therapy of invasive aspergillosis in haematological malignancies. Int J Antimicrob Agents. 2015 Mar;45(3):283-8. 25. Sandherr M, Maschmeyer G. Pharmacology and metabolism of voriconazole and posaconazole in the treatment of invasive aspergillosis-review of the literature. European Journal of Medical Research. 2011;16(4):139-144. doi:10.1186/2047-783X-16-4-139.\ 26. Sebaaly JC1, MacVane SH2, Hassig TB3. Voriconazole concentration monitoring at an academic medical center. Am J Health Syst Pharm. 2016 Mar 1;73(5 Suppl 1):S14-21. 27. Smith A1, Leung-Pineda V2. Determination of Voriconazole Concentrations in Serum by GC-MS. J Clin Lab Anal. 2016 Sep;30(5):411-7. 28. Sobolewska B1, Guerel G, Hofmann J, Tarek B, Bartz-Schmidt KU, Yoeruek E. Cytotoxic Effect of Voriconazole on Human Corneal Epithelial Cells. Ophthalmic Res. 2015;54(1):41-7. 29. Vanstraelen K1, Maertens J2, Augustijns P3, Lagrou K4, de Loor H5, Mols R3, Annaert P3, Malfroot A6, Spriet I7. Investigation of Saliva as an Alternative to Plasma Monitoring of Voriconazole. Clin Pharmacokinet. 2015 Nov;54(11):1151-60. 30. Vishkautsan P, Papich MG, Thompson GR 3rd, Sykes JE. Pharmacokinetics of voriconazole after intravenous and oral administration to healthy cats. Am J Vet Res. 2016 Sep;77(9):931-9. 31. Wang T1, Zhu H2, Sun J1, Cheng X3, Xie J1, Dong H1, Chen L4, Wang X5, Xing J6, Dong Y7. Efficacy and safety of voriconazole and CYP2C19 polymorphism for optimised dosage regimens in patients with invasive fungal infections. Int J Antimicrob Agents. 2014 Nov;44(5):436-42. 32. Wang T1, Xie J1, Wang Y1, Zheng X1, Lei J2, Wang X3, Dong H1, Yang Q1, Chen L4, Xing J5, Dong Y1. Pharmacokinetic and Pharmacodynamic Properties of Oral Voriconazole in Patients with Invasive Fungal Infections. Pharmacotherapy. 2015 Sep;35(9):797-804 33. Yamada T1, Mino Y, Yagi T, Naito T, Kawakami J. Saturated Metabolism of Voriconazole NOxidation Resulting in Nonlinearity of Pharmacokinetics of Voriconazole at Clinical Doses. Biol Pharm Bull. 2015;38(10):1496-503. 37. Zabalza A, Gorosquieta A, Equiza EP, Olavarria E. Voriconazole and its clinical potential in the prophylaxis of systemic fungal infection in patients with hematologic malignancies: a perspective review. Therapeutic Advances in Hematology. 2013;4(3):217-230. 474 7.4. Allylamine Derivatives            The allylamines are antifungal agents with exceptionally high activity against dermatophytes and rather variable against yeasts such as Candida species Allylamines act as potent selective inhibitors of fungal squalene epoxidase via a novel mechanism, which does not depend on cytochrome P450 Niftifine is an Allylamine derivative, discovered by accident after acid hydrolysis of heterocyclic spiro-naphtalenones, and its antifungal activity was discovered during routine screening. Naftifine provided the starting point for synthetic modifications aimed at the development of more potent, orally active compounds. many related compounds synthesized were found to have considerable antifungal activity. They are collectively termed allylamine dericatives, reflecting the fundamental importance of this structural feature for biological activity. The exploration of structure-activity relationships on the basis of naftifine and new synthetic strategies led to the discovery of the currently most active compound of this type, terbinafine, Terbinafine is the first pharmaceutical agent to contain a (E)-1, 3-enyne structural element. Terbinafine exhibits considerably higher activity than the original ―lead‖ structure naftifine both in vitro and in vivo; Terbinafine is active against a wider range of fungi including Aspergillus, Histoplasma, and Candida species. Terbinafine is most active against dermatophytes Terbinafine is also up to one order of magnitude more effective than standard preparations in various chemotherapeutic animal tests after topical or oral administration. According to clinical experience gained so far, Terbinafine is well tolerated and shows promising activity against various types of mycoses.. , 475 1. Naftifine Synonyms: Naftifine; Naftifin; 65472-88-0; Naftifinum; Naftifina; Naftifinum [INN-Latin]     Naftifine is a synthetic, broad spectrum, antifungal agent and allylamine derivative for the topical treatment of tinea pedis, tinea cruris, and tinea corporis caused by the organisms Trichophyton rubrum, Trichophyton mentagrophytes, Trichophyton tonsurans and Epidermophyton floccosum. Naftifine can be fungicidal or fungistatic depending on the concentration and the organisms involved. Naftifine has triple action: antifungal, antibacterial and anti-inflammatory Formula: C21H21N Indication For the topical treatment of tinea pedis, tinea cruris, and tinea corporis caused by the organisms Trichophyton rubrum, Trichophyton mentagrophytes, Trichophyton tonsurans and Epidermophyton floccosum. Mechanism of action Although the exact mechanism of action against fungi is not known, naftifine appears to interfere with sterol biosynthesis by inhibiting the enzyme squalene 2,3-epoxidase. This inhibition of enzyme activity results in decreased amounts of sterols, especially ergosterol, and a corresponding accumulation of squalene in the cells. Pharmacodynamics  Naftifine is a synthetic, broad spectrum, antifungal agent and allylamine derivative.  Naftifine has been shown to exhibit fungicidal activity in vitro against a broad spectrum of organisms including Trichophyton rubrum, Trichophyton mentagrophytes, Trichophyton tonsurans, Epidermophyton floccosum, 476 and Microsporum canis, Microsporum audouini, and Microsporum gypseum; and fungistatic activity against Candida species including Candida albicans. Absorption Following single topical applications of 3H-labeled naftifine gel 1% to the skin of healthy subjects, up to 4.2% of the applied dose was absorbed. Route of elimination Naftifine and/or its metabolites are excreted via the urine and feces with a half-life of approximately two to three days. Half life Approximately 2 to 3 days following topical administration Pharmacokinetics    In vitro and in vivo bioavailability studies have demonstrated that naftifine penetrates the stratum corneum in sufficient concentration to inhibit the growth of dermatophytes. Following a single topical application of 1% naftifine cream to the skin of healthy subjects, systemic absorption of naftifine was approximately 6% of the applied dose. Naftifine and/or its metabolites are excreted via the urine and feces with a half-life of approximately two to three days. Naftin Dosage and Administration  For topical use only.  Naftin Cream is not for ophthalmic, oral, or intravaginal use Dosage Forms and Strengths Each gram of Naftin Cream contains 20 mg of naftifine hydrochloride (2%) in a white to offwhite base. Adverse Reactions  The most common adverse reaction (≥1%) is pruritus.  Most adverse reactions were mild in severity.  The following adverse reactions have been identified during post-approval use of naftifine hydrochloride: redness/irritation, inflammation, maceration, swelling, burning, blisters, serous drainage, crusting, headache, dizziness, leukopenia, agranulocytosis. Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure. 477 Brands 478 Recent reports: Erdal et al. (2016) carried out a study to exploit the feasibility of colloidal carriers as to improve skin transport of naftifine, which is an allylamine antifungal drug. The microemulsions were formulated by construction of pseudoternary phase diagrams and composed of oleic acid (oil phase), Kolliphor(®) EL or Kolliphor(®) RH40 (surfactant), Transcutol(®) (cosurfactant), and water (aqueous phase). The plain and drug-loaded microemulsions were characterized in terms of isotropy, particle size and size distribution, pH value, refractive index, viscosity, and conductivity. The in vitro skin uptake of naftifine from microemulsions was studied using tape stripping technique in pig skin. The drug penetrated significantly into stratum corneum from microemulsions compared to its marketed cream (P<0.05). Moreover, the microemulsion formulations led to highly significant amount of naftifine deposition in deeper layers of skin than that of commercial formulation (P<0.001). Microemulsion-skin interaction was confirmed by attenuated total reflectance - Fourier transformed infrared spectroscopy data, in vitro. The results of the in vivo tape stripping experiment showed similar trends as the in vitro skin penetration study. Topical application of the microemulsion on human forearms in vivo enhanced significantly the distribution and the amount of naftifine penetrated into the stratum corneum as compared to the marketed formulation (P<0.05). The relative safety of the microemulsion formulations was demonstrated with 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide viability test. This study indicated that the nanosized colloidal carriers developed could be considered as an effective and safe topical delivery system for naftifine Goldet al. (2016) evaluated the efficacy and safety of two-weeks once daily application of naftifine cream 2% in the treatment of tinea corporis among pediatric subjects. At baseline, 231 subjects were randomly assigned 1:1 to naftifine cream 2% (n=116) and vehicle (n=115). Treatment effect consisting of mycologic determination (KOH and dermatophyte cultures) and scoring of clinical symptom severity was evaluated at baseline, week 2 (end of treatment) and week 3. Efficacy was analyzed in 181 subjects (n=88, naftifine; n=93, vehicle) with a positive baseline dermatophyte culture and KOH for whom week 3 assessments were available. Safety was evaluated by adverse events (AE) and laboratory values in 231 subjects (n=116, naftifine; n=115, vehicle). Children with tinea corporis treated with naftifine cream 2% demonstrated significantly greater improvements from baseline over vehicle for mycological cure and treatment effectiveness as early as 2 weeks (end of treatment). Response rates continued to increase post-treatment and were the highest 1-week after completion of the therapy for complete cure; and for mycological cure and treatment effectiveness). Treatment related adverse events were minimal. Vlahovic et al. (2016) studied Naftifine 2% gel, an allylamine, in a clinical trial that enrolled patients who had interdigital or both interdigital and moccasin-type tinea pedis. In the moccasin group, the primary efficacy endpoint of complete cure at week 2 (end of treatment) was 1.7% (gel) vs 0.9% (vehicle) and week 6 (four weeks post-treatment) was 19.2% (gel) vs 0.9% (vehicle). Naftifine 2% cream in combination with urea 39% also showed improvement in hyperkeratotic moccasin tinea pedis. Stein Gold et al. (2015) presented data from two pooled randomized, vehicle-controlled studies that evaluated efficacy of once daily topical naftifine gel 2% and vehicle at end of treatment (week 2) and at 4 weeks post-treatment in subjects with moccasin tinea pedis. At visit 1, subjects were randomized to naftifine gel 2% or vehicle groups and subjects underwent baseline 479 mycology culture, KOH, and symptom (erythema, scaling, and pruritus) severity grading. Naftifine gel 2% and vehicle treatment were applied once daily for 2 weeks and the subjects returned at weeks 2 and 6 for efficacy evaluation (mycology culture and grading of symptom severity). A total of 1174 subjects were enrolled with interdigital tinea pedis with or without moccasin infection. Of these subjects, 674 subjects had interdigital presentation while 500 subjects had moccasin infection in addition to the interdigital presentation. All 1174 subjects with interdigital presentation satisfied the inclusion criteria of a minimum of moderate erythema and scaling, and mild pruritus. Of the 500 subjects who had moccasin presentation, 380 satisfied the same inclusion criteria as mentioned above. Since data was analyzed as observed cases, between 337 and 349 subjects had data available for analysis of efficacy. Mycologic cure is defined as a negative dermatophyte culture and KOH, treatment effectiveness is defined as mycologic cure and symptom severity scores of 0 or 1, and complete cure is defined as mycologic cure and symptoms severity scores of 0. At week 6, the cure rates in the naftifine arm vs. the vehicle were statistically higher (P < 0.0001) for mycological cure rate (65.8% vs. 7.8%), treatment effectiveness (51.4% vs 4.4%), and complete cure rate (19.2% vs 0.9%). Verma et al. (2015) assessed trends in efficacy, tolerability, safety, and to quantify the pharmacokinetics (PK) of topical naftifine hydrochloride gel 2% in pediatric subjects with tinea pedis. Twenty-eight subjects (22 pediatric and 6 adult controls) were enrolled and treated in the study. Approximately 2 grams of naftifine hydrochloride gel 2% was applied to each foot (4 grams total) for subjects with tinea pedis. Pharmacokinetic blood and urine samples were collected at various time points throughout the study. Efficacy was assessed based on potassium hydroxide, dermatophyte culture, and signs and symptom results at days 7, 14, and 28. Adverse event information was collected routinely. The rate and extent of systemic exposure among the pediatric and adult control subjects was low. Adverse events were minimal and were not related to treatment. Positive results were observed as early as day 7; however the proportion of subjects achieving success generally increased over time through day 28 in both treatment groups. References: 1. Erdal MS1, Özhan G2, Mat MC3, Özsoy Y1, Güngör S1. Colloidal nanocarriers for the enhanced cutaneous delivery of naftifine: characterization studies and in vitro and in vivo evaluations. Int J Nanomedicine. 2016 Mar 14;11:1027-37. 2. Gold M, Dhawan S, Verma A, Kuligowski M, Dobrowski D. Efficacy and Safety of Naftifine HCl Cream 2% in the Treatment of Pediatric Subjects With Tinea Corporis. J Drugs Dermatol. 2016 Jun 1;15(6):743-8. 3. Stein Gold LF, Vlahovic T, Verma A, Olayinka B, Fleischer AB Jr. Naftifine Hydrochloride Gel 2%: An Effective Topical Treatment for Moccasin-Type Tinea Pedis. J Drugs Dermatol. 2015 Oct;14(10):1138-44. 4. Verma A, Olayinka B, Fleischer AB Jr. An Open-Label, Multi-Center, MultipleApplication Pharmacokinetic Study of Naftifine HCl Gel 2% in Pediatric Subjects With Tinea Pedis. J Drugs Dermatol. 2015 Jul;14(7):686-91. 5. Vlahovic TC. The Role of Naftifine HCl 2% Gel and Cream in Treating Moccasin Tinea Pedis. J Drugs Dermatol. 2016 Feb;15(2 Suppl):s56-9. 481 2. Terbinafine      Terbinafine is a synthetic allylamine derivative with antifungal activity. Terbinafine exerts its effect through inhibition of squalene epoxidase, thereby blocking the biosynthesis of ergosterol, an important component of fungal cell membranes. As a result, this agent disrupts fungal cell membrane synthesis and inhibits fungal growth. Terbinafine is an orally and topically active allylamine fungicidal which is used to treat superficial fungal infections of the skin and nails. Terbinafine has been clearly linked to rare instances of acute liver injury that can be severe and sometimes fatal. Terbinafine hydrochloride (Lamisil) is highly lipophilic in nature and tends to accumulate in skin, nails, and fatty tissues. Formula: C21H25N Indication  For the treatment of dermatophyte infections of the toenail or fingernail caused by susceptible fungi.  Also for the treatment of tinea capitis (scalp ringworm) and tinea corporis (body ringworm) or tinea cruris (jock itch). Mechanism of action  Terbinafine is hypothesized to act by inhibiting squalene monooxygenase, thus blocking the biosynthesis of ergosterol, an essential component of fungal cell membranes.  This inhibition also results in an accumulation of squalene, which is a substrate catalyzed to 2,3-oxydo squalene by squalene monooxygenase.  The resultant high concentration of squalene and decreased amount of ergosterol are both thought to contribute to terbinafine's antifungal activity. Pharmacodynamics  Terbinafine is an allylamine antifungal agent and acts by inhibiting squalene epoxidase, thus blocking the biosynthesis of ergosterol, an essential component of fungal cell membranes.  In vitro, mammalian squalene monooxygenase (squalene 2,3-epoxidase) is only inhibited at higher (4000 fold) concentrations than is needed for inhibition of the dermatophyte enzyme.  Depending on the concentration of the drug and the fungal species test in vitro, Terbinafine may be fungicidal. However, the clinical significance of in vitro data is unknown. 481 Brands 482 Recent reports: Almeida-Paes et al. (2016) evaluated whether Sporothrix melanins impact the efficacy of antifungal drugs. Minimal inhibitory concentrations (MIC) and minimal fungicidal concentrations (MFC) of two Sporothrix brasiliensis and four Sporothrix schenckii strains grown in the presence of the melanin precursors L-DOPA and L-tyrosine were similar to the MIC determined by the CLSI standard protocol for S. schenckii susceptibility to amphotericin B, ketoconazole, itraconazole or terbinafine. When MICs were determined in the presence of inhibitors to three pathways of melanin synthesis, we observed, in four strains, an increase in terbinafine susceptibility in the presence of tricyclazole, a DHN-melanin inhibitor. In addition, one S. schenckii strain grown in the presence of L-DOPA had a higher MFC value when compared to the control. Growth curves in presence of 2×MIC concentrations of terbinafine showed that pyomelanin and, to a lesser extent, eumelanin were able to protect the fungi against the fungicidal effect of this antifungal drug. Dürrbeck and Nenoff (2016) mentioned that the allylamine terbinafine is the probably most frequently prescribed systemic antifungal agent in Germany for the treatment of dermatomycoses and onychomycoses. According to the German drug law, terbinafine is approved for patients who are 18 years and older; however, this antifungal agent is increasingly used off-label for treatment of onychomycoses and tinea capitis in children. Terbinafine is associated with only a few interactions with other drugs, which is why terbinafine can generally be used without problems in older and multimorbid patients. Nevertheless, some potential interactions of terbinafine with certain drug substances are known, including substances of the group of antidepressants/antipsychotics and some cardiovascular drugs. Decisive for the relevance of interactions is-along with the therapeutic index of the substrate and the possible alternative degradation pathways-the genetically determined type of metabolism. When combining terbinafine with tricyclic antidepressants or selective serotonin reuptake inhibitors and serotonin/noradrenalin reuptake inhibitors, the clinical response and potential side effects must be monitored. Lee et al. (2016) evaluated the effect of terbinafine on gap junctional intercellular communication (GJIC). Fluorescence recovery after photobleaching (FRAP) and I-YFP GJIC assays revealed that terbinafine inhibits GJIC in a reversible and dose-dependent manner in FRTCx43 and LN215 cells. Treatment with terbinafinedid not affect Cx43 phosphorylation status or 483 intracellular Ca(2+) concentration, well-known action mechanisms of various GJIC blockers. While a structurally related chemical, naftifine, attenuated GJIC, epigallocatechin gallate, another potent squalene epoxidase inhibitor with a different structure, did not. Mayser et al. (2016) summarized the literature concerning Terbinafine as one of the drugs able to induce subcutaneous lupus erythematosus (SCLE)-with a relatively high risk. The clinical picture of terbinafine-induced SCLE may be highly variable and can also include erythema exsudativum multiforme-like or bullous lesions. Thus, differentiation of terbinafine-induced Stevens-Johnson syndrome or toxic epidermal necrolysis may be difficult. Therefore, terbinafine should be prescribed with caution in patients who show light sensitivity, arthralgias, positive antinuclear antibodies or have a history of SLE or SCLE. Case reports include wide-spread, but mostly nonlife-threatening courses, which did not require systemic therapy with steroids or antimalarials in every case. Terbinafine is also able to induce or to aggravate psoriasis. The latency period seems to be rather short (<4 weeks). Saarikoski et al. (2015) investigated the possible interaction of tramadol with the antifungal agents terbinafine (CYP2D6 inhibitor) and itraconazole (CYP3A4 inhibitor). A randomized placebo-controlled crossover study design s performed with 12 healthy subjects, of which 8 were extensive and 4 were ultrarapid CYP2D6 metabolizers. On the pretreatment day 4 with terbinafine (250 mg once daily), itraconazole (200 mg once daily) or placebo, subjects were given tramadol 50 mg orally. Plasma concentrations of tramadol and M1 were determined over 48 h and some pharmacodynamic effects over 12 h. Pharmacokinetic variables were calculated using standard non-compartmental methods. Terbinafine increased the area under plasma concentration-time curve (AUC0-∞) of tramadol by 115 % and decreased the AUC0-∞ of M1 by 64 % (P < 0.001). Terbinafine increased the peak concentration (C max) of tramadol by 53 % (P < 0.001) and decreased the C max of M1 by 79 % (P < 0.001). After terbinafine pretreatment the elimination half-life of tramadol and M1 were increased by 48 and 50 %, respectively (P < 0.001). Terbinafine reduced subjective drug effect of tramadol (P < 0.001). Itraconazole had minor effects on tramadol pharmacokinetics. Yadav et al. (2015) compared the efficacy of terbinafine in continuous and pulse dosing schedules in the treatment of toenail dermatophytosis. Seventy-six patients of potassium hydroxide (KOH) and culture positive dermatophyte toenail onychomycosis were randomly allocated to two treatment groups receiving either continuous terbinafine 250 mg daily for 12 weeks or 3 pulses of terbinafine (each of 500 mg daily for a week) repeated every 4 weeks. Patients were followed up at 4, 8 and 12 weeks during treatment and post-treatment at 24 weeks. At each visit, a KOH mount and culture were performed. In each patient, improvement in a target nail was assessed using a clinical score; total scores for all nails and global assessments by physician and patient were also recorded. Mycological, clinical and complete cure rates, clinical effectivity and treatment failure rates were then compared. The declines in target nail and total scores from baseline were significant at each follow-up visit in both the treatment groups. However, the inter-group difference was statistically insignificant. References: 1. Almeida-Paes R1, Figueiredo-Carvalho MH1, Brito-Santos F1, Almeida-Silva F1, Oliveira MM1, Zancopé-Oliveira RM1. Melanins Protect Sporothrix brasiliensis and Sporothrix 484 2. 3. 4. 5. 6. schenckii from the Antifungal Effects of Terbinafine. PLoS One. 2016 Mar 31;11(3):e0152796. Dürrbeck A1, Nenoff P2. Terbinafine : Relevant drug interactions and their management]. Hautarzt. 2016 Sep;67(9):718-23. Lee JY1, Yoon SM2, Choi EJ3, Lee J4. Terbinafine inhibits gap junctional intercellular communication. Toxicol Appl Pharmacol. 2016 Sep 15;307:102-107. Mayser P1. [Terbinafine : Drug-induced lupus erythematodes and triggering of psoriatic skin lesions]. Hautarzt. 2016 Sep;67(9):724-31 Saarikoski T1, Saari TI, Hagelberg NM, Backman JT, Neuvonen PJ, Scheinin M, Olkkola KT, Laine K. Effects of terbinafine and itraconazole on the pharmacokinetics of orally administered tramadol. Eur J Clin Pharmacol. 2015 Mar;71(3):321-7. Yadav P, Singal A1, Pandhi D, Das S. Comparative efficacy of continuous and pulse dose terbinafine regimes in toenail dermatophytosis: A randomized double-blind trial. Indian J Dermatol Venereol Leprol. 2015 Jul-Aug;81(4):363-9. 3. Butenafine    Butenafine is a synthetic benzylamine antifungal agent that may be fungicidal against susceptible organisms, e.g., dermatophytes. Butenafine hydrochloride is a synthetic benzylamine antifungal, marketed under the trade names Mentax, Butop and is the active ingredient in Lotrimin Ultra. It is structurally related to synthetic allylamine antifungals such as terbinafine. Wikipedia Butenafine works by inhibiting the synthesis of sterols by inhibiting squalene epoxidase, an enzyme responsible for the creation of sterols needed in fungal cell membranes. Formula: C23H27N Butenafine hydrochloride Butenafine Mode of action 485   Butenafine hydrochloride is a synthetic benzylamine derivative with a mode of action similar to that of the allylamine class of antifungal drugs. Butenafine, like the allylamines, inhibits the fungal enzyme squalene epoxidase, thereby blocking the biosynthesis of ergosterol, which is an essential component of fungal cell membranes. In Vitro Activity   Butenafine is thought to be fungicidal in certain concentrations and against susceptible organisms, such as dermatophytes,. Butenafine hydrochloride is active in vitro against many species of fungi, including Trichophyton rubrum, T. mentagrophytes, T. tonsurans, Epidermophyton floccosum, Microsporum canis, and yeasts including C. parapsilosis, C. albicans, and Malassezia spp. Tolerability    In controlled clinical trials, 9 of 815 patients (approx. 1%) treated with butenafine cream 1% reported adverse reactions related to the skin. These reactions included burning/stinging of the skin and worsening of the dermatosis. No patients discontinued therapy due to an adverse event. Two of 624 patients receiving the vehicle discontinued therapy because of treatment site related events including severe burning/stinging and itching. In uncontrolled trials, the adverse events most commonly associated with the use of butenafine 1% cream included contact dermatitis, erythema, irritation, and itching, with each occurring in less than 2% of patients. Dosage and Administration    Butenafine cream 1% is indicated in the US for the topical treatment of interdigital tinea pedis, tinea corporis, and tinea cruris due to T. rubrum, T. tonsurans, T. mentagrophytes, and E. floccosum. In tinea pedis interdigitalis, butenafine cream 1% may be applied twice daily for 7 days or once daily for 4 weeks. In patients with tinea corporis and tinea cruris, it is indicated for once daily application for 2 weeks. For the treatment of pityriasis versicolor, butenafine cream 1% should be applied once daily for 2 weeks. Butenafine is FDA Pregnancy Category B. In December 2001, butenafine cream 1% was approved by the US FDA as a nonprescription treatment (Lotrimin Ultra®, ScheringPlough).http://www.skintherapyletter.com/2002/7.7/1.html 486 Brands Recent reports: Bezerra-Souza et al. (2016) evaluated the anti-leishmanicidal activity of this drug in 2 major species of Leishmania responsible for causing the American tegumentar leishmaniasis (L. (L.) amazonensis and L. (V.) braziliensis). Butenafine eliminated promastigote forms of L. amazonensis and L. braziliensis with efficacy similar to miltefosine, a standard anti-leishmania drug. In addition, butenafine induced alterations in promastigote forms of L. amazonensis that resemble programmed cell death. Butenafine as well as miltefosine presented mild toxicity in peritoneal macrophages, however, butenafine was more effective to eliminate intracellular amastigotes of both L. amazonensis and L. braziliensis, and this effect was not associated with elevated levels of nitric oxide or hydrogen peroxide. Mitra et al. (2016) investigated, using an in vitro human skin permeation study, whether changes in the excipients of butenafine hydrochloride cream would have any effect on bioperformance of the formulation. Such in vitro data would be a surrogate for any requirement of a bioequivalence (BE) study to demonstrate formulation similarity. A LC-MS/MS method for quantitation of butenafine in various matrices was developed and validated. A pilot study was performed to validate the in vitro skin permeation methodology using three cream formulations containing butenafine hydrochloride at concentrations of 0.5, 1.0 and 1.5% (w/w). Finally, a definitive in vitro human skin permeation study was conducted, comparing the extent 487 of butenafine hydrochloride permeation from the new formulation to that from the current formulation. The results of the study comparing the two formulations showed that there was no statistically significant difference in the extent of butenafine permeation into human skin. Pillai et al. (2015) designed topical microemulsion systems for the antifungal drug, butenafine hydrochloride (BTF) and developed to overcome the problems associated with the cutaneous delivery due to poor water solubility. The solubility of BTF in oils, surfactants and co-surfactants was evaluated to screen the components of the microemulsion. Isopropyl palmitate was used as the oil phase, aerosol OT as the surfactant and sorbitan monooleate as co-surfactant. The pseudoternary diagrams were constructed to identify the area of microemulsion existence and optimum systems were designed. The systems were assessed for drug-loading efficiency and characterized for pH, robustness to dilution, globule size, drug content and stability. Viscosity analysis, spreadability, drug content assay, ex vivo skin permeation study and antifungal activity assay were performed for the optimized microemulsion-loaded hydrogel. The optimized BTF microemulsion had a small and uniform globule size. The incorporation of microemulsion system into Carbopol 940 gel was found to be better as compared to sodium alginate or hydroxyl propyl methyl cellulose (HPMC K4 M) gel. The developed gel has shown better ex vivo skin permeation and antifungal activity when compared to marketed BTF cream. References: 1. Bezerra-Souza A1, Yamamoto ES1, Laurenti MD1, Ribeiro SP2, Passero LF3. The antifungal compound butenafine eliminates promastigote and amastigote forms of Leishmania (Leishmania) amazonensis and Leishmania (Viannia) braziliensis. Parasitol Int. 2016 Dec;65(6 Pt A):702-707. 2. Mitra A1, Kim N2, Spark D3, Toner F3, Craig S3, Roper C3, Meyer TA4. Use of an in vitro human skin permeation assay to assess bioequivalence of two topical cream formulations containing butenafine hydrochloride (1%, w/w). Regul Toxicol Pharmacol. 2016 Dec;82:14-19. 3. Pillai AB1, Nair JV, Gupta NK, Gupta S. Microemulsion-loaded hydrogel formulation of butenafine hydrochloride for improved topical delivery. Arch Dermatol Res. 2015 Sep;307(7):625-33. 488 7.5. Fluoropyrimidines  Fluoropyrimidines are a class of compounds, of which only 5-fluorocytosine (5-FC) and 5-fluorouracil (5-FU) are used in human drugs and are synthetic structural analogues of the DNA nucleotide cytosine of candidiasis. 1. Flucytosine Fluoropyrimidines are a class of compounds, of which only 5-fluorocytosine (5-FC) and 5fluorouracil (5-FU) are used in human drugs and are synthetic structural analogues of the DNA nucleotide cytosine of candidiasis .          Flucytosine, also known as 5-fluorocytosine, is an antifungal medication. Flucytosine is specifically used, together with amphotericin B, for serious Candida infections and cryptococcosis. Flucytosine may be used by itself or with other antifungals for chromomycosis. Flucytosine is used by mouth and by injection into a vein. Flucytosine was first made in 1957. Flucytosine is on the World Health Organization's List of Essential Medicines, the most effective and safe medicines needed in a health system. Flucytosine, as of 2016, in the United States the medication cost about 2,000 USD per day while in the United Kingdom it is about 22 USD per day. Flucytosine is not available in much of the developing world Formula: C4H4FN3O Uses  Flucytosine by mouth is used for the treatment of serious infections caused by susceptible strains of Candida or Cryptococcus neoformans. 489     Flucytosine can also be used for the treatment of chromomycosis (chromoblastomycosis), if susceptible strains cause the infection. Flucytosine must not be used as a sole agent in life-threatening fungal infections due to relatively weak antifungal effects and fast development of resistance, but rather in combination with amphotericin B and/or azole antifungals such as fluconazole or itraconazole. Minor infections such as candidal cystitis may be treated with flucytosine alone. In some countries, treatment with slow intravenous infusions for no more than a week is also a therapeutic option, particular if the disease is life-threatening. Spectrum of Activity and Resistance       Flucytosine activity is limited to the common pathogenic yeasts. Flucytosine spectrum includes many Candida spp, including C albicans, C glabrata, C parapsilosis, and C tropicalis. C krusei and C lusitaniae are also included in the spectrum but MICs are higher. Flucytosine is rarely used for the treatment of candidiasis alone because resistance rapidly develops with monotherapy. Flucytosine demonstrates activity against Cryptococcus spp and is commonly administered in conjunction with amphotericin B. Flucytosine is not active against the dimorphic fungi or filamentous fungal pathogens. Resistance to Candida albicans is reported to be near 10%, often related to decreased drug Mechanism of action  Flucytosine acts directly on fungal organisms by competitive inhibition of purine and pyrimidine uptake and indirectly by intracellular metabolism to 5fluorouracil.  Flucytosine enters the fungal cell via cytosine permease; thus, flucytosine is metabolized to 5-fluorouracil within fungal organisms.  5-fluorouracil is extensively incorporated into fungal RNA and inhibits synthesis of both DNA and RNA. The result is unbalanced growth and death of the fungal organism.  Flucytosine also appears to be an inhibitor of fungal thymidylate synthase. Pharmacodynamics  Flucytosine is an antimetabolite that acts as an antifungal agent with in vitro and in vivo activity against Candida and Cryptococcus.  Antifungal synergism between Ancobon and polyene antibiotics, particularly amphotericin B, has been reported. Pharmacology 491      Flucytosine is highly bioavailable (80%–90%) and the only formulation available in the United States is an oral capsule. Flucytosine is dosed frequently, 4 times daily, due to its short half-life and pharmacodynamic characteristics. Flucytosine accumulates ubiquitously throughout host compartments. Specifically, high cerebrospinal fluid and vitreal fluid levels are achievable. Flucytosine is not significantly metabolized. Flucytosine is primarily excreted renally and the unchanged drug exhibits excellent antifungal activity in the urine. o Patients with renal insufficiency have impaired drug clearance. o Therefore, a 2-fold to 4-fold longer dosing interval is recommended for patients with a glomerular filtration rate (GFR) less than 50. o These dosing changes are guided by therapeutic drug monitoring with peak concentration targets ranging from 30 to 100 mg/L. Clinical Indications      Flucytosine is a first-line therapy for the treatment of cryptococcal meningitis. Flucytosine is administered with amphotericin B during the induction period. Flucytosine exhibits activity against most Candida spp, however resistance develops quickly during use, limiting its treatment potential as a single agent. Flucytosine can be coadministered with an additional antifungal drug, such as amphotericin B, in select situations to prevent emergence of resistance. Flucytosine monotherapy may be an option for treatment of Candida cystitis given the high urinary concentrations of flucytosine and the relatively short course of therapy. Toxicities     Flucytosine is associated with 2 main toxicities: bone marrow suppression and liver toxicity. o Bone marrow toxicity, in particular, can be limiting, leading to the lowering of the drug dose or drug discontinuation. o Cytopenias, including anemia, leukopenia, and thrombocytopenia, are dosedependent, occurring more frequently with serum flucytosine concentrations of 125 mg/mL or greater. Flucytosine treatment of patients with renal insufficiency represent a high risk for toxicity. o Both peak drug levels and cell counts should be monitored during therapy. o Dose reductions are often needed. Flucytosine administration can also be associated with gastrointestinal upset and rash. Flucytosine in animal studies demonstrated teratogenic effects and thus flucytosine is contraindicated in pregnancy. Drug–Drug Interactions   Flucytosine is not a substrate or inhibitor of the CYP450 enzymes. There are very few drug–drug interactions. 491  Because flucytosine is renally cleared, medications altering renal function may affect drug levels and the risk of toxicity http://www.medicine.wisc.edu/sites/default/files/antifungal_agents_spectrum_nett_andes.pdf Recent reports Wani et al. (2017) revisited their approach and synthesized structural analogues of flucytosine, which is a synthetic antifungal and is being studied for its use in combination therapy with other antifungal drugs. Pyrimidin-one and -thione (often known as DHPM's) as flucytosine analogues were obtained through a Biginelli reaction of corresponding aldehydes, ethylacetoacetate and urea/thiourea. Structure was confirmed by FTIR, HNMR, CNMR, COSY and MS (ESI+) analysis. All the newly synthesized derivatives were evaluated for the antifungal activity alone and in combination of two most commonly used antifungal drugs, amphotericin B and fluconazole against different clinically isolated Candida albicans strains. Minimum inhibitory concentration results confirmed that BG4 possess high antifungal activity against all the tested strains (MIC = 1-32 μg/ml). For all the combinations with amphotericin B and fluconazole, 37% were synergistic followed by 30% additive and 24% indifferent interactions. Interestingly, 9% antagonistic interaction was observed when BG1 and BG3 were combined with fluconazole, however, no antagonistic interaction was observed with amphotericin B. In-depth studies of all the synergies were done by constructing isobolograms with nine different ratio combinations. These results warrant the use of DHPM derivatives as chemosensitising agents which could lower down the dosages of the antifungal drugs to treat invasive fungal diseases. Folk et al. (2016) evaluated the hepatotoxicity induced by combined therapy of flucytosine and amphotericin B, at three different doses administered to mice for 14 days: 50 mg/kg flucytosine and 300 μg/kg amphotericin B; 100 mg/kg flucytosine and 600 μg/kg amphotericin B; 150 mg/kg flucytosine and 900 μg/kg amphotericin B. Liver injuries were evaluated by analysis of optic and electron microscopy samples, changes in TNF-α, IL-6, and NF-κB inflammation markers levels of expression, and evaluation of mRNA profiles. Histological and ultrastructural analysis revealed an increase in parenchymal and portal inflammation in mice and Kupffer cells activation. Combined antifungal treatment stimulated activation of an inflammatory pathway, demonstrated by a significant dose-dependent increase of TNF-α and IL-6 immunoreactivity, together with mRNA upregulation. Also, NF-κB was activated, as suggested by the high levels found in hepatic tissue and upregulation of target genes. Our results suggest that antifungal combined therapy exerts a synergistic inflammatory 492 activation in a dose-dependent manner, through NF-κB pathway, which promotes an inflammatory cascade during inflammation. The use of combined antifungal therapy needs to be dose limiting due to the associated risk of liver injury, especially for those patients with hepatic dysfunction. Salem et al. (2016) used liposomes as an ocular carrier for nanogold capped with flucytosine antifungal drug. Gold nanoparticles were used as a contrasting agent that provides tracking of the drug to the posterior segment of the eye for treating fungal intraocular endophthalmitis. The nanoliposomes were prepared with varying molar ratios of lecithin, cholesterol, Span 60, a positive charge inducer (stearylamine), and a negative charge inducer (dicetyl phosphate). Formulation F6 (phosphatidylcholine, cholesterol, Span 60, and stearylamine at a molar ratio of 1:1:1:0.15) demonstrated the highest extent of drug released, which reached 7.043 mg/h. It had a zeta potential value of 42.5±2.12 mV and an average particle size approaching 135.1±12.0 nm. The ocular penetration of the selected nanoliposomes was evaluated in vivo using a computed tomography imaging technique. It was found that F6 had both the highest intraocular penetration depth (10.22±0.11 mm) as measured by the computed tomography and the highest antifungal efficacy when evaluated in vivo using 32 infected rabbits' eyes. The results showed a strong correlation between the average intraocular penetration of the nanoparticles capped with flucytosine and the percentage of the eyes healed. After 4 weeks, all the infected eyes (n=8) were significantly healed (P<0.01) when treated with liposomal formulation F6. Overall, the nanoliposomes encapsulating flucytosine have been proven efficient in treating the infected rabbits' eyes, which proves the efficiency of the nanoliposomes in delivering both the drug and the contrasting agent to the posterior segment of the eye. References: 1. Folk A1, Cotoraci C2, Balta C3, Suciu M3, Herman H3, Boldura OM4, Dinescu S5, Paiusan L1, Ardelean A3, Hermenean A6. Evaluation of Hepatotoxicity with Treatment Doses of Flucytosine and Amphotericin B for Invasive Fungal Infections. Biomed Res Int. 2016;2016:5398730. 2. Salem HF1, Ahmed SM2, Omar MM3. Liposomal flucytosine capped with gold nanoparticle formulations for improved ocular delivery. Drug Des Devel Ther. 2016 Jan 13;10:277-95. 3. Wani MY1, Ahmad A2, Kumar S3, Sobral AJ4. Flucytosine analogues obtained through Biginelli reaction as efficient combinative antifungal agents. Microb Pathog. 2017 Apr;105:57-62. 493 7.6. Morpholine Derivatives      The morpholines were discovered in the late 1960s as a sequel from research into plant growth regulators and were initially used as agricultural fungicides. Tridemorph and dodemorph are the examples of the agricultural fungicides. These plant fungicides led the foundation for search of morpholines with applications in the field of human mycoses via fenpropimorph and culminating in the discovery of amorolfine in 1981. Amorolfine and fenpropimorph are strong inhibitors of fungal pathogens in both plants and humans and are highly active against dermatophytes. Depending upon the substituent, morpholines act at multiple sites in the ergosterol biosynthetic pathway each to a different degree. Amorolfine   Amorolfine is a morpholine antifungal drug that inhibits Δ¹⁴-sterol reductase and cholestenol Δ-isomerase, which depletes ergosterol and causes ignosterol to accumulate in the fungal cytoplasmic cell membranes. Chemical Names: Amorolfine; 78613-35-1; Amorolfinum; Amorolfina; Amorolfin; Loceryl  PubChem CID: 54260 Formula: C21H35NO   Amorolfine is a structurally unique, topically active antifungal agent, which possesses both fungistatic and fungicidal activity in vitro. Amorolfine spectrum of in vitro activity includes dermatophyte, dimorphic, some dematiaceous and filamentous fungi, and some yeasts. Mode of action  Amorolfine is a morpholine derivative which is chemically distinct from other currently available antifungal agents. 494  Amorolfine acts primarily by inhibiting ergosterol biosynthesis, a component of fungal cell membrane, and possesses both fungistatic and fungicidal activity. As a consequence of this inhibition the delta 14 sterol ignosterol is accumulated in the cell membrane and ergosterol is depleted. Pharmacokinetic Properties, Malini Haria and Harriet M. Bryson, 1995      Amorolfine penetration through human nail follows an exponential relationship between drug concentration and nail layer. In vitro data suggest that soft diseased nails will retain less drug than hard compact nails. After a single application of nail lacquer (formulated with methylene chloride), permeation of [3H]amorolfine 5% through the thumbnail ranged from 20 to 100 μg/L/h. Mean percutaneous absorption of amorolfine through healthy human skin following a single application of 0.25% cream did not exceed 10% of the total administered dose. Systemically absorbed radioactive amorolfine was slowly excreted via urine and faeces over 3 weeks; plasma concentrations of <0.5 μg/L were detected in all samples. Further studies in volunteers indicate that active concentrations of amorolfine may be retained in healthy skin for 2 or 3 days after single applications of 0.5% cream or alcohol solution, respectively. Tolerability     Amorolfine (5% nail lacquer and 0.25% cream) appeared to be well tolerated, with up to 5% of patients reporting minor symptoms. In patients using the nail lacquer, these events included burning, itching, redness and local pain which were tolerable and confined to the site of application. Additional events of scaling, weeping, blistering and oedema were also described for the cream. A similar adverse event profile was reported for both the alcohol solution and vaginal tablets. Dosage and Administration      Amorolfine 5% nail lacquer should be applied to the affected nail once or twice weekly. Treatment should be continued without interruption until the nail has regenerated and affected areas are cured. Treatment may require up to 6 months for fingernails and between 9 and 12 months for toenails. Amorolfine 0.25% cream should be applied to affected skin areas once daily for up to 6 weeks. Therapy should be continued until clinical cure is achieved, and for several days thereafter. Generic Names  Amorolfine (OS: BAN, DCF, USAN)  Ro 14-4767/000 (IS: Roche) 495   Ro 14-4767/002 (IS: Roche) Amorolfine Hydrochloride (OS: BANM, JAN) Brand Names 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. Amofin Belupo, Croatia (Hrvatska) Amorolak Sun-Farm, Poland Amorolfine Pierre Fabre Pierre Fabre Dermatologie, Poland Arivil Farmal, Croatia (Hrvatska) Fungilac Farmal, Croatia (Hrvatska) Funtrol Axxon, Poland Laquifun Panalab, Argentina Loceryl Galderma, Argentina; Galderma, Hong Kong; Galderma, India; Galderma, Malaysia; Galderma, Peru; Galderma Chile Laboratorios, Chile; Galderma Laboratories, South Africa Locéryl Galderma, Tunisia Locetar Galderma, Philippines Micobutina Ariston, Argentina Myconail AFT, New Zealand Myconolak Axxon, Poland Amocoat Hwang's, Taiwan Amofin 5% Galenpharma, Germany Amorocutan Dermapharm, Austria; Dermapharm, Germany Amorolfin AL 5% Aliud, Germany Amorolfin Apofri Apofri, Sweden Amorolfin Evolan Evolan, Sweden Amorolfin Mylan Mylan, Sweden Amorolfin STADA 5% Stada Arzneimittel, Germany Amorolfina Ciclum Ciclum, Portugal 29. Amorolfina Teva Teva, Spain; Teva Pharma, Portugal 30. Amorolfine 5% Actavis Actavis UK, United Kingdom 31. Amorolfine 5% Zentiva Zentiva, United Kingdom 32. Amorolfine Arrow 5% Arrow, France 33. Amorolfine BGR 5% Biogaran, France 34. Amorolfine Biogaran 5% Biogaran, France 35. Amorolfine Chanelle Chanelle Medical, Hong Kong 36. Amorolfine Cristers 5% CristerS, France 37. Amorolfine EG 5% EG Labo, France 38. Amorolfine Hydrochloride 5% Genus Genus Pharmaceuticals, United Kingdom 39. Amorolfine Isomed 5% Teva Santé, France 40. Amorolfine Mylan 5% Mylan, France 41. Amorolfine Pierre Fabre 5% Pierre Fabre Dermatologie, France 42. Amorolfine Ranbaxy 5% Ranbaxy, France 43. Amorolfine Ratiopharm Ratiopharm, Iceland 44. Amorolfine Ratiopharm 5% Teva Santé, France 45. Amorolfine Sandoz Sandoz, Taiwan 46. Amorolfine Sandoz 5% Sandoz, France 47. Amorolfine Teva Teva, Belgium; Teva, Sweden 48. Amorolfine Teva 5% Teva Santé, France 49. Amorolfine Urgo 5% Urgo, France 50. Amorolfine Zentiva 5% Sanofi Aventis, France 51. Amorolfine Zydus 5% Zydus, France 52. Amorolfin-Mepha 5% Mepha Pharma, Switzerland 496 57. Curanail 5% Galderma, France 58. Curanel Galderma Spirig, Switzerland 59. Finail Orifarm Generics, Denmark; Orifarm Generics, Sweden 60. Funtrol Chanelle, Bulgaria 61. Loceryl Galderma, Austria; Galderma, Belgium; Galderma, Bahrain; Galderma, Brazil; Galderma, China; Galderma, Czech Republic; Galderma, Germany; Galderma, Ecuador; Galderma, Estonia; Galderma, Greece; Galderma, Hungary; Galderma, Ireland; Galderma, Iceland; Galderma, Lebanon; Galderma, Lithuania; Galderma, Latvia; Galderma, Malta; Galderma, Mexico; Galderma, Norway; Galderma, New Zealand; Galderma, Poland; Galderma, Singapore; Galderma, Thailand; Galderma, Taiwan; Galderma Nordic, Denmark; Galderma Nordic, Sweden; Galderma Spirig, Switzerland; Laboratories Galderma, Israel 62. Loceryl 5% Galderma, France; Galderma, Slovakia; Galderma Nordic AB, Finland 63. Locetar Galderma, Spain; Galderma, Portugal; Galderma Italia, Italy 64. Micocide A Atlas Farmc., Argentina; Mediderm, Chile 65. Myconxin Root, Taiwan 66. Nailcure Sandoz Sandoz, Switzerland 67. Neolaque PharmaSwiss, Hungary 68. Odenil Galderma, Spain 69. Onilaq Galderma Italia, Italy 23. Amorolfina Generis Generis, Portugal 24. Amorolfina Isdin Isdin, Spain 1.25.Amorolfina Mylan Mylan, Spain 26. Amorolfina Mylan Generics Mylan, Italy 27. Amorolfina ratiopharm Ratiopharm, Portugal 28. Amorolfina Stada STADA, Spain 2.53.Amorolfin-ratiopharm 5% ratiopharm, Germany 54. Avoza UBI, Taiwan 55. Boots Once Weekly Fungal Nail Treatment 5% The Boots Company, United Kingdom 56. Curanail Galderma, Ireland; Laboratoires Galderma, Georgia 497 70. Onylaq Galderma, Mexico 71. Pekiron Shinlin Sinseng, Taiwan 72. Pekiron 0.5% Galderma, Japan 73. Sanail-Mepha Mepha Pharma, Switzerland 74. Sinibal Atral, Portugal 75. Zaonail Pharmazac SA, Greece 498 Recent reports: Bunyaratavej et al. (2016) demonstrated efficacy and treatment outcomes of amorolfine nail lacquer in N. dimidiatum onychomycosis, compared with topical urea treatment. This was a retrospective study of patients daiagnosed as N. dimidiatum onychomycosis at dermatologic clinic between April 2010 and August 2014. Clinical manifestations and laboratory results were collected. The evaluation included 50% improvement, which meant 50% decrease in subungual hyperkeratosis thickness from original untreated nails. Mycological cure is defined by negative result of both KOH and fungal culture. Moreover, complete cure means infected nails return to its normal condition as well as KOH and fungal culture yield negative results. Among 53 outpatients of N. dimidiatum infection, 28 (52.8%) were treated by amorolfine nail lacquer and other 26 (47.2%) by conventional topical urea cream with occlusion. Comparison between amorolfine and topical urea groups, mycological cure rate was significantly shown in amorolfine group (89.3% vs. 32%; p < 0.0001). Moreover, 50% clinical improvement and complete cure rate of amorolfine group were significantly higher than those of topical urea group (85.7% vs. 48%; p = 0.003 and 50% vs. 20%; p = 0.023, respectively). Median time to mycological cure and complete cure in amorolfine group was significantly shorter than that of topical urea group (p = 0.001 and p = 0.013, respectively). CONCLUSION: This study supported that amorolfine nail lacquer provided promising efficacy in the treatment of Neoscytalidium onychomycosis as a novel monotherapy regimen which were superior to topical urea cream with occlusion in every aspect. Sigurgeirsson et al. (2016) evaluated whether the antifungal efficacy of amorolfine 5% nail lacquer (NL) was affected by a masking, natural-coloured, cosmetic nail varnish applied 24 h later; in vitro investigations were also performed. Subjects with mild-to-moderate distal subungual toenail onychomycosis were randomised to receive amorolfine 5% NL once weekly with or without cosmetic nail varnish applied 24 h later. After 12-week treatment, antifungal activity of affected toenail clippings was assessed by measurement of zones of inhibition (ZOIs) on Trichophyton mentagrophytes seeded agar plates. Mean diameters were 53.5 mm for the amorolfine 5% NL-alone group (n = 23) and 53.6 mm for amorolfine 5% NL plus cosmetic nail varnish group (n = 25). Also, mycological cultures of subungual debris at week 12 were negative for all subjects in both groups. Most subjects (88%) reported that cosmetic nail varnish masked their infected toenails. Additionally, cadaver human nails coated in vitro with or without cosmetic nail varnish 10 min or 24 h post amorolfine NL application all gave ZOIs on Trichophyton rubrum agar plates representing potent antifungal activity. In conclusion, cosmetic nail varnish applied post amorolfinehad no effect on the subungual antifungal activity of amorolfine 5% NL or its penetration through toenails. 499 Zhang et al. (2016) evaluated the efficacy of combination therapy with a fractional erbium yttrium aluminum garnet (Er:YAG) laser and 5 % amorolfine lacquer on onychomycosis. Nine patients with bilateral nails affected by distal and lateral subungual onychomycosis were included. The bilateral nails of each patient were divided into two groups. The 20 affected nails on one side of each patient as group 1 were treated with a fractional Er:YAG laser once a week and 5 % amorolfine lacquer twice weekly, while the 20 nails on the symmetrical side of each patient as group 2 were treated with amorolfine lacquer only. The laser treatment was conducted at weeks 1, 2, 3, 4, 8, and 12 in group 1. The clinical improvement, onychomycosis severity index (OSI), maximum linear clear nail growth (MLCNG), and mycological cure rate were evaluated. At week 24, 18 of 20 (90 %) nails in group 1 had achieved obvious clinical responses. The mean OSI score showed a significant decrease (5.24) and the average MLCNG was 3.1 mm in group 1. At week 24, 15 of 20 (75 %) nails achieved a negative mycological examination in group 1, compared with four of 20 (20 %) nails in group 2. The treatments were well-tolerated by most patients. This clinical study suggests that combination therapy of a fractional 2940-nm Er:YAG laser and 5 % amorolfine lacquer is an effective, safe, and convenient treatment method for onychomycosis. References: 1. Bunyaratavej S1, Leeyaphan C1, Rujitharanawong C1, Surawan TM1, Muanprasat C1, Matthapan L1. Efficacy of 5% amorolfine nail lacquer in Neoscytalidium dimidiatum onychomycosis. J Dermatolog Treat. 2016 Aug;27(4):359-63. 2. Sigurgeirsson B1, Ghannoum MA2, Osman-Ponchet H3, Kerrouche N3, Sidou F3. Application of cosmetic nail varnish does not affect the antifungal efficacy of amorolfine 5% nail lacquer in the treatment of distal subungual toenail onychomycosis: results of a randomised active-controlled study and in vitro assays. Mycoses. 2016 May;59(5):319-26. 3. Zhang J1,2, Lu S1,2, Huang H3, Li X1, Cai W1, Ma J1, Xi L4. Combination therapy for onychomycosis using a fractional 2940-nm Er:YAG laser and 5 % amorolfine lacquer. Lasers Med Sci. 2016 Sep;31(7):1391-6. 511 7.7. Thiocarbamates     Thiocarbamates were found to have strong and selective in vitro antifungal properties against Trichophyton spp. Thiocarbamates are mostly used for the topical treatment of skin mycoses like athlete‘s foot, but are not very effective against nail and scalp mycoses. However, they are very active against actively growing cells only. Thiocarbamates inhibit the activity of squalene epoxidase, a key enzyme in the biosynthetic pathway of sterol production. Thiocarbamates are commonly administered as a 1 % solution or cream in polyethylene glycol. 1. Tolnaftate   Tolnaftate is a synthetic over-the-counter anti-fungal agent. It may come as a cream, powder, spray, or liquid aerosol, and is used to treat jock itch, athlete's foot and ringworm. Tolnaftate is sold under several brand names, most notably Tinactin and Odor Eaters. Formula: C19H17NOS Mechanism of action  Tolnaftate is a topical fungicide. Though its exact mechanism unknown, it is believed to prevent ergosterol biosynthesis by inhibiting squalene epoxidase.  Tolnaftate has also been reported to distort the hyphae and to stunt mycelial growth in susceptible organisms. Indication    Tolnaftate topical is used to treat skin infections such as athlete's foot, jock itch, and ringworm infections. Tolnaftate is also used, along with other antifungals, to treat infections of the nails, scalp, palms, and soles of the feet. Tolnaftate powder and powder aerosol may be used to prevent athlete's foot. 511 Uses   Tolnaftate comes as a cream, liquid, powder, gel, spray powder, and spray liquid for application to the skin. Tolnaftate usually is applied twice a day. Follow the directions on the package or on your prescription label carefully, and ask your doctor or pharmacist to explain any part you do not understand. Toxicity Oral rat LD50: 891 mg/kg. Inhalation rat LC50: > 900 mg/m3/1hr. Irritation: skin rabbit: 500 mg/24H mild. Eye rabbit: 100 mg severe. Investigated a mutagen and reproductive effector. Generic Name: Tolnaftate topical Brand Name: Absorbine Athletes Foot, Absorbine Jr. Antifungal, Blis-To-Sol, Clarus Antifungal, Fungi-Guard, LamISIL Defense, Mycocide NS, Tinactin, Tinaderm, Tinaspore, Genaspor, NP 27, Tinactin Jock Itch, Ting, Aftate For Athletes Foot, Aftate For Jock Itch, Absorbine Jock Itch, Fungatin, Hongos, Q-Naftate, Podactin, T-Athlete, Desenex Spray, Tinactin Deodorant Spray, Dr Scholl's Odor Destroyers Sport Spray, LamISIL AT Defense, LamISIL AT Defense Cream to Powder, Athlete's Foot Antifungal Liquid, Fungoid-D 512 513 Recent reports: AbouSamra and Salama (2016) prepared provesicular systems according to full-factorial experimental design. Plain provesicular systems were compared with systems containing Phospholipon 80 H and Lipoid S45 as penetration enhancers. Design expert software was used to analyze the effect of formulation variables (type of Span used as well as the presence or the absence of the penetration enhancer and its type) on the dependent variables: percent encapsulation efficiency (EE%), vesicle size and percent in vitro drug released). Three formulations were chosen; a plain provesicular system (PV-2), one containing Phospholipon 80H (PV-6) and another containing Lipoid S45 (PV-10) with the goal to reveal the effect of penetration enhancer on morphology, rheological properties and ex vivo permeation using confocal laser scanning microscopy (CLSM). Analysis of CLSM results showed that the penetration enhancing effect for the tested formulations followed the order PV-10 > PV-6 > PV2. Promising clinically active treatment for tinea patients could be expected as shown by the in vivo permeation results for the provesicular systems as suggested by the CLSM results. Kezutyte et al. (2011) incorporated 5 fatty acids (oleic, linoleic, myristic, lauric and capric) in 10% (w/w) into ointment formulation and their influence on lipophilic model drug tolnaftate release in vitro and enhancing effect on tolnaftate penetration into epidermis and dermis of human skin ex vivo were investigated. The prepared ointments were tested for homogeneity, pH and theological properties. In vitro release studies and ex vivo skin penetration experiments were carried out using Hanson and Bronaugh-type flow-through diffusion cells, respectively. Tolnaftatecumulative amount liberated from semisolids was assayed using UV-Vis spectrophotometer. After in vitro skin penetration studies, appropriately extracted human skin layers were analyzed for tolnaftate content using a validated HPLC method. Statistical analysis revealed that release rate of tolnaftate from control ointment and ointments with fatty acids was not significantly different and only 7.34-8.98% of drug was liberated into an acceptor medium after 6 h. Tolnaftate amount penetrating into 1 cm2 of epidermis from ointments containing oleic, linoleic, myristic and lauric acids was significantly greater (p < 0.05) than from the control ointment. Penetration enhancing ratios for these fatty acids for tolnaftate penetration into epidermis ranged from 1.48 to 1.75. References: 1. AbouSamra MM1, Salama AH1. Enhancement of the topical tolnaftate delivery for the treatment of tinea pedis via provesicular gel systems. J Liposome Res. 2016 Oct 19:1-11. 2. Kezutyte T1, Drevinskas T, Maruska A, Rimdeika R, Briedis V. Study of tolnaftate release from fatty acids containing ointment and penetration into human skin ex vivo. Acta Pol Pharm. 2011 Nov-Dec;68(6):965-73. 514 7.8. Antifungal organic acids 1. Acetic acid  Acetic acid is one of the simplest carboxylic acids.  Acetic acid is a synthetic carboxylic acid with antibacterial and antifungal properties.  Acetic acid is produced and excreted by certain bacteria, notably the Acetobacter genus and Clostridium acetobutylicum.  Molecular formula : CH3COOH  Structural formula : Mode of action  Although its mechanism of action is not fully known, undissociated acetic acid may enhance lipid solubility allowing increased fatty acid accumulation on the cell membrane or in other cell wall structures.  Acetic acid, as a weak acid, can inhibit carbohydrate metabolism resulting in subsequent death of the organism. Uses:  Acetic acid is an important chemical reagent and industrial chemical that is used in the production of plastic soft drink bottles, photographic film; and polyvinyl acetate for wood glue, as well as many synthetic fibres and fabrics.  Diluted acetic acid is often used as a cleaning agent.  In the food industry acetic acid is used as an acidity regulator.  Acetic acid is used for the treatment of superficial infections of the external auditory canal caused by organisms susceptible to the action of the antimicrobial.  Acetic acid Otic Solution is available as a nonaqueous otic solution buffered at pH 3 for use in the external ear canal. Brands 515 Recent reports: Şehirli and Saydam (2016) selected propionic, formic and acetic acid to state antifungal activities on some soilborne plant pathogens that are in the GRAS chemicals list. GRAS compounds were tested on, Macrophomina phaseolina, Botrytis cinerea, Sclerotinia sclerotiorum, Fusarium oxysporum and Rhizoctonia solani to understand the efficiencies of organic acids on the plant pathogen development. The mycelial growth inhibition of propionic, formic and acetic acids was determined. Minimum inhibition concentration (MIC) and minimum fungicidal concentrations (MFC) of the organic compounds were stated also. Propionic was significantly better than formic and acetic acid. Propionic acid at 0.7%, formic acid at 0.9% and acetic acid at 1.8% concentration totally inhibited mycelial growth of all fungi, respectively. Organic compounds efficiency was variable and shown a different impact on fungi based on their resistance. B. cinerea, S. sclerotiorum and F. oxysporum resistance was higher than R. solani and M. phaseolina. Rogawansamy et al. (2015) assessed the relative efficacies of five commercially available cleaning agents with published or anecdotal use for indoor fungal remediation. The five agents included two common multi-purpose industrial disinfectants (Cavicide® and Virkon®), 70% ethanol, vinegar (4.0%−4.2% acetic acid), and a plant-derived compound (tea tree (Melaleuca alternifolia) oil) tested in both a liquid and vapour form. Tea tree oil has recently generated interest for its antimicrobial efficacy in clinical settings, but has not been widely employed for fungal remediation. Each antifungal agent was assessed for fungal growth inhibition using a disc diffusion method against a representative species from two common fungal genera, (Aspergillus fumigatus and Penicillium chrysogenum), which were isolated from air samples and are commonly found in indoor air. Tea tree oil demonstrated the greatest inhibitory effect on the growth of both fungi, applied in either a liquid or vapour form. Cavicide® and Virkon® demonstrated similar, although less, growth inhibition of both genera. Vinegar (4.0%– 4.2% acetic acid) was found to only inhibit the growth of P. chrysogenum, while 70% ethanol was found to have no inhibitory effect on the growth of either fungi. There was a notable inhibition in sporulation, distinct from growth inhibition after exposure to tea tree oil, Virkon ®, Cavicide® and vinegar. Lastauskienė et al. (2014) detected chemical compound inducing apoptosis in pathogenic Candida species with the lowest toxicity to the mammalian cells. Five chemical compounds-acetic acid, sodium bicarbonate, potassium carbonate, lithium acetate, and formic acid--were tested for evaluation of antifungal activity on C. albicans, C. guilliermondii, and C. lusitaniae. 516 The results showed that acetic acid and formic acid at the lowest concentrations induced yeast cells death. Apoptosis analysis revealed that cells death was accompanied by activation of caspase. Minimal inhibitory concentrations of potassium carbonate and sodium bicarbonate induced Candida cells necrosis. Toxicity test with mammalian cell cultures showed that formic acid has the lowest effect on the growth of Jurkat and NIH 3T3 cells. In conclusion, our results show that a low concentration of formic acid induces apoptosis-like programmed cell death in the Candida yeast and has a minimal effect on the survivability of mammalian cells, suggesting potential applications in the treatment of these infections. Niknejad et al. (2009) evaluated of Proxy Acetic Acid (PAA) compounds (persidin 1% and 513) on Microsporum gypseum, Candida albicans, Aspergillus niger with Tnvitro method. Materials and methods: Tree times sub cultured standard strains (PTCC) on malt extract agar. Suspensions contain 4* 10 7 CFU/ml conidia and yeast cell were prepared and contact with 1%, 3%, 5%, 10%, 20% of persidin at 3, 5, 10, 20, 30 minutes and persidin 513 with 2% concentration at 3, 5, 15, 30, 45, 60 minutes. After the end of time, number of conidia and yeast cells and colonies were counted. Results: On the base of protocol 6986 of Institute of Standards and Industrial Research of IRAN (lSIR) 10000 reduce in vital conidia is suitable. The optimum effect on C.albicans and M. gypseum was started in 1% and 3% of persidin after 10 minute but, in 5% after 3 minute was seen. On the other hand, optimum effect on A. niger was started in 3% after 20 minute and in 5%, 10% and 20% after 10 and 5 minutes respectively. The suitable effect of persidin 513 with 0.2% concentration on M. gypseum after IS minutes and C. albicans after 5 minute was seen. But optimum reductions of A. niger conidia after 30 minutes were started. Conclusion: On the base of protocol No 6980 (ISIR) persidin can be used as a high capability disinfectant against fungi. References: 1. Lastauskienė E1, Zinkevičienė A, Girkontaitė I, Kaunietis A, Kvedarienė V. Formic acid and acetic acid induce a programmed cell death in pathogenic Candida species. Curr Microbiol. 2014 Sep;69(3):303-10. 2. Niknejad F., Kar A.A.K., Mirhend H., Shahmorad M., Kiaee M.R.Antifungal activity of Proxy Acetic Acid (PAA) compounds on a group of fungi (Dermatophyte, Saprophyte) with Invitro method. abstract No: PP-03-6717th International Society for Human and Animal Mycology, 2009 3. Rogawansamy S, Gaskin S, Taylor M, Pisaniello D. An Evaluation of Antifungal Agents for the Treatment of Fungal Contamination in Indoor Air Environments. Toscano WA, Tchounwou PB, eds. International Journal of Environmental Research and Public Health. 2015;12(6):6319-6332. doi:10.3390/ijerph120606319. 4. Sercan Şehirli* and Cansu Saydam. The Effect of Acetic, Formic and Propionic Acids on Plant Pathogenic Fungi. J. BIOL. ENVIRON. SCI., 2016, 10(30), 129-137 517 2. Benzoic acid        Benzoic acid is a colorless crystalline solid and a simple aromatic carboxylic acid. The name is derived from gum benzoin, which was for a long time its only known source. Benzoic acid is a fungistatic compound that is widely used as a food preservative. Benzoic acid occurs naturally free and bound as benzoic acid esters in many plant and animal species. Appreciable amounts have been found in most berries (around 0. 05%) Benzoic acid is a byproduct of phenylalanine metabolism in bacteria Benzoic acid is also produced when gut bacteria process polyphenols (from ingested fruits or beverages). Benzoic acid is conjugated to GLYCINE in the liver and excreted as hippuric acid. Chemical Names: Benzoic acid; 65-85-0; Dracylic acid; Benzenecarboxylic acid; Carboxybenzene; Benzeneformic acid Formula: C7H6O2 Mechanism of the antifungal action, Krebs et al., 1983      Benzoate at higher concentrations (2-10mM) enters the yeast cell in the undissociated form, and its neutralization within the cell can cause a shift of the pH of the intracellular water by more than 1 pH unit. Benzoate causes an accumulation of the two hexose monophosphates of yeast glucose fermentation and a decrease in intermediates beyond phosphofructokinase, suggesting inhibition at this stage. Benzoate also causes a concomitant fall in [ATPI. Phosphofructokinase is inhibited to a greater extent than hexokinase at acid pH. There is a relationship between intracellular pH, phosphofructokinase inhibition and CO2 production, suggesting that the antifungal action of benzoate is caused by an accumulation of benzoate at low external pH, which lowers the intracellular pH into the range where phosphofructokinase is sensitive. Brands 518 Recent reports: Lima et al. (2017) evaluated the antifungal effect of 23 ester derivatives of the cinnamic and benzoic acids against 3 C. albicans strains (ATCC-76645, LM-106 and LM-23), as well as discuss their Structure-Activity Relationship (SAR). The antifungal assay results revealed that the screened compounds exhibited different levels of activity depending on structural variation. Among the ester analogues, methyl caffeate (5) and methyl 2-nitrocinnamate (10) were the analogues that presented the best antifungal effect against all C. albicans strains, presenting the same MIC values (MIC = 128 μg/mL), followed by methyl biphenyl-2-carboxylate (21) (MIC = 128, 128 and 256 μg/mL for C. albicans LM-106, LM-23, and ATCC-76645, respectively). Our results suggest that certain molecular characteristics are important for the antifungal action. Berne et Al. (2015) performed similarity-based virtual screening and synthesis to obtain benzoic acid-derived compounds and assessed their antifungal activity against Cochliobolus lunatus, Aspergillus niger and Pleurotus ostreatus. In addition, we generated structural models of CYP53 enzyme and used them in docking trials with 40 selected compounds. Finally, we explored CYP53–ligand interactions and identified structural elements conferring increased antifungal activity to facilitate the development of potential new antifungal agents that specifically target CYP53 enzymes of animal and plant pathogenic fungi. References: 1. Berne,Sabina,LidijaKovačičbcMatejSovadNadaKraševeceStanislavGobecdIgorKrižajbfRad ovanKomelae Benzoic acid derivatives with improved antifungal activity: Design, synthesis, structure–activity relationship (SAR) and CYP53 docking studies. Bioorganic & Medicinal Chemistry Volume 23, Issue 15, 1 August 2015, Pages 4264-4276 2. Lima TC1, Ferreira AR2, Silva DF2, Lima EO2, de Sousa DP2. Antifungal activity of cinnamic acid and benzoic acid esters against Candida albicans strains. Nat Prod Res. 2017 Apr 20:1-4. doi: 10.1080/14786419.2017.1317776. 519 3. Caprylic acid   Caprylic acid is the common name for the eight-carbon saturated fatty acid known by the systematic name octanoic acid. Caprylic acid compounds are found naturally in the milk of various mammals, and as a minor constituent of coconut oil and palm kernel oil. Formula: C8H16O2 Mode of action    Capric acid and caprylic acid are the dietary food components. They are found to inhibit the virulence factors like morphogenesis, adhesion, and biofilm formation in the human pathogenic yeast Candida albicans. Ashwini et al. (2017) Caprylic acid works by destroying the protective membrane of the Candida cells. As it‘s not water soluble it can penetrate the wet mucosal tissues where Candida cells can be found. As it can get deep within the membranes, it‘s more effective than other natural remedies for Candida which are water soluble and will only kill Candida cells that are found on the surface of mucous membranes/ Caprylic acid was demonstrated to be effective against all tested species and strains of the genus Candida, particularly the 4 strains of C. albicans which appeared to be the most sensitive to the anti-fungal agent. The minimum amount of acid required to kill the cells of those strains of C. albicans was equally at a concentration of 1/400 M. These antimycolic data strongly suggest that caprylic acid is considered as being fungicidal on the organism. Tsukahara, 1961 Brands 511 Recent reports: Ashwini et al. (2017) demonstrated that yeast-to-hyphal signal transduction pathways were affected by capric acid and caprylic acid. The expression profile of genes associated with seruminduced morphogenesis showed reduced expressions of Cdc35, Hwp1, Hst7, and Cph1 by the treatment with both the fatty acids. Cell elongation gene, Ece1, was surprisingly downregulated by 5208-fold by the treatment of caprylic acid. Nrg1 and Tup1, negative regulators of hyphal formation, were overexpressed in presence of capric or caprylic acid. Cell cycle studies revealed that capric and caprylic acids arrested cell cycle at G2/M and S phase. Targeting the virulence factors like yeast-to-hyphal transition is efficacious for treatment of opportunistic fungal infections. This research suggests that both capric and caprylic acid may be effective interventions for treating C. albicans yeast infections. Takahashi et al. (2012) assessed anti-C. albicans activities of the 4 fatty acids : caproic acid, caprylic acid, capric acid and lauric acid in vitro. All four inhibited not only the mycelial but also the yeast-form growth of Candida albicans. In particular, capric acid and caprylic acid inhibited Candida mycelia growth at very low concentrations. The effects of treatment of these two fatty acids on oral candidiasis were examined using a murine model. When 50 µl of capric acid (more than 48.8 µM) was administered three times into the oral cavity of Candidainfected mice, symptom scores of tongues of the mice were significantly improved. Histological studies of the capric acid-treated animals indicated that the fatty acid suppressed mycelial growth of the fungus on the tongue surface. These results suggest that all four fatty acids, and especially capric acid, have potential as substances supporting anti-Candida treatment. References: 1. Ashwini Jadhav,1 Supriya Mortale,1 Shivkrupa Halbandge,1 Priyanka Jangid,1 Rajendra Patil,2 Wasudev Gade,2 Kiran Kharat,3 and Sankunny Mohan KaruppayiJournal of Medicinal Food. September 2017, ahead of print.https://doi.org/10.1089/jmf.2017.3971 2. Takahashi M1, Inoue S, Hayama K, Ninomiya K, Abe S. Inhibition of Candida mycelia growth by a medium chain fatty acids, capric acid in vitro and its therapeutic efficacy in murine oral candidiasis]. Med Mycol J. 2012;53(4):255-61. 511 4. Citric acid   Citric acid is a weak organic tricarboxylic acid having the chemical formula C₆H₈O₇. It occurs naturally in citrus fruits. In biochemistry, it is an intermediate in the citric acid cycle, which occurs in the metabolism of all aerobic organisms. Chemical formula: C6H8O7 Uses:    Citric acid is a weak organic acid found in citrus fruits. Citric acid is a natural preservative and is also used to add an acidic (sour) taste to foods and soft drinks. In biochemistry, it is important as an intermediate in the citric acid cycle and therefore occurs in the metabolism of almost all living things. Citric acid is a natural preservative and is also used to add an acidic (sour) taste to foods and soft drinks. In biochemistry, it is important as an intermediate in the citric acid cycle and therefore occurs in the metabolism of almost all living things. Antifungal activities   Citric acid had more fungistatic and fungicidal activities than those of tartaric acid against all pathogenic fungi tested, Trichophyton mentagrophytes var. mentagrophytes, Candida albicans, Aspergillus fumigatus, and Malassezia furfur. Citric acid effect on filamentous fungi was higher than that on the yeasts. Hojjatollah Shokri, 2011 512 Recent reports: Lopez-Abarrategui et al. (2016) indicated that the citric acid-modified manganese ferrite nanoparticles used in this study were characterized by high-resolution transmission electron microscopy, which confirmed the formation of nanocrystals of approximately 5 nm diameter. These nanoparticles were able to inhibit Candida albicans growth in vitro. The minimal inhibitory concentration was 250 µg/mL. However, the nanoparticles were not capable of inhibiting Gram-negative bacteria (Escherichia coli) or Gram-positive bacteria (Staphylococcus aureus). Finally, an antifungal peptide (Cm-p5) from the sea animal Cenchritis muricatus (Gastropoda: Littorinidae) was conjugated to the modified manganese ferrite nanoparticles. The antifungal activity of the conjugated nanoparticles was higher than their bulk counterparts, showing a minimal inhibitory concentration of 100 µg/mL. This conjugate proved to be nontoxic to a macrophage cell line at concentrations that showed antimicrobial activity. Perera et al. (2015) focused on the encapsulation of citric acid which has anti-fungal properties into a Mg-Al- layered double hydroxide (LDH) in order to be used as slow release topical skin formulations. Citrate ions were encapsulated into Mg-Al LDH using one step co-precipitation reaction. The successful intercalation of citrate ions into the layered structure has been proved referring to the expansion in the interlayer spacing as observed by the shift in the basal peak of the powder X-ray diffraction pattern. Fourier transform infra-red spectroscopy data suggests the change in the electron density around the carboxylate groups of the citrate ion thus providing evidences for formation of encapsulated hybrid composite. The resulting nanohybrid has been then, introduced into a general body cream formulation containing cocoa-butter. Both citrate LDH and the resulting body cream formulations demonstrated prolonged slow release characteristics up to 8 h in aqueous medium under different pH values (3, 4, and 5) compared to quick and fast release of pure citric acid. It was observed that the slow reelase was most efficient at low pH values. The encapsulation between the nano-layers and citrate ions are the key to the slow release characteristics. The body cream has been tested for the anti-fungal activity against three common Candida species (C. albicans, C. glabrata, C. tropicalis). The novel nanohybrid has shown an improved activity and slow release characteristics up to 48 h against the C. albicans and C. glabrata but not for C. tropicalis. Arroyo-López et al. (2012) used a logistic/probabilistic model to obtain the growth/no growth interfaces of Saccharomyces cerevisiae, Wickerhamomyces anomalus and Candida boidinii (three yeast species commonly isolated from table olives) as a function of the diverse 513 combinations of natamycin (0-30 mg/L), citric acid (0.00-0.45%) and sodium chloride (3-6%). Mathematical models obtained individually for each yeast species showed that progressive concentrations of citric acid decreased the effect of natamycin, which was only observed below 0.15% citric acid. Sodium chloride concentrations around 5% slightly increased S. cerevisiae and C. boidinii resistance to natamycin, although concentrations above 6% of NaCl always favoured inhibition by this antimycotic. An overall growth/no growth interface, built considering data from the three yeast species, revealed that inhibition in the absence of citric acid and at 4.5% NaCl can be reached using natamycin concentrations between 12 and 30 mg/L for growth probabilities between 0.10 and 0.01, respectively. References: 1. Arroyo-López FN1, Bautista-Gallego J, Romero-Gil V, Rodríguez-Gómez F, Garrido-Fernández A. Growth/no growth interfaces of table olive related yeasts for natamycin, citric acid and sodium chloride. Int J Food Microbiol. 2012 Apr 16;155(3):257-62. 2. Lopez-Abarrategui C1, Figueroa-Espi V2, Lugo-Alvarez MB1, Pereira CD3, Garay H4, Barbosa JA5, Falcão R6, Jiménez-Hernández L2, Estévez-Hernández 7 8 9 3 O , Reguera E , Franco OL , Dias SC , Otero-Gonzalez AJ1. The intrinsic antimicrobial activity of citric acid-coated manganese ferrite nanoparticles is enhanced after conjugation with the antifungal peptide Cm-p5. Int J Nanomedicine. 2016 Aug 9;11:3849-57. 3. Perera J1, Weerasekera M2, Kottegoda N3. Slow release anti-fungal skin formulations based on citric acid intercalated layered double hydroxides nanohybrids. Chem Cent J. 2015 May 21;9:27. 5. Formic acid      Formic acid is the simplest carboxylic acid. In nature, formic acid is found in the stings and bites of many insects of the order Hymenoptera, including bees and ants. Chemical Names: Formic acid; Methanoic acid; Formylic acid; Aminic acid; 64-18-6; Bilorin Molecular Formula: HCOOH or CH2O2 Formic acid takes part in the metabolism of one-carbon compounds and its carbon may appear in methyl groups undergoing transmethylation 514  Formic acid is responsible for both metabolic acidosis and disrupting mitochondrial electron transport and energy production by inhibiting cytochrome oxidase activity, the terminal electron acceptor of the electron transport chain. Cell death from cytochrome oxidase inhibition by formate is believed to result partly from depletion of ATP, reducing energy concentrations so that essential cell functions cannot be maintained. Furthermore, inhibition of cytochrome oxidase by formate may also cause cell death by increased production of cytotoxic reactive oxygen species (ROS) secondary to the blockade of the electron transport chain. Uses:   The principal use of formic acid is as a preservative and antibacterial agent in livestock feed. When sprayed on fresh hay or other silage, it arrests certain decay processes and causes the feed to retain its nutritive value longer. Antifungal Activity of Formic Acid The effectiveness of propolis, formic acid, formic acids + propolis (1:1) and formic acid+propolis (2:1) on the pathogen of chalkbrood disease (Ascosphera apis) was studied. The propolis extract was prepared by mixing 1900 ml 70% ethanol and 100 g propolis. Isolated A.apis pathogen were cultured in PDA(Potato Dextrose Agar). Five mm in diameter A.apis culture discs were placed in the petri dishes containing PDA and 50 ppm, 25ppm, 12.5 ppm , 6.25 ppm, 3.125 ppm and 1.56 ppm of 5% propolis extract, same doses formic acid and formic acid+ propolis(1:1) mixed and formic acid+propolis (2:1) mixed and incubated at 31 ? 1 C. The growth of the pathogen was evaluated after the 1 month of incubation period. Propolis extract, formic acid, formic acis+propolis (1:1) and formic acid+propolis (2:1) was found to be highly effective against to A.apis pathogen in vitro conditions. Nuray Sahinler and Sener Kurt , 2004. Brands: Recent reports: 515 Şehirli and Saydam (2016) selected propionic, formic and acetic acid to state antifungal activities on some soilborne plant pathogens that are in the GRAS chemicals list. GRAS compounds were tested on, Macrophomina phaseolina, Botrytis cinerea, Sclerotinia sclerotiorum, Fusarium oxysporum and Rhizoctonia solani to understand the efficiencies of organic acids on the plant pathogen development. The mycelial growth inhibition of propionic, formic and acetic acids was determined. Minimum inhibition concentration (MIC) and minimum fungicidal concentrations (MFC) of the organic compounds were stated also. Propionic was significantly better than formic and acetic acid. Propionic acid at 0.7%, formic acid at 0.9% and acetic acid at 1.8% concentration totally inhibited mycelial growth of all fungi, respectively. Organic compounds efficiency was variable and shown a different impact on fungi based on their resistance. B. cinerea, S. sclerotiorum and F. oxysporum resistance was higher than R. solani and M. phaseolina. Lastauskienė et al. (2014) detected chemical compound inducing apoptosis in pathogenic Candida species with the lowest toxicity to the mammalian cells. Five chemical compounds-acetic acid, sodium bicarbonate, potassium carbonate, lithium acetate, and formic acid--were tested for evaluation of antifungal activity on C. albicans, C. guilliermondii, and C. lusitaniae. The results showed that acetic acid and formic acid at the lowest concentrations induced yeast cells death. Apoptosis analysis revealed that cells death was accompanied by activation of caspase. Minimal inhibitory concentrations of potassium carbonate and sodium bicarbonate induced Candida cells necrosis. Toxicity test with mammalian cell cultures showed that formic acid has the lowest effect on the growth of Jurkat and NIH 3T3 cells. References: 1. Lastauskienė E1, Zinkevičienė A, Girkontaitė I, Kaunietis A, Kvedarienė V. Formic acid and acetic acid induce a programmed cell death in pathogenic Candida species. Curr Microbiol. 2014 Sep;69(3):303-10. 2. Nuray Sahinler and Sener Kurt , 2004. A Study on Antifungal Activity of Formic Acid and Propolis Extract Against Chalkbrood Disease Pathogen Ascosphera apis . Journal of Animal and Veterinary Advances, 3: 554-556.\ 3. Sercan Şehirli* and Cansu Saydam. The Effect of Acetic, Formic and Propionic Acids on Plant Pathogenic Fungi. J. BIOL. ENVIRON. SCI., 2016, 10(30), 129-137 516 6. Lactic acid       Lactic acid is an organic compound with the formula CH3CH(OH)COOH. In its solid state, it is white and water-soluble. In its liquid state, it is colorless. Lactic acid is produced both naturally and synthetically. With a hydroxyl group adjacent to the carboxyl group, lactic acid is classified as an alpha-hydroxy acid (AHA). Chemical Names: Lactic acid; 2-hydroxypropanoic acid; DL-Lactic acid; 50-21-5; 2hydroxypropionic acid; Lactate Formula: C3H6O3 or CH3CHOHCOOH or HC3H5O3 Antifungal activity    The antifungal activity of the crude supernatant (cell free supernatant, CFS) of 4 isolates of LAB isolated from honey was evaluated using well diffusion method. The CFS showed high antifungal activity against Candida spp. especially The CFS of L. curvatus HH was significantly (p < 0.05) inhibited growth of C. glabrata ATCC 2001, C. parapsilosis ATCC 2201, and C. tropicalis ATCC 750 with inhibitory zone 22.0, 15.6, and 14.7 mm, respectively. Bulgasem et al. (2016) Lactobacillus brevis G25 (80 ± 0.5 mm) and Lactobacillus cellobiosus (82 ± 0.1 mm) had the greatest antifungal activities after 48 hours against Aspergillus carbonarius G23 and Aspergillus carbonarius G24. However, the antifungal activity was more efficient in liquid medium and Lactobacillus brevis G11 and Lactobacillus fermentum N33 totally inhibited the growth of the 21 molds tested in liquid medium. Thus organic acids were identified as substances responsible for the antifungal activity of the LAB. Tatsadjieu et al. (2016) Approximately 10% of of more than 120 isolates of lactic acid bacteria showed inhibitory activity and only 4.16% (five isolates) exhibited strong activity against the indicator fungus A. fumigatus. The five isolates showed a wide rang of antifungal activity against A. flavus, Fusarium moniliforme, Penicillium commune, and Rhizopus oryzae. They were identified by 16S rDNA sequencing as Lactobacillus cruvatus, L. lactissubsp. lactis, L. casei, L. pentosus, and L. sakei. The effect of Lactobacillus on mycelial growth and fungal biomass as well as its ability to produce toxic compounds were determined. The results indicate that the three species, Lactobacillus casei, L. lactis subsp. lactis, and L. pentosus, are active against A. fumigatus. Kim et al., 2005 Brands 517 Recent reports: Bulgasem et al. (2016) isolated LAB from honey samples from Malaysia, Libya, Saudi Arabia, and Yemen. Twenty-five isolates were confirmed LAB by catalase test and Gram staining, and were screened for antifungal activity. Four LAB showed inhibitory activity against Candida spp. using the dual agar overlay method. And they were identified as Lactobacillus plantarum HS isolated from Al-Seder honey, Lactobacillus curvatus HH isolated from Al-Hanon honey, Pediococcus acidilactici HC isolated from Tualang honey and Pediococcus pentosaceus HM isolated from Al-Maray honey by the 16S rDNA sequence. The growth of Candida glabrata ATCC 2001 was strongly inhibited (>15.0 mm) and (10~15 mm) by the isolates of L. curvatus HH and P. pentosaceusHM, respectively. The antifungal activity of the crude supernatant (cell free supernatant, CFS) was evaluated using well diffusion method. The CFS showed high antifungal activity against Candida spp. especially The CFS of L. curvatus HH was significantly (p < 0.05) inhibited growth of C. glabrata ATCC 2001, C. parapsilosis ATCC 2201, and C. tropicalis ATCC 750 with inhibitory zone 22.0, 15.6, and 14.7 mm, respectively. While CFS of P. pentosaceus HM was significantly (p < 0.05) effective against C. krusei, C. glabrata, and C. albicans with inhibition zone 17.2, 16.0, and 13.3 mm, respectively. The results indicated that LAB isolated from honey produced compounds which can be used to inhibit the growth of the pathogenic Candida species. Hassan et al. (2016) mentioned that sourdough starter cultures are rich sources of endogenous lactic acid bacteria. The extended shelf lives of sourdough breads are attributed to a large array of organic acids and low-molecular-weight metabolites produced during the fermentation process. Different species belonging to the lactic acid bacteria group of microorganisms, mainly Lactobacillus and Leuconostoc, are increasingly gaining the attention as possible means for inhibiting mold growth in animal feed and human food chains. In addition, certain lactic acid bacteria strains isolated from sourdough starters were also shown to reduce mycotoxins concentrations in contaminated products either by binding or degradation. Tatsadjieu et al. (2016) isolated 336 molds from dried corn, soaked corn and fermented corn paste. The macroscopic and microscopic studies of fungal growth in the following identification media, grouped all the 336 molds into 21 strains. The strains belonged mainly to 4 fungal genera: Aspergillus, Fusarium, Penicillium and Rhizopus. In addition, the aflatoxinogenic strains were dominant and were mostly isolated from Maroua (63 strains of Aspergillus flavus). Moreover, the antifungal activity of 53 Lactic acid bacteria (LAB) 518 isolated from the samples was performed against 21 fungal strains. After a screening test, 06 were selected for their potent antifungal activity and were identified as Lactobacillus brevis (2 isolates), Lactobacillus buchneri (1 isolate), Lactobacillus cellobiosus (1 isolate) and Lactobacillus fermentum (2 isolates). During the antifungal tests in solid medium, most of the LAB inhibited the growth of molds but Lactobacillus brevis G25 (80 ± 0.5 mm) and Lactobacillus cellobiosus (82 ± 0.1 mm) had the greatest antifungal activities after 48 hours against Aspergillus carbonarius G23 and Aspergillus carbonarius G24. However, the antifungal activity was more efficient in liquid medium and Lactobacillus brevis G11 and Lactobacillus fermentum N33 totally inhibited the growth of the 21 molds tested in liquid medium. Thus organic acids were identified as substances responsible for the antifungal activity of the LAB. These results show the possibility of exploiting some of these LABs as starters to fight against spoilage molds in fermented corn paste. Valerio et al. (2016) improved the antifungal activity of eight lactic acid bacterial (LAB) strains by the addition of phenylpyruvic acid (PPA), a precursor of the antifungal compound phenyllactic acid (PLA), to a defined growth medium (DM). The effect of PPA addition on the LABs antifungal activity related to the production of organic acids (PLA, d-lactic, l-lactic, acetic, citric, formic and 4-hydroxy-phenyllactic acids) and of other phenylpyruvic-derived molecules, was investigated. In the presence of PPA the inhibitory activity (expressed as growth inhibition percentage) against fungal bread contaminants Aspergillus niger and Penicillium roqueforti significantly increased and was, even if not completely, associated to PLA increase (from a mean value of 0.44 to 0.93 mM). While the inhibitory activity against Endomyces fibuliger was mainly correlated to the low pH and to lactic, acetic and p-OH-PLA acids. When the PCA analysis based on data of growth inhibition percentage and organic acid concentrations was performed, strains grown in DM+PPA separated from those grown in DM and the most active strains Lactobacillus plantarum 21B, Lactobacillus fermentum 18B and Lactobacillus brevis 18F grouped together. The antifungalactivity resulted to be strain-related, based on a different mechanism of action for filamentous fungi and the yeast and was not exclusively associated to the increase of PLA. Therefore, a further investigation on the unique unidentified peak in HPLC-UV chromatograms, was performed by LC-MS/MS analysis. Actually, full scan mass spectra (negative ion mode) recorded at the retention time of the unknown compound, showed a main peak of m/z 291.0 which was consistent with the nominal mass of the molecular ion [M-H](-) of polyporic acid, a PPA derivative whose antifungal activity has been previously reported (Brewer et al., 1977). Hassan et al (2015) studied he effect of eight organic acids (propionic, acetic, formic, lactic, tartaric, citric, oxalic and malic acids) as antifungal agents on the growth of four fungi (Aspergillus flavus, Penicillium purpurogenum, Rhizopus nigricans and Fusarium oxysporum). The high acidity appeared for oxalic acid being 0.14 at the high concentration (10%), while the lowest acidity recorded for propionic acid and acetic acid being 2.71 and 2.56 at the low concentration (5%). It was observed that, there was no relationship between the efficacy of organic acid and its final pH. Acetic acid (10%) has the highest inhibitory effect on A. flavus being 45.21%, but tartaric acid (5%) and citric acid (5%) gave the same lowest inhibition effect (0.42%). The lowest value of mycelium dry weight (MDW) of P. purpurogenum was 5.92 g/l when acetic acid was used (10%), but the highest value was 9.38 g/l when tartaric acid (5%) was used. Formic acid (10%) had a strong effect on the inhibition growth of R. nigricans being 28.65%, similar to propionic acid (10%), acetic acid (10%), lactic acid (10%), tartaric acid (10%) 519 and citric acid (10%) being 26.57%, 26.38%, 26.19%, 23.53% and 24.48%, respectively. But malic acid (5%) and oxalic acid (5%) were having a week effect on R. nigricans being 5.31% and 6.45%, respectively. Lactic acid (10%) has the highest inhibitory effect on F. oxysporum being 34.45% and the lowest value was in the case of tartaric acid (5%) being 1.68%. Four treatments were used to determine aflatoxin B1 production. The highest inhibition (50%) was observed by R. nigricans in the presence of formic acid (10%). Acetic acid in 10% level inhibited the toxic secretion of A. flavus and P. purpurogenum to become 25% and 40%, respectively. Lactic acid (10%) gave 35% inhibition of toxin production in the presence of F. oxysporum. References: 1. Bulgasem BY, Lani MN, Hassan Z, Wan Yusoff WM, Fnaish SG. Antifungal Activity of Lactic Acid Bacteria Strains Isolated from Natural Honey against Pathogenic Candida Species. Mycobiology. 2016;44(4):302-309. 2. Hassan , Yousef , Ting Zhou, Lloyd B Bullerman. Sourdough lactic acid bacteria as antifungal and mycotoxin-controlling agents. Food Science and Technology International. Vol 22, Issue 1, 2016 3. Kim J-D. Antifungal Activity of Lactic Acid Bacteria Isolated from Kimchi Against Aspergillus fumigatus. Mycobiology. 2005;33(4):210-214. doi:10.4489/MYCO.2005.33.4.210. 4. Leopold Ngoune Tatsadjieu1,, Roger Tchikoua2, Carl Moses Mbofung Funtong, Antifungal Activity of Lactic Acid Bacteria against Molds Isolated from Corn and Fermented Corn Paste. American Journal of Microbiological Research Vol. 4, No. 4, 2016, pp 90-100. 5. Ramadan Hassan , Sherif El-Kadi2 and Mostafa Sand. Effect of some organic acids on some fungal growth and their toxins production . International Journal of Advances in Biology (IJAB) Vol 2. No .1, February 2015 6. Valerio F1, Di Biase M1, Lattanzio VM1, Lavermicocca P2. Improvement of the antifungal activity of lactic acid bacteria by addition to the growth medium of phenylpyruvic acid, a precursor of phenyllactic acid. Int J Food Microbiol. 2016 Apr 2;222:1-7. . 521 7. Propionic acid  Propionic acid is a naturally occurring carboxylic acid. It is a liquid with a pungent and unpleasant smell somewhat resembling body odor.  Chemical Names: Propionic acid; Propanoic acid; Ethylformic acid; Methylacetic acid; Carboxyethane; Ethanecarboxylic acid  Formula: C3H6O2 or C₂H₅COOH  Propionic acid (PPA) is a weak acid that has been used in food products as a preservative because of its inhibitory effect on microorganisms. Uses   Propionic acid (PA) is widely used as an antifungal agent in food. Propionic acid is present naturally at low levels in dairy products and occurs ubiquitously, together with other short-chain fatty acids (SCFA), in the gastro-intestinal tract of humans and other mammals as an end-product of the microbial digestion of carbohydrates. Antifungal activity  Propionic acid was significantly better than formic and acetic acids. Propionic acid at 0.7%, formic acid at 0.9% and acetic acid at 1.8% concentration totally inhibited mycelial growth of all fungi, respectively. Organic compounds efficiency was variable and shown a different impact on fungi based on their resistance. B. cinerea, S. sclerotiorum and F. oxysporum resistance was higher than R. solani and M. phaseolina. Şehirli and Saydam (2016) Brands 521 Recent reports: Fernandez et al. (2017) select a new protective culture and validate its effectiveness as an inhibitor of fungal proliferation in cottage-type cheese. Food-grade bacteria (88 strains) were screened for inhibition of four spoilage molds commonly isolated from cheese. Strains of Propionibacterium and Lactobacillus were the most active. Seven strains were selected and tested further, alone and in pairs, for their abilities to prevent Penicillium chrysogenum growth in a solidified dairy matrix and in cottage cheese. Lactobacillus rhamnosus A238 alone or in combination with Bifidobacterium animalis subsp. lactisA026 inhibited mold growth for at least 21 days at 6 °C, due probably to the production of secondary metabolites and/or competition for nutrients. Overall, our findings show that these strains inhibit molds, some of them acting in synergy, and have potential for use as bio-preservatives in fresh cheese. Şehirli and Saydam (2016) selected propionic, formic and acetic acid to state antifungal activities on some soilborne plant pathogens that are in the GRAS chemicals list. GRAS compounds were tested on, Macrophomina phaseolina, Botrytis cinerea, Sclerotinia sclerotiorum, Fusarium oxysporum and Rhizoctonia solani to understand the efficiencies of organic acids on the plant pathogen development. The mycelial growth inhibition of propionic, formic and acetic acids was determined. Minimum inhibition concentration (MIC) and minimum fungicidal concentrations (MFC) of the organic compounds were stated also. Propionic was significantly better than formic and acetic acid. Propionic acid at 0.7%, formic acid at 0.9% and acetic acid at 1.8% concentration totally inhibited mycelial growth of all fungi, respectively. Organic compounds efficiency was variable and shown a different impact on fungi based on their resistance. B. cinerea, S. sclerotiorum and F. oxysporum resistance was higher than R. solani and M. phaseolina. Yun and Lee (2016) investigated the PPA fungal killing mechanism, which showed apoptotic features. First, reactive oxygen species (ROS) accumulation and metacaspase activation were detected by 2',7'-dichlorodihydrofluorescein diacetate and CaspACE FITC-VAD-FMK staining, respectively. Increased fluorescence intensities were observed following exposure to PPA, indicating that PPA produced an oxidative environment through the generation of ROS and activation of metacaspase, which can promote apoptosis signaling. They also examined phosphatidylserine externalization (an early apoptosis marker) and DNA and nuclear fragmentation (late apoptosis markers) after exposure to PPA. Based on the results, we determined that PPA exerts its antifungal effect by inducing apoptotic cell death. Moreover, three additional mitochondrial experiments showed mitochondrial membrane depolarization, calcium accumulation and cytochrome c release after cells were exposed to PPA, indicating that the PPA-induced apoptosis pathway is mediated by mitochondria. In conclusion, PPA induces fungal cell death through mitochondria-mediated apoptosis. Krinjar et al. (1995) reported that Propionate at concentrations up to 0.05 % decreased at 25 ~ the growth and sporulation of Penicillium aurantiogriseum. The standard size of conidiogenous structures (metulae, phialids) and conidia was diminished. The effect was more pronounced at a higher temperature (30 *C). Inhibition of ochratoxin production by propionate was also demonstrated. 522 References: 1. Benoît Fernandez, Allison Vimont, Émilie Desfossés-Foucault, Monica Dagac, Gulshan Arora, Ismaïl Fliss . Antifungal activity of lactic and propionic acid bacteria and their potential as protective culture in cottage cheese. Food Control Volume 78, August 2017, Pages 350-35 2. M. ~KRINJAR a, M. DANEV b and G. DIMI~ Interactive Effects of Propionic Acid and Temperature on Growth and Ochratoxin A Production by Penicillium aurantiogriseum. Folia Microbiol. 40 (3), 253-256 (1995 3. Sercan Şehirli* and Cansu Saydam. The Effect of Acetic, Formic and Propionic Acids on Plant Pathogenic Fungi. J. BIOL. ENVIRON. SCI., 2016, 10(30), 129-137 4. Yun J1, Lee DG2. A novel fungal killing mechanism of propionic acid. FEMS Yeast Res. 2016 Nov;16(7). pii: fow089. Epub 2016 Oct 4.\ 8. Salicylic acid    Salicylic acid is a compound obtained from the bark of the white willow and wintergreen leaves. It has bacteriostatic, fungicidal, and keratolytic actions. Salicylic Acid is a beta hydroxy acid that occurs as a natural compound in plants. It has direct activity as an anti-inflammatory agent and acts as a topical antibacterial agent due to its ability to promote exfoliation. Salicylic acid as a medication is used to help remove the outer layer of the skin. As such it is used to treat warts, calluses, psoriasis, dandruff, acne, ringworm, and ichthyosis Chemical Names: Salicylic acid; 2-Hydroxybenzoic acid; 69-72-7; O-hydroxybenzoic acid; 2Carboxyphenol; O-Carboxyphenol Molecular Formula: C7H6O3 or HOC6H4COOH Antifungal effects  Salicylic acid (SA) inhibited mycelial growth of Eutypa lata (Pers. Fr.)Tul. in a solid as well as in a liquid culture medium, in a concentration-dependent manner, the threshold 523    value being 0.1 mM. In conditions mimicking the plant environment (in particular, a pH near the apoplastic value, i.e. 5.5), 1 mM SA showed only fungistatic properties. Modifications were observed in the structural organization of the mycelium at various levels (wall, mitochondria, vacuole and nucleus). A fungicidal effect was obtained at 2 mM or higher concentrations and following this treatment, fungal filaments appeared empty. Antifungal efficiency of the molecule was increased when the experimental pH was brought to more acidic values (pH 4). This observation was correlated with the increased capacity of compound uptake by the fungus. Chollet and Roblin. 2002 Salicylic acid for ringworm  Topical salicylic acid can be in lotion, ointment or in liquid form. It can be in single form or in combination (e.g. Rhea Ap-Ap solution, DouFilm and United Home Whitfield’s ointment). Topical salicylic acid is usually applied three times a day. Although, salicylic acid falls under category C regarding pregnancy safety, it has no controlled studies on pregnant women therefore it is not advised for use. Brands Recent reports: 524 Rocha Neto et al. (2015) assessed the effect of salicylic acid (SA) against P. expansum, elucidating its mechanisms of action. The antimicrobial effect was determined by exposing conidia to a 2.5 mM SA solution for 0 to 120 min, followed by incubation. The effect of pH on the efficacy of SA against P. expansum was assessed both in vitro and in situ. The action mechanisms were investigated through fluorescence assays, measurement of protein leakage, lipid damage, and transmission electronic microscopy. SA was capable of inhibiting 90% of the fungal germination after 30 min, causing damage to the conidial plasma membrane and leading to protein leakage up to 3.2 μg of soluble protein per g of mycelium. The pH of the SA solution affected the antimicrobial activity of this secondary metabolite, which inhibited the germination of P. expansum and the blue mold incidence in apples in solutions with pH≤3 by 100%, gradually losing its activity at higher pH. Panahirad et al. (2014) assessed the inhibitory effect of salicylic acid on the growth of A. flavus in vitro and in vivo. For this purpose, seven concentrations (0, 1, 3, 5, 7, 9 and 11 mmol L(-1)) of salicylic acid were used in both experiments. Also, aflatoxin B1 contents of the samples were analysed using immunoaffinity chromatography. The results obtained from in vitro experiments showed that salicylic acid significantly reduced Aspergillus growth at all concentrations, and at 9 mmol L(-1) growth was completely suppressed. In vivo evaluation showed relatively high levels of inhibition, though the intact treated fruits as compared with the injured treated fruits demonstrated higher inhibitory effects. CONCLUSION: Regarding the inhibitory effects of salicylic acid on the control of A. flavus contamination, its application on pistachio fruits after harvesting could be a promising approach to control the fungus infection and reduce aflatoxin production in treated fruits Qi et al. (2012) showed that the F. graminearum mycelial growth and conidia germination were significantly inhibited, and eventually halted in the presence of increasing concentration of SA in both liquid and solid media. Addition of SA also significantly reduced the production of the mycotoxin deoxynivalenol (DON). However the inhibitory effect of SA required acidic growth conditions to be observed while basic conditions allowed F. graminearum to use SA as a carbon source. High performance liquid chromatography (HPLC) analysis confirmed the capacity of F. graminearum to metabolize SA. To better understand the effect of SA on F. graminearum mycelial growth, we have compared the expression profiles of SA-treated and untreated F. graminearum liquid cultures after 8 and 24 h of treatment, using an F. graminearum customcommercial microarray. The microarray analysis suggested that F. graminearum can metabolize SA through either the catechol or gentisate pathways that are present in some fungal species. Inoculation of F. graminearum conidia in a SA-containing solution has led to reduced FHB symptoms in the very susceptible Triticum aestivum cv. Roblin. In contrast, no inhibition was observed when SA and conidia were inoculated sequentially. The expression patterns for the wheat PR1, NPR1, Pdf1.2, and PR4 genes, a group of indicator genes for the defence response, suggested that SA-induced resistance contributed little to the reduction of symptoms in our assay conditions. Our results demonstrate that, although F. graminearum has the capacity to metabolize SA, SA has a significant and direct impact on F. graminearum through a reduction in efficiency of germination and growth at higher concentrations. References: 525 1. Chollet, F. and Roblin.. G. Antifungal effects of salicylic acid and other benzoic acid derivatives towards Eutypa lata: structure–activity relationship. Plant Physiology and Biochemistry Volume 40, Issue 12, December 2002, Pages 1051-1060 2. da Rocha Neto AC1, Maraschin M2, Di Piero RM3. Antifungal activity of salicylic acid against Penicillium expansum and its possible mechanisms of action. Int J Food Microbiol. 2015 Dec 23;215:64-70. 3. Panahirad S1, Zaare-Nahandi F, Mohammadi N, Alizadeh-Salteh S, Safaie N. Effects of salicylic acid on Aspergillus flavus infection and aflatoxin B₁ accumulation in pistachio (Pistacia vera L.) fruit. J Sci Food Agric. 2014 Jul;94(9):1758-63. 4. Qi PF1, Johnston A, Balcerzak M, Rocheleau H, Harris LJ, Long XY, Wei YM, Zheng YL, Ouellet T. Effect of salicylic acid on Fusarium graminearum, the major causal agent of fusarium head blight in wheat. Fungal Biol. 2012 Mar;116(3):413-26. 9. Sorbic acid   Sorbic acid is an antimycotic agent which demonstrates broad spectrum activity against yeast and fungal molds. Sorbic acid, or 2,4-hexadienoic acid, is a natural organic compound used as a food preservative. It is a colourless solid that is slightly soluble in water and sublimes readily.Wikipedia Formula: C6H8O Antifungal activity    Sorbic acid was active against most against Candida spp., Sporothrix sp., Fusarium sp., Penicillium spp., Paecilomyces sp. and Aspergillus spp, and in the presence of EDTA, which enhanced the effect of sorbic acid, all the organisms tested were inhibited. Sorbic acid was most effective at low pH. The inhibitory effect of sorbic acid increased with increasing NaCl concentration for all test organisms. RAZAVI-ROHANI and. GRIFFITHS, 1999 At concentrations of 0.1% (w/v), sorbic hydroxamic acid prevented the growth of Aspergillus niger, Penicillium notatum, Botrytis cinerea, Cladosporium herbarum, and a Rhizopus species in grape juice over the pH range 3.6 to 9.2, although sorbic acid was not effective at pH 5.7 and above. Dudman, 1963 526       Sorbic acid with its calcium and sodium salts is a fatty acid commonly used as food preservatives in a wide variety of food products (Chichester and Tanner 1972; Sofos et al. 1979). Sorbic acid and its potassium salt are the most widely used forms of the compounds and are collectively known as sorbates. Sorbate was first patented by Gooding (1945) as an antifungal agent, and has been used to a growing extent to protect a variety of foods against spoilage by microorganisms (Liewen and Marth 1985). The microbial activity of sorbates was reported to be selective, inhibiting the growth of yeasts and molds, but exhibiting less activity against bacteria (Chichester and Tanner 1972; Gardner 1972; Bullerman 1985; Sofos 1989). Sorbates are also highly effective in inhibiting toxin production by some mold strains (Chipley et nl. 1981; Bullerman 1984). There are reports that lower pH and higher NaCl concentrations increase the inhibitory effect of sorbates against fungi (Gooding et al. 1955; Costilow et al. 1955). Brands Recent reports: Gerez et al. (2016) studied the efficiency of preservatives on growth and ochratoxin a (ota) production by Aspergillus niger 13 d at pH values often found in bakery products. The fungal growth inhibition was concentration and pH dependent. Differences between calcium propionate (Cp) and potassium sorbate (ks) were found, observing that ks was less effective than Cp. No fungal growth was observed with 0.4% (w/w) of Cp at pH 6.0, while that the maximum concentration of ks (0.2%, w/w) was not able to inhibit 100% of fungal growth independently of pH evaluated. This study also demonstrated the influence of preservatives on ota production. ota was not detected when the growth was 100% inhibited, i.e., at pH 6.0 and 0.4% (w/w) of Cp. the concentration of Cp could be reduced at 0.3% (w/w) when the pH was lowered to 5.5 without risk of contamination with ota. In presence of ks, a moderate depletion of ota production was observed, however, the maximum concentration (0.2%, w/w) did not completely inhibit ota production. In addition, no stimulating effects on growth or ota levels were observed in any condition assayed. These ―in vitro‖ studies must be corroborated by ―in situ‖ conditions in bakery products and other Aspergillus fungus. 527 Stratford et al. (2009) showed that sorbic and acetic acids do not both inhibit cells by lowering of internal pH alone and that the "classical weak-acid theory" must be revised. The "classical weak-acid theory" suggests that all lipophilic acids with identical pK(a) values are equally effective as preservatives, causing inhibition by diffusion of molecular acids into the cell, dissociation, and subsequent acidification of the cytoplasm. Using a number of spoilage fungi from different genera, we have shown that sorbic acid was far more toxic than acetic acid, and no correlation existed between resistance to acetic acid and resistance to sorbic acid. The molar ratio of minimum inhibitory concentrations (MICs) (acetic: sorbic) was 58 for Paecilomyces variotii and 14 for Aspergillus phoenicis. Using flow cytometry on germinating conidia of Aspergillusniger, acetic acid at pH 4.0 caused an immediate decline in the mean cytoplasmic pH (pH(i)) falling from neutrality to approximately pH 4.7 at the MIC (80 mM). Sorbic acid also caused a rapid but far smaller drop in pH(i), at the MIC (4.5 mM); the pH remained above pH 6.3. Over 0-5 mM, a number of other weak acids caused a similar fall in cytoplasmic pH. It was concluded that while acetic acid inhibition of A. niger conidia was due to cytoplasmic acidification, inhibition by sorbic acid was not. A possible membrane-mediated mode of action of sorbic acid is discussed. Plumridge et al. (2004) noted that the growth of the filamentous fungus Aspergillus niger, a common food spoilage organism, is inhibited by the weak acid preservative sorbic acid (transtrans-2,4-hexadienoic acid). Conidia inoculated at 10(5)/ml of medium showed a sorbic acid MIC of 4.5 mM at pH 4.0, whereas the MIC for the amount of mycelia at 24 h developed from the same spore inoculum was threefold lower. The MIC for conidia and, to a lesser extent, mycelia was shown to be dependent on the inoculum size. A. niger is capable of degrading sorbic acid, and this ability has consequences for food preservation strategies. The mechanism of action of sorbic acid was investigated using (31)P nuclear magnetic resonance (NMR) spectroscopy. We show that a rapid decline in cytosolic pH (pH(cyt)) by more than 1 pH unit and a depression of vacuolar pH (pH(vac)) in A. niger occurs in the presence of sorbic acid. The pH gradient over the vacuole completely collapsed as a result of the decline in pH(cyt). NMR spectra also revealed that sorbic acid (3.0 mM at pH 4.0) caused intracellular ATP pools and levels of sugarphosphomonoesters and -phosphodiesters of A. niger mycelia to decrease dramatically, and they did not recover. The disruption of pH homeostasis by sorbic acid at concentrations below the MIC could account for the delay in spore germination and retardation of the onset of subsequent mycelial growth. References: 1. Gerez CL, Bustos AY, de Valedz GF. Antifungal and Antiochratoxigenic Properties of Chemical Preservatives In/of Bread. J Food Technol Pres. 2016;1:6-10 2. Plumridge A1, Hesse SJ, Watson AJ, Lowe KC, Stratford M, Archer DB. The weak acid preservative sorbic acid inhibits conidial germination and mycelial growth of Aspergillus niger through intracellular acidification. Appl Environ Microbiol. 2004 Jun;70(6):350611. 3. RAZAVI-ROHANI, M.W. GRIFFITHS. Antifungal effects of sorbic acid and propionic acid at different ph and nacl conditions J Food Safety. Volume 19, Issue 2 August 1999 Pages 109–120 528 4. Stratford M1, Plumridge A, Nebe-von-Caron G, Archer DB. Inhibition of spoilage mould conidia by acetic acid and sorbic acid involves different modes of action, requiring modification of the classical weak-acid theory. Int J Food Microbiol. 2009 Nov 30;136(1):37-43. 10. Undecylenic acid     Undecylenic acid is an organic compound Undecylenic is an unsaturated fatty acid and forms a colorless oil at room temperature and pressure. Undecylenic acid is a natural or synthetic fungistatic fatty acid, antifungal Undecylenic acid is used topically as a zinc salt in various creams against fungal infections, eczemas, ringworm, and other cutaneous conditions. The zinc provides an astringent action, reducing rawness and irritation. Molecular Formula: C11H20O2 . Mechanism of action        Compound undecylenic acid has a fungistatic action. The zinc present in the zinc undecylenate component provides a beneficial astringent action, which aids in reducing rawness and irritation. Undecylenic acid is an organic compound with the formula CH2=CH(CH2)8CO2H. Undecylenic acid is an unsaturated fatty acid and forms a colorless oil at room temperature and pressure. Undecylenic acid is mainly used for the production of Nylon-11 and in the treatment of fungal infections of the skin, Undecylenic acid is also a precursor in the manufacture of many pharmaceuticals, personal hygiene products, cosmetics, and perfumes. Undecylenic acid salts and esters are known as undecylenates. Brands 529 Recent reports: Shi et al. (2016) investigated antifungal mechanisms of undecylenic acid by evaluating the virulence factors of C. albicans during biofilm formation. They found that undecylenic acid inhibits biofilm formation of C. albicans effectively with optimal concentration above 3 mM. In the presence of this compound, the morphological transition from yeast to filamentous phase is abolished ultimately when the concentration of undecylenic acid is above 4 mM. Meanwhile, the cell surface is crumpled, and cells display an atrophic appearance under scanning electron microscopy even with low concentration of drug treatment. On the other hand, the drug treatment decreases the transcriptions of hydrolytic enzymes such as secreted aspartic protease, lipase, and phospholipase. Hyphal formation related genes, like HWP1, are significantly reduced in transcriptional level in drug-treated biofilm condition as well. The downregulated profile of these genes leads to a poorly organized biofilm in undecylenic acid treated environment. Gonçalves et al. (2012) investigated the effects of UDA released from DL on Candida biofilms. The concentrations of UDA released from commercial DL were determined by gas chromatography-mass spectrometry (GC-MS). Minimum inhibitory concentration (MIC) and minimum fungistatic concentration (MFC) tests were performed for C. albicans or C. glabrata, with UDA for comparison with the concentrations released from DL. Specimens of DL with (experimental group) and without UDA (control group) were fabricated, and Candida biofilms were developed on DL surfaces. Biofilms were evaluated by cell counts, metabolic activity, structure, and secretion of proteinase or phospholipase. The concentrations of UDA released were within the MIC and MFC ranges. In the presence of UDA, C. albicans biofilms were thinner and had lower numbers of viable and active cells, although no significant enzymatic changes were observed relative to the control group (p > 0.05). In contrast, C. glabrata biofilms exhibited higher cell counts and greater metabolic activity and also increased proteinase activity in the presence of UDA relative to the control group (p < 0.05). Overall, UDA did not prevent Candida biofilm formation. References: 1. Gonçalves LM1, Del Bel Cury AA, Sartoratto A, Garcia Rehder VL, Silva WJ. Effects of undecylenic acid released from denture liner on Candida biofilms. J Dent Res. 2012 Oct;91(10):985-9. 2. Shi D, Zhao Y, Yan H, Fu H, Shen Y, Lu G, Mei H, Qiu Y, Li D, Liu W. Antifungal effects of undecylenic acid on the biofilm formation of Candida albicans. Int J Clin Pharmacol Ther. 2016 May;54(5):343-53. 531 7.9. Antifungal fatty acids Interaction of fatty acids with cell membranes , Pohl et al., 2011     Antifungal fatty acids naturally insert themselves into the lipid bi-layer of the fungal membranes and physically disturb the membrane, resulting in increased fluidity of the membrane. These elevations in membrane fluidity will cause a generalized disorganization of the cell membrane that leads to conformational changes in membrane proteins, the release of intracellular components, cytoplasmic disorder and eventually cell disintegration. Sterols, especially the fungal sterol, ergosterol, tend to buffer such induced elevations in membrane fluidity, therefore fungal membranes with low sterol content are sensitive and unable to cope with such excessive elevations in membrane fluidity. The chemical composition of fatty acids as well as the pH of the medium plays an important role in the ability of these compounds to inhibit fungi. Saturated fatty acids Antifungal free fatty acids can be saturated or unsaturated and in general the antifungal efficiency of fatty acids increases with an increase in chain length. 531 532 Unsaturated fatty acids Unsaturated fatty acids contain fixed bend C=C bonds and will therefore occupy a greater cross section when inserted into the membrane. They are proposed to have increased fungicidal activity due to their increased motional freedom inside the membrane. Table 2 lists unsaturated free fatty acids with antifungal activity 533 Recent reports Era et al. (2016) focused on the antifungal effect of fatty acids potassium salts. The antifungal activity of nine fatty acid salts (butyrate, caproate, caprylate, caprate, laurate, myristate, oleate, linoleate, and linolenate) was tested on the spores of Trichophyton violaceum NBRC 31064. The results show that C6K, C8K, C10K, C12K, C18:2K, C18:3K was the most inhibit 4-log unit (99.99 %) of the fatty acids potassium incubated time for 10 min. It was observed that C12K and C18:3K was most high antifungal activity MIC. Commercially soap was lowest antifungal activity. This is because of the oleic acid is a major component of soap. Although further investigation is necessary to make clear antifungal mechanisms, our results suggest that fatty acid potassium will use to the development of a coating agent such as furniture. Abdelillah et al. (2013) evaluated the antifungal activity of the major fraction of fatty acids methyl esters (FAMEs) isolated from Linum usitatissimum L. seeds oil collected from Bechar department (Algeria). The assessment of antifungal activity was carried out in terms of percentage of radial growth on solid medium (potatoes dextrose agar PDA) and biomass growth inhibition on liquid medium (potatoes dextrose broth PDB) against two fungi. The FAMEs was found to be effective in inhibiting the radial mycelial growth of Aspergillus flavus more than Aspergillus ochraceus on all tested concentrations. The highest antifungal index was found to be (54.19%) compared to Aspergillus ochraceus (40.48%). The results of the antifungal activity of the FAMEs inhibition of biomass on liquid medium gave no discounted results, but this does not exclude the antifungal activity. Era et al. (2015) tested the antifungal activity of nine fatty acid salts (butyrate, caproate, caprylate, caprate, laurate, myristate, oleate, linoleate, and linolenate) on the spores of Penicillium pinophilum NBRC 6345 and Penicillium digitatum NBRC 9651. Potassium caprate showed the strongest antifungal activity at 4 log-units. At incubation times of 180 min, potassium caprylate and potassium laurate showed antifungal activities of 2 log-units against P. pinophilum NBRC 6345. These results suggest medium-chain fatty acid salts showed the highest antifungal activity. The minimum inhibitor y concentration of potassium caprate against P. pinophilum NBRC 6345 was 175 mM, and >175 mM for other fatty acid salts. When mixed with short-chain fatty acid salts (potassium butyrate, potassium caproate) or medium-chain fatty acid salts (potassium caprylate or potassium laurate), potassium caprate caused a 4 log-unit reduction in fungal growth; however, when mixed with long-chain fatty acid salts (potassium myristate, potassium oleate, potassium linoleate, or potassium linolenate) it had no antifungal effect. Thus, long-chain fatty acid salts inhibited antifungal activity of C10K. We also evaluated the ability of C10K to inhibit fungal growth on orange rind. C10K effectively inhibited P. pinophilum NBRC 6345 growth on orange rind. Abubacker et al. (2014) identified bioactive compound oleic acid, 3-(octadecyloxy) propyl ester from Lepidagathis cristata Willd. (L. cristata) and to assess antifungal potentials of the isolated compound. Aqueous extracts of L. cristata inflorescence were used for this study. The major bioactive compound isolated was tested for antifungal activities. The major bioactive compound oleic acid, 3-(octadecyloxy) propyl ester was isolated from the inflorescence of L. cristata. The bioactive compound was tested for antifungal potentials and found to be highly effective to plant pathogenic fungi Colletotrichum fulcatum NCBT 146, Fusarium oxysporum NCBT 156 and Rhizoctonia solani NCBT 196 as well as for the human pathogenic fungi Curvularia lunata MTCC 2030 and Microsporum canis MTCC 2820. 534 Liu et al. (2014) examined the fungicidal activity of a medium-chain fatty acids mixture comprising caprylic acid (C8:0), pelargonic acid (C9:0) and capric acid (C10:0), against Rhizoctonia solani, Phytophthora infestans, Colletotrichum gloeosporioides, Botrytis cinerea, Fusarium oxysporum and Sphaerotheca cucurbitae. The mixture of caprylic, pelargonic and capric acids (2/5/3, w/w/w) is prepared into a micro-emulsion concentrate and tested for its inhibitory effect on fungal growth using disc diffusion method except for S. cucurbitae using pot bioassay method. Results show that the fatty acids mixture is self-stabilized under either 4°C during a seven-day-storage or 54°C during fortnight. The doses of the mixed fatty acids completely inhibiting the mycelial growth are 100 ppm for P. infestans and 125 ppm C. gloeosporioides after three days and 200 ppm for B. cinerea after 4 days. A dose of 100 ppm reduces the mycelial growth in R. solani by 93.7% after 4 days and that in F. oxysporum by 92.9% after 3 days. For S. cucurbitae, a dose of 250 ppm results in a control effect of 81.0% in the pot bioassay. Jung et al. (2013) investigated antifungal effects of fatty acid salts in soap against S. apiospermum under different water conditions. Ultrapure soft water (UPSW) was generated by the water softener with cation-exchange resin. The calcium and magnesium ions were replaced with sodium ions in UPSW. Scedosporium apiospermum was incubated with different fatty acid salts that constituted soap in distilled water (DW), tap water (TW) and UPSW. After incubation, the number of fungi was counted. Among the fatty acids, palmitic acid salt (C16) reduced the number of S. apiospermum. UPSW enhanced the antifungal effect of C16 on S. apiospermum. The absence of both calcium and magnesium ions and the existence of sodium chloride in UPSW were responsible for its antifungal effect. In addition, repeated short-term treatment with UPSW and C16 decreased the number of S. apiospermum. References: 1. Abdelillah A, Houcine B, Halima D, et al. Evaluation of antifungal activity of free fatty acids methyl esters fraction isolated from Algerian Linum usitatissimum L. seeds against toxigenic Aspergillus. Asian Pacific J. Tropical Biomedicine. 2013;3(6):443-448. 2. Abubacker MN1, Devi PK2. In vitro antifungal potentials of bioactive compound oleic acid, 3-(octadecyloxy) propyl ester isolated from Lepidagathis cristata Willd. (Acanthaceae) inflorescence. Asian Pac J Trop Med. 2014 Sep;7S1:S190-3. 3. ERA, Mariko, Takayoshi KAWAHARA 2 , Takahide KANYAMA 2 and Hiroshi MORITA. Effects of Fatty Acid Salts against Trichophyton Violaceum. 03004 (2016) DOI: 10.1051/ I MATEC Web of Conferences 60, matecconf/2016600 CCBS 2016 3004 4. M. Era, S. Sakai, A. Tanaka, T. Kawahara, T. Kanyama and H. Morita ; Antifungal Activity of Fatty Acid Salts Against Penicillium pinophilum. Japan Journal of Food Engineering., 16, 99-108 (2015) 5. Jung K1, Miyagawa M, Matsuda A, Amagai Y, Oida K, Okamoto Y, Takai M, Nishikawa S, Jang H, Ishizaka S, Ahn G, Tanaka A, Matsuda H. Antifungal effects of palmitic acid salt and ultrapure soft water on Scedosporium apiospermum. J Appl Microbiol. 2013 Sep;115(3):711-7. 6. Xiaojin Liu, Ruiming Han, Yueh Wang, Xiuxia Li, Min Zhang and Yu Yan, 2014. Fungicidal Activity of a Medium-chain Fatty Acids Mixture Comprising Caprylic, Pelargonic and Capric Acids. Plant Pathology Journal, 13: 65-70 535 7.10. Antifungal Essential Oils           Essential oils (volatile oils) are complex mixtures of odorous principles stored in special plant cells, glands, glandular hairs, oil ducts, or resin ducts in any part of a plant which are obtained by living organisms and isolated by pressing and hydro or steam distillation from a whole plant or different parts of plants such as leaves, flowers, fruits, grass, root, wood, bark, gum, and blossom in some plant families. The most important plant families which are used to extract essential oil are Lamiaceae, Myrtaceae, Rutaceae, and Apiaceae. Essential oils are soluble in alcohol and fats but only slightly soluble in water. Most essential oils are colorless, but some of them are colored (e.g., Matricaria chamomilla oil has azulene, which is blue). Upon exposure to light and air, they readily oxidize and resinify. The total essential oil content of plants is generally very low (<1 %). Plant essential oils have various applications such as fragrances, flavorings, preservative agents, condiments or spices, as well as medicinal uses in food, cosmetic, and pharmaceutical industries. In addition, they are the most concentrated part of a plant‘s vital force or energy, and they have antimicrobial and insecticidal properties (Ahmad et al. 2006; Rai and Cecilia Carpinella 2006; Baser and Buchbauer 2010; Silva and Fernandes 2010). Essential oils obtained from aromatic herbs and spice plants are known to be inhibitive or lethal to fungi. Essential oils have been reported to control moulds and various fungi such as food-borne and phytopathogenic fungi which cause different postharvest diseases and animal and human disorders (Banihashemi and Abivardi 2011). Essential oils could be useful alternative substances replacing synthetic fungicides in the plant disease management (Gwinn et al. 2010; Nguefack et al. 2013). Aromatic plants such as members of the Asteraceae, Lamiaceae, Rutaceae, and Verbenaceae contain essential oils which have bioactivity against several fungi (Lahlou 2004; Edris 2007). Mechanism of the inhibitory action   Essential oils mechanism of the inhibitory action on the fungi is not well understood. As yet, there are a limited number of studies describing the mode of action of many essential oils. Essential oils antifungal property has been supposed to be because of their lipophilic nature, responsible for disruption of plasma membrane, loss of membrane integrity, and leakage of cellular material and thereby negatively affecting the main cellular components particularly mitochondria as has been supported by the transmission electron 536  microscopy studies on essential oil-treated Aspergillus flavus culture (Tian et al. 2011, 2012; Da Silva Bomfim et al. 2015). Essential oils contain different kinds of volatile molecules such as terpenes and terpenoids and phenol-derived aromatic and aliphatic components. Different constituents of essential oils are responsible for their mode of antifungal action (Bakkali et al. 2008).  In general, the antifungal activity of essential oils against pathogenic fungi can be attributed to morphological changes in the cell wall and interference in enzymatic reactions of wall synthesis, which affect fungal growth and morphogenesis (Sharma and Tripathi 2008). This causes either an increase in ion permeability and leakage of vital intracellular constituents or impairment of the fungal enzyme systems (De Billerbeck et al. 2001; Romagnoli et al. 2005). Metabolism       Essential oils are mainly soluble in alcohol. The main function of essential oil metabolism is to alter the alcohol solubility of their molecules to excrete via urine; however, some essential oil molecules can be directly excreted in the urine without metabolism. Essential oils metabolism is usually carried out by enzymes which take place in the liver or epidermal layers of the skin. Essential oils that are inhaled or applied topically do not go through the first stage of metabolism by the liver. Essential oils are lipid soluble, and their components are easily accessible to the brain. While being carried by the bloodstream, the constituents travel readily to the adrenal glands and kidneys. The rate of essential oil removal from the body is related to the concentration of the oil in the bloodstream. It is complicated because the essential oil begins to be eliminated while it is still being absorbed. Essential oils are excreted via the kidneys, lungs, skin, and feces. Distribution Distribution is determined as the movement of essential oil substances between two locations in the body. The distribution of any essential oil is controlled by the bloodstream to the tissue or organ, as well as by the oil‘s ability to bind to plasma proteins. 537 The pathway of essential oils through different parts of the body from absorption to excretion (Bowles 2003) 1. Anise essential oil      Anise essential oil can be obtained from the fruits of Star anise by either steam distillation or extraction using supercritical carbon dioxide. Anise essential oil main component is anethole (80–90%), with minor components including 4-anisaldehyde, estragole and pseudoisoeugenyl-2-methylbutyrates, amongst others Star anise is an evergreen tree native to Asis which grows up to 35 feet in height. o The fruits can be eaten fresh or dried. o The leaves are poisonous. Traditional Chinese medicine has used star anise plant for centuries for a variety of ailments. o star anise has been used for constipation, breath freshening, joint aches, muscle spasms, sleep and toothaches. o star anise is chewed after meals as it is thought to promote good digestion and sweeten the breath. o star anise is an ingredient in cough medicines and cough drops in Japan. Aromatherapy for anise star essential oil include: o analgesic, antiseptic, antispasmodic, aperitive, aphrodisiac, calmative, cardiac, carminative, digestive, disinfectant, diuretic (mild), stomachic, tonic, warming.estrogenic, expectorant, insecticide, stimulant (circulatory and digestive system; respiratory tract), Antifungal activity:  MIC values (expressed in _g/_L) of tested anise oil essential oil were 2.44, 4.88. 2.44, 2.44, 0.59, 9.78, 2.44 against Candida albicans, Candida tropicalis, Aspergillus niger, Aspergillus terreus, Aspergillus fumigatus, Trichosporon sp. And Rhodotorula sp., respectively. Ebani et al., 2017  Growth reduction of Aspergillus flavus, Aspergillus parasiticus and Fusarium verticillioides by 83.2%, 72.8% and 65.11%, respectively when using 100 ppm of the star anise essential oil, where a complete inhibition was achieved at 200 ppm for A. flavus and A. parasiticus respectively. Aflatoxin B1 and Fumonisin B1 production were inhibited completely at 100 and 200 ppm respectively. Bassem et al. (2016)  MICs between 2 and 4% v/v for anise essential oils, with values >4% v/v for some Candida albicans strains. Bona et al. (2016) 538 Recent reports: Bassem et al. (2016) characterised star anise (Illicium verum) and assessed its antioxidant and antifungal and antimycotoxigenic properties using different methods. Results revealed that the major components of star anise essential oil identified by GC/MS were trans-anethole (82.7%), carryophyllene (4.8%) and limonene (2.3%). Total phenolics of ethanol and methanol extracts recorded 112.4 and 96.3 mg GAE/g DW respectively, whereas higher total flavonoid content was recorded for the ethanol extract than the methanol extract. Star anise essential oil showed lower antioxidant activity (55.6 mg/mL) than the extracts using DPPH-scavenging and βcarotene/linoleic acid assays. Results revealed growth reduction of Aspergillus flavus, Aspergillus parasiticus and Fusarium verticillioides by 83.2%, 72.8% and 65.11%, respectively when using 100 ppm of the star anise essential oil, where a complete inhibition was achieved at 200 ppm for A. flavus and A. parasiticus respectively. Aflatoxin B1 and Fumonisin B1 production were inhibited completely at 100 and 200 ppm respectively. It could be concluded that star anise extracts could be considered an important substance that should be explored for the discovery and development of newer and safer food supplements as well as drug products. Bona et al. (2016) assessed the sensitivity of 30 different vaginal isolated strains of C. albicans to 12 essential oils, compared to the three main used drugs (clotrimazole, fluconazole and itraconazole). Thirty strains of C. albicans were isolated from vaginal swab on CHROMagar™ Candida. The agar disc diffusion method was employed to determine the sensitivity to the essential oils. The antifungal activity of the essential oils and antifungal drugs (clotrimazole, itraconazole and fluconazole) were investigated using a microdilution method. Transmission and scanning electron microscopy analyses were performed to get a deep inside on cellular damages. The results showed MICs between 2 and 4% v/v for laurel, anise, basil, mint, rosemary and tea tree essential oils, with values >4% v/v for some strains. A variable efficacy was observed for lavender essential oil against C. albicans, with MICs ranging from 0·25 to 4% v/v. Candida albicans strains were also rather sensitive to grapefruit essential oil, showing MICs of 0·25 or 0·125% v/v, even if a value of 0·0039% v/v was recorded for a single strain. Mint, basil, lavender, tea tree oil, winter savory and oregano essential oilsinhibited both the growth and the activity of C. albicans more efficiently than clotrimazole. Damages induced by essential oils at the cellular level were stronger than those caused by clotrimazole. Candida albicans is more sensitive to different essential oils compared to the main used drugs. Moreover, the essential oilaffected mainly the cell wall and the membranes of the yeast. 539 References: 1. Bassem ,Soher E.Alya A.SabryaMohamed S.ShaheenbAmal S.Hathou. Assessment of antimycotoxigenic and antioxidant activity of star anise (Illicium verum) in vitro. Journal of the Saudi Society of Agricultural Sciences. Volume 15, Issue 1, January 2016, Pages 20-27 2. Bona E1, Cantamessa S1, Pavan M1, Novello G1, Massa N1, Rocchetti A2, Berta G1, Gamalero E1. Sensitivity of Candida albicans to essential oils: are they an alternative to antifungal agents? J Appl Microbiol. 2016 Dec;121(6):1530-1545. 3. Ebani, V. V. et al., 2017. Antibacterial and Antifungal Activity of Essential Oils against Pathogens Responsible for Otitis Externa in Dogs and Cats. Medicines 2017, 4, 21; doi:10.3390/medicines4020021 2. Arborvitae essential oil    Arborvitae oil comes from the woody fibers of the Giant Arborvitae tree. Arborvitae oil can be used aromatically or topically. If used topically it can be applied neat or with a carrier oil like fractionated coconut oil for children or those with sensitive skin. Arborvitae oil has antibacterial, antifungal, cleansing, cell protecting, insect repellent,. Latin Name:Thuja plicata This particular species is commonly called Western or Pacific Red Cedar, Giant or Western Arborvitae, Giant Cedar or Shinglewood. 541     One chemical component, Thujaplicin, is found in mature trees and serves as a natural fungicide, thereby preventing the wood from rotting. This effect lasts around a century even after the tree is felled. However, thujaplicin is only found in older trees. Arborvitae essential oil is concentrated in tropolones, such as hinokitiol, which are a group of chemical compounds that protect against environmental and seasonal threats and have powerful purifying properties. Thujic acid, another tropolone found in Arborvitae, also contribute to Arborvitae‘s natural insect repellent properties. Arborvitae essential oil is antibacterial, antifungal, antiseptic, anticancer, antitumor, astringent, expectorant, insect repellent Thujaplicins Thujaplicins (isopropyl cycloheptatrienolones) are series of related chemical substances discovered in the 1930s and isolated from Thuja plicata (western redcedar tree).[1] The three compounds are α-thujaplicin, β-thujaplicin (hinokitiol), and γ-thujaplicin. They are known for potent anti-fungal and anti-bacterial properties.[2] They are also known to be potent antioxidants Chemical structure of α-thujaplicin Chemical structure of hinokitiol (β-thujaplicin Antifungal activity:  β-thujaplicin showed a statistically significant (p <0.001) growth inhibition effect on Sclerotinia sclerotiorum as a pathogen of sclerotium disease, Rhizoctonia solani AG-4 as a pathogen of damping off, Phytophthora capsici as a pathogen of phytophthora blight, and Colletotrichum coccodes as a pathogen of anthracnose at a concentration of 50 ppm and on Stemphylium solani as a pathogen of spotting disease and Alternaria alternata as a pathogen of black mold at a concentration of 100 ppm. Kwon et al., 2017  In vitro, β-thujaplicin profoundly, but nonselectively, inhibits fungal growth in soil samples at moderately high levels. Baumgardner, 2015 541 Recent reports: Puškárová et al. (2017) mentioned that six essential oils (from oregano, thyme, clove, lavender, clary sage, and arborvitae) exhibited different antibacterial and antifungal properties. Antimicrobial activity was shown against pathogenic (Escherichia coli, Salmonella typhimurium, Yersinia enterocolitica, Staphylococcus aureus, Listeria monocytogenes, and Enterococcus faecalis) and environmental bacteria (Bacillus cereus, Arthrobacter protophormiae, Pseudomonas fragi) and fungi (Chaetomium globosum, Penicillium chrysogenum, Cladosporium cladosporoides, Alternaria alternata, and Aspergillus fumigatus). Oregano, thyme, clove and arborvitae showed very strong antibacterial activity against all tested strains at both full strength and reduced concentrations. These essential oils showed different fungistatic and fungicidal activities when tested by direct application and in the vapor phase. The genotoxic effects of these oils on HEL 12469 human embryo lung cells were evaluated using an alkaline comet assay for the first time, revealing that none of the oils induced significant DNA damage in vitro after 24 h. This study provides novel approaches for assessing the antimicrobial potential of essential oils in both direct contact and the vapor phase and also demonstrates the valuable properties of the phenol-free arborvitae oil. These results suggest that all the tested essential oils might be used as broad-spectrum anti-microbial agents for decontaminating an indoor environment. Yooussef et al. (2016) evaluated the antifungal activities of seventeen essential oils on the growth of the aflatoxigenic form of A. parasiticus in contaminated peanuts from commercial outlets in Georgia. The agar dilution method was used to test the antifungal activity of essential oils against this form of A. parasiticus at various concentrations: 500; 1,000; 1,500; 2,000; 2,500 ppm. Among the seventeen essential oils tested, the antifungal effect of cinnamon, lemongrass, clove and thyme resulted in complete inhibition of mycelial growth. Cinnamon oil inhibited mycelial growth at ≥ 1,000 ppm, lemongrass and clove oils at ≥ 1,500 ppm and thyme at 2,500 ppm. However, cedar wood, citronella, cumin and peppermint oils showed partial inhibition of mycelial growth. Eucalyptus oil, on the other hand, had less antifungal properties against growth of A. parasiticus, irrespective of its concentration. The results indicate that the aflatoxigenic form of A. parasiticus is sensitive to selected essential oils, especially cinnamon. These findings clearly indicate that essential oils may find a practical application in controlling the growth of A. parasiticus in stored peanuts. 542 Rhafouri et al. (2014) determined the chemical composition and studied the antibacterial and the antifungal activity of the hydrodistilized essential oil from both the winged and wingless seeds of the High Atlas Cedrus atlantica (Morocco). The essential oil is analyzed by gas chromatography and gas chromatography mass spectrometry. The essential oil yields of winged as well as wingless seeds were respectively 2.6% and 3.6%.The main constituents of the cedar wingless seeds are the α-pinene, the manool, and the bornyl acetate; whereas, the major constituents of the cedar winged seeds are the manool and the α-pinene. The antibacterial and antifungal activities of the essential oils were tested on four bacteria, three molds and four fungi of wood rot. The fungal strains tested were revealed more sensitive to the essential oil studied than the bacterial strains. Takao et al. (2012) prepared essential oil (EO) from waste wood chips made from used sake barrels (USBs) of Japanese cedar (i.e., EO-USB) by steam distillation. We found that EO-USB and three commercially purchased EOs derived from xylem tissue of Japanese woods, such as Japanese cedar (Cryptomeria japonica), Japanese cypress (Chamaecyparis obtusa) and false arborvitae (Thujopsis dolabrata), suppressed fungal growth activity against Trichophyton rubrum, which is the cause of tinea disease. The magnitude of the suppressive effects of the EOs ranked as follows: T. dolabrata > USB = C. japonica > C. obtusa. These EOs also inhibited the activity of DNA polymerase in an extract from T. rubrum mycelia with the following ranking: T. dolabrata > USB = C. japonica > C. obtusa. In addition, 50 µg/ml of EO-USB showed antifungal properties, killing T. rubrum mycelia at 27-42˚C in 20 min. By gas chromatography/mass spectrometry analysis, the main sesquiterpenes in EO-USB were δcadinene (25.94%) and epi-cubenol (11.55%), and the composition of EO-USB was approximately the same as that of EO-C. japonica. Three prepared sesquiterpenes, δ-cadinene, epi-cubenol and β-eudesmol, inhibited the fungal growth and DNA polymerase activities of T. rubrum, and epi-cubenol showed the strongest inhibition among the compounds tested. These sesquiterpenes had no inhibitory effects on the activities of other DNA metabolic enzymes, such as DNA topoisomerase II, IMP dehydrogenase, polynucleotide kinase and deoxyribonuclease from T. rubrum. Taken together, these results suggest that EO-USB containing epi-cubenol may be useful for its anti-tinea disease properties, which are based on DNA polymerase inhibition. References: 1. Baumgardner DJ. β-Thujaplicin: A Soil Antifungal. J Patient Cent Res Rev 2015;2:211212.http://dx.doi.org/10.17294/2330-0698.1237] 2. Kwon, Yubin · Hyun-Sang Kim1 · Hyun-Woo Kim1 · Dong Woon Lee2 Yong-Hwa Choi. Antifungal activities of β-thujaplicin originated in Chamaecyparis obtuse. J Appl Biol Chem (2017) 60(3), 265−269 3. Puškárová A1, Bučková M2, Kraková L2, Pangallo D2, Kozics K3. The antibacterial and antifungal activity of six essential oils and their cyto/genotoxicity to human HEL 12469 cells. Sci Rep. 2017 Aug 15;7(1):8211. 4. Rhafouri Rachid 1,2, Badr Strani2, Touria Zair3, Mohamed Ghanmi2,Abderrahman Aafi2, Mohamed El Omari1 and Amar Bentayeb1. Chemical composition, antibacterial and antifungal activities of the Cedrus atlantica (Endl.) Manettiex Carrière seeds essential oil. Mediterranean Journal of Chemistry 2014, 3(5), 1034-1043 543 5. Takao Y1, Kuriyama I, Yamada T, Mizoguchi H, Yoshida H, Mizushina Y. Antifungal properties of Japanese cedar essential oil from waste wood chips made from used sake barrels. Mol Med Rep. 2012 May;5(5):1163-8. 6. Yooussef , Quyen Pham1, Premila N. Achar1*, Marikunte Yanjarappa Sreenivasa2 Antifungal activity of essential oils on Aspergillus parasiticus isolated from peanuts. Journal Of Plant Protection Research Vol. 56, No. 2 (2016) 3. Basil essential oil        Basil (Ocimum basilicum) is most commonly known and used as a culinary herb. Basil was long favored throughout history for its therapeutic and alleged healing benefits. Basil essential oil is steam distilled from the leaves and flowers of the basil plant. Basil essential oil is a thin essential oil in its consistency and is normally clear in color. Basil essential oil is a top note, and can often times overpower other essential oils when creating blends or synergies. Basil essential oil has shown antimicrobial activity against a wide range of foodborne bacteria, yeasts and mold. Basil essential oil (from sweet basil) primarily consists of monoterpenes and phenylpropanoids. Of the 25 different active constituents found in basil essential oil that compromise 98.6 percent of the total oil, the most prominent include methyl eugenol (39.3 percent) and methyl chavicol (38.3 percent). Antifungal activity   Mycelial growth of the plant pathogenic fungus Botrytis fabae was reduced significantly by both the methyl chavicol chemotype oil and the linalol chemotype oil, and the major individual components of the basil oils all reduced fungal growth, with methyl chavicol, linalol, eugenol and eucalyptol reducing growth significantly. Combining the pure oil components in the same proportions as found in the whole oil led to very similar reductions in fungal growth, suggesting that the antifungal effects of the whole oils were due primarily to the major components. When the fungus was exposed to the oils in liquid culture, growth was reduced by concentrations considerably smaller than those used in the Petri dish studies. Botrytis fabae and the rust fungus Uromyces fabae were also controlled in vivo, with the whole oils of both chemotypes, as well as pure methyl chavicol and linalol, reducing infection of broad bean leaves significantly. Most effective control of fungal infection was achieved if the treatments were applied 3 h postinoculation. Oxenham et al., 2005 Ocimum basilicum L. essential oil showed significant antifungal activity that was dependent on the used oil concentration. The complete inhibition of A. flavusgrowth was observed at 1000 ppm oil concentration, while marked inhibition of aflatoxin B1 production was observed at all oil concentrations tested (500, 750 and 1000 ppm). ElSoud et al., 2015 544  Basil essential oil seems to be a promising option as an antifungal compound, making possible its use as substitute for chemical additives. Saggiorato et al., 2012 Recent reports: Bona et al. (2016) assessed the sensitivity of 30 different vaginal isolated strains of C. albicans to 12 essential oils, compared to the three main used drugs (clotrimazole, fluconazole and itraconazole).Thirty strains of C. albicans were isolated from vaginal swab on CHROMagar™ Candida. The agar disc diffusion method was employed to determine the sensitivity to the essential oils. The antifungal activity of the essential oils and antifungal drugs (clotrimazole, itraconazole and fluconazole) were investigated using a microdilution method. Transmission and scanning electron microscopy analyses were performed to get a deep inside on cellular damages. The results showed MICs between 2 and 4% v/v for laurel, anise, basil, mint, rosemary and tea tree essential oils, with values >4% v/v for some strains. A variable efficacy was observed for lavender essential oil against C. albicans, with MICs ranging from 0·25 to 4% v/v. Candida albicans strains were also rather sensitive to grapefruit essential oil, showing MICs of 0·25 or 0·125% v/v, even if a value of 0·0039% v/v was recorded for a single strain. Mint, basil, lavender, tea tree oil, winter savory and oregano essential oilsinhibited both the growth and the activity of C. albicans more efficiently than clotrimazole. Damages induced by essential oils at the cellular level were stronger than those caused by clotrimazole. CONCLUSIONS: Candida albicans is more sensitive to different essential oils compared to the main used drugs. Moreover, the essential oilaffected mainly the cell wall and the membranes of the yeast. El-Soud et al. (2015) assessed the chemical composition as well as the in vitro antifungal activity of O. basilicum L. essential oil against Aspergillus flavus fungal growth and aflatoxin B1 production. The essential oil of O. basilicum was obtained by hydrodistillation and analysed using gas chromatography (GC) and GC coupled with mass spectrometry (GC/MS). The essential oil was tested for its effects on Aspergillus flavus (A. flavus) mycelial growth and aflatoxin B1 production in Yeast Extract Sucrose (YES) growth media. Aflatoxin B1 production was determined by high performance liquid chromatography (HPLC). Nineteen compounds, representing 96.7% of the total oil were identified. The main components were as follows: linalool (48.4%), 1,8-cineol (12.2%), eugenol (6.6%), methyl cinnamate (6.2%), α-cubebene (5.7%), caryophyllene (2.5%), β-ocimene (2.1%) and α-farnesene (2.0%). The tested oil showed significant antifungal activity that was dependent on the used oil concentration. The complete inhibition of A. flavusgrowth was observed at 1000 ppm oil concentration, while marked 545 inhibition of aflatoxin B1 production was observed at all oil concentrations tested (500, 750 and 1000 ppm).CONCLUSION:These results confirm the antifungal activities of O. basilicum L. oil and its potential use to cure mycotic infections and act as pharmaceutical preservative against A. flavus growth and aflatoxin B1 production. References: 1. Bona E1, Cantamessa S1, Pavan M1, Novello G1, Massa N1, Rocchetti A2, Berta G1, Gamalero E1. Sensitivity of Candida albicans to essential oils: are they an alternative to antifungal agents? J Appl Microbiol. 2016 Dec;121(6):1530-1545. 2. El-Soud NHA, Deabes M, El-Kassem LA, Khalil M. Chemical Composition and Antifungal Activity of Ocimum basilicum L. Essential Oil. Open Access Macedonian Journal of Medical Sciences. 2015;3(3):374-379. doi:10.3889/oamjms.2015.082. 3. S. K. Oxenham, K. P. Svoboda, and D. R. Walters. Antifungal Activity of the Essential Oil of Basil (Ocimum basilicum). J. Phytopathol. Volume 153, Issue 3 March 2005 Pages 174–18 4. Saggiorato, Adriana Galon , Iloir Gaio, Helen Treichel, Débora de Oliveira, Alexandre José Cichoski,Rogério Luis Cansian. Antifungal Activity of Basil Essential Oil (Ocimum basilicum L.): Evaluation In Vitro and on an Italian-type Sausage Surface. Food and Bioprocess TechnologyJanuary 2012, Volume 5, Issue 1, pp 378–384 4. Caraway (Carum carvi) essential oil   Caraway, also known as meridian fennel, and Persian cumin, (Carum carvi) is a biennial plant in the family Apiaceae, native to western Asia, Europe, and North Africa. Caraway is similar in appearance to other members of the carrot family, with finely divided, feathery leaves with thread-like divisions, growing on 20–30 cm (7.9–11.8 in) stems. Scientific name: Carum carvi Other Names: Alcaravea, Anis Canadien, Anis des Prés, Anis des Vosges, Apium carvi, Carraway, Carum carvi, Carum velenovskyi, Carvi, Carvi Commun, Carvi Fructus, Cumin des Montagnes, Cumin des Prés, Faux Anis, Haravi, Jeera, Jira, Kala Jira, Karwiya, Krishan Jeeraka, Krishnajiraka, Kummel, Kummich, Roman Cumin, Semen Cumini Pratensis, Semences de Carvi, Shahijra, Shiajira, Wiesen-Feldkummel, Wild Cumin.   Caraway is used for digestive problems including heartburn, bloating, gas, loss of appetite, and mild spasms of the stomach and intestines. Caraway oil is also used to help people cough up phlegm, improve control of urination, kill bacteria in the body, and relieve constipation The Ebers Papyrus of the African medicine, dated 1500 B.C. prescribe Caraway for treating gastrointestinal problems. 546   Caraway essential oil has been in use since antiquity for its countless therapeutic properties like carminative, astringent, antispasmodic, eupeptic, antihistaminic, antiseptic, aperitif, antimicrobial, disinfectant, emmenagogue, expectorant, stimulant, stomachic, digestive, insecticide, diuretic, galactogogue, cardiac, antioxidant, antidiabetic, anti-ulcerogenic, anti-carcinogenic, anti-stress and vermifuge. Caraway essential oil has carvone and limonene as its major components and the other constituents are carvacrol, α-pinene, γ-terpinene, linalool, furfurol, thujone, carvenone, and p-cymene. Antifungal activity    Caraway essential oil antimycotic effect of CEO was evaluated in cake during 60 days storage and results indicated that CEO at 0.10 and 0.15% could prevent the growth of fungi in it. Darougheh et al. (2014) Caraway essential oil demonstrated the strongest antifungal effect against three Candida albicans strains of different origin (laboratory-CAL, human pulmonary-CAH and ATCC10231-CAR), showing the lowest MIC values (0.03mg/ml for CAL, 0.06mg/ml for CAH, and 0.11mg/ml for CAR, respectively). S k r o b o n j a et al. (2013) Recent reports: Darougheh et al. (2014) analyzed the essential oil of caraway (CEO) by GC-MS. Its predominant components were (Z)-anethole (26.34%), carvone (17.85%), limonene (15.45%), hydrocinnamyl acetate (8.29%) and carvacrol (6.68%). Antioxidant activity (AOA) of CEO was evaluated in cake during 60 days storage at 25°C. CEO at 0.10 and 0.15% could inhibit the rate of oxidation products formation in cake and their effect was almost equal to BHA at 0.02% (p<0.01). AOA of CEO maybe due to the presence of carvone, limonene and carvacrol. Also, the antimycotic effect of CEO was evaluated in cake during 60 days storage and results indicated that CEO at 0.10 and 0.15% could prevent the growth of fungi in it. Organoleptic evaluation of cakes containing 0.05, 0.10 and 0.15% of CEO showed no significant difference between them and the control sample (p<0.01). This essential oil could be used as natural preservative in foodstuffs especially those containing lipid. 547 S k r o b o n j a et al. (2013) examined in vitro antifungal activity of Foeniculum vulgare (Apiaceae), Carum carvi (Apiaceae) and Eucalyptus sp.(Myrtaceae) essential oils against three Candida albicans strains of different origin (laboratory-CAL, human pulmonary-CAH and ATCC10231-CAR). The essential oils were screened on C. albicans using disc and welldiffusion and microdilution method, and compared to Nystatine and Fluconazole as standard anti-mycotics. The activity of tested oils was expressed by inhibition zone diameter (mm), minimum inhibitory concentration (MIC) and minimum fungicidal concentration (MFC) (mg/ml). The results indicated that studied essential oils show antifungal activity against all three isolates of C. albicans. It was observed that each oil exhibits different degree of antifungal activity depending on the oil concentration applied as well as on analyzed strain of C. albicans. Carum carvi demonstrated the strongest antifungal effect to all tested strains, showing the lowest MIC values (0.03mg/ml for CAL, 0.06mg/ml for CAH, and 0.11mg/ml for CAR, respectively). Eucalyptus sp. exhibited the lowest antifungal activity, with MIC values ranging from 0.11 mg/ml for CAL to 0.45 mg/ml for both CAH and CA Reference: 1. Darougheh, Fatemeh; Barzegar, Mohsen; Ali Sahari, Mohammad. Antioxidant and Antifungal Effect of Caraway (Carum Carvi L.) Essential Oil in Real Food System. Current Nutrition & Food Science, Volume 10, Number 1, February 2014, pp. 70-76(7) 2. S k r o b o n j a , J e l i c a R., D a f i n a N. D e l i ć 2 , M a j a A. K a r a m a n2 , M i l a n N. M a t a v u l j 2 , M i r j a n a A. B o g a v a c . Antifungal properties of foeniculum vulgare, carum carvi and eucalyptus sp. Essential oils against candida albicans strains. Jour. Nat. Sci, Matica Srpska Novi Sad, № 124, 195—202, 2013 5. Ajowain (Carum copticum ) essential oil      Carum copticum names Ajwain or Ajowan, Trachyspermum ammi; Carum copticum and Trachyspermum copticum. Carom and bishop‘s weed all Carum copticum (Ajowain) is a flowering plant in the family Apiaceae. The medicinal part of this plant is a strongly aromatic seed-like fruit. Carum copticum was initially known for its highly spiced nature and used as a flavor. C. copticum essential oil has a light orange to reddish color and it has a peppery, thymelike smell. C. copticum essential oil compounds include: thymol, gamma-terpinene, p-cymene, and beta-pinene. There is also alpha-pinene, alpha-thujene, beta-myrcene, carvacrol, limonene, and terpinene-4-ol in the oil. Antifungal activity 548    C. copticum essential oil exhibited noticeable inhibition on dry mycelium and synthesis of aflatoxin B1 (AFB1) by Aspergillus flavus, completely inhibiting AFB1 production at 4 μL/mL. C. copticum EOs showed the lowest percentages of decayed cherry tomatoes for all fungi compared with the control at 100 μL/mL with values of 5.01 ± 67% for A. flavus and 5.98 ± 54% for Aspergillus niger. Kazemi (2015) C. copticum essential oil inhibited the growth and virulence of drug-resistant strains of Aspergillus spp. and Trichophyton rubrum. Khan et al. (2014) C. copticum essential oil minimal inhibitory concentration (MIC) for Aspergillus niger, and Candida albicans were 1.3, and 8.8 ± 2.2 μg/mL , respectively. Kavoosi et al. (2013) Recent reports: Kazemi (2015) determined the antiaflatoxin B1 activity in vitro of the essential oil (EO) extracted from the seeds of Carumcopticum and to evaluate its antifungal activity in vivo as a potential food preservative. The C. copticum EO exhibited noticeable inhibition on dry mycelium and synthesis of aflatoxin B1 (AFB1) by Aspergillus flavus, completely inhibiting AFB1 production at 4 μL/mL. C. copticum EOs showed the lowest percentages of decayed cherry tomatoes for all fungi compared with the control at 100 μL/mL with values of 5.01 ± 67% for A. flavus and 5.98 ± 54% for Aspergillus niger. The results indicated that the percentage of infected fruits is significantly (p < 0.01) reduced by the EO at 16°C for 30 days. In this case, the oil at 100 μL/mL concentration showed the highest inhibition of fungal infection with a value of 80.45% compared with the control. Thus, the EO of dill could be used to control food spoilage and as a potential source of food preservative. Khan et al. (2014) evaluated the effects of oils of C. copticum and T. vulgaris on the growth and virulence of drug-resistant strains of Aspergillus spp. and Trichophyton rubrum. The gas chromatography-mass spectrometry analysis revealed thymol constituting 44.71% and 22.82% of T. vulgaris and C. copticum, respectively. Inhibition of mycelial growth by essential oils was recorded in the order of thymol > T. vulgaris > C. copticum against the tested strains. RBC lysis assay showed no tested oils to be toxic even up to concentration two folds higher than their respective MFCs. Thymol exhibited highest synergy in combination with fluconazole against Aspergillus fumigatus MTCC2550 (FICI value 0.187) and T. rubrum IOA9 (0.156) as determined by checkerboard method. Thymol and T. vulgaris essential oil were equally effective 549 against both the macro and arthroconidia growth (MIC 72 μg/mL). A > 80% reduction in elastase activity was recorded for A. fumigatus MTCC2550 by C. copticum, T. vulgaris oils and thymol. The effectiveness of these oils against arthroconidia and synergistic interaction of thymol and T. vulgaris with fluconazole can be exploited to potentiate the antifungal effects of fluconazole against drug-resistant strains of T. rubrum and Aspergillus spp. Kavoosi et al. (2013) examined reactive oxygen species (ROS), reactive nitrogen species (RNS), hydrogen peroxide (H(2) O(2) ), and thiobarbituric acid reactive substances (TBARS) scavenging activities of Carum and Ferula oils along with their antibacterial and antifungal activities. Thymol (40.25%), γ-terpinene (38.7%) and p-cymene (15.8%) were detected as the main components of Carum oil while, β-pinene (47.1%), α-pinene (21.36%), and 1, 2-dithiolane (18.6%) were the main components of Ferula oil. Inhibitory concentrations (IC50) for total radical scavenging were between 40 and 60 and 130 and 160 μg/mL of Carum and Ferula oil, respectively. Minimal inhibitory concentration (MIC) for Salmonella typhi, Escherichia coli, Staphylococcus aureus, Bacillus subtilis, Aspergillus niger, and Candida albicans were 78 ± 8, 65 ± 7, 14 ± 3, 5 ± 2, 5.6 ± 1.3, and 8.8 ± 2.2 μg/mL of Carum oil, respectively. MIC for S. typhi, E. coli, S. aureus, B. subtilis, A. niger, and C. albicans were >200, >200, 125 ± 17, 80 ± 12, 85 ± 5, and 90 ± 11 μg/mL of Ferula oil, respectively. Accordingly, Carum and Ferula oils could be used as safe and effective natural antioxidants to improve the oxidative stability of fatty foods during storage and to preserve foods against food burn pathogens. This study clearly demonstrates the potential of Carum and Ferula oil especially Carum oil as natural antioxidant and antimicrobial agent. The chemical composition of essential oils was identified. Thus, identification of such compounds also helps to discover of new antioxidant, antibacterial and antifungal agents for potential applications in food safety and food preservation. References: 1. Kazemi M1. Effect of Carum copticum essential oil on growth and aflatoxin formation by Aspergillus strains. Nat Prod Res. 2015;29(11):1065-8. 2. Kavoosi G1, Tafsiry A, Ebdam AA, Rowshan V. Evaluation of antioxidant and antimicrobial activities of essential oils from Carum copticum seed and Ferula assafoetida latex. J Food Sci. 2013 Feb;78(2):T356-61. 3. Khan MS1, Ahmad I2, Cameotra SS3. Carum copticum and Thymus vulgaris oils inhibit virulence in Trichophyton rubrum and Aspergillus spp. Braz J Microbiol. 2014 Aug 29;45(2):523-31. 551 6. Cinnamomum cassia oil Cinnamon oil; Cassia oil; Chinese cinnamon; Cassia bark oil; Oils, cinnamon; Oil of cassia      Cassia oil is the oils extracted from the leaves or bark of Cinnamomum verum. Cassia oil is used as a flavoring, in parfumary, and in medicinal preparations. Cinnamon leaf oil has similar uses but is often used for its industrial applications. The main chemical components of cassia oil are cinnamic aldehyde, cinnamyl acetate, benzaldehyde, linalool and chavicol. Chemical formula : C19H22O2 Antifungal mechanism , Li et al. (2014)      Cassia oil can inhibit the mycelia growth of R. nigricans, Scanning electron microscope (SEM) observations revealed that the mycelia morphology alterations of R. nigricans were the markedly shriveled and collapsed hypha, even flatted empty hyphae, swelled cell wall, disrupted plasma membrane, with cytoplasmic matrix leakage. Cassia oil inhibited the biosynthesis of ergosterol significantly, damaging the cell membrane structure, causing the leakage of intracellular ions, protein and the higher absorbance at 260nm. Cassia oil affected the energy metabolism of R. nigricans by decreasing the activities of succinate dehydrogenase (SDH) and malate dehydrogenase (MDH) in tricarboxylic acid (TCA) cycle. The main compounds of cinnamon oil transcinnamicaldehyde, cinnmyl cinnamate, andbenzyl cinnamate are responsible for the antimicrobial activity Uses:  Cassia oil cinnamon oil is useful as a food preservative to inhibit the growth of foodrelated microorganisms, such as Escherichia coli, Listeria monocytogenes, 551  Staphylococcus aureus, Rhizopus species, Aspergillus species and Penicillium species etc. Cassia oil has been used in medicine and granted generally recognized as safe (GRAS) status as a food additive by the FDA. Brands Recent reports: Li et al. (2014) investigated the effects of cinnamon oil on the cell morphology, cell membrane and the activities of the key enzymes in tricarboxylic acid (TCA) cycle. Cinnamon oil can inhibit the mycelia growth of R. nigricans, and scanning electron microscope (SEM) observations revealed that the mycelia morphology alterations of R. nigricans were the markedly shriveled and collapsed hypha, even flatted empty hyphae, swelled cell wall, disrupted plasma membrane, with cytoplasmic matrix leakage. Furthermore, cinnamon oil inhibited the biosynthesis of ergosterol significantly, damaging the cell membrane structure, causing the leakage of 552 intracellular ions, protein and the higher absorbance at 260nm. Moreover, cinnamon oil affected the energy metabolism of R. nigricans by decreasing the activities of succinate dehydrogenase (SDH) and malate dehydrogenase (MDH) in tricarboxylic acid (TCA) cycle. Kocevski et al. (2013) tested the antifungal activity of Allium tuberosum (AT), Cinnamomum cassia (CC), and Pogostemon cablin (Patchouli, P) essential oils against Aspergillus flavus strains 3.2758 and 3.4408 and Aspergillus oryzae at 2 water activity levels (aw : 0.95 and 0.98). Main components of tested essential oils were: allyl trisulfide 40.05% (AT), cinnamaldehyde 87.23% (CC), and patchouli alcohol 44.52% (P). The minimal inhibitory concentration of the plant essential oils against A. flavus strains 3.2758 and 3.4408 and A. oryzae was 250 ppm (A. tuberosum and C. cassia), whereas Patchouli essential oil inhibited fungi at concentration > 1500 ppm. The essential oils exhibited suppression effect on colony growth at all concentrations (100, 175, and 250 ppm for A. tuberosum; 25, 50, and 75 for C. cassia; 100, 250, and 500 for P. cablin essential oil). Results of the study represent a solution for possible application of essential oil of C. cassia in different food systems due to its strong inhibitory effect against tested Aspergillus species. In real food system (table grapes), C. cassia essential oilexhibited stronger antifungal activity compared to cinnamaldehyde. Zhenhua et al. (2013) tested the effects of cinnamon oil and its components on the growth of S. sclerotiorum. The cinnamon oil was first separated into carbonyl and noncarbonyl parts by treatment with sodium bisulfite. Then two main cinnamaldehyde derivatives, that is 2′methoxycinnamaldehyde and coniferyl aldehyde, were further separated by column chromatography from the carbonyl parts. Cinnamon oil demonstrated a significant antifungal effect against S. sclerotiorum with a minimum inhibitory concentration (MIC) of 256 μg/mL in agar and 64 μg/mL air, respectively. trans-Cinnamaldehyde exhibited the highest antifungal activity among all the three cinnamaldehydes tested. In addition, thymol and carvacrol had an additive effect with trans-cinnamaldehyde in preventing the mycelial growth of S. sclerotiorum. Almeida et al. (2012) evaluated the antifungal activity of essential oils from Ocimum basilicum L. (basil), Cymbopogon martinii L. (palmarosa), Thymus vulgaris L. (thyme) and Cinnamomum cassia Blume (Chinese cinnamon) against Candida albicans strains isolated from HIV-positive patients and the standard strain (ATCC 76845). Fifteen clinical samples of C. albicans (C1-C15) were subcultured in Sabouraud Dextrose agar to prepare suspensions in sterile saline solution (0.9%) containing 1.5 x 106CFU mL-1. The emulsions of essential oils were prepared in sterile distilled water and Tween 80, with concentrations ranging between 1024 µg mL-1and 4 µg mL-1. The antifungal action was determined by means of the Minimum Inhibitory Concentration (MIC), using the microdilution technique. Nystatin and miconazole (50 µg mL-1) were used as positive controls. The tests were performed in triplicate and the MIC was the lowest concentration capable of inhibiting the growth of yeasts, which was observed by the visual method, according to the turbidity of the culture medium. For C. albicans(ATCC 76845), the MIC of C. cassia essential oil was 64 µg mL-1, while the MIC for C. martini was 1024 µg mL-1. Considering the clinical strains, the MIC of C. cassia was 64 µg mL-1 for 80% of the strains, and the variation in MIC values was between 128 µg mL-1 and 64 µg mL-1. For 66.6% of the clinical samples, the MIC of C. matinii was 612 µg mL-1. Nystatin did not present activity against the clinical strains (C1-C15), while the antifungal activity of miconazole was noticed for 100% of the samples. The antimicobrial activity of essential oils from O. basilicum and T. vulgaris was not identified at the evaluated concentrations. It was concluded that the essential oils from C. 553 cassia and C. martinii, at different concentrations, presented antifungal activity against C. albicans strains isolated from HIV-positive patients and the standard strain (ATCC 76845). However, antifungal activity was not observed for the essential oils from O. basilicum and T. vulgaris. Xu et al. )2012) developed a food-grade water-dilutable microemulsion system with cassia oil as oil, ethanol as cosurfactant, Tween 20 as surfactant and water and assessed its antifungal activity in vitro and in vivo against Geotrichum citri-aurantii. The phase diagram results confirmed the feasibility of forming a water-dilutable microemulsion based on cassia oil. One microemulsion formulation, cassia oil/ethanol/Tween 20 = 1:3:6 (w/w/w), was selected with the capability to undergo full dilution with water. The average particle size was 6.3 nm. The in vitro antifungal experiments showed that the microemulsion inhibited fungal growth on solid medium and prevented arthroconidium germination in liquid medium and that cassia oil had stronger activity when encapsulated in the microemulsion. The in vivo antifungal experiments indicated that the water-dilutable microemulsion was effective in preventing postharvest diseases of citrus fruits caused by G. citri-aurantii. CONCLUSION: The results of this study suggest a promising utilisation of water-dilutable microemulsions based on essential oils for the control of postharvest diseases. References: 1. Almeida, L.F.D.; Cavalcanti, Y.W.; Castro, R.D. and lima, E.O..Antifungal activity of essential oils against clinical samples of Candida albicans isolated from HIV-positive patients. Rev. bras. plantas med. [online]. 2012, vol.14, n.4, pp.649-655. ISSN 15160572. http://dx.doi.org/10.1590/S1516-05722012000400012. 2. Kocevski D1, Du M, Kan J, Jing C, Lačanin I, Pavlović H. Antifungal effect of Allium tuberosum, Cinnamomum cassia, and Pogostemon cablin essentialoils and their components against population of Aspergillus species. J Food Sci. 2013 May;78(5):M731-7. 3. Li, Yaru , Ying Nie1 , Linyan Zhou1 , Shurong Li2 *, Xuanming Tang1 , Yang Ding1 and Shuying Li. The possible mechanism of antifungal activity of cinnamon oil against Rhizopus nigricans. Journal of Chemical and Pharmaceutical Research, 2014, 6(5):12-20 4. Xu SX1, Li YC, Liu X, Mao LJ, Zhang H, Zheng XD. In vitro and in vivo antifungal activity of a water-dilutable cassia oil microemulsion against Geotrichum citri-aurantii. J Sci Food Agric. 2012 Oct;92(13):2668-71. 5. Zhenhua Jiang, Hong Jiang & Pengfei Xie. Antifungal activities against Sclerotinia sclerotiorum by Cinnamomum cassia oil and its main components. Journal of Essential Oil Research Volume 25, 2013 - Issue 6 Pages 444-451 554 7. Citronella oil  Citronella oil is one of the essential oils obtained from the leaves and stems of different species of Cymbopogon (lemongrass).  Chemical structure  The main components are citronellal (35% to 45% Java type; 5% to 16% Ceylon type), geraniol (85% Java type; 60% Ceylon), citral, eugenol, vanillin, eugenol, butanedione, benzaldehyde, methylheptenone, juniperene, isovaleraldehyde, geranyl and its esters, etc Uses    Citronella oil oil is used extensively as a source of perfumery chemicals such as citronellal, citronellol, and geraniol. These chemicals find extensive use in soap, candles and incense, perfumery, cosmetic, and flavouring industries throughout the world. Citronella oil is also a plant-based insect repellent and has been registered for this use in the United States since 1948. The United States Environmental Protection Agency considers oil of citronella as a biopesticide with a non-toxic mode of action Citronella oil is antimicrobial Fate in the environment   Citronellol, citronellal, and geraniol are the major components of oil of citronella. o If they get into the environment a portion is expected to turn into vapors. o In water, they vaporize from the surface at a moderate rate. o Once vapors are airborne, they break down in a matter of hours, with halflives ranging from 38 minutes to 3.2 hours. o Citronellol and geraniol are also readily broken down by microbes. Oil of citronella is practically non-toxic to birds. It is slightly toxic to fish and other aquatic organisms. Antifungal activity has been reported against:  A. flavus, Asparagus racemosus (Singh et al. 2010)  Aspergillus niger (Li et al. 2013), 555  Colletotrichum gloeosporioides (Sellamuthu et al. 2013) Džamić et al., 2014 current science, vol. 80, no. 10, 25 may 2001 Toxicity  In studies using laboratory animals, oil of citronella generally has been shown to be of low acute toxicity. o The acute oral toxicity for oil of citronella derived from "Ceylon type" (LD50 > 5000 mg/kg) places it in Toxicity Category IV, while the acute oral toxicity for oil of citronella derived from "Java type" (LD > 4380 mg/kg) is in Toxicity Category III. 50 o The dermal toxicity for oil of citronella (LD50 > 2000mg/kg -- both "Ceylon type" and "Java type") is in Toxicity Category III. Acute inhalation (LC50 > 5000mg/kg -- "Ceylon type" and LC50 > 3.1 mg/l -- "Java type") is in Toxicity Category IV. o Eye irritation ("Ceylon type" - irritation cleared in 72 hrs. and "Java type" irritation cleared within 7 days or less) is in Toxicity Category III. Dermal irritation is in Toxicity Category III (Refer to Section III for additional information). 556 o Oil of citronella derived from "Ceylon type" oil is a weak dermal sensitizer while citronella oil derived from "Java type" is a non-sensitizer. Recent reports: Jantamas et al. (2016) investigated the inhibitory effect of citronella oil (10, 30 and 50 μg mL1) with heat curing (30, 90 and 150 °C) and drying periods (1, 12 and 24 hours) against a major mould (Aspergillus flavus) found on the surface of rubberwood using response surface methodology. Specimens were incubated at 25 °C in 100% relative humidity for 90 days and individually rated for the period it took to achieve zero mould growth on rubberwood. Citronella oil components were analysed by gas chromatography–mass spectrometry. Citronella oil (50 μg mL-1) with heat curing (30 and 90 °C) and drying periods (1 to 24 hours) completely inhibited spore germination for at least 90 days. Microscopy investigation confirmed that no spore germination was found in treated rubberwood. Citronellal (27.5%), geraniol (20.4%), citronellol (13.4%) were major constituents of citronella oil. Heat curing may be important for 557 transformation of components and enhancement of antifungal activity of citronella oil. This study showed that a combination of citronella oil and heat curing could protect rubberwood. Pereira et al. (2015) investigated the inhibitory effects and possible mechanism of antifungal activity of geraniol and citronellol against strains of T. rubrum. The minimum inhibitory concentration (MIC) of each drug against 14 strains was determined by broth microdilution. The effects of the drugs on dry mycelial weight, conidial germination, infectivity on human nail fragments, and morphogenesis of T. rubrum were analyzed. The effects on the cell wall (test with sorbitol) and cell membrane (release of intracellular material and ergosterol biosynthesis) were investigated. MIC values of geraniol ranged between 16 and 256 µg/mL while citronellol showed MIC values from 8 to 1024 µg/mL. The drugs (MIC and 2 × MIC) inhibited the mycelial growth, conidia germination, and fungal growth on nail fragments. The drugs (half of MIC) induced the formation of wide, short, and crooked hyphae in T. rubrum morphology. With sorbitol, geraniol MIC was increased by 64-fold and citronellol by 32-fold. The drugs caused leakage of intracellular material and inhibited ergosterol biosynthesis. Džamić et al. (2014) described the chemical composition, antifungal and antioxidant activity of Pelargonium graveolens essential oil. The essential oil profile was determined by GC and GCMS. The main compounds were citronellol (24.54%), geraniol (15.33%), citronellyl formate (10.66%) and linalool (9.80%). Minimal inhibitory concentrations (MIC) and minimal fungicidal concentrations (MFC) were recorded using the microdilution and macrodilution methods. Commercial antimycotic bifonazol was used as a control. The concentration of 0.25-2.5 mg/ml showed fungicidal activity. The most resistant fungi were Mucor mucedo and Aspergillus species. The antioxidant activity of pure essential oil was evaluated by means of the 2,2diphenyl-1-picrylhydrazil (DPPH) radical assay. The essential oil of P. graveolens was able to reduce DPPH radicals into the natural DPPH-H form, and this activity was dose-dependent. The oil exhibited antioxidant activity and reduced DPPH to 50% at EC50 value of 0.802 mg/ml of oil solution. Li et al. (2013) explored the antifungal effect of citronella oil with Aspergillus niger ATCC 16404. The antifungal activity of citronella oil on conidia of A. niger was determined by poisoned food technique, broth dilution method, and disc volatility method. Experimental results indicated that the citronella oil has strong antifungal activity: 0.125 (v/v) and 0.25 % (v/v) citronella oil inhibited the growth of 5 × 10⁵ spore/ml conidia separately for 7 and 28 days while 0.5 % (v/v) citronella oil could completely kill the conidia of 5 × 10⁵ spore/ml. Moreover, the fungicidal kinetic curves revealed that more than 90 % conidia (initial concentration is 5 × 10⁵ spore/ml) were killed in all the treatments with 0.125 to 2 % citronella oil after 24 h. Furthermore, with increase of citronella oil concentration and treatment time, the antifungal activity was increased correspondingly. The 0.5 % (v/v) concentration of citronella oil was a threshold to kill the conidia thoroughly. The surviving conidia treated with 0.5 to 2 % citronella oil decreased by an order of magnitude every day, and no fungus survived after 10 days. With light microscope, scanning electron microscope, and transmission electron microscope, we found that citronella oil could lead to irreversible alteration of the hyphae and conidia. Based on our observation, we hypothesized that the citronella oil destroyed the cell wall of the A. niger hyphae, passed through the cell membrane, penetrated into the cytoplasm, and acted on the main organelles. Subsequently, the hyphae was collapsed and squashed due to large cytoplasm loss, and the organelles were severely destroyed. Similarly, citronella oil could lead to the rupture of 558 hard cell wall and then act on the sporoplasm to kill the conidia. Nevertheless, the citronella oil provides a potential of being a safe and environmentally friendly fungicide in the future. References: 1. Džamić Ana M. 1*, Marina D. Soković 2 , Mihailo S. Ristić 3 , Slavica M. Grujić 1 , Ksenija S. Mileski 1 , Petar D. Marin. Chemical composition, antifungal and antioxidant activity of Pelargonium graveolens essential oil. Journal of Applied Pharmaceutical Science Vol. 4 (03), pp. 001-005, March, 2014 2. Gâlea Carmen , Gabriel Hancu. Antimicrobial and Antifungal Activity of Pelargonium roseum Essential Oils. Adv Pharm Bull, 2014, 4(Suppl 2), 511-514 3. Jantamas, S, N Matan, N Matan & T Aewsiri. Improvement of antifungal activity of citronella oil against aspergillus flavus on rubberwood (hevea Brasiliensis) using heat curing. Journal of Tropical Forest Science 28(1): 39–47 (2016) 4. Li WR1, Shi QS, Ouyang YS, Chen YB, Duan SS. Antifungal effects of citronella oil against Aspergillus niger ATCC 16404. Appl Microbiol Biotechnol. 2013 Aug;97(16):7483-92. 8. Clove essential oil (Eugenol)       Eugenol is a phenylpropene, an allyl chain-substituted guaiacol. Eugenol is a member of the phenylpropanoids class of chemical compounds. Eugenol is a colourless to pale yellow, aromatic oily liquid extracted from certain essential oils especially from clove oil, nutmeg, cinnamon, basil and bay leaf. Eugenol is present in concentrations of 80–90% in clove bud oil and at 82–88% in clove leaf oil Eugenol shows relevant pharmacological activities, especially the antibacterial and antifungal actions. Eugenol antimicrobial actions seem to be related to cellular membranes interferences. 559 Natural occurrence Eugenol naturally occurs in several plants, including the following:                 Cloves (Syzygium aromaticum) Wormwood Cinnamon Cinnamomum tamala Nutmeg (Myristica fragrans) Ocimum basilicum (sweet basil) Ocimum gratissimum (African basil) Ocimum tenuiflorum (syn. Ocimum sanctum, tulsi or holy basil) Japanese star anise Lemon balm Dill Pimenta racemosa Vanilla Bay laurel Celery Ginger Spectrum of antifungal activity    Clove oil was found to possess strong antifungal activity against opportunistic fungal pathogens such as Candida albicans, Cryptococcus neoformans and Aspergillus fumigatus, etc. The oil was found to be extremely successful in the treatment of experimental murine vaginitis in model animals. On evaluating various formulations, topical administration of the liposomized clove oil was found to be most effective against treatment of vaginal candidiasis. Ahmed et al., 2005 After 60 minutes, clove oleoresin dispersed (0.4% v/v) in concentrated sugar solution caused a 99.6% reduction of the initial population (106 c.f.u./ml) of Trichophyton mentagrophytes. The fungicidal activity of clove-sugar on C. albicans, after 2 min contact, was similar to that presented by disinfectants commonly used in hospitals, such as povidone-iodine and chloroxylenol. NUNEZ et al. (2001) Mode of action   To clarify Clove oil and eugenol mechanism of action on yeasts and filamentous fungi, flow cytometric and inhibition of ergosterol synthesis studies were performed. Propidium iodide rapidly penetrated the majority of the yeast cells when the cells were treated with concentrations just over the MICs, meaning that the fungicidal effect resulted from an extensive lesion of the cell membrane. Clove oil and eugenol also caused a considerable reduction in the quantity of ergosterol, a specific fungal cell membrane component. 561   Germ tube formation by Candida albicans was completely or almost completely inhibited by oil and eugenol concentrations below the MIC values. (Pinto et al., 2008) Eugenol increased the concentration of potassium ion and cellular materials in the medium. Furthermore, light and scanning electron microscopy observations on hyphae exposed to eugenol revealed considerable morphological alterations in hyphae, such as cytoplasmic coagulation, vacuolation, and hyphal shriveling. Eugenol induced the generation of H2 O2 and increased free Ca2+ in the cytoplasm. These results strongly support the idea that the antifungal activity of eugenol is due to membrane binding and permeability alteration, leading to destabilization and disruption of the plasma membrane Wang et al. (2010) Toxicity    Eugenol is hepatotoxic, meaning it may cause damage to the liver. Eugenol overdose may cause a wide range of symptoms from blood in the patient's urine, to convulsions, diarrhoea, nausea, unconsciousness, dizziness, or rapid heartbeat. According to a published 1993 report, a 2-year-old boy nearly died after taking between 5 and 10 ml. In context, this would represent a toxic dose in the range of 500–1000 mg/kg, approximately one third that of table salt. Allergy  Eugenol is subject to restrictions on its use in perfumery as some people may become sensitised to it, however, the degree to which eugenol can cause an allergic reaction in humans is disputed.  Eugenol is a component of balsam of Peru, to which some people are allergic.  Eugenol is used in dental preparations such as surgical pastes, dental packing, and dental cement, it may cause contact stomatitis and allergic cheilitis. Brands Recent reports: da Silva et al. (2017) evaluated the anti-Candida effect of eugenol and its antimicrobial interaction with nystatin. The antimicrobial potential was assessed by microdilution technique (M27A3 reference method), by determining the minimum inhibitory concentration (MIC) and 561 the minimum fungicidal concentration (MFC) against C. albicans (ATCC 90028). The possible action of eugenol on the fungal cell wall was evaluated with the assistance of the osmotic protector sorbitol (0.8 M). The antimicrobial interaction with nystatin was assessed through the checkerboard method. All tests were performed in triplicate. All groups showed reductions in PI and GBI values and improvements in oral health knowledge, but IG1 and IG2 showed statistically significant differences in these variables compared to CG. Conclusion: The eugenol has antifungal activity against C. albicans and its mechanism of action is probably not related to damage to the fungal cell wall. Association between eugenol and nystatin was not found to be an advantageous possibility for growth inhibition of C. albicans. de Carvalho et al. (2017) described the design, synthesis, and the biological results for benzoxazole type derivatives of eugenol as antifungal agents. The products were obtained in good yields by a four-step synthetic sequence involving aromatic nitration, nitroreduction, amide formation, and cycle condensation. They were evaluated against species of Candida spp. in microdilution assays, and four products (5a, 5b′, 5c, and 5d′) were about five times more active than eugenol against C. albicans and C. glabrata. Two of them (5b′ and 5d′) showed good activity against C. krusei, a species which is naturally resistant to fluconazole. Furthermore, the active products were more selective than eugenol against human blood cells, showing that they are interesting substances for further optimization. Pinheiro et al. (2017) evaluated the effect of the combined use of eugenol / isoeugenol, compounds with recognized antimicrobial activity, in association with antifungal amphotericin B against strains of Cryptococcus neoformans. The combined antifungal effect were be determined from the Fraction Inhibitory Concentration index - checkerboard technique. The results obtained in this study showed that eugenol in combination with amphotericin B had antagonistic effect against the strains of C. neoformans, LM 615 and INCQS 40221 (FIC index 6.0 and 4.0), respectively. The combination of the isoeugenol and amphotericin B also showed antagonistic effects for both the LM 615 strain and INCQS 40221 (FIC index 6.0 and 5.0), respectively. This study contributed to the understanding of the antifungal effects of the association of phenylpropanoids (eugenol / isoeugenol) with amphotericin B. Further studies are needed to evaluate and compare the effects of the association of these phytochemicals with other conventional antifungal drugs used against C. neoformans. Pereira et al. (2016) chemically characterized and explored Sideroxylon obtusifolium T.D. Penn (Sapotacea) and Syzygium cumini (L.) Skeels (Myrtaceae), from the Caatinga biome in Brazil for their antifungal potential against C. albicans. The effects of hydroalcoholic extracts/fractions were determined upon fungal growth (minimum inhibitory and fungicidal concentrations, MIC/MFC), biofilm morphology (scanning electron microscopy) and viability (confocal laser scanning microscopy), proposed their mode of action (sorbitol and ergosterol assays), and finally investigated their effects against macrophage and keratinocyte cells in a cell-based assay. Data were analysed using one-way analysis of variance with Tukey-Kramer post-test (α = 0.05). Results The n-butanol (Nb) fraction from S. obtusifolium and S. cumini extract (Sc) showed flavonoids (39.11 ± 6.62 mg/g) and saponins (820.35 ± 225.38 mg/g), respectively, in their chemical composition and demonstrated antifungal activity, with MICs of 62.5 and 125 μg/mL, respectively. Nb and Sc may complex with ergosterol as there was a 4-16-fold increase in MICs in the presence of exogenous ergosterol, leading to disrupted permeability of cell membrane. Deleterious effects were observed on morphology and viability of treated biofilms from 562 concentrations as low as their MICs and higher. Sc was not toxic to macrophages and keratinocytes at these concentrations (p > 0.05), unlike Nb. Conclusions Nb and Sc demonstrated considerable antifungal activity and should be further investigated as potential alternative candidates to treat Candida Abd-Elsalam and Khokhlov (2015) characterized eugenol oil nanoemulsion by dynamic light scattering, stability test, transmission electron microscopy and thin layer chromatography. The nanoemulsion droplets were found to have a Z-average diameter of 80 nm and TEM study reveals the spherical shape of eugenol oil nanoemulsion (EON). The size of the nanoemulsion was found to be physically stable up to more than 1-month when it was kept at room temperature (25 °C). The TEM micrograph showed that the EON was spherical in shape and moderately mono or di-dispersed and was in the range of 50–110 nm. Three concentrations of the nanoformulation were used to evalute the anti-fusarium activity both in vitro and in vivo experiments. SDS-PAGE results of total protein from the Fusarium oxysporum f. sp. vasinfectum (FOV) isolate before and after treatment with eugenol oil nanoemulsion indicate that the content of extra cellular soluble small molecular proteins decreased significantly in EON-treated fungus. Light micrographs of mycelia and spores treated with EON showed the disruption of the fungal structures. The analysis of variance (ANOVA) for Fusarium wilt incidence indicated highly significant (p = 0.000) effects of concentration, genotype, and their interaction. The difference in wilt incidence between concentrations and control was not the same for each genotype, that is, the genotypes responded differently to concentrations. Effects of three EON concentration on germination percentage, and radicle length, were determined in the laboratory. One very interesting finding in the current study is that cotton genotypes was the most important factors in determining wilt incidence as it accounted for 93.18 % of the explained (model) variation. In vitro experiments were conducted to evaluate the potential phytotoxic effect of three EON concentrations. Concentration, genotype and concentration x genotype interaction were all highly significant sources of variation in seed germination; however, interaction was the first in importance as a source of variation followed by the concentration, while genotype was the least important source of variation. These results suggest the potential use of eugenol oil nanoemulsion for protecting seedcotton from Fusarium wilt infection. Mansourian et al. (2014) studied the antifungal effects of herbal extracts of Syzygium aromaticum and Punica granatum. Twenty-one isolates of oral C. albicans in patients with denture stomatitis referred to prosthesis department, Dental faculty of Tehran University of Medical Sciences were prepared and cultured. Plant extracts were prepared from the herbs market. Tests on patient samples and standard strains 5027ATCC (PTCC10231) yeast C. albicans were performed via well diffusion method. In addition, nystatin and methanol were used as positive and negative control, respectively. Finally, the antifungal effect of extracts using Statistical Repeated measurement ANOVA test was investigated. Both S. aromaticum and P. granatum showed noticeable antifungal activity in well method. Syzygium aromaticum showed better anti candida activity than nystatin (P<0.001). CONCLUSION: Due to increasing problems with fungal diseases, these findings suggest that the plant extracts of S. aromaticum and P. granatum showed good antifungal effects (P-value<0.001). S. aromaticum (inhibition zone diameter: 29.62) showed better antifungal effects than nystatin (inhibition zone diameter: 28.48). 563 de Oliveira et al. (2013) investigated the antifungal activity of eugenol against 14 strains of T. rubrum which involved determining its minimum inhibitory concentration (MIC) and effects on mycelial growth (dry weight), conidial germination and morphogenesis. The effects of eugenol on the cell wall (sorbitol protect effect) and the cell membrane (release of intracellular material, complex with ergosterol, ergosterol synthesis) were investigated. Eugenol inhibited the growth of 50% of T. rubrum strains employed in this study at an MIC = 256 μg/ml, as well as mycelial growth and conidia germination. It also caused abnormalities in the morphology of the dermatophyte in that we found wide, short, twisted hyphae and decreased conidiogenesis. The results of these studies on the mechanisms of action suggested that eugenol exerts antifungaleffects on the cell wall and cell membrane of T. rubrum. Eugenol act on cell membrane by a mechanism that seems to involve the inhibition of ergosterol biosynthesis. The lower ergosterol content interferes with the integrity and functionality of the cell membrane. Finally, our studies support the potential use of the eugenol as an antifungal agent against T. rubrum. References: 1. Abd-Elsalam, Kamel A. and Alexei R. Khokhlov. Eugenol oil nanoemulsion: antifungal activity against Fusarium oxysporum f. sp. vasinfectum and phytotoxicity on cottonseeds. Applied Nanoscience. February 2015, Volume 5, Issue 2, pp 255–265 2. da Silva, I.C. G., Hellen Bandeira de Pontes Santos, Yuri Wanderley Cavalcanti, Cassiano Francisco Weege Nonaka, Simone Alves de Sousa, Ricardo Dias de Castro. Antifungal Activity of Eugenol and its Association with Nystatin on Candida albicans. Pesquisa Brasileira em Odontopediatria e Clinica Integrada 2017, 17(1):e3235 DOI: http://dx.doi.org/10.4034/PBOCI.2017.171.16 ISSN 1519-0501 3. de Carvalho, L. I., Dalila Junqueira Alvarenga, Letícia Cruz Ferreira do Carmo, et al., ―Antifungal Activity of New Eugenol-Benzoxazole Hybrids against Candida spp.,‖ Journal of Chemistry, vol. 2017, Article ID 5207439, 8 pages, 2017. doi:10.1155/2017/5207439 4. de Oliveira Pereira F1, Mendes JM, de Oliveira Lima E. Investigation on mechanism of antifungal activity of eugenol against Trichophyton rubrum. Med Mycol. 2013 Jul;51(5):507-13. 5. Mansourian A1, Boojarpour N2, Ashnagar S3, Momen Beitollahi J1, Shamshiri AR2. The comparative study of antifungal activity of Syzygium aromaticum, Punica granatum and nystatin on Candida albicans; an in vitro study. J Mycol Med. 2014 Dec;24(4):e163-8. 6. Pereira JV1, Freires IA2, Castilho AR2, da Cunha MG2, Alves Hda S3, Rosalen PL2. Antifungal potential of Sideroxylon obtusifolium and Syzygium cumini and their mode of action against Candida albicans. Pharm Biol. 2016 Oct;54(10):2312-9. 7. Pinheiro L S1* , Sousa J P2 , Barreto N A2 , Dantas T B1 , Menezes C P1 , Lima A L A1 , Silva A C L1 , Santos J M C G2 , Oliveira-Filho A A3 , Lima E. Eugenol and Isoeugenol In Association with Antifungal Against Cryptococcus neoformans Available Online:25th April, 2017 564 9. Coriander essential oils       Coriander (Coriandrum sativum), belonging to family Umbelliferae, is a native plant of the Mediterranean region and is widely cultivated in India, Russia, Central Europe, Asia, and Morocco. Coriander was widely applied in producing chutneys and sauces, flavoring pastry, cookies, buns, and tobacco products, and extensively employed for preparation of curry powder, pickling spices, sausages, seasonings, and food preservatives Coriander is recognized as one of the most important spices in the world and is of the great significance in international trade. Coriander essential oils and various extracts from coriander have been shown to possess antibacterial, antidiabetic, anticancerous, antimutagenic, antioxidant and free radical scavenging activities. Coriander essential oils are obtained by steam distillation of the dried, fully ripe fruits (seeds) of C. sativum L. (oil yield ranges between 0.3 and 1.1 %) and the oil has a mild, sweet, warm and aromatic flavor Coriander essential oils main components are Linalool (73.05 %), α-pinene (9.18 %), gamma-terpinene (7.65 %), geranyl acetate (2.71 %). Antifungal activity      800 ppm coriander essential oils (CEO) and mixture of cinnamon (250 ppm) and coriander (800 ppm) essential oils inhibited Byssochlamys fulva up to 32 and 90 %, respectively. Zamindar et al. (2016) Coriander essential oils inhibited Candida biofilm adherence to a polystyrene substrate at low concentrations, and decreased the proteolytic activity of Candida albicans at minimum inhibitory concentration. Freires Ide et al. (2014) The essential oil from Coriandrum sativum inhibited all oral species with MIC values from 0.007 to 0.250 mg/mL, and MBC/MFC (Minimal Bactericidal/Fungicidal Concentrations) from 0.015 to 0.500 mg/mL. Bersan et al. (2014) The essential oil from C. sativum L. fruits induced growth inhibition zones of 28 ± 5.42 and 9.25 ± 0.5 for M. canis and Candida spp. respectively. The MICs and MFCs for M. canis strains ranged from 78 to 620 and 150 to 1,250 μg/mL, and the MICs and MFCs for Candida spp strains ranged from 310 to 620 and 620 to 1,250 μg/mL, respectively. C. sativum essential oilis active in vitro against M. canis and Candida spp. demonstrating good antifungal activity. Soares et al. (2012 Coriander essential oil has a fungicidal activity against the Candida strains tested with MLC values equal to the MIC value and ranging from 0.05 to 0.4% (v/v). Flow cytometric evaluation of BOX, PI and DRAQ5 staining indicates that the fungicidal effect is a result of cytoplasmic membrane damage and subsequent leakage of intracellular components such as DNA. Also, concentrations bellow the MIC value caused a marked reduction in the percentage of germ tube formation for C. albicans 565 strains. A synergetic effect between coriander oil and amphotericin B was also obtained for C. albicans strains, while for C. tropicalis strain only an additive effect was observed. This study describes the antifungal activity of coriander essential oil on Candida spp., which could be useful in designing new formulations for candidosis treatment. Silva et al. (2011) Recent reports: Zamindar et al. (2016) analyzed essential oils (EOs) of coriander by gas chromatography–mass spectrometry. Linalool (73.05 %), α-pinene (9.18 %), gamma-terpinene (7.65 %), geranyl acetate (2.71 %), were the main components of coriander essential oil. The minimum inhibitory concentration (MIC) of coriander was 2700 ppm in broth macrodilution. 3 × 105 CFU/g Byssochlamys fulva was inoculated in tomato sauce and different concentrations of EOs were added to each sample. Sodium benzoate at MIC concentration (250 ppm) was added to tomato sauce as a negative control. Samples were kept at 30 ± 0.5 °C for 2 months. The results showed that sodium benzoate completely stopped the fungi growth but 800 ppm coriander essential oils (CEO) and mixture of cinnamon (250 ppm) and coriander (800 ppm) essential oils inhibited up to 32 and 90 %, respectively. Bersan et al. (2014) evaluated essential oils (EO) obtained from twenty medicinal and aromatic plants for their antimicrobial activity against the oral pathogens Candida albicans, Fusobacterium nucleatum, Porphyromonas gingivalis, Streptococcus sanguis and Streptococcus mitis. The antimicrobial activity of the EO was evaluates by microdilution method determining Minimal Inhibitory Concentration. Chemical analysis of the oils compounds was performed by Gas chromatography-mass spectrometry (CG-MS). The most active EO were also investigated as to their actions on the biolfilm formation. Most of the essential oils (EO) presented moderate to strong antimicrobial activity against the oral pathogens (MIC--Minimal Inhibitory Concentrations values between 0.007 and 1.00 mg/mL). The essential oil from Coriandrum sativum inhibited all oral species with MIC values from 0.007 to 0.250 mg/mL, and MBC/MFC (Minimal Bactericidal/Fungicidal Concentrations) from 0.015 to 0.500 mg/mL. On the other hand the essential oil of C. articulatus inhibited 63.96% of S. sanguis biofilm formation. Through Scanning Eletronic Microscopy (SEM) images no changes were observed in cell morphology, despite a decrease in biofilm formation and changes on biofilm structure. Chemical analysis by Gas Chromatography-Mass Spectrometry (GC-MS) of the C. 566 sativum essential oil revealed major compounds derivatives from alcohols and aldehydes, while Cyperus articulatus and Aloysia gratissima (EOs) presented mono and sesquiterpenes. Freires Ide et al. (2014) investigated the antifungal activity and mode of action of the EO from Coriandrum sativum L. (coriander) leaves on Candida spp. In addition, they detected the molecular targets affected in whole-genome expression in human cells. The EO phytochemical profile indicates monoterpenes and sesquiterpenes as major components, which are likely to negatively impact the viability of yeast cells. There seems to be a synergistic activity of the EO chemical compounds as their isolation into fractions led to a decreased antimicrobial effect. C. sativum EO may bind to membrane ergosterol, increasing ionic permeability and causing membrane damage leading to cell death, but it does not act on cell wall biosynthesis-related pathways. This mode of action is illustrated by photomicrographs showing disruption in biofilm integrity caused by the EO at varied concentrations. The EO also inhibited Candida biofilm adherence to a polystyrene substrate at low concentrations, and decreased the proteolytic activity of Candida albicans at minimum inhibitory concentration. Finally, the EO and its selected active fraction had low cytotoxicity on human cells, with putative mechanisms affecting gene expression in pathways involving chemokines and MAP-kinase (proliferation/apoptosis), as well as adhesion proteins. These findings highlight the potential antifungal activity of the EO from C. sativum leaves and suggest avenues for future translational toxicological research. References: 1. Bersan SM, Galvão LC, Goes VF, Sartoratto A, Figueira GM, Rehder VL, Alencar SM, Duarte RM, Rosalen PL, Duarte MC1. Action of essential oils from Brazilian native and exotic medicinal species on oral biofilms. BMC Complement Altern Med. 2014 Nov 18;14:451. 2. Freires Ide A1, Murata RM2, Furletti VF3, Sartoratto A3, Alencar SM4, Figueira GM3, de Oliveira Rodrigues JA5, Duarte MC3, Rosalen PL1. Coriandrum sativum L. (Coriander) essential oil: antifungal activity and mode of action on Candida spp., and molecular targets affected in human whole-genome expression. PLoS One. 2014 Jun 5;9(6):e99086. doi: 10.1371/journal.pone.0099086. eCollection 2014. 3. Silva F1, Ferreira S, Duarte A, Mendonça DI, Domingues FC. Antifungal activity of Coriandrum sativum essential oil, its mode of action against Candida species and potential synergism with amphotericin B. Phytomedicine. 2011 Dec 15;19(1):42-7. 4. Soares BV1, Morais SM, dos Santos Fontenelle RO, Queiroz VA, Vila-Nova NS, Pereira CM, Brito ES, Neto MA, Brito EH, Cavalcante CS, Castelo-Branco DS, Rocha MF. Antifungal activity, toxicity and chemical composition of the essential oil of Coriandrum sativum L. fruits. Molecules. 2012 Jul 11;17(7):8439-48. doi: 10.3390/molecules17078439. 5. Zamindar , Nafiseh , Mahsa Sadrarhami, Monir Doudi. Antifungal activity of coriander (Coriandrum sativum L.) essential oil in tomato sauce. Journal of Food Measurement and Characterization September 2016, Volume 10, Issue 3, pp 589–594| 567 10. Cumin essential oils       Cuminum cyminum (Apiaceae) is an annual herbaceous plant (height: 15-50 cm) with green seeds which have aromatic characteristics. Cuminum cyminum is applied in Iranian folk medicine since more than 200 years ago. Cuminum cyminum fruits have medicinal application in treatment of diarrhea, toothache, and epilepsy Cuminum cyminum has diuretic, carminative, emmanogogic, and antispasmodic properties. Cuminum cyminum is one of the popular spices regularly used as a flavoring agent and possesses numerous antimicrobial activities. Cuminum cyminum essential oil major constituents are gamma-terpinene, 2-methyl-3phenyl-propanal, myrtenal, and glucopyranosides. Antifungal activity    The antifungal activity of the oil was studied with regard to the inhibition of the growth of Aspergillus flavus PICC-AF39 , Aspergillus flavus PICC-AF24, Aspergillus parasiticus NRRL-2999 and Aspergillus niger. The minimal inhibitory (MIC) and minimal fungicidal (MFC) concentrations of the oil were determined. α–Pinene (29.2%), limonene (21.7%), 1,8-cineole (18.1%), linalool (10.5%), linalyl acetate (4.8%), and αterpineole (3.17%) were the major components of the essential oil from C. cyminum L., and the oil showed a strong inhibitory effect on fungal growth. Mohammadpour et al. (2012) C. cyminum oil exhibited the strongest activity against A. fumigatus and A. flavus with MIC90 ranging from 0.25 to 1.5 mg/ml. Khosravi et al. (2011) Minimum inhibitory concentration (MIC) values of C. cyminum oil against F. verticillioides strains varied from 0.195 to 0.781 µl.ml-1 (mean MIC value: 0.461 µl.ml-1) indicating 54.5% of the fungal strains inhibited at 0.390 µl.ml-1. PCR analysis of FUM1 gene expression revealed that DNA fragment of 183 bp was amplified in all the isolates of F. verticillioides before treatment with C. cyminum essential oil. Based on RTPCR analyses, reduction in the expression of fumonisin biosynthetic genes was significant only for FUM1 gene (p<0.05), while no effect was observed on ITS gene. Khosravi et al. (2015) 568 Recent reports: Swamy et al. (2016) reviewed the antimicrobial potential of essential oils secreted from MAPs and their possible mechanisms of action against human pathogens. This comprehensive review will benefit researchers who wish to explore the potential of essential oils in the development of novel broad-spectrum key molecules against a broad range of drug-resistant pathogenic microbes. Khosravi et al.(2015) evaluated the effect of Cuminum cyminum (C. cyminum) essential oil on the growth and FUM1 gene expression of fumonisin-producing Fusarium verticillioides (F. verticillioides) strains isolated from maize. All fungal strains were cultured on potato dextrose agar (PDA) slopes at 30°C for 7 days. The antifungal activity was evaluated by broth microdilution assay. One set of primers was F. verticillioides species specific, which selectively amplified the intergenic space region of rDNA. The other set of primers was specific to FUM1 gene region of fumonisin-producing F. verticillioides. FUM1 transcript levels were quantified using a reverse transcription-polymerase chain reaction (RT-PCR) protocol. Minimum inhibitory concentration (MIC) values of C. cyminum oil against F. verticillioides strains varied from 0.195 to 0.781 µl.ml-1 (mean MIC value: 0.461 µl.ml-1) indicating 54.5% of the fungal strains inhibited at 0.390 µl.ml-1. PCR analysis of FUM1 gene expression revealed that DNA fragment of 183 bp was amplified in all the isolates of F. verticillioides before treatment with C. cyminum essential oil. Based on RT-PCR analyses, reduction in the expression of fumonisin biosynthetic genes was significant only for FUM1 gene (p<0.05), while no effect was observed on ITS gene. Conclusions: This study showed that all F. verticillioides isolates were susceptible to C. cyminum essential oil, indicating a significant reduction in the growth of fungal isolates. In addition, this oil completely inhibited the expression of FUM1 gene in concentrations dosedependently. Mohammadpour et al. (2012) provided experimental data on the antifungal activity of cumin oils and their components that could be considered suitable for application in foods and drugs. The essential oil (EO) of Cuminum cyminum L. collected from Alborz Mountain, Iran, was obtained by hydro-distillation. The oil was analyzed by gas chromatography (GC) and chromatography/mass spectrophotometry (GC/MS). The antifungal activity of the oil was studied with regard to the inhibition of the growth of Aspergillus flavus PICC-AF39 , Aspergillus flavus PICC-AF24, Aspergillus parasiticus NRRL-2999 and Aspergillus niger. The minimal inhibitory (MIC) and minimal fungicidal (MFC) concentrations of the oil were determined. α– Pinene (29.2%), limonene (21.7%), 1,8-cineole (18.1%), linalool (10.5%), linalyl acetate (4.8%), and α-terpineole (3.17%) were the major components of the essential oil from C. cyminum L., and the oil showed a strong inhibitory effect on fungal growth.Conclusions Essential oils could be safely used as preservatives in pharmaceuticals as well as health and food products to protect them against toxigenic fungal infections. Khosravi et al. (2011) evaluated the effectiveness of Cuminum cyminum, Ziziphora clinopodioides and Nigella sativa essential oils to inhibit the growth of Aspergillus fumigatusand A. flavus and to evoke ultrastructural changes. The fungi were cultured into RPMI 1640 media in the presence of oils at concentrations of 8, 6, 5, 4, 3, 2, 1.5, 1.25, 1, 0.75 and 0.5 mg/ml in broth microdilution and 2, 1.5, 1 and 0.5 mg/ml in broth macrodilution methods with shaking for 48 h at 28oC. Conidial and mycelial samples exposed to 0.25, 0.5, 1, 1.5 and 2 mg essential oils/ml for 5 days in 2% yeast extract granulated plus 15% Saccharose media were 569 processed for transmission electron microscopy (TEM). Based on broth dilution methods, C. cyminum and to a lesser extent Z. clinopodioides oils exhibited the strongest activity against A. fumigatus and A. flavus with MIC90 ranging from 0.25 to 1.5 mg/ml, while the oil from N. sativa exhibited relatively moderate activity against two above fungi with MIC90 ranging from 1.5 to 2 mg/ml. The main changes observed by TEM were in the cell wall, plasma membrane and membranous organelles; in particular, in the nuclei and mitochondria. These modifications in fungal structure were associated with the interference of the essential oils with the enzymes responsible for cell wall synthesis, which disturbed normal growth. Moreover, the essential oils caused high vacuolation of the cytoplasm, detachment of fibrillar layer of cell wall, plasma membrane disruption and disorganization of the nuclear and mitochondrial structures. Aspergillus fumigatus and A. flavus growth inhibition induced by these oils were found to be well-correlated with subsequent morphological changes of the fungi exposed to different fungistatic concentrations of the oils. Our results show the anti-Aspergillus activities of C. cyminum, Z. clinopodioides and N. sativa essential oils, which strengthens the potential use of these substances as anti-mould in the future. References: 1. Swamy MK, Akhtar MS, Sinniah UR. Antimicrobial Properties of Plant Essential Oils against Human Pathogens and Their Mode of Action: An Updated Review. Evidencebased Complementary and Alternative Medicine : eCAM. 2016;2016:3012462. doi:10.1155/2016/3012462. 2. Mohammadpour H, Moghimipour E, Rasooli I, et al. Chemical Composition and Antifungal Activity of Cuminum cyminum L. Essential Oil From Alborz Mountain Against Aspergillus species. Jundishapur Journal of Natural Pharmaceutical Products. 2012;7(2):50-55. 3. Khosravi AR, Minooeianhaghighi MH, Shokri H, Emami SA, S.M. A, Asili J. The Potential Inhibitory Effect of Cuminum Cyminum, Ziziphora Clinopodioides and Nigella Sativa Essential Oils on the Growth of Aspergillus Fumigatus and Aspergillus. Brazilian Journal of Microbiology. 2011;42(1):216-224. doi:10.1590/S1517838220110001000027. 4. Khosravi AR, Shokri H, Mokhtari AR. Efficacy of Cuminum cyminum essential oil on FUM1 gene expression of fumonisin-producing Fusarium verticillioidesstrains. Avicenna Journal of Phytomedicine. 2015;5(1):34-42. 571 11. Eucalyptus essential oil  Eucalyptus (Myrtaceae) represents an important genus of about 800 species, hybrids, and varieties that are native to Australia and Tasmania Antifungal activity  Numerous pharmacological and phytochemical studies have reported antifungal potential of various extracts from E. camaldulensis. o Aqueous and organic extracts of E. camaldulensis have been reported to have antifungal activity against Fusarium solani. Bashir and Tahira (2012). o Methanolic extracts of E. camaldulensis have also been found to be active against Alternaria alternata, a phytopathogenic fungus that is responsible for causing leaf spot and other diseases on over 380 host species. Singh et al. (2014)  Eucalyptus essential oil caused complete inhibition of mycelial growth in P. ultimum and R. solani on all concentration of essential oil after 30 days. Katooli et al. (2011)  Eucalyptus essential oil inhibited mycelial growth in the five test fungi, F. oxysporum, F. solani, F. verticillioides, F. proliferatum, and F. subglutinans. In all the test fungi, complete mycelial growth inhibition was observed at an essential oil concentration of 10 μL/mL. Gakuubi et al. (2017) Growth inhibition rates (%) with MIC and MFC concentrations of E. camaldulensis essential oil against five Fusarium species after five days of incubation. Gakuubi et al. (2017) Essential (µL/mL) oil concentration Mycelial growth inhibition (%) F. solani (1) 35.22 1.66 ± (2) 53.46 1.26 ± (3) 44.65 2.27 ± (4) 75.47 2.18 ± (5) 78.62 1.66 ± (6) 84.28 1.66 ± (7) 93.71 1.66 ± (8) 100 F. oxysporum F. verticillioides F. proliferatum F. subglutinans 31.48 ± 2.13 40.32 ± 1.61 46.03 ± 1.83 32.20 ± 1.96 54.94 ± 1.63 57.53 ± 2.34 60.85 ± 1.06 51.98 ± 2.04 61.73 ± 163 62.90 ± 0.93 65.08 ± 1.59 57.63 ± 1.96 70.99 ± 163 67.20 ± 2.43 74.07 ± 2.31 68.36 ± 2.04 80.25 ± 1.63 76.88 ± 1.42 79.89 ± 1.4 86.44 ± 0.98 89.51 ± 1.63 84.95 ± 1.04 85.71 ± 0.92 88.70 ± 1.13 100 87.63 ± 1.42 93.12 ± 1.40 89.83 ± 0.98 100 100 100 100 571 (9) 100 100 100 100 100 (10) 100 100 100 100 100 Values are mean ± standard error of the mean for bioassay conducted in triplicate. Means followed by the same letter(s) are not significantly different (multivariate analysis, Fisher‘s protected LSD at ). Minimum inhibitory concentration; minimum fungicidal concentration Inhibition zone (mm) on test fungi by different concentrations of Eucalyptus camaldulensis essential oil after five days of incubation. Gakuubi et al. (2017) Essential oil concentration (% v/v) 6.25 3.13 1.56 Apron star (+ control) 6.00 6.00 6.00 15.00 6.00 25.33 6.00 6.00 31.67 6.00 6.00 34.33 6.00 6.00 36.33 Fungi 100 50 25 12.5 F. solani 20.33 1.20 ± 22.33 1.20 ± 17.43 1.20 ± 7.31 0.33 ± F. oxysporum 24.67 1.20 ± 18.00 1.53 ± 13.67 0.33 ± 11.67 0.33 ± F. verticillioides 12.67 1.20 ± 10.67 0.67 ± 8.00 1.84 ± 7.00 0.57 ± F. proliferatum 12.00 0.58 ± 13.00 1.53 ± 11.67 0.88 ± 9.33 0.33 ± 12.00 0.58 ± F. subglutinans 15.33 0.88 ± 12.33 1.20 ± 11.33 0.33 ± 10.00 0.58 ± 9.00 0.58 ± 9.00 0.58 ± 6.00 7.33 0.33 ± Values are mean ± standard error of the mean for bioassay conducted in triplicates. Means followed by the same letter(s) are not significantly different (multivariate analysis, Fisher‘s protected LSD at ) Brands 572 Recent reports: Gakuubi et al. (2017) evaluated the antifungal activity of essential oil (EO) of Eucalyptus camaldulensis Dehnh. against five Fusarium spp. commonly associated with maize. The essential oil had been extracted by steam distillation in a modified Clevenger-type apparatus from leaves of E. camaldulensis and their chemical composition characterized by gas chromatography mass spectrometry. Poisoned food technique was used to determine the percentage inhibition of mycelial growth, minimum inhibitory concentration, and minimum fungicidal concentration of the EO on the test pathogens. Antifungal activity of different concentrations of the EO was evaluated using disc diffusion method. The most abundant compounds identified in the EO were 1,8-cineole (16.2%), α-pinene (15.6%), α-phellandrene (10.0%), and p-cymene (8.1%). The EO produced complete mycelial growth inhibition in all the test pathogens at a concentration of 78 μL/mL after five days of incubation. The minimum inhibitory concentration and minimum fungicidal concentration of the EO on the test fungi were in the range of 7-8 μL/mL and 8– 10 μL/mL, respectively. These findings confirm the fungicidal properties of E. camaldulensis essential oils and their potential use in the management of economically important Fusarium spp. and as possible alternatives to synthetic fungicides. Mehani et al. (2014) determined the effect of antifungal essential oil of Eucalyptus camaldulensis plant. Eucalyptus is an herb used in traditional therapy. The test adopted is based on the diffusion method in solid medium (sensitivity). This method determined the sensitivity or resistance of the organism vis-à-vis the study sample. The analysis obtained by hydrodistillation of plant samples of an essential oil in a clear yellow color with a return of 0, 99%. The study revealed that essential oil of Eucalyptus camaldulensis extracted have significant antifungal activity and can successfully replace antibiotic that show their inefficiencies against resistant microorganisms. Singh et al. (2014) in vitro screened methanolic extracts of six selected plant leaves viz Parthenium hysterophorus, Vernonia amygdalina, Eucalyptus camaldulensis, Nerium oleander, Lantana camara and Ocimum sanctum for their antifungal activity against A. alternata at 5, 10 and 20% concentrations. Highest reduction in mycelial growth was achieved by Oleander followed by Parthenium, Ocimum, Lantana, Vernonia and Eucalyptus, respectively. Thin Layer Chromatography (TLC) was carried out by using solvent system of Toluene: Ethyl acetate: Formic acid (3:1:2) to separate the compounds responsible for antifungal activity. Phytochemical analysis of leaf extracts revealed the presence of Alkaloids, Terpenoids, Phenols, Saponins and Tannins at various concentrations. 573 Bashir and Tahira (2012) evaluated Eucalyptus camaldulensis for its antifungal properties against F. solani, the causal organism of root rot disease. For this purpose the test fungal species was grown in 100 mL ME broth medium in various concentrations (0, 5, 10 & 15% w/v) of aqueous and organic solvent extract for 10 days. The results of this study showed strong allelopathic effects of test plant parts however, eucalyptus leaf extracts proved more effective than stem and bark for controlling the growth of target fungus. Katooli et al. (2011) evaluated antifungal activity of eucalyptus (Eucalyptus camaldulensis Dehnh.) essential oil on pathogenic fungi. The experiment was carried out with Whatman paper disc method in 25, 50, 75 and 100% concentration of essential oil on PDA culture at 25°C and mycelial growth measured daily for 30 days. The antifungal activity was evaluated under a randomized completely factorial design with three replications. The results showed complete inhibition of mycelial growth in P. ultimum and R. solani on all concentration of essential oil after 30 days. B. sorokiniana and C. gloeosporioides showed complete inhibition until 5 days, but after that there was fungi mycelium growth and no inhibition. This essential oil in P. digitatum and A. flavus had no inhibition. References: 1. U. Bashir and J. J. Tahira, ―Evaluation of Eucalyptus camaldulensis against Fusarium solani,‖ International Journal of Agriculture and Biology, vol. 14, no. 4, pp. 675–677, 2012. 2. Martin Muthee Gakuubi, Angeline W. Maina, and John M. Wagacha, ―Antifungal Activity of Essential Oil ofEucalyptus camaldulensis Dehnh. against Selected Fusarium spp.,‖ International Journal of Microbiology, vol. 2017, Article ID 8761610, 7 pages, 2017. doi:10.1155/2017/8761610 3. N. Katooli, R. Maghsodlo, and S. E. Razavi, ―Evaluation of eucalyptus essential oil against some plant pathogenic fungi,‖ Journal of Plant Breeding and Crop Science, vol. 3, no. 2, pp. 41–43, 2011. 4. M. Mehani, N. Salhi, T. Valeria, and S. Ladjel, ―Antifungal effects of essential oil of Eucalyptus camaldulensis plant on Fusarium graminearum and Fusarium sporotrichioides,‖ International Journal of Current Research, vol. 6, no. 12, pp. 10795– 10797, 2014. 5. G. Singh, S. Gupta, and N. Sharma, ―In vitro screening of selected plant extracts against Alternaria alternate,‖ Journal of Experimental Biology, vol. 2, no. 3, pp. 344–351, 2014. 574 12. Garlic essential oils History of garlic antimicrobial activity  The earliest recorded use of garlic as a medicine is probably the therapeutic formulas written in the Codex Ebers, an Egyptian medical papyrus dating to approximately 1550 BC.  The papyrus mentions garlic as an effective medicine against tumours, worms and heart problems among other things.  Garlic was also prescribed as a vermifuge by Dioscorides, the chief physician to the Roman army during the first century AD.  In India, garlic has long been used as a treatment for otitis externa, as well as an antiseptic lotion for washing wounds and ulcers.  In France, an antibiotic concoction called ‗vinaigre des quatre voleurs’ is available, and it consists of macerated garlic in wine.  Louis Pasteur described garlic as antibacterial in the 19th century,  Albert Schweitzer, in the 20th century, used garlic in Africa for the treatment of amoebic dysentery.  During both world wars of the 20th century, garlic was used as an antiseptic in the prevention of gangrene.  The antifungal properties of garlic was demonstrated by Cavallito and his colleagues at the Sterling-Winthrop Chemical Company in New York in 1944, Allicin, was subsequently patented as an antifungal. Bioactive components    Garlic (Allium sativum) bulbs contain between 6 and 14 mg g−1 of a non-odiferous chemical called ‗alliin‘ (S-allylcysteine sulfoxide). When crushed, an enzyme called alliinase (normally enclosed in a separate compartment unless the cell is damaged) is mixed with the alliin, resulting in the formation of allicin (diallyl thiosulfinate, the initial odiferous compound within garlic). A more recent paper, however, has demonstrated that the liver can metabolize diallyl disulfide (one of the allicin breakdown products) back into allicin. The proprietary garlic derivative that has been successfully used as a systemic in vivo antifungal in China, allitridi (or allitridium), has been shown to be mainly diallyl trisulfide, a substance that can be obtained by the steam distillation of garlic cloves, and one of the main breakdown products of allicin 575 The molecular structures of alliin, allicin and the relevant allicin derivatives. Allicin         Allicin is an organosulfur compound obtained from garlic, a species in the family Alliaceae. Allicin was first isolated and studied in the laboratory by Chester J. Cavallito and John Hays Bailey in 1944. When fresh garlic is chopped or crushed, the enzyme alliinase converts alliin into allicin, which is responsible for the aroma of fresh garlic. Allicin generated is unstable and quickly changes into a series of other sulfur-containing compounds such as diallyl disulfide. Allicin is part of a defense mechanism against attacks by pests on the garlic plant. Allicin as an antifungal have demonstrated in vitro MICs of 2–16 μg ml−1 against 31 clinical isolates of Aspergillus fumigatus. Allicin treatment significantly prolonged the mean survival time of the mice compared with controls not receiving allicin treatment. Clinical use of allicin as an antifungal was eventually abandoned because of the substance's odour. Allitridi (‘allitridium’) Davis, 2005  Allitridi’ (‗allitridium‘), a garlic derivative, has been successfully used to treat both systemic fungal and bacterial infections.  Allitridi is non-toxic  Allitridi has been successfully used i.v. on a daily basis for over a month, with adverse side effects such as nausea, abdominal discomfort and thrombophlebitis at the i.v. site occurring in only 25% of the patients studied),  Allitridi appears to be effective, with reports particularly focussing on its use in the effective treatment of cryptococcosis. In vitro studies have demonstrated broad spectrum antifungal activity, 576 o MICs in the range of 4–16 μg ml−1 for activity against Scedosporium prolificans, o MICs of less than 0.25 μg ml−1 for activity against Cryptococcus neoformans. o Allitridi is synergistic with amphotericin B in vitro. Ajoene      Ajoene is an organosulfur compound found in garlic. Ajoene is a colorless liquid that contains sulfoxide and disulfide functional groups. Ajoene name is derived from "ajo", the Spanish word for garlic Ajoene is a condensate product of allicin, is formed when garlic is macerated in vegetable oil Ajoene inhibited spore germination of Alternaria solani, Alternaria tenuissima, Alternariatriticina, Alternaria sp., Colletotrichum sp., Curvularia sp., Fusari um lini, Fusarium oxysporum, Fusarium semitectum, and Fusarium udum. The compound was very effective in checking spore germination at a concentration of 25 μg/mL in some of the above fungi and, in most cases, there was 100% inhibition of germination at 100 μg/mL. Structure and occurrence of allicin  Allicin features the thiosulfinate functional group, R-S(O)-S-R. The compound is not present in garlic unless tissue damage occurs, and is formed by the action of the enzyme alliinase on alliin.[1] Allicin is chiral but occurs naturally only as a racemate.  The racemic form can also be generated by oxidation of diallyl disulfide: (SCH2CH=CH2)2 + RCO3H → CH2=CHCH2S(O)SCH2CH=CH2 + RCO2H  Allicin is generally not produced in the body from the consumption of fresh or powdered garlic.  Allicin can be unstable, breaking down within 16 hours at 23 °C. Biosynthesis  Allicin is an oily, slightly yellow liquid that gives garlic its unique odor.  Allicin is a thioester of sulfenic acid and is also known as allyl thiosulfinate.  Allicin biological activity can be attributed to both its antioxidant activity and its reaction with thiol-containing proteins. o In the biosynthesis of allicin (thio-2-propene-1-sulfinic acid S-allyl ester), cysteine is first converted into alliin (+ S-allyl-L-cysteine sulfoxide). 577 o The enzyme alliinase, which contains pyridoxal phosphate (PLP), cleaves alliin, generating allysulfenic acid, pyruvate, and ammonium. o At room temperature allysulfenic acid is unstable and highly reactive, which cause two molecules of it to spontaneously combine in a dehydration reaction to form allicin. o Produced in garlic cells, allicin is released upon disruption, producing a potent characteristic scent when garlic is cut or cooked. https://ipfs.io/ipfs/QmXoypizjW3WknFiJnKLwHCnL72vedxjQkDDP1mXWo6uco/wiki/Al licin.html Mechanism of action        Allicin and/or its breakdown products that are the main biologically active ingredients in garlic, has activity against bacteria, viruses, fungi, parasites, and cancer cells, as well as the inhibition of cholesterol synthesis in mammalian cells. Although the mechanism of action of these molecules in vivo is complex, and not fully studied, there appears to be an underlying common mode of action by allicin and its derivatives against these distinct medically important entities. The antimicrobial action of allicin and its breakdown products has been explained as the general reaction between sulfide-containing molecules and sulfhydril (SH) groups in amino acids and cellular proteins within these organisms. It has been demonstrated that it is the disulfide group in ajoene, and the sulfide bonds in the diallyl sulfide breakdown products of allicin that appear to be necessary for antimicrobial activity, with diallyl trisulfide having greater activity than diallyl disulfide, which, in turn has greater activity than diallyl monosulfide. The biological effectiveness of allicin is because of its high intracellular reactivity with both low and high molecular weight thiols (CHS groups), as well as its accessibility resulting from high membrane permeability. Aqueous garlic extract was tested against Candida albicans, and was found to inhibit the growth of this yeast. It appears that the mechanism of action of this treatment was to entirely block lipid synthesis of the yeast, while inhibiting both protein and nucleic acid synthesis. Interestingly, a later study on the inhibition of human cholesterol synthesis by various allicin breakdown products, including diallyl trisulfide and S-allyl cysteine (a sulfur containing, biologically active water soluble allicin breakdown product), implicates them as inhibitors of squalene monooxygenase (earlier called squalene epoxidase), an essential precursor in the biosynthesis of cholesterol. o Squalene monooxygenase is also an important enzyme used in the formation of the fungal cell wall. o Its inhibition is the mechanism by which the allylamines (a class of antifungal compounds containing a chemical group naturally found in garlic, and typified by terbinafine) cause squalene to accumulate. o This blockage prevents the formation of ergosterol, essential for synthesis of the fungal cell wall. 578 Safety      The i.v. use of the proprietary garlic preparation ‗allitridium‘ in China is reported to be remarkably safe. Various studies and observations have been made about the safety of oral ingestion of garlic and its derivatives over the years. o A clinical study was performed in 1980 in which 200 people ingested 15 g of raw garlic daily for 3.5 weeks. No side effects were noted. o Another study in 1991 had 50 participants ingesting 10 g daily for 8 weeks, with no apparent side effects. Gastrointestinal toxicity has been reported in people who ingest raw garlic concomitantly with taking protease inhibitors as medication for the treatment of HIV. Contact dermatitis has been demonstrated in susceptible individuals by topical application of raw garlic, There have been cases of allergic asthma in workers exposed to garlic dusts and powders. Reports : 579 Fratianni et al. (2016) analyzed extracts of the bulbs of the two endemic varieties "Rosato" and "Caposele" of Allium sativum of the Campania region, Southern Italy. The phenolic content, ascorbic acid, allicin content, and in vitro antimicrobial and antifungal activity were determined. Ultra performance liquid chromatography with diode array detector performed polyphenol profile. The extract of Caposele was more effective in inhibiting the growth of Aspergillus versicolor and Penicillum citrinum. On the other hand, the extract of Rosato was effective against Penicillium expansum. Hayat et al. (2016) evaluated the genetic diversity among Chinese garlic cultivars for their antifungal potency as well as allicin content distribution and, furthermore; a bioassay was performed to study the bio-stimulation mechanism of aqueous garlic extracts (AGE) in the growth and physiology of cucumber (Cucumis sativus). Initially, 28 garlic cultivars were evaluated against four kinds of phytopathogenic fungi; Fusarium oxysporum, Botrytis cinerea, Verticillium dahliae and Phytophthora capsici, respectively. A capricious antifungal potential among the selected garlic cultivars was observed. HPLC fingerprinting and quantification confirmed diversity in allicin abundance among the selected cultivars. Cultivar G025, G064, and G074 had the highest allicin content of 3.98, 3.7, and 3.66 mg g(-1), respectively, whereas G110 was found to have lowest allicin content of 0.66 mg g(-1). Cluster analysis revealed three groups on the basis of antifungal activity and allicincontent among the garlic cultivars. Cultivar G025, G2011-4, and G110 were further evaluated to authenticate the findings through different solvents and shelf life duration and G025 had the strongest antifungal activity in all conditions. minimum inhibitory concentration and minimum fungicidal concentration of Allicin aqueous standard (AAS) and AGE showed significant role of allicin as primary antifungalsubstance of AGE. Leaf disk bioassay against P. capsici and V. dahliae to comparatively study direct action of AGE and AAS during infection process employing eggplant and pepper leaves showed a significant reduction in infection percentage. To study the bioactivity of AGE, a bioassay was performed using cucumber seedlings and results revealed that AGE is biologically active inside cucumber seedlings and alters the defense mechanism of the plant probably activating reactive oxygen species at mild concentrations. However, at higher concentrations, it might cause lipid peroxidation and membrane damage which temper the growth of cucumber seedlings. At the outcome of the study, an argument is advanced that current research findings provide bases for cultivar selection in antifungal effectivity as well as genetic variability of the cultivars. Allicin containing AGE can be used in specialized horticultural situations such as plastic tunnel and organic farming as a bio-stimulant to enhance cucumber growth and attenuate fungal degradation of agricultural produce. Aala et al. (2014) investigated the effects of Garlic (Allium sativum) and pure allicin on the growth of hypha in T. rubrum using Electron miscroscopy. This study was carried out to observe the morphological changes of T. rubrum treated with allicin as well as aqueous garlic extract using scanning electron microscopy (SEM) and transmission electron microscopy (TEM). SEM surveys, showed that hypha treated with allicin has rough and granular like surface, abnormal and irregularly-shape. However, hypha treated with garlic extract had rough and fluffy surface and also irregularly-shape. TEM studies also found that hypha treated with allicin displays disintegration of cytoplasm, breaking down in cell membrane and the cell wall, and collapsing of hypha, meanwhile hypha treated with garlic extract exhibiting degradation and dissolution of cytoplasm components, demolition of cell wall and cell membrane, and hypha appeared to break 581 Kim et al. (2012) investigated the antifungal activity of allicin and its synergistic effects with the antifungal agents flucytosine and amphotericin B (AmB) in Candida albicans (C. albicans). C. albicans was treated with different conditions of compounds alone and in combination (allicin, AmB, flucytosine, allicin + AmB, allicin + flucytosine, allicin + AmB + flucytosine). After a 24hour treatment, cells were examined by scanning electron microscopy (SEM) and atomic force microscopy (AFM) to measure morphological and biophysical properties associated with cell death. The clearing assay was conducted to confirm the effects of allicin. The viability of C. albicans treated by allicin alone or with one antifungal drug (AmB, flucytosine) in addition was more than 40% after a 24-hr treatment, but the viability of groups treated with combinations of more than two drugs was less than 32%. When the cells were treated with allicin alone or one type of drug, the morphology of the cells did not change noticeably, but when cells were treated with combinations of drugs, there were noticeable morphological changes. In particular, cells treated with allicin + AmB had significant membrane damage (burst or collapsed membranes). Classification of cells according to their cell death phase (CDP) allowed us to determine the relationship between cell viability and treatment conditions in detail. The adhesive force was decreased by the treatment in all groups compare to the control. Cells treated with AmB + allicin had a greater adhesive force than cells treated with AmB alone because of the secretion of molecules due to collapsed membranes. All cells treated with allicin or drugs were softer than the control cells. These results suggest that allicin can reduce MIC of AmB while keeping the same efficacy. Khodavandi et al. (2010) used allicin, an allyl sulfur derivative of garlic, to demonstrate both its intrinsic antifungal activity and its synergy with the azoles, in the treatment of these yeasts in vitro. In this study, the MIC(50) and MIC(90) of allicin alone against six Candida spp. ranged from 0.05 to 25 microg/ml. However, when allicin was used in combination with fluconazole or ketoconazole, the MICs were decreased in some isolates. Our results demonstrated the existing synergistic effect between allicin and azoles in some of the Candida spp. such as C. albicans, C. glabrata and C. tropicalis, but synergy was not demonstrated in the majority of Candida spp. tested. Nonetheless, In vivo testing needs to be performed to support these findings. Khodavandi et al. (2011) investigated the antifungal activity of allicin, an active compound of garlic on various isolates of C. albicans. The effect of allicin on biofilm production in C. albicans as compared to fluconazole, an antifungal drug, was investigated using the tetrazolium (XTT) reduction-dependent growth and crystal violet assays as well as scanning electron microscopy (SEM). Allicin-treated cells exhibited significant reduction in biofilm growth (p<0.05) compared to fluconazole-treated and also growth control cells. Moreover, observation by SEM of allicin and fluconazole-treated cells confirmed a dose-dependent membrane disruption and decreased production of organisms. Finally, the expression of selected genes involved in biofilm formation such as HWP1 was evaluated by semi-quantitative RT-PCR and relative real time RTPCR. Allicin was shown to down-regulate the expression of HWP1. Davis (200-5) made reports about the safe and successful intravenous (i.v.) use of garlic derivatives in China against invasive fungal infections, but little has been done to seriously investigate the in vivo use of these derivatives in the West. Laboratories have demonstrated impressive in vitro MICs using allitridium, one of these derivatives, against a range of medically important fungi. In addition, it has been demonstrated that allitridium shows in vitro synergy with amphotericin B, one of the main i.v. antifungal agents. Some of the breakdown products of 581 allicin, the main parent antifungal compound in garlic, have been investigated for their general antimicrobial, anticancer and anticholesterol properties, and it appears that there is a common mode of action that underlies these activities. It appears that these small molecules have the ability to cross cell membranes and combine with sulfur-containing molecular groups in amino acids and proteins, thus interfering with cell metabolism. It has been suggested that the reason human cells are not poisoned by allicin derivatives is that they contain glutathione, a sulfurcontaining amino acid that combines with the allicin derivative, thus preventing cell damage. In addition to their biochemical mechanism, these derivatives appear to stimulate cellular immunity, an important ability lacking in conventional antifungal chemotherapy. These derivatives appear to be safe, cheap, wide-spectrum and immunostimulatory, as well as possibly synergistic with conventional antifungal therapy, making them ideal candidates for investigation into their use as prophylactic antifungal agents References: 1. Aala F1, Yusuf UK2, Nulit R2, Rezaie S3. Inhibitory effect of allicin and garlic extracts on growth of cultured hyphae. Iran J Basic Med Sci. 2014 Mar;17(3):150-4. 2. AnnaMarchese,RamonaBarbieria AnaSanches-Silvabc MariaDagliadSeyed FazelNabavie Nematollah JonaidiJafarif MortezaIzadif MarjanAjamig Seyed MohammadNabavi. Antifungal and antibacterial activities of allicin: A review. Trends in Food Science & Technology Volume 52, June 2016, Pages 49-5 3. Cavallito, Chester J.; Bailey, John Hays (1944). "Allicin, the Antibacterial Principle of Allium sativum. I. Isolation, Physical Properties and Antibacterial Action". Journal of the American Chemical Society. 66 (11): 1950. doi:10.1021/ja01239a048. 4. Fratianni F1, Riccardi R2, Spigno P2, Ombra MN1, Cozzolino A1,3, Tremonte P3, Coppola R1,3, Nazzaro F1. Biochemical Characterization and Antimicrobial and Antifungal Activity of Two Endemic Varieties of Garlic (Allium sativum L.) of the Campania Region, Southern Italy. J Med Food . 2016 Jul;19(7):686-91. 5. Hayat S1, Cheng Z1, Ahmad H1, Ali M1, Chen X2, Wang M1. Garlic, from Remedy to Stimulant: Evaluation of Antifungal Potential Reveals Diversity in Phytoalexin Allicin Content among Garlic Cultivars; Allicin Containing Aqueous Garlic Extracts Trigger Antioxidants in Cucumber. Front Plant Sci. 2016 Aug 25;7:1235. 6. Khodavandi A1, Alizadeh F, Aala F, Sekawi Z, Chong PP. In vitro investigation of antifungal activity of allicin alone and in combination with azoles against Candida species. Mycopathologia. 2010 Apr;169(4):287-95. 7. Khodavandi A1, Harmal NS, Alizadeh F, Scully OJ, Sidik SM, Othman F, Sekawi Z, Ng KP, Chong PP. Comparison between allicin and fluconazole in Candida albicans biofilm inhibition and in suppression of HWP1 gene expression. Phytomedicine. 2011 Dec 15;19(1):56-63. 8. Kim Y-S, Kim KS, Han I, Kim M-H, Jung MH, Park H-K (2012) Quantitative and Qualitative Analysis of the Antifungal Activity of Allicin Alone and in Combination with Antifungal Drugs. PLoS ONE7(6): e38242. https://doi.org/10.1371/journal.pone.0038242 582 13. Fennel essential oil  Fennel (Foeniculum vulgare L.), a member of the Apiaceae, is a popular aromatic herb and spice. Fennel seeds are used as flavourings in baked goods, ice cream, meat and fish dishes, herb mixtures and alcoholic beverages. Fennel is also used in local and traditional medicine due to its therapeutic effects. Fennel is widely used as a carminative, digestive, lactogogue and diuretic, and in treating respiratory and gastrointestinal disorders        Fennel essential oil is steam distilled from the seeds of the perennial fennel herb. Fennel essential oil contains a very high percentage of Methyl Chavicol or Estragole. Fennel essential oil is also high in Alpha Pinene, Limonene and Trans-Anethole. Fennel essential oil is a very effective anti-fungal with the ability to treat a variety of fungal and yeast infections. Antifungal activity  Fennel essential oil can help combat infections of the nails, skin and the hair as well as common yeast infections like candida albicans.  Fennel essential oil was recently proved to be very effective against dermatophytes indicating that fennel essential oil had excellent anti-fungal potential to treat common skin, nail and hair fungus. Zeng et al. (2015)  Fennel seed essential oil (FSEO) exhibited antifungal effects against pathogens such as Aspergillus spp., Fusarium spp., Candida spp., Sclerotinia sclerotiorum and Trichophyton mentagrophytes (Roby et al., 2013; Viuda-Martos et al., 2011; Inouye et al., 2006)  The essential oils of fennel (Foeniculum vulgare) has a marked antifungal effect against S. sclerotiorum. Soil amendment with essential oils has significant effect on reducing sclerotial viability. Both essential oils significantly inhibited the fungal growth in soil, thereby increasing the number of surviving tomato seedling by 69.8% and 53.3%, respectively. Light and SEM observations on pathogen hyphae and sclerotia revealed considerable morphological alterations in hyphae and sclerotia. Soylu et al. (2007) 583 Recent reports: Zeng et al. (2015) nvestigated the antifungal effects of FSEO from varied aspects, such as MIC and minimum fungicidal concentration, mycelia growth, spore germination and biomass. The results indicated that FSEO had potent antifungal activities on Trichophyton rubrum ATCC 40051, Trichophyton tonsurans 10-0400, Microsporum gypseum 44693-1 and Trichophyton mentagrophytes 10-0060, which is better than the commonly used antifungal agentsfluconazole and amphotericin B. Flow cytometry and transmission electron microscopy experiments suggested that the antifungal mechanism of FSEO was to damage the plasma membrane and intracellular organelles. Further study revealed that it could also inhibit the mitochondrial enzyme activities, such as succinate dehydrogenase, malate dehydrogenase and ATPase. With better antifungal activity than the commonly used antifungal agents and less possibility of inducing drug resistance, FSEO could be used as a potential antidermatophytic agent. Roby et al. (2013) examined essential oil and extracts of two Egyptian plants, fennel and chamomile for their antioxidant and antimicrobial activities. The essential oil for fennel seeds and chamomile flowers were found to be 1.95 and 0.73%, respectively. Gas chromatography/mass spectrometry analysis of the essential oils revealed the presence of 15 major monoterpenoids in all two plant essential oil but their percentages in each plant were greatly different. Trans-anethole, estragole, fenchone and limonene were highly abundant in all of the examined oils. Antioxidant activities of the extracts were evaluated using the DPPH radical scavenging. The statistical analysis showed that the highest antiradical power (ARP) was noticed for chamomile extracted by methanol, where is fennel extracted be hexane gave the least value which was 243. Antimicrobial activities of each plant extracts and essential oil were measured. The lowest MIC values of essential oils for Aspergillus flavus, Candida albicans, Bacillus cereus, and Staphylococcus aureus was obtained. The essential oils exhibit different degrees of antimicrobial activities depending on the doses applied. The results of the present investigation demonstrated significant variations in the antioxidant and antimicrobial activities of fennel and chamomile essential oil and extracts. Viuda-Martos et al. (2011) performed a study to (i) determine the chemical composition of the essential oils (EOs) of five spices widely cultivated in Egypt as: Fennel (Foeniculum vulgare), parsley (Petroselinum crispum), lavender (Lavandula officinalis), black cumin (Nigella sativa) and thyme (Thymus vulgaris); (ii) determine the total phenolic compound (TPC) content (iii) determine the antioxidant activity of the Egyptian essentials oils by means of three different antioxidant test and (iv) determine the effectiveness of the Egyptian essentials oils on the inhibition of the growth of some indicators of spoilage bacteria strains. There is a great variability in the chemical composition of EOs obtained from the five Egyptian aromatic plants. Thyme EO had the highest content of total phenols (913.17 mg GAE/L). Black cumin (highest % of inhibition of DPPH radical: 95.89% and highest FRAC values 3.33 mmol/L Trolox) and thyme (highest % of inhibition of TBARS: 80.76) essential oils presented the best antioxidant profile. Only the essential oil of thyme showed inhibitory effects on the three tested bacteria at all added doses. 584 References: 1. Roby, M. H. H., Sarhan, M. A., Selim, K. A.-H. & Khalel, K. I. (2013). Antioxidant and antimicrobial activities of essential oil and extracts of fennel (Foeniculum vulgare L.) and chamomile (Matricaria chamomilla L.). Ind Crops Prod 44, 437–445. 2. Soylu S1, Yigitbas H, Soylu EM, Kurt S. Antifungal effects of essential oils from oregano and fennel on Sclerotinia sclerotiorum. J Appl Microbiol. 2007 Oct;103(4):1021-30. 3. Viuda-Martos, M., Mohamady, M. A., Ferna´ndez-Lo´ pez, J., Abd ElRazik, K. A., Omer, E. A., Pe´rez-Alvarez, J. A. & Sendra, E. (2011). In vitro antioxidant and antibacterial activities of essentials oils obtained from Egyptian aromatic plants. Food Control 22, 1715– 1722. 4. Zeng H1, Chen X2, Liang J3. In vitro antifungal activity and mechanism of essential oil from fennel (Foeniculum vulgare L.) on dermatophyte species. J Med Microbiol. 2015 Jan;64(Pt 1):93-103. 14. Galangal essential oil      Galangal (Alpinia galangal) has been used as a food additive in Thailand and other Asian countries since ancient time. Alpinia galanga (L.) Sw. (Zingiberaceae) is known by various names – galangal, galanga, greater galangal, Java galangal and Siamese ginger (English). n Galangal is a native of Indonesia although its exact origin is not known, but it has become naturalized in many parts of South and South East Asia. Galangal is cultivated in all South East Asian countries, India, Bangladesh, China and Surinam. Galangal rhizome contains 1,8-cineole (47.3 %), α-pinene (11.5 %), β-pinene (7.1 %), αthujene (6.2 %), terpinen-4-ol (6.0 %), α-terpineol, limonene (4.3 % each) and many other compounds in lesser concentrations. Medicinal uses  The galanga rhizomes may be chewed and ingested, and are considered to have many beneficial properties, i.e. stimulatory, expectorant, carminative and diuretic (Khare, 2007  The galanga rhizomes are used in the preparation of gargles and administered with honey for treatment of coughs and respiratory ailments.  The galanga rhizomes, in Thailand, are used as a cardiotonic (CSIR, 1959).  The galanga rhizomes, in India, along with some other plants are used for heart diseases. It is also used for treatment of abdominal pain, vomiting, diarrhoea and toothache with the functions of promoting vital energy circulation and alleviating pain. 585    The galanga rhizomes mixed with oil is used externally for healing wounds and applied to warm rheumatic regions. A lotion prepared from the rhizome is used to remove dandruff or scales from the head (Duke, 2003). The galanga essential oil from the root induced glutathione-s-transferase activities in the stomach, liver and small intestine of mouse. The galanga essential oil from the root showed antibacterial activity against Escherichia coli and Staphylococcus aureus, and antifungal activity against Cladosporium sp. (Ravindran and Pillai, 2006). Antifungal activity:  The inhibitory effect of A. calcarata extract against crop pathogens Curvularia spp. and Colletorichum spp. using the agar plate method varied with time period and its effects were better than the positive control drug, daconil. A promising antifungal effect of A. calcarata essential oil is suggested. Rahman and Islam (2015)  The essential oils from fresh and dried rhizomes of Alpinia galanga showed an antimicrobial activity against gram-positive bacteria, a yeast and some dermatophytes, using the agar overlay technique. The main components of the oils were also tested and terpinen-4-ol was found most active. An N-pentane/diethyl ether extract of dried rhizomes was active against Trichophyton mentagrophytes. 1'-Acetoxychavicol acetate, in the antifungally active fractions obtained by LSC, was active against the seven fungi tested and its MIC value for dermatophytes ranged from 50 to 250 microg/ml. Janssen and Scheffer (1985) Recent reports: Rahman and Islam (2015) mentioned that Alpinia calcarata Roscoe (Family: Zingiberaceae), is a rhizomatous perennial herb, which is commonly used in the traditional medicinal systems in Sri Lanka. Alpinia calcarata is cultivated in tropical countries, including Sri Lanka, India, and Malaysia. Experimentally, rhizomes of Alpinia calcarata are shown to possess antibacterial, antifungal, anthelmintic, antinociceptive, anti-inflammatory, antioxidant, aphrodisiac, gastroprotective, and antidiabetic activities. Phytochemical screening revealed the 586 presence of polyphenols, tannins, flavonoids, steroid glycosides and alkaloids in the extract and essential oil of this plant. Essential oil and extracts from this plant have been found to possess wide range of pharmacological and biological activities. This article provides a comprehensive review of its ethnomedical uses, chemical constituents and the pharmacological profile as a medicinal plant. Particular attention has been given to the pharmacological effects of the essential oil of Alpinia calcarata in this review so that the potential use of this plant either in pharmaceutics or as an agricultural resource can be evaluated. Arambewela et al. (2010) investigated the antifungal activities against crop pathogens Curvularia spp. and Colletorichum spp. using the agar plate method. Fifty percent effective concentration (EC(50)) and % antioxidant index of the essential oil were 45 ± 0.4 and 16.1 ± 0.2 for DPPH and TBARS assays, respectively. The degree of, the essential oil's inhibition of the growth of crop pathogens Curvularia spp. and Colletorichum spp. varied with time period its effects were higher than greater than for the positive control, daconil. In conclusion, the essential oil of A. calcarata rhizomes possess moderate antioxidant property and promising antifungal activity. References: 1. Arambewela LS1, Arawwawala LD, Athauda N. Antioxidant and antifungal activities of essential oil of Alpinia calcarata Roscoe rhizomes. J Ayurveda Integr Med. 2010 Jul;1(3):199-202. 2. Janssen AM1, Scheffer JJ. Acetoxychavicol Acetate, of Alpinia galangal. Planta Med. 1985 Dec;51(6):507-11. an Antifungal Component 3. Rahman MA1, Islam MS2. Alpinia calcarata Roscoe: A potential phytopharmacological source of natural medicine. Pharmacogn Rev. 2015 JanJun;9(17):55-62. 15. Geraniol essential oil        Geraniol is a monoterpenoid and an alcohol. Geraniol is the primary part of rose oil, palmarosa oil, and citronella oil (Java type). Geraniol also occurs in small quantities in geranium, lemon, and many other essential oils. Geraniol appears as a clear to pale-yellow oil that is insoluble in water, but soluble in most common organic solvents. Geraniol has a rose-like scent and is commonly used in perfumes. It is used in flavors such as peach, raspberry, grapefruit, red apple, plum, lime, orange, lemon, watermelon, pineapple, and blueberry. In acidic solutions, geraniol is converted to the cyclic terpene alpha-terpineol The functional group based on geraniol (in essence, geraniol lacking the terminal -OH) is called geranyl. It is important in biosynthesis of other terpenes 587 Chemical structure: C10H18O   Geraniol, one of the principal components of rose geranium oil, has a sweet, mildly floral aroma, Geraniol belongs to a large class of plant chemicals known as isoprenoids, compounds that are concentrated in essential oils; they include chemicals such as menthol and vitamin E. Uses:   Geraniol has been considered a revolutionary insect repellent ingredient since 1999. Geraniol has shown antifungal activity against yeasts and dermatophytes Antifungal activity and mode of action  Geraniol inhibited pseudohyphae and chlamydoconidia formation. Time-dependent kill curve assay demonstrated that the fungicidal activity for MIC × 2 started at 2 to 4 h. Leite et al. (2015)  Geraniol MIC values in case of Trichophyton rubrum ranged between 16 and 256 µg/mL. Geraniol MIC values inhibited the mycelial growth, conidia germination, and fungal growth on nail fragments. The drugs (half of MIC) induced the formation of wide, short, and crooked hyphae in T. rubrum morphology.. Geraniol damages cell wall and cell membrane of T. rubrum through a mechanism that seems to involve the inhibition of the ergosterol biosynthesis. Pereira et al. (2015)  Geraniol with an MIC of 30-130μg/mL completely suppressed growth of Candida species. Geraniol was fungicidal at concentrations 2×MIC. There was complete suppression of fungal growth at MIC values. Geraniol disrupts cell membrane integrity by interfering with ergosterol biosynthesis and inhibiting the very crucial PM-ATPase. Sharma et al. (2016) Safety   Geraniol is classified as D2B (Toxic materials causing other effects) using the Workplace Hazardous Materials Information System(WHMIS). Geraniol is considered a severe eye (and moderate skin) irritant. 588 Recent reports: Sharma et al. (2016) made an attempt to understand the antifungal activity of geraniol at the cell membrane level in three Candida species. With an MIC of 30-130μg/mL, this natural compound was fungicidal at concentrations 2×MIC. There was complete suppression of fungal growth at MIC values (growth curves) and encouragingly geraniol is non-toxic even at the concentrations approaching 5×MIC (hemolysis assay). Exposed cells showed altered morphology, wherein the cells appeared either broken or shrivelled up (SEM studies). Significant reduction was seen in ergosterol levels at sub-MIC and glucose-induced H(+) efflux at concentrations>MIC values. Results suggest that geraniol disrupts cell membrane integrity by interfering with ergosterol biosynthesis and inhibiting the very crucial PM-ATPase. It may hence be used in the management and treatment of both superficial and invasive candidiasis but further studies are required to elaborate its mode of action. Singh et al. (2016) observed that the repertoire of antifungal activity was not only limited to C. albicans and its clinical isolates but also against non-albicans species of Candida. The membrane tampering effect was visualized through transmission electron micrographs, depleted ergosterol levels and altered plasma membrane ATPase activity. Ger also affects cell wall as revealed by spot assays with cell wall-perturbing agents and scanning electron micrographs. Functional calcineurin pathway seems to be indispensable for the antifungal effect of Ger as calcineurin signaling mutant was hypersensitive to Ger while calcineurin overexpressing strain remained resistant. Ger also causes mitochondrial dysfunction, impaired iron homeostasis and genotoxicity. Furthermore, Ger inhibits both virulence attributes of hyphal morphogenesis and biofilm formation. Taken together, our results suggest that Ger is potential antifungal agent that warrants further investigation in clinical applications so that it could be competently employed in therapeutic strategies to treat Candida infections. Leite et al. (2015) investigated possible geraniol activity on the fungal cell wall (sorbitol protect effect), cell membrane (geraniol to ergosterol binding), the time-kill curve, and its biological activity on the yeast's morphology. Amphotericin B was used as control, and all tests were performed in duplicate. The MIC of geraniol was 16 μg/ml (for 90% of isolates) but its probable mechanism of action did not involve the cell wall and ergosterol binding. In the morphological interference assay, they observed that the product inhibited pseudohyphae and 589 chlamydoconidia formation. Time-dependent kill curve assay demonstrated that the fungicidal activity for MIC × 2 started at 2 h for the ATCC 76485 strain, and at 4 h for the LM70 strain. Geraniol showed in vitro antifungal potential against strains of C. albicans but did not involve action on the cell wall or ergosterol. Pereira et al. (2015) investigatef the inhibitory effects and possible mechanism of antifungal activity of geraniol and citronellol against strains of T. rubrum. The minimum inhibitory concentration (MIC) of each drug against 14 strains was determined by broth microdilution. The effects of the drugs on dry mycelial weight, conidial germination, infectivity on human nail fragments, and morphogenesis of T. rubrum were analyzed. The effects on the cell wall (test with sorbitol) and cell membrane (release of intracellular material and ergosterol biosynthesis) were investigated. MIC values of geraniol ranged between 16 and 256 µg/mL while citronellol showed MIC values from 8 to 1024 µg/mL. The drugs (MIC and 2 × MIC) inhibited the mycelial growth, conidia germination, and fungal growth on nail fragments. The drugs (half of MIC) induced the formation of wide, short, and crooked hyphae in T. rubrum morphology. With sorbitol, geraniol MIC was increased by 64-fold and citronellol by 32-fold. The drugs caused leakage of intracellular material and inhibited ergosterol biosynthesis. References: 1. Leite MC1, de Brito Bezerra AP2, de Sousa JP2, de Oliveira Lima E2. Investigating the antifungal activity and mechanism(s) of geraniol against Candida albicans strains. Med Mycol. 2015 Apr;53(3):275-84. 2. Pereira Fde O1, Mendes JM, Lima IO, Mota KS, Oliveira WA, Lima Ede O. Antifungal activity of geraniol and citronellol, two monoterpenes alcohols, against Trichophyton rubrum involves inhibition of ergosterol biosynthesis. Pharm Biol. 2015 Feb;53(2):228-34. 3. Sharma Y1, Khan LA1, Manzoor N2. Anti-Candida activity of geraniol involves disruption of cell membrane integrity and function. J Mycol Med. 2016 Sep;26(3):244-54. 4. Singh S1, Fatima Z1, Hameed S2. Insights into the mode of action of anticandidal herbal monoterpenoid geraniol reveal disruption of multiple MDR mechanisms and virulence attributes in Candida albicans. Arch Microbiol. 2016 Jul;198(5):459-72. 16. Geranium essential oil   Geranium essential oil is extracted through steam distillation of stems and leaves of the Geranium plant, bearing the scientific name Pelargonium Odorantissimum. Geranium essential oil main components of this oil are Alpha Pinene, Myrcene, Limonene, Menthone, Linalool, Geranyl Acetate, Citronellol, Geraniol and Geranyl Butyrate. Antifungal activities  Growth of F. solani was inhibited 75 and 70% by crude extract and its ethyl acetate fraction, respectively. 591  Crude extract also showed moderate activity against the growth of C. albicans, and M. canis. Antifungal activity of crude extract and fractions of rhizomes of Geranium wallichianum (Miconazole as standard drug), Ismail et al., 2012. Fungi −ve co trol Standard MIC (μg/mL) Crude extract LG (mm) -hexane LG (mm) Chloroform LG (mm) Ethyl acetate LG (mm) -butanol LG (mm) Aqueous LG (mm) T. longifusus 100 70 100 100 100 100 100 100 C. albicans 100 110.8 40 100 100 50 100 00 M. canis 100 98 4 35 100 100 48 100 20 A. flavusi 100 20 100 100 100 100 100 100 F. solani 100 73.3 25 100 100 30 100 100 Inhibition of 0–40%: no activity; 40–60%: low activity; 60–70%: moderate activity; 70–100%: significant activity; LG: linear growth (mm). Brands 591 Rececent reports: Gülin Renda et al. (2016) used solid phase microextraction (SPME) method with gas chromatography-mass spectrometry (GC-MS) for analyses of the volatile compounds of six Geraniumspecies; G. asphodeloides, G. psilostemon, G. purpureum, G. pyrenaicum, G. robertianum and G. sanguineum. The results were compared with those obtained by hydrodistillation. According to the results of the study, the major compounds identified in the SPME extracts were sabinen (33.5%) (G. asphodeloides), caryophyllene (34.1%, 21.7%, 11.2%) (G. psilostemon, G. purpureum and G. robertianum), germacrene D (25.2%) (G. pyrenaicum), and alloa romadendrene (19.8%) (G. sanguineum) whereas hydrodistillation (HD) essential oils were rich in benzene acetaldehyde (30%, 25.7%) (G. asphodeloides, G. sanguineum), caryophyllene (34.3%, 11.3%) (G. psilostemon and G. robertianum), hexadecanoic acid (36.2%, 15.1%) (G. purpureum and G. pyrenaicum). The oils were screened for antimicrobial activity against 10 microorganisms and showed antibacterial and antifungal activities against Staphylococcus aureus, Bacillus cereus, Mycobacterium smegmatis, Candida albicansand Saccharomyces cerevisiae. Ismail et al. (2012) described the phytochemical investigations of the crude extracts of rhizomes and leaves of Geranium wallichianum. The crude extracts were fractionated to obtain n-hexane, ethyl acetate, and n-butanol fractions, which were subjected to different biological activities and enzyme inhibition assays to explore the therapeutic potential of this medicinally important herb. The results indicated that the crude extracts and different fractions of rhizomes and leaves showed varied degree of antimicrobial activities and enzyme inhibitions in different assays. Overall, the rhizome extract and its different fractions showed comparatively better activities in various assays. Furthermore, the purified constituents from the repeated chromatographic separations were also subjected to enzyme inhibition studies against three different enzymes. The results of these studies showed that lipoxygenase enzyme was significantly inhibited as compared to urease. In case of chemical constituents, the sterols (2-4) showed no inhibition, while ursolic acid (1) and benzoic ester (6) showed significant inhibition of urease enzymes. Khosravi et al. (2012) evaluated and assessed the capability of Zataria multiflora, Geranium herbarium, and Eucalyptus camaldolensis essential oils in treating Saprolegnia parasitica-infected rainbow (Oncorhynchus mykiss) trout eggs. A total of 150 592 infected eggs were collected and plated on glucose-pepton agar at 24°C for 2 weeks. The antifungal assay of essential oils against S. parasitica was determined by a macrodilution broth technique. The eggs were treated with essential oils at concentrations of 1, 5, 10, 25, 50, and 100 ppm daily with three repetitions until the eyed eggs stage. Of 150 eggs examined, S. parasitica (54.3%), Saprolegnia spp. (45%), and Fusarium solani (0.7%) were isolated. The minimum inhibitory concentrations of Z. multiflora, E. camaldolensis, and G. herbarium essential oils against S. parasitica were 0.9, 2.3, and 4.8 ppm, respectively. Zataria multiflora and E. camaldolensis at concentrations of 25, 50, and 100 ppm, and G. herbarium at concentration of 100 ppm had significant differences in comparison with negative control (p<0.05). The results revealed that malachite green, followed by Z. multiflora, E. camaldolensis, and G. herbarium treated eggs had remained the most number of final eyed eggs after treatment. The highest final larvae rates belonged to malachite green, E. camaldolensis, Z. multiflora, and G. herbarium, respectively. The most hatching rates were recorded with malachite green (22%), and then Z. multiflora (11%), E. camaldolensis (7%), G. herbarium (3%), and negative control (1%). Zataria multiflora and E. camaldolensis were more effective than G. herbarium for the treatment of S. parasitica-infected rainbow trout eggs in aquaculture environment. Zore et al. (2011) evaluated Fluconazole (FLC) susceptibility of isolates of Candida spp., (n = 42) and efficacy as well as mechanism of anti-Candida activity of three constituents of geranium oil in this study. No fluconazole resistance was observed among the clinical isolates tested, however 22% were susceptible-dose-dependent (S-DD) [minimal inhibitory concentration (MIC) ≥ 16 μg ml(-1)] and a standard strain of C. albicans ATCC 10231 was resistant (≥ 64 μg ml(-1)). Geraniol and geranyl acetate were equally effective, fungicidal at 0.064% v/v concentrations i.e. MICs (561 μg ml(-1) and 584 μg ml(-1) respectively) and killed 99.9% inoculum within 15 and 30 min of exposures respectively. Citronellol was least effective and fungistatic. C. albicans dimorphism (Y → H) was highly sensitive to geranium oil constituents tested (IC50 approximately 0.008% v/v). Geraniol, geranyl acetate and citronellol brought down MICs of FLC by 16-, 32- and 64-fold respectively in a FLC-resistant strain. Citronellol and geraniol arrested cells in G1 phase while geranyl acetate in G2-M phase of cell cycle at MIC(50). In vitro cytotoxicity study revealed that geraniol, geranyl acetate and citronellol were non-toxic to HeLa cells at MICs of the C. albicans growth. The results indicate that two of the three geranium oil constituents tested exhibit excellent anti-Candida activity and significant synergistic activity with fluconazole. Inouye et al. (2006) examined the vapor activity of six essential oils against a Trichophyton mentagrophytes using a closed box. The antifungal activity was determined from colony size, which was correlated with the inoculum size. As judged from the minimum inhibitory dose and the minimum fungicidal dose determined after vapor exposure for 24 h, the vapor activity of the six essential oils was ranked in the following order: oregano > clove, perilla > geranium, lavender, tea tree. The vapors of oregano, perilla, tea tree, and lavender oils killed the mycelia by short exposure, for 3 h, but the vapors of clove and geranium oils were only active after overnight exposure. The vapor of oregano and other oils induced lysis of the mycelia. Morphological examination by scanning electron microscope (SEM) revealed that the cell membrane and cell wall were damaged in a dose- and time-dependent manner by the action of oregano vapor, causing rupture and peeling of the cell wall, with small bulges coming from the cell membrane. The vapor activity increased after 24 h, but mycelial accumulation of the active oil constituents was maximized around 15 h, and then decreased in parallel with the decrease of 593 vapor concentration. This suggested that the active constituent accumulated on the fungal cells around 15 h caused irreversible damage, which eventually led to cellular death. References: 1. Gülin Renda,Gonca Celik,Büsra Korkmaz,Sengül Alpay Karaoglu &Nurettin YayliAntimicrobial Activity and Analyses of Six Geranium L. Species with Headspace SPME and Hydrodistillation. Journal of Essential Oil Bearing Plants Volume 19, 2016 Issue 8 Pages 2003-2016 | Received 27 Mar 2016 2. Inouye S1, Nishiyama Y, Uchida K, Hasumi Y, Yamaguchi H, Abe S. The vapor activity of oregano, perilla, tea tree, lavender, clove, and geranium oils against a Trichophyton mentagrophytes in a closed box. J Infect Chemother. 2006 Dec;12(6):34954. 3. Ismail M1, Hussain J, Khan AU, Khan AL, Ali L, Khan FU, Khan AZ, Niaz U, Lee IJ. Antibacterial, Antifungal, Cytotoxic, Phytotoxic, Insecticidal, and Enzyme Inhibitory Activities of Geranium wallichianum. Evid Based Complement Alternat Med. 2012;2012:305906. doi: 10.1155/2012/305906. 4. Khosravi AR1, Shokri H, Sharifrohani M, Mousavi HE, Moosavi Z. Evaluation of the antifungal activity of Zataria multiflora, Geranium herbarium, and Eucalyptus camaldolensis essential oils on Saprolegnia parasitica-infected rainbow trout (Oncorhynchus mykiss) eggs. Foodborne Pathog Dis. 2012 Jul;9(7):674-9. 5. Zore GB1, Thakre AD, Rathod V, Karuppayil SM. Evaluation of anti-Candida potential of geranium oil constituents against clinical isolates of Candida albicans differentially sensitive to fluconazole: inhibition of growth, dimorphism and sensitization. Mycoses. 2011 Jul;54(4):e99-109. 17. Ginger essential oil      Ginger essential oil is a popular essential oil with a warm, energizing aroma. Ginger essential oil is steam distilled from the rhizome of the ginger plant and is part of the Zingiberaceae family. Ginger essential oil was used anciently in India and China and was taken to the Mediterranean as early the 1st century AD Ginger essential oil benefits include its topical and aromatic uses, whether the oil is being diffused during a long road trip or applied during a massage. Its spicy, invigorating aroma also makes it popular in the perfume industry. Ginger essential oil contains several ingredients which have antifungal properties, with shagelol and gingerol being the most active. Antifungal activity 594     The ethanolic extract of ginger powder was effective on Candida albicans (2 mg mL−1 ) at the concentration of 1:5. The study indicates that ginger extract might have promise in treatment of oral candidiasis.Atai et al. (2009) The ethanolic extract of ginger powder has pronounced inhibitory activities against Candida albicans. From the obtained results it can be concluded that although ethanol in itself has antifungal activity, ethanolic extract of ginger has a synergistic activity. Supreetha et al. (2011) Gas chromatography-mass spectrometry showed that the predominant components of ginger essential oils (GEO) were α-zingiberene (23.9%) and citral (21.7%). GEO exhibited inhibitory activity, with a MIC of 2500 μg/mL, and 4000 and 5000 μg/mL reduced ergosterol biosynthesis by 57% and 100%, respectively. The inhibitory effect on fumonisin B1 (FB1) and fumonisin B2 (FB2) production was significant at GEO concentrations of 4000 and 2000 μg/mL, respectively. Thus, the inhibition of fungal biomass and fumonisin production was dependent on the concentration of GEO. These results suggest that GEO was able to control the growth of F. verticillioides and subsequent fumonisin production. Yamamoto-Ribeiro et al. (2013) The ginger essential oils at 0.045% was found to be highly effective on the fungal pathogen causing anthracnose disease on mango and can be recommended for the postharvest treatment of mango. Sefu et al. (2015) Recent reports: Noshirvani et al (2017) investigated the effect of cinnamon and ginger oils on some biological, physical and physico-chemical properties of chitosan-carboxymethyl cellulose films emulsified with oleic acid. Films containing cinnamon oil showed higher antifungal activity in vitro against Aspergillus niger than those containing ginger. Unlike ginger-based materials, the film crystallinity decreased with an increasing concentration of cinnamon oil. The microstructure of the active films was evaluated by scanning electron microscopy and results showed a distinct morphology depending on the composition of essential oils (EOs). As expected, both EOs decreased water vapor permeability of the active films, with a higher decreasing effect for cinnamon. Resulting water contact angles were improved by 36– 59% for ginger films and 65–93% for cinnamon films, depending on the EO concentration. Regarding mechanical properties, highest concentrations of EOs led to an improvement of 328% and 111% of the elongation with cinnamon and ginger, respectively. The different behavior of both EOs regarding physical, mechanical, thermal and water vapor permeability properties could be attributed to differences in their chemical compositions. The presence of cinnamaldehyde, in cinnamon essential oil, can create many kinds of interactions with the network made 595 by carboxymethyl cellulose, chitosan and oleic acid. Findings in this work suggest that EOs and especially cinnamon oil could be used to plasticize chitosan-carboxymethyl cellulose films while improving moisture permeability and maintaining antifungal activity. This bio-based material could be of interest for food preservation. Sefu et al. (2015) investigated the effect of ginger and cinnamon essential oils concentrations on mango anthracnose disease causing fungi. In the present study anthracnose affected mango fruits were collected from the field and the pathogenic fungi was isolated, identified and purified scientifically. Further, in-vitro studies were conducted with the three different concentration levels of each type of essential oils, 0.025, 0.050, 0.075% cinnamons and 0.15, 0.30, and 0.45% ginger and the control (distilled water). In the study they successfully isolated the responsible fungi for the anthracnose disease. The cinnamons and gingers essential oils at 0.075% and 0.045% respectively, were found to be highly effective on the fungal pathogen causing anthracnose disease on mango and can be recommended for the post harvest treatment of mango. Yamamoto-Ribeiro et al. (2013) evaluated the antifungal activity of ginger essential oil (GEO; Zingiber officinale Roscoe) against Fusarium verticillioides (Saccardo) Nirenberg. The minimum inhibitory concentration (MIC) of GEO was determined by micro-broth dilution. The effects of GEO on fumonisin and ergosterol production were evaluated at concentrations of 500-5000 μg/mL in liquid medium with a 5mm diameter mycelial disc of F. verticillioides. Gas chromatography-mass spectrometry showed that the predominant components of GEO were αzingiberene (23.9%) and citral (21.7%). GEO exhibited inhibitory activity, with a MIC of 2500 μg/mL, and 4000 and 5000 μg/mL reduced ergosterol biosynthesis by 57% and 100%, respectively. The inhibitory effect on fumonisin B1 (FB1) and fumonisin B2 (FB2) production was significant at GEO concentrations of 4000 and 2000 μg/mL, respectively. Thus, the inhibition of fungal biomass and fumonisin production was dependent on the concentration of GEO. These results suggest that GEO was able to control the growth of F. verticillioides and subsequent fumonisin production. Supreetha et al. (2011) assessed the effect of ethanolic extract of ginger on candida albicans in vitro. The shunti Choorna (ginger powder) was procured from commercial source (S.N.Pandit and sons, Mysore). The antifungal activity of the agent was tested in the following dilution range- 1g, 2g, 4g of shunti choorna in 99.9% ethanol. Ginger paste at room temperature showed inhibition zone better than ethanol alone, but cold ethanolic ginger extract showed the maximum inhibition zone at 24 hrs. The study showed that the ethanolic extract of ginger powder has pronounced inhibitory activities against Candida albicans. From the obtained results it can be concluded that although ethanol in itself has antifungal activity, ethanolic extract of ginger has a synergistic activity. References: 1. Atai , Zahra, 2Manijeh Atapour and 3Maryam Mohseni. Inhibitory Effect of Ginger Extract on Candida albicans. American Journal of Applied Sciences 6 (6): 1067-1069, 2009 2. Noshirvani ,Nooshin, Babak Ghanbarzadeh, Christian Gardrat, Mokarram Reza Rezaei, Mahdi Hashemi, CédricLe Coz, Véronique Coma. Cinnamon and ginger essential oils to 596 improve antifungal, physical and mechanical properties of chitosan-carboxymethyl cellulose films. Food Hydrocolloids. Volume 70, September 2017, Pages 36-45 3. Supreetha.S. , Sharadadevi Mannur , Sequeira Peter Simon , Jithesh Jain , Shreyas Tikare , Amit MahuliAntifungal Activity of Ginger Extract on Candida Albicans: An In-vitro Study. Journal of Dental Sciences and Research Pages 1-5 Vol. 2, Issue 2, September 2011 4. Sefu, Gerefa; Satheesh, Neela; Berecha, Gezahegn. ANTIFUNGAL ACTIVITY OF GINGER AND CINNAMON LEAF ESSENTIAL OILS ON MANGO ANTHRACNOSE DISEASE CAUSING FUNGI (C. gloeosporioides).Carpathian Journal of Food Science & Technology . Jun2015, Vol. 7 Issue 2, p26-34. 9p. 5. Yamamoto-Ribeiro MM1, Grespan R, Kohiyama CY, Ferreira FD, Mossini SA, Silva EL, Filho BA, Mikcha JM, Machinski M Jr. Effect of Zingiber officinale essential oil on Fusarium verticillioides and fumonisin production. Food Chem. 2013 Dec 1;141(3):314752. 18. Lavender essential oil      Lavender essential oil is an essential oil obtained by distillation from the flower spikes of certain species of lavender. Lavender essential oil has two forms, lavender flower oil, a colorless oil, insoluble in water, having a density of 0.885 g/mL; and lavender spike oil, a distillate from the herb Lavandula latifolia, having density 0.905 g/mL. Lavender essential oil is not a pure compound; Lavender essential oil is a complex mixture of naturally occurring phytochemicals, including linalool and linalyl acetate. Kashmir Lavender oil is famous for being produced from lavender at the foothills of the Himalayas.[citation needed] As of 2011, the biggest lavender oil producer in the world is Bulgaria The main chemical components of lavender oil are a-pinene, limonene, 1,8-cineole, cis-ocimene, trans-ocimene, 3-octanone, camphor, linalool, linalyl acetate, caryophyllene, terpinen-4-ol and lavendulyl acetate Linalool Linalyl acetate Antifungal activity, Auria et al. (2005) 597      Lavender oil inhibited C. albicans growth: mean minimum inhibitory concentration (MIC) of 0.69% (vol./vol.) (vaginal strains) and 1.04% (oropharyngeal strains); mean MFC of 1.1% (vaginal strains) and 1.8% (oropharyngeal strains). o Linalool was more effective than essential oil: mean MIC of 0.09% (vaginal strains) and 0.29% (oropharyngeal strains); mean MFC of 0.1% (vaginal strains) and 0.3% (oropharyngeal strains). o Linalyl acetate was almost ineffective. Lavender oil (2%) killed 100% of the C. albicans ATCC 3153 cells within 15 min; linalool (0.5%) killed 100% of the cells within 30 s. Lavender oil inhibited germ tube formation (mean MIC of 0.09%), as did the main components (MIC of 0.11% for linalool and 0.08% for linalyl acetate). Lavender oil and its main components inhibited hyphal elongation of C. albicans ATCC 3153 (about 50% inhibition at 0.016% with each substance). Lavender oil shows both fungistatic and fungicidal activity against C. albicans strains. At lower concentrations, it inhibits germ tube formation and hyphal elongation, indicating that it is effective against C. albicans dimorphism and may thus reduce fungal progression and the spread of infection in host tissues. Recent reports: Miroslava Císarová et al. (2016) evaluated the antifungal activity of lemon (Citrus lemon L.), eucalyptus (Eucalyptus globulus LABILL.), thyme (Thymus vulgaris L.), oregano (Origanum vulgare L.) sage (Salvia officinalis L.) and lavender (Lavandula angustifolia MILLER.) EOs against Aspergillus niger and Aspergillus tubingensis isolated from grapes and their ability to affect the growth. It was tested by using the vapor contact with them. At first both tested isolates were identified by using PCR method. Sequence data of 18S rRNA supported the assignment of these isolates to the genus Aspergillus and species A. niger (ITS region: KT824061; RPB2: KT824060) and A. tubingensis (ITS region: KT824062; RPB2: KT824059). Second, EO antifungal activity was evaluated. The effect of the EO volatile phase was confirmed to inhibit growth of A. niger and A tubingensis. EOs were diluted in DMSO (dimethyl sulfoxide) final volume of 100 μL. Only 50 μL this solution was distributed on a round sterile filter paper (1 x 1 cm) by micropipette, and the paper was placed in the center of the lid of Petri dishes. Dishes were kept in an inverted position. The essential oils with the most significant activity were determined by method of graded concentration of oils - minimum inhibitory doses (MIDs). The 598 most effective tested EOs were oregano and thyme oils, which totally inhibited growth of tested isolates for all days of incubation at 0.625 μL.cm-3 (in air) with MFDs 0.125 μL.cm-3 (in air). Lavender EO was less active aginst tested strains (MIDs 0.313 μL.cm-3). The results showed that the tested EOs had antifungal activity, except lemon and eucalyptus. Sage EO was the only one which decelerated the radial growth of colony of both tested strains after all days of cultivation in comparison with a control sets. Our study provides the support that essential oils can be used to control plant pathogens such as A. niger and A. tubingensis. Erland et al. (2016) tested essential oils of Lavandula angustifolia, Lavandula x intermedia cv Grosso, and Lavandida x intermedia cv Provence as well as various mono- and sesquiterpene essential oil constituents in order to assess their antifungal potential on three important agricultural pathogens: Botrytis cinerea, Mucor piriformis, and Penicillium expansum. Fungal susceptibility testing was performed using disk diffusion assays. The majority of essential oil constituents tested did not have a significant effect; however, 3-carene, carvacrol, geraniol, nerol and perillyl alcohol demonstrated significant inhibition at concentrations as low as 1 µ/mL. In vivo testing using strawberry fruit as a model system supported in vitro results and revealed that perillyl alcohol, carvacrol and 3-carene were effective in limiting infection by postharvest pathogens. Behmanesh et al. (2015a) compared the in vitro effects of Lavender brew, Lavender essential oil, and Clotrimazole on the growth of the standard strains of Candida albicans. The fungus cell count was done through Thoma counting chambers and Hemocytometer slide. Having prepared the dilution (6 × 106 of standard Candida albicans, S.C.a-PTCC-2657) in the Sabouraud Agar liquid medium, the Lavender essential oil, brew and Clotrimazole were added to different dilutions (½ , ¼ , ⅛) (in 4 stages) before the fungus cell count was done. Having obtained the necessary information, the data were analyzed through Statistical Package for the Social Sciences (SPSS), and a general linear model was used for the analysis of the data. The test results were then compared. Results: The number of fungi cells in Lavender brew (14 × 106) and Lavender essential oil (35× 106) decreased significantly compared with those of Clotrimazole (93 × 106) and fungus control (188 × 106) (p< 0.01), and Clotrimazole had the least antifungal effect. Conclusion: Lavender brew and Lavender essential oil had more antifungal effect on the standard Candida albicans when compared with Clotrimazole. Behmanesh et al. (2015b) investigated the in vitro effect of lavender essential oil and clotrimazole on isolated C. albicans from vaginal candidiasis. In this clinical trial, C. albicans isolated from the vaginal discharge samples was obtained. The pairwise comparison showed that lavender and clotrimazole had a significant difference; this difference in the lavender group was lower than clotrimazole. But, after 48 hours, there was no difference seen between groups. There was a significant difference between clotrimazole and DMSO groups. Comparing the changes between groups based on the same dilution, at 24 h and 48 h in clotrimazole group, showed a significant difference two times in the fungal cell count that its average during 48 h was less than 24 h. A significant difference was observed between the two periods in lavender group, only at the dilutions of 1/20 and 1/80. The average fungal cell count after 48 h was also lower in lavender group. Conclusions. Given that the lavender has antifungal activity, this can be used as an antifungal agent. However, more clinical studies are necessary to validate its use in candida infection. Haghighi et al. (2011) evaluated antifungal effect essential oil of Lavandula angustifolia against standard strain of C.albicans. Materials and Methods: 20 grams leaf of L.angustifolia was dried 599 and grinded after that the essential oil of plant was prepared by Clevenger system. Essence sterilized through a 0.44 m-poresize filter. For evaluation of antifungal activity essential oil of L.angustifolia was used standard strain of Candida albicans ATCC 10231. Minimum Inhibitory Concentration (MIC) was determined for essence and Fluconazole as control with Broth micro dilution techniques. Micro dilution was done in 96 well microtiter, after 48 h incubation each well was cultured and then compared colony count of wells with each other. Results: In this study results showed that essential oil of L.angustifolia has antifungal effect on standard strain of C.albicans. MIC50 essence and Fluconazole were 0.06, 0.125 956;g/ml and MIC90 were 0.11, 0.5 956;g/ml respectively. Minimal Fungicide Concentration (MFC) were 0.2, 1 956;g/ml respectively. Conclusion: According to findings of this study essential oil of L.angustifolia showed suitable antifungal effect against the most important human pathogenic fungi, C.albicans. Thus this herbal essence after supplementary studies possibly can be suitable substitute for chemical medicine on Candida infections especially on mucocutaneous Candidiasis. Auria et al. (2005) investigated the antifungal activity of the essential oil of Lavandula angustifolia Mill. (lavender oil) and its main components, linalool and linalyl acetate, against 50 clinical isolates of Candida albicans (28 oropharyngeal strains, 22 vaginal strains) and C. albicansATCC 3153. Growth inhibition, killing time and inhibition of germ tube formation were evaluated. The chemical composition of the essential oil was determined by gas chromatography and mass spectrometry. Lavender oil inhibited C. albicans growth: mean minimum inhibitory concentration (MIC) of 0.69% (vol./vol.) (vaginal strains) and 1.04% (oropharyngeal strains); mean MFC of 1.1% (vaginal strains) and 1.8% (oropharyngeal strains). Linalool was more effective than essential oil: mean MIC of 0.09% (vaginal strains) and 0.29% (oropharyngeal strains); mean MFC of 0.1% (vaginal strains) and 0.3% (oropharyngeal strains). Linalyl acetate was almost ineffective. Lavender oil (2%) killed 100% of the C. albicans ATCC 3153 cells within 15 min; linalool (0.5%) killed 100% of the cells within 30 s. The essential oil inhibited germ tube formation (mean MIC of 0.09%), as did the main components (MIC of 0.11% for linalool and 0.08% for linalyl acetate). Both the essential oil and its main components inhibited hyphal elongation of C. albicans ATCC 3153 (about 50% inhibition at 0.016% with each substance). Lavender oil shows both fungistatic and fungicidal activity against C. albicans strains. At lower concentrations, it inhibits germ tube formation and hyphal elongation, indicating that it is effective against C. albicans dimorphism and may thus reduce fungal progression and the spread of infection in host tissues. References: 1. Auria F. D. D ,M. Tecca,V. Strippoli,G. Salvatore,L. Battinelli &G. Mazzanti. Antifungal activity of Lavandula angustifoliaessential oil against Candida albicans yeast and mycelial form. J. Medical Mycology Volume 43, 2005 - Issue 5 Pages 391-396 Jul 2009 2. Behmanesh F, Hajar Pasha 2,*, Seyyed Ali Asghar Sefidgar 3 , Aliakbar Moghadamnia4 , Zahra Basirat. A comparative study of antifungal activity of Lavender brew, Lavender essential Oil, and Clotrimazole: an in vitro study. Caspian J Reprod Med, 2015, 1(1): 2630 3. Behmanesh F1, Pasha H2, Sefidgar AA3, Taghizadeh M4, Moghadamnia AA5, Adib Rad H2, Shirkhani L6. Antifungal Effect of Lavender Essential Oil (Lavandula angustifolia) 611 and Clotrimazole on Candida albicans: An In Vitro Study. Scientifica (Cairo). 2015;2015:261397. 4. Miroslava Císarová, Dana Tančinová, Juraj Medo. Antifungal activity of lemon, eucalyptus, thyme, oregano, sage and lavender essential oils against Aspergillus niger and Aspergillus tubingensis isolated from grapes. Potravinarstvo Slovak Journal of Food Sciences, Vol 10, No 1 (2016) 5. Erland LA , Bitcon CR , Lemke AD , Mahmoud SS Antifungal Screening of Lavender Essential oils and Essential Oil Constituents on three Post-harvest Fungal Pathogens.Natural Product Communications [01 Apr 2016, 11(4):523-527] 6. F. Haghighi, S. Roudbar Mohammadi, E. Farahbakhsh. Evaluation of antifungal effect of Lavandula angustifolia (lavender) essential oil on standard strain of Candida albicans in vitro. Iranian Congress on Medical Mycology. 2011 19. Laurel essential oil     Laurus nobilis L. (bay) is an evergreen tree or shrub that belongs to the Lauraceae family and is cultivated in many temperate and warm parts of the world, particularly the Mediterranean countries of Turkey, Greece, Spain, Portugal and Morocco, and in Mexico. Laurus nobilis leaves and berries are widely used. Dried leaves, also called ‗sweet bay‘, Laurus nobilis essential oils (EO) have a strong spicy aroma and are widely used as flavor enhancers for foods such as meats, soups, sauces and confectionery Laurus nobilis essential oils major component is 1,8-Cineole Antifungal activity  Laurus nobilis essential oils has antifungal activity probably due to monoterpenes and sesquiterpenes in its composition. This EO may affect cell wall biosynthesis and membrane permeability, and showed deleterious effects against C. albicans biofilms. Peixoto et al. (2017)  Laurus nobilis essential oils showed in vitro antifungal potential against strains of C. neoformans Pinheiro et al. (2017) Laurus nobilis essential oils inhibited the growth of C. albicans with MICs between 2 and  4% v/v Bona et al. (2016) 611 Recent reports Peixoto et al. (2017) demonstrated the antifungal potential of the chemically characterized essential oil (EO) of Laurus nobilis L. (bay laurel) against Candida spp. biofilm adhesion and formation, and further established its mode of action on C. albicans. L. nobilis EO was obtained and tested for its minimum inhibitory and fungicidal concentrations (MIC/MFC) against Candida spp., as well as for interaction with cell wall biosynthesis and membrane ionic permeability. Then we evaluated its effects on the adhesion, formation, and reduction of 48hC. albicans biofilms. The EO phytochemical profile was determined by gas chromatography coupled to mass spectrometry (GC/MS). The MIC and MFC values of the EO ranged from (250 to 500) μg/mL. The MIC values increased in the presence of sorbitol (osmotic protector) and ergosterol, which indicates that the EO may affect cell wall biosynthesis and membrane ionic permeability, respectively. At 2 MIC the EO disrupted initial adhesion of C. albicans biofilms (p<0.05) and affected biofilm formation with no difference compared to nystatin (p>0.05). When applied for 1min, every 8h, for 24h and 48h, the EO reduced the amount of C. albicans mature biofilm with no difference in relation to nystatin (p>0.05). The phytochemical analysis identified isoeugenol as the major compound (53.49%) in the sample.CONCLUSIONS: L. nobilis EO has antifungal activity probably due to monoterpenes and sesquiterpenes in its composition. This EO may affect cell wall biosynthesis and membrane permeability, and showed deleterious effects against C. albicans biofilms. Pinheiro et al. (2017) investigated the antifungal activity in vitro of the essential oil of Laurus nobilis L. (leaves) against Cryptococcus neoformans strains. The chemical composition of the oil was analyzed by gas chromatography coupled to mass spectrometry (GC / MS) and minimum inhibitory concentration (MIC) and the minimum fungicidal concentration (MFC) were determined by the broth micro dilution techniques. The MIC100 of essential oil were 256 g/mL and the MFC50 was 1024 g/mL. In conclusion the essential oil showed in vitro antifungal potential against strains of C. neoformans. Bona et al. (2016) assessed the sensitivity of 30 different vaginal isolated strains of C. albicans to 12 essential oils, compared to the three main used drugs (clotrimazole, fluconazole and itraconazole). Thirty strains of C. albicans were isolated from vaginal swab on CHROMagar™ Candida. The agar disc diffusion method was employed to determine the sensitivity to the essential oils. The antifungal activity of the essential oils and antifungal drugs 612 (clotrimazole, itraconazole and fluconazole) were investigated using a microdilution method. Transmission and scanning electron microscopy analyses were performed to get a deep inside on cellular damages. The results showed MICs between 2 and 4% v/v for laurel, anise, basil, mint, rosemary and tea tree essential oils, with values >4% v/v for some strains. A variable efficacy was observed for lavender essential oil against C. albicans, with MICs ranging from 0·25 to 4% v/v. Candida albicans strains were also rather sensitive to grapefruit essential oil, showing MICs of 0·25 or 0·125% v/v, even if a value of 0·0039% v/v was recorded for a single strain. Mint, basil, lavender, tea tree oil, winter savory and oregano essential oils inhibited both the growth and the activity of C. albicans more efficiently than clotrimazole. Damages induced by essential oils at the cellular level were stronger than those caused by clotrimazole. Candida albicans is more sensitive to different essential oils compared to the main used drugs. Moreover, the essential oilaffected mainly the cell wall and the membranes of the yeast. References: 1. Bona E1, Cantamessa S1, Pavan M1, Novello G1, Massa N1, Rocchetti A2, Berta G1, Gamalero E1. Sensitivity of Candida albicans to essential oils: are they an alternative to antifungal agents? J Appl Microbiol. 2016 Dec;121(6):1530-1545. 2. Peixoto LR1, Rosalen PL2, Ferreira GL1, Freires IA2, de Carvalho FG1, Castellano LR3, de Castro RD4. Antifungal activity, mode of action and anti-biofilm effects of Laurus nobilis Linnaeus essential oil against Candida spp. Arch Oral Biol. 2017 Jan;73:179-185. 3. Pinheiro , Lílian Sousa 1* , Abrahão Alves de Oliveira Filho2 , Felipe Queiroga Sarmento Guerra1 , Camilla Pinheiro de Menezes1 , Socrates Golzio dos Santos3 , Janiere Pereira de Sousa1 , Tassiana Barbosa Dantas1 , Edeltrudes de Oliveira Lima. Antifungal activity of the essential oil isolated from Laurus nobilis L. against Cryptococcus neoformans strains. Journal of Applied Pharmaceutical Science Vol. 7 (05), pp. 115-118, May, 2017 20. Linalool     linalool refers to two enantiomers of a naturally occurring terpene alcohol found in the essential oils of many flowers and spice plants. These have multiple commercial applications, the majority of which are based on its pleasant scent (floral, with a touch of spiciness). linalool has other names such as β-linalool, linalyl alcohol, linaloyl oxide, p-linalool, allo-ocimenol, and 3,7-dimethyl-1,6-octadien-3-ol. linalool is produced by over 200 species of plants produce linalool, mainly from the families Lamiaceae (mint and other herbs), Lauraceae (laurels, cinnamon, rosewood), and Rutaceae (citrus fruits), but also birch trees and other plants, from tropical to boreal climate zones, including fungi Linalool has a stereogenic center at C3 and therefore there are two stereoisomers: (R)-(–)linalool is also known as licareol and (S)-(+)-linalool is also known as coriandrol. 613 (S)-(+)-linalool (left) and (R)-(–)-linalool Antifungal activity  Linalool is active against Candida species Diaz et al., 2017 o The best antifungal activity of linalool was observed on Candida tropicalis (MIC = 500 mg/mL), followed by Candida albicans (MIC = 1.000 mg/mL), and Candida krusei (MIC = 2.000 mg/mL). o Values for minimum inhibitory concentration (MIC) and minimum fungicidal concentration (MFC) of phytochemical and Nystatin against C. albicans, C. tropicalis and C. krusei in µg/mL. Linalool Microorganisms MIC (µg/mL) MFC (µg/mL) MIC (µg/mL) MFC (µg/mL) Candida albicans 051 Candida tropicalis 011 Candida krusei 032 Candida krusei 031  Nystatin 1000 500 2000 2000 2000 500 2000 2000 0.39 0.39 0.39 0.39 0.78 0.39 0.78 0.78 Linalool as a potential antifungal agent against M. canis and M. gypseum. Silva et al., 2017 o Linalool MFC values ranged between 128 and 256 μg/mL, whereas ketoconazole showed MFC values of from 64 to 256 μg/mL. o Linalool (at MIC and 2xMIC) and ketoconazole (at 1/2MIC, MIC, 2xMIC) inhibited mycelial growth (P < 0.05). o Linalool and ketoconazole (1/2MIC, MIC, 2xMIC) were also active on conidiogenesis and conidia germination, causing complete inhibition (P < 0.05). o Linalool caused leakage of intracellular material. Safety and potential toxicity  Linalool can be absorbed by inhalation of its aerosol and by oral intake or skin absorption, potentially causing irritation, pain and allergicreactions. 614   Between 5 and 7% of patients undergoing patch testing in Sweden were found to be allergic to the oxidized form of linalool. Upon inhalation, it may also cause drowsiness or dizziness. Brands Recent reports: de Oliveira et al. (2017) investigated the activity of the monoterpene linalool against clinical isolates of Trichophyton rubrum. Initially, a sensitivity assay for commercial antifungals with solid disks in diffusion medium was performed. Minimum inhibitory concentration (MIC) of linalool and ketoconazole (positive control) were determined by microdilution in RPMI 1640 medium (CLSI M38-A2). We then evaluated the action of linalool and ketoconazole at different concentrations (1/2MIC, MIC and 2×MIC) on mycelial growth (radial mycelial growth), conidia production and conidia germination using a hemacytometer. The effects on cell membrane (release of intracellular material) were also investigated. Finally, changes in fungal morphology as induced by the test drugs were analyzed. Based on the sensitivity tests, the fungal strains showed resistance to 5-fluorocytosine and fluconazole. The linalool MIC values ranged from 256μg/mL to 512μg/mL, whereas ketoconazole showed values of 4μg/mL to 8μg/mL. For the LM 305 strain, the test drugs showed the following MIC values: linalool 256μg/mL and ketoconazole 8μg/mL. The mycelial growth of T. rubrum LM 305 was inhibited by linalool (2×MIC) and ketoconazole (1/2MIC, MIC, 2×MIC), in 7 days of treatment (P<0.05). The test-drugs also inhibited conidial germination and conidiogenesis (P<0.05). Linalool also caused leakage of intracellular material (P<0.05). Finally, we verified the effectiveness of linalool and ketoconazole to induce micro-morphological changes, forming abnormal, wide, short and crooked hyphae. Based on these results, we conclude that linalool presents as an antifungalagent with anti-Trichophyton rubrum potential, an important dermatophytosis agent. Dias et al. (2017) analyzed the antifungal activity of phytoconstituents from linalool on Candida spp. strains, in vitro, isolated from patients with clinical diagnoses of oral candidiasis associated with the use of a dental prosthesis. Biological samples were collected from 12 patients using 615 complete dentures or removable partial dentures and who presented mucous with diffuse erythematous or stippled features, indicating a clinical diagnosis of candidiasis. To identify fungal colonies of the genus Candida, samples were plated onto CHROMagar Candida®. The antifungal activity of linalool, a monoterpene unsaturated constituent of basil oil, was performed using the broth microdilution technique. Then, the minimum inhibitory concentration (MIC), the two subsequent stronger concentrations and the positive controls were subcultured on Sabouraud Dextrose Agar plates to determine the minimum fungicidal concentration (MFC). The experiments were performed in triplicate and nystatin was used as a positive control in all tests. Diagnoses of oral candidiasis were verified in eight patients (66.6%) and the most prevalent fungal species was Candida albicans (37.5%), followed by Candida krusei (25.0%); and Candida tropicalis (4.2%). The best antifungal activity of linalool was observed on Candida tropicalis (MIC = 500 mg/mL), followed by Candida albicans (MIC = 1.000 mg/mL), and Candida krusei (MIC = 2.000 mg/mL).Under the study conditions and based on the results obtained, it can be concluded that the Candida strains tested were susceptible to linalool. Souza et al. (2016) described the effectiveness of fifteen essential oils (EOs) against C. tropicalis. The EOs were obtained by hydrodistillation and were chemically characterized by gas chromatography-mass spectrometry. The antifungal activities of the EOs were evaluated by the microdilution method and showed that Pelargonium graveolens (Geraniaceae) (PG-EO) was the most effective oil. Geraniol and linalool were the major constituents of PG-EO. The 2,3-Bis-(2Methoxy-4-Nitro-5-Sulfophenyl)-2H-Tetrazolium-5- Carboxanilide (XTT) assay showed that all the clinical C. tropicalis strains formed viable biofilms. Scanning electron microscopy examination of the biofilms revealed a complex architecture with basal layer of yeast cells and an upper layer of filamentous cells. Treatments with PG-EO, linalool, and geraniol significantly reduced the number of viable biofilm cells and inhibited biofilm formation after exposure for 48 h. PG-EO, geraniol, and linalool were not toxic to normal human lung fibroblasts (GM07492A) at the concentrations they were active against C. tropicalis. Together, results indicated that C. tropicalis is susceptible to treatment with PG-EO, geraniol, and linalool, which could become options to prevent or treat this infection. Costa et al. (2014) evaluated the antidermatophytic potential of linalool-rich essential oil (EO) from L. alba and analyze the ability of this EO to inhibit peptidase and keratinase activities, which are important virulence factors in dermatophytes. The minimum inhibitory concentrations (MICs) of L. alba EO were 39, 156 and 312 µg/mL against Trichophyton rubrum, Epidermophyton floccosum and Microsporum gypseum, respectively. To evaluate the influence of L. alba EO on the proteolytic and keratinolytic activities of these dermatophytes, specific inhibitory assays were performed. The results indicated that linalool-rich EO from L. alba inhibited the activity of proteases and keratinases secreted from dermatophytes, and this inhibition could be a possible mechanism of action against dermatophytes. Due to the effective antidermatophytic activity of L. alba EO, further experiments should be performed to explore the potential of this linalool-rich EO as an alternative antifungal therapy. Shimada et al. (2014) isolated 3 cDNA clones from Satsuma mandarin (Citrus unshiu Marc.) and expressed them in Escherichia coli. CuSTS3-1 and CuSTS3-2 encode linalool synthases and CuSTS4 encodes a nerolidol/linalool synthase. Transcripts of CuSTS3-1, CuSTS3-2 and CuSTS4 were abundant in young fruit at 60 days after flowering (DAF), flowers and leaves, respectively. Treatments with Xanthomonas citri subsp. citri (XCC), the causal agent of citrus canker and Penicillium italicum (PI), the cause of post-harvest fruit decay, and wounding up616 regulated CuSTS3-1 in fruit and mainly CuSTS4 in leaves. Linalool, citral, geraniol and citronellol showed strong antibacterial and antifungal activities against XCC and PI in vitro, while most other mono-and sesquiterpenes, including limonene and gamma-terpinene, did not. Linalool, used at levels similar to those present in resistant Ponkan mandarin (Citrus reticulata Blanco) leaves, was able to inhibit growth of XCC in vitro. Compared to other five citrus types, linalool accumulated at extraordinarily high levels in Ponkan mandarin leaves and was released at high amounts from their leaves, while it was hardly detectable in the most susceptible species, indicating that linalool biosynthesis and accumulation might be involved in plant defense against bacterial and fungal pathogens and be associated with field resistance to citrus canker. References: 1. de Oliveira Lima MI1, Araújo de Medeiros AC1, Souza Silva KV1, Cardoso GN1, de Oliveira Lima E2, de Oliveira Pereira F3. Investigation of the antifungal potential of linalool against clinical isolates of fluconazole resistant Trichophyton rubrum. J Mycol Med. 2017 Jun;27(2):195-202. 2. Costa DC1, Vermelho AB, Almeida CA, de Souza Dias EP, Cedrola SM, Arrigoni-Blank Mde F, Blank AF, Alviano CS, Alviano DS. Inhibitory effect of linalool-rich essential oil from Lippia alba on the peptidase and keratinase activities of dermatophytes. J Enzyme Inhib Med Chem. 2014 Feb;29(1):12-7. Dias IJ1, Trajano ERIS1, Castro RD2, Ferreira GLS2, Medeiros HCM3, Gomes DQC1. Antifungal activity of linalool in cases of Candida spp. isolated from individuals with oral candidiasis. Braz J Biol. 2017 Sep 28:0. doi: 10.1590/1519-6984.171054. [Epub ahead of print] 3. 4. 5. Shimada T1, Endo T2, Fujii H3, Rodríguez A4, Peña L5, Omura M6. Characterization of three linalool synthase genes from Citrus unshiu Marc. and analysis of linalool-mediated resistance against Xanthomonas citri subsp. citri and Penicilium italicum in citrus leaves and fruits. Plant Sci. 2014 Dec;229:154-166. Souza Caio Marcelo Cury 1, Silvio Alves Pereira Junior1, Tha´ıs da Silva Moraes1, Jaqueline Lopes Damasceno1, Suzana Amorim Mendes1, Herbert Junior Dias ´ 2, Ricardo Stefani3, Denise Crispim Tavares1, Carlos Henrique Gomes Martins1, Antonio Eduardo Miller Crotti ˆ 2, Maria Jose Soares Mendes-Giannini ´ 4 and Regina Helena Pires. Antifungal activity of plant-derived essential oils on Candida tropicalis planktonic and biofilms cells. Medical Mycology, 2016, 54, 515–523 21. Lemongrass essential oil (Citral)     Lemongrass essential oil is characterized for monoterpenes compounds Lemongrass essential oil consists of small quantities of geraniol, geranylacetate and monoterpene olefins, such as myrcene Lemongrass essential oil major component is citral, which is present at levels of, approximately, 65-85%. Citral, or 3,7-dimethyl-2,6-octadienal or lemonal, is either a pair, or a mixture of terpenoids with the molecular formula C10H16O. o The two compounds are double bond isomers. o The E-isomer is known as geranial or citral A. o The Z-isomer is known as neral or citral B. 617  Citral is present in the oils of several plants, including lemon myrtle (90–98%), Litsea citrata (90%), Litsea cubeba (70–85%), lemongrass (65–85%), lemon tea-tree (70– 80%), Ocimum gratissimum (66.5%), Lindera citriodora (about 65%), Calypranthes parriculata (about 62%), petitgrain (36%), lemon verbena (30–35%), lemon ironbark (26%), lemon balm (11%), lime (6–9%), lemon (2–5%), and orange.  Chemical Names: Citral; GERANIAL; 5392-40-5; Trans-Citral; 3,7-dimethylocta-2,6dienal; Geranialdehyde  Molecular Formula: C10H16O Antifungal activity:   Citral showed in vitro antifungal potential against strains of C. albicans. Leite et al. (2014) o The MIC and MFC of citral were, respectively, 64 µg/mL and 256 µg/mL o Citral inhibited pseudohyphae and chlamydoconidia formation. o The MIC and the MFC of citral required only 4 hours of exposure to effectively kill 99.9% of the inoculum Citral vapor and its two isomers generated from 15 μL L-1 aqueous solutions in Petri dishes inhibited development of the three pathogens, with concentrations of 2-6 μL L1 also being effective against P. italicum. Vapors of citral and geranial from 15 μL L1 solutions were fungicidal to P. digitatum and G. candidum, Wuryatmo et al. (2003) Mode of action:      Zhou et al. (2014) demonstrated that citral has the ability to destroy the integrity of the cell membrane, releasing the cellular components of Geotrichum citri-aurantii Tao et al. (2014) demonstrated that citral dramatically inhibited the mycelial growth of Penicillium italicum through a mechanism of cell membrane damage, compromising its integrity and permeability. Da silva et al. (2008) have demonstrated that citral exhibits significant in vitroactivity against C. glabrata, C. krusei, C. parapsilosis, and C. tropicalis, and especially against species of C. albicans. Zore et al. (2011) demonstrated the anti-Candida activity of six terpenoids; all showed excellent activity against C. albicans isolates, being the most effective linalool and citral. Zheng et al. (2015) stated that Citral exerts its antifungal activity against Penicillium digitatum by affecting the mitochondrial morphology and function Brands 618 Recent reports: Ekpenyong and Akpan. (2017) provided an overview of recent advances and future prospects in assessing the efficacy of the use of Cymbopogon citratus (lemongrass) essential oil in food preservation. The possible mechanisms of action and toxicological profile as well as evidence for or against the use of this essential oil as an alternative to synthetic food preservatives in domestic and industrial applications are discussed.\ Vazirian et al. (2017) investigated the antifungal activity of Cymbopogon citratus (DC) Stapf. (lemongrass) essential oil against food-borne pathogens to determine its potential for reducing microbial population of cream-filled baked goods. The chemical composition of the oil was analyzed by gas chromatography (GC)/mass spectrometry (MS) and fifteen components were identified, where neral (39.0%), geranial (33.3%), limonene (5.8%) and geranyl acetate (4.2) were the most abundant constituents. Five main food-borne pathogens including Staphylococcus aureus, Escherichia coli, Candida albicans, Bacillus cereus and Salmonella typhimurium were added to cream-filled cakes. Lemongrass essential oil showed potent antimicrobial activity against selected microorganisms. Minimum inhibitory concentration (MIC) values for essential oil against all tested microorganisms were determined as 0.5 μL/disc except for S. aureus, in which the oil was ineffective. By using 1 μL/mL of essential oil, more than a 99.9% reduction in susceptible microorganisms was observed. After baking the cream-filled cake with four main susceptible pathogens manually added, after 72 hours of baking, no observable microorganism was observed. The same as in previous works, we suggested lemongrass essential oil as a safe natural preservative and food spoilage inhibitor. It can also reduce the risk of diseases associated with the consumption of contaminated products. 619 OuYang et al (2016) analyzed the transcriptional profiling of the control and 1/2MICcitral treated P. digitatum mycelia after 30 min of exposure by RNA-Seq. A total of 6355 genes, including 2322 up-regulated and 4033 down-regulated genes, were found to be responsive to citral. These genes were mapped to 155 KEGG pathways, mainly concerning mRNA surveillance, RNA polymerase, RNA transport, aminoacyl-tRNA biosynthesis, ABC transporter, glycolysis/gluconeogenesis, citrate cycle, oxidative phosphorylation, sulfur metabolism, nitrogen metabolism, inositol phosphate metabolism, fatty acid biosynthesis, unsaturated fatty acids biosynthesis, fatty acid metabolism, and steroid biosynthesis. Particularly, citral exposure affected the expression levels of five ergosterol biosynthetic genes (e.g. ERG7, ERG11, ERG6, ERG3 and ERG5), which corresponds well with the GC-MS results, the reduction in ergosterol content, and accumulation of massive lanosterol. In addition, ERG11, the gene responsible for lanosterol 14α-demethylase, was observed to be the key down-regulated gene in response to citral. Aldawsari et al. (2015) formulated lemongrass-loaded ethyl cellulose nanosponges with a topical hydrogel with an enhanced antifungal effect and decreased irritation. The minimal inhibitory concentration and minimal fungicidal concentration of LGO against Candida albicans strain ATC 100231, determined using the broth macrodilution method, were found to be 2 and 8 μL/mL, respectively. The emulsion solvent evaporation technique was used for the preparation of the nanosponges. The nanosponge dispersions were then integrated into carbopol hydrogels (0.4%). Nine formulations were prepared based on a 32 full factorial design employing the ethyl cellulose:polyvinyl alcohol ratio and stirring rate as independent variables. The prepared formulations were evaluated for particle size, citral content, and in vitro release. Results revealed that all the nanosponge dispersions were nanosized, with satisfactory citral content and sustained release profiles. Statistical analysis revealed that both ethyl cellulose:polyvinyl alcohol ratio and stirring rate have significant effects on particle size and percentage released after 6 hours; however, the effect of the stirring rate was more prominent on both responses. The selected hydrogel formulation, F9, was subjected to surface morphological investigations, using scanning and transmission electron microscopy, where results showed that the nanosponges possess a spherical uniform shape with a spongy structure, the integrity of which was not affected by integration into the hydrogel. Furthermore, the selected formulation, F9, was tested for skin irritation and antifungal activity against C. albicans, where results confirmed the nonirritancy and the effective antifungal activity of the prepared hydrogel. Zheng et al. (2015) investigated the effect of citral on the mitochondrial morphology and function of Penicillium digitatum. Citral at concentrations of 2.0 or 4.0 μL/mL strongly damaged mitochondria of test pathogen by causing the loss of matrix and increase of irregular mitochondria. The deformation extent of the mitochondria of P. digitatum enhanced with increasing concentrations of citral, as evidenced by a decrease in intracellular ATP content and an increase in extracellular ATP content of P. digitatum cells. Oxygen consumption showed that citral resulted in an inhibition in the tricarboxylic acid cycle (TCA) pathway of P. digitatum cells, induced a decrease in activities of citrate synthetase, isocitrate dehydrogenase, αketoglutarate dehydrogenase, succinodehydrogenase and the content of citric acid, while enhancing the activity of malic dehydrogenase in P. digitatum cells. Our present results indicated that citral could damage the mitochondrial membrane permeability and disrupt the TCA pathway of P. digitatum. 611 Leite et al. (2014) investigated the antifungal activity of citral against C. albicans. Methodology. The minimum inhibitory concentration (MIC) and the minimum fungicidal concentration (MFC) were determined by the broth microdilution techniques. They also investigated possible citral action on cell walls (0.8 M sorbitol), cell membranes (citral to ergosterol binding), the time-kill curve, and biological activity on the yeast‘s morphology. Results. The MIC and MFC of citral were, respectively, 64 µg/mL and 256 µg/mL. Involvement with the cell wall and ergosterol binding were excluded as possible mechanisms of action. In the morphological interference assay, it was observed that the product inhibited pseudohyphae and chlamydoconidia formation. The MIC and the MFC of citral required only 4 hours of exposure to effectively kill 99.9% of the inoculum. Conclusion. Citral showed in vitro antifungal potential against strains of C. albicans. Citral‘s mechanism of action does not involve the cell wall or ergosterol, and further study is needed to completely describe its effects before being used in the future as a component of new antifungals. Wuryatmo et al. (2003) examined vapors of citral, its isomers geranial and neral, and its related compounds for their effect on Penicillium digitatum, Penicillium italicum, and Geotrichum candidum, the major fungi responsible for postharvest spoilage of citrus. Vapor of citral and its two isomers generated from 15 μL L-1 aqueous solutions in Petri dishes inhibited development of the three pathogens, with concentrations of 2-6 μL L-1 also being effective against P. italicum. Vapors of citral and geranial from 15 μL L-1 solutions were fungicidal to P. digitatum and G. candidum, while neral was fungicidal to G. candidum. Citral-related compounds were much less effective, with effectiveness decreasing from citronellal to citronellol and citronellic acid. R and S isomers of these three citral-related compounds generally had similar effects on the fungi tested. References: 1. Aldawsari HM1, Badr-Eldin SM2, Labib GS3, El-Kamel AH4. Design and formulation of a topical hydrogel integrating lemongrass-loaded nanosponges with an enhanced antifungal effect: in vitro/in vivo evaluation. Int J Nanomedicine. 2015 Jan 29;10:893-902. doi: 2. da Silva, C. D. B., S. S. Guterres, V. Weisheimer, and E. E. S. Schapoval, ―Antifungal activity of the lemongrass oil and citral against Candida spp,‖ Brazilian Journal of Infectious Diseases, vol. 12, no. 1, pp. 63–66, 2008. 3. Ekpenyong, Christopher E., Ernest E. Akpan. (2017) Use of Cymbopogon citratus essential oil in food preservation: Recent advances and future perspectives. Critical Reviews in Food Science and Nutrition 57:12, pages 2541-2559. 4. Leite , Maria Clerya Alvino, André Parente de Brito Bezerra, Janiere Pereira de Sousa, Felipe Queiroga Sarmento Guerra, and Edeltrudes de Oliveira Lima, ―Evaluation of Antifungal Activity and Mechanism of Action of Citral against Candida albicans,‖ Evidence-Based Complementary and Alternative Medicine, vol. 2014, Article ID 378280, 9 pages, 2014. doi:10.1155/2014/378280 5. OuYang Q1, Tao N2, Jing G1. Transcriptional profiling analysis of Penicillium digitatum, the causal agent of citrus green mold, unravels an inhibited ergosterol biosynthesis pathway in response to citral. BMC Genomics. 2016 Aug 11;17(1):599. 611 6. Tao,N., Q. OuYang, and L. Jia, ―Citral inhibits mycelial growth of Penicillium italicum by a membrane damage mechanism,‖ Food Control, vol. 41, pp. 116–121, 2014. 7. Vazirian Mahdi , Somayeh Taheri Kashani,Mohammad Reza Shams Ardekani,Mahnaz Khanavi ,Hossein Jamalifar,Mohammad Reza Fazeli &Abolfazl Najarian Toosi show less. Antimicrobial activity of lemongrass (Cymbopogon citratus (DC) Stapf.) essential oil against food-borne pathogens added to cream-filled cakes and pastries. Critical Reviews in Food Science and Nutrition Volume 57, 2017 Issue 12 Pages 579-582 8. Wuryatmo,E., A. Klieber, and E. S. Scott, ―Inhibition of citrus postharvest pathogens by vapor of citral and related compounds in culture,‖ Journal of Agricultural and Food Chemistry, vol. 51, no. 9, pp. 2637–2640, 2003. 9. Zheng S1, Jing G2, Wang X1, Ouyang Q1, Jia L1, Tao N3. Citral exerts its antifungal activity against Penicillium digitatum by affecting the mitochondrial morphology and function. Food Chem. 2015 Jul 1;178:76-81 10. Zhou, H., N. Tao, and L. Jia, ―Antifungal activity of citral, octanal and α-terpineol against Geotrichum citri-aurantii,‖ Food Control, vol. 37, pp. 277–283, 2014. 11. Zore G. B., A. D. Thakre, S. Jadhav, and S. M. Karuppayil, ―Terpenoids inhibit Candida albicans growth by affecting membrane integrity and arrest of cell cycle,‖ Phytomedicine, vol. 18, no. 13, pp. 1181–1190, 2011. 22. Oregano essential oil     Oregano is native to temperate western and southwestern Eurasia and the Mediterranean region. Oregano is a perennial herb, growing from 20–80 cm (7.9–31.5 in) tall, with opposite leaves 1–4 cm (0.39–1.57 in) long. Scientific name: Origanum vulgare Oregano oil contains the terpenoid phenols carvacrol, thymol, and eugenol. These agents work to fight Candida overgrowth by reacting with the water in your bloodstream, which effectively dehydrates and kills Candida yeast cells. Antifungal activity    Oregano oil totally inhibited growth of Aspergillus niger and Aspergillus tubingensis isolated from grapes for all days of incubation at 0.625 μL.cm-3 (in air) with MFDs 0.125 μL.cm-3 (in air). Miroslava Císarová et al. (2016) Oregano oil showed the best antifungal activity towards Fusarium species and Bipolaris oryzae with a total inhibition of the mycelial growth. In inoculated rice grains at lower doses (100 and 200 μg/mL) significantly reduced the fungal infection. Santamarina et al. (2015) Oregano oil retards or inhibits mold germination stage. Further, minimum fungistatic and fungicide essential oil concentrations at 30 and 35°C were determined. 612     Mexican oregano essential oil applied in gas phase exerts important antifungal activity on the growth of A. flavus, suggesting its potential to inhibit other food spoilage molds. Gómez-Sánchez et al. (2011) Oregano oil can be used as an additive to tissue conditioner to reduce the adherence of Candida albicans without significantly affecting its bond strength to heat-polymerized acrylic resin.Srivatstava et al. (2013) Results of in vivo trials confirmed the strong efficacy of Oregano oil against brown rot of peach fruits. Elshafie et al. (2015) Oregano oil caused a dramatic reduction of the growth of natural contaminating molds on the surface of Spanish fermented sausage, the treatment was more effective against A. fumigatus than against M. racemosus. Chaves-López et al. (2012) Oregano oil jnhibited the growth of several Candida species. C. albicans isolates obtained from animal mucous membranes exhibited MIC and MFC values of 2.72 µL mL-1 and 5 µL mL-1, respectively. MIC and MFC values for C. albicans standard strains were 2.97 µL mL-1 and 3.54 µL mL-1, respectively. The MIC and MFC for non-albicans species were 2.10 µL mL-1 and 2.97 µL mL-1, respectively. The antifungal activity of O. vulgare essential oil against Candida spp. observed in vitro suggests its administration may represent an alternative treatment for candidiasis. MB Cleff, 2010 Uses     Wild Oregano is one of the most powerful natural antifungals created by Mother Nature, and its amazing oil has been used as an effective medicinal treatment for centuries. It‘s also one of the most sought-after herbs to include as part of a Candida treatment program. Oregano‘s many therapeutic properties include antifungal, antiviral, antibacterial, and antibacterial. Recent research has even suggested it may harbor cancer-preventative properties. The wild oregano shrub originates high in the mountains of Europe and central Asia, where traditional herbalists prescribed it as a treatment for a variety of ailments. One of its most popular uses was as a natural alternative to antibiotics. Today, Oregano oil is particularly useful for treating a Candida albicans overgrowth. A major advantage to oregano oil is that, unlike other natural antifungals, the Candida yeast is less likely to develop a resistance to it. 613 Brands Recent reports: Miroslava Císarová et al. (2016) evaluated the antifungal activity of lemon (Citrus lemon L.), eucalyptus (Eucalyptus globulus LABILL.), thyme (Thymus vulgaris L.), oregano (Origanum vulgare L.) sage (Salvia officinalis L.) and lavender (Lavandula angustifolia MILLER.) EOs against Aspergillus niger and Aspergillus tubingensis isolated from grapes and their ability to affect the growth. It was tested by using the vapor contact with them. At first both tested isolates were identified by using PCR method. Sequence data of 18S rRNA supported the assignment of these isolates to the genus Aspergillus and species A. niger (ITS region: KT824061; RPB2: KT824060) and A. tubingensis (ITS region: KT824062; RPB2: KT824059). Second, EO antifungal activity was evaluated. The effect of the EO volatile phase was confirmed to inhibit growth of A. niger and A tubingensis. EOs were diluted in DMSO (dimethyl sulfoxide) final volume of 100 μL. Only 50 μL this solution was distributed on a round sterile filter paper (1 x 1 cm) by micropipette, and the paper was placed in the center of the lid of Petri dishes. Dishes were kept in an inverted position. The essential oils with the most significant activity were determined by method of graded concentration of oils - minimum inhibitory doses (MIDs). The most effective tested EOs were oregano and thyme oils, which totally inhibited growth of tested isolates for all days of incubation at 0.625 μL.cm-3 (in air) with MFDs 0.125 μL.cm-3 (in air). Lavender EO was less active aginst tested strains (MIDs 0.313 μL.cm-3). The results showed that the tested EOs had antifungal activity, except lemon and eucalyptus. Sage EO was the only one which decelerated the radial growth of colony of both tested strains after all days of cultivation in 614 comparison with a control sets. The study provides the support that essential oils can be used to control plant pathogens such as A. niger and A. tubingensis. Elshafie et al. (2015) evaluated in vitro and in vivo effectiveness of thymol, carvacrol, linalool, and trans-caryophyllene, single constituents of the EO of Origanum vulgare L. ssp. hirtum against Monilinia laxa, M. fructigena, and M. fructicola, which are important phytopathogens and causal agents of brown rot of pome and stone fruits in pre- and postharvest. Moreover, the possible phytotoxic activity of these constituents was assessed and their minimum inhibitory concentration (MIC) was determined. In vitro experiment indicated that thymol and carvacrol possess the highest antifungal activity. Results of in vivo trials confirmed the strong efficacy of thymol and carvacrol against brown rot of peach fruits. The thymol MIC resulted to be 0.16 μg/μL against M. laxa and M. fructigena and 0.12 μg/μL against M. fructicola, whereas for carvacrol they were 0.02 μg/μL against the first two Monilinia species and 0.03 μg/μL against the third. Results of this study indicated that thymol and carvacrol could be used after suitable formulation for controlling postharvest fruit diseases caused by the three studied Monilinia species. Santamarina et al. (2015) investigated chemical composition of commercial Origanum compactum and Cinnamomum zeylanicum essential oils and the antifungal activity against pathogenic fungi isolated from Mediterranean rice grains. Sixtyone compounds accounting for more than 99.5% of the total essential oil were identified by using gas chromatography (GC) and gas chromatography-mass spectrometry (GC-MS). Carvacrol (43.26%), thymol (21.64%) and their biogenetic precursors p-cymene (13.95%) and γ-terpinene (11.28%) were the main compounds in oregano essential oil, while the phenylpropanoids, eugenol (62.75%), eugenol acetate (16.36%) and (E)-cinnamyl acetate (6.65%) were found in cinnamon essential oil. Both essential oils at 300 μg/mL showed antifungal activity against all tested strains. O. compactum essential oil showed the best antifungal activity towards Fusarium species and Bipolaris oryzae with a total inhibition of the mycelial growth. In inoculated rice grains at lower doses (100 and 200 μg/mL) significantly reduced the fungal infection, so O. compactum essential oil could be used as ecofriendly preservative for field and stored Valencia rice Altintas et al. (2013) analyzed essential oils obtained by hydrodistillation (HD) and microwaveassisted HD (MWHD) of Origanum onites aerial parts by GC and GCIMS. Thirty-one constituents representing 98.6% of the water-distilled oil and 52 constituents representing 99.6% of the microwave-distilled oil were identified. Carvacrol (76.8% HD and 79.2% MWHD) and thymol (4.7% HD and 4.4% MWHD) were characterized as major constituents in both essential oils. Separation of carvacrol and thymol was achieved by overpressured layer chromatography. HPTLC and TLC separations were also compared. Essential oils were evaluated for antifungal activity against the strawberry anthracnose-causing fungal plant pathogens Colletotrichum acutatum, C. fragariae, and C. gloeosporioides using a direct overlay bioautography assay. Furthermore, main oil components carvacrol and thymol were then evaluated for antifungal activity; only carvacrol demonstrated nonselective antifungal activity against the three Colletotrichum species. Thymol and carvacrol were subsequently evaluated in a 96-well microdilution broth assay against Phomopsis obscurans, Fusarium oxysporum, three Colletotrichum species, and Botrytis cinerea. No activity was observed against any of the three Colletotrichum species at or below 30 pM. However, thymol demonstrated antifungal activity and produced 31.7% growth inhibition of P. obscurans at 120 h and 0.3 pM, whereas carvacrol 615 appeared inactive. Thymol and carvacrol at 30 pM showed 51.5 and 36.9% growth inhibition of B. cinerea at 72 h. Srivatstava et al. (2013) investigated the antifungal activity and properties of a tissue conditioner by incorporating origanum oil. Origanum oil at varying concentrations was incorporated into a poly(methyl methacrylate) based tissue conditioner (Visco-gel), and its antifungal activity against Candida albicans was evaluated at 1 day and 1 week by using the agar punch well method. The adherence of Candida albicans, surface roughness, tensile strength, and bond strength of the tissue conditioner with an optimized origanum oil concentration were evaluated. The data were subjected to 2-way ANOVA (α=.05). Sixty vol% origanum oil in tissue conditioner (Visco-gel) showed a mean inhibitory zone of 21.00 ± 1.58 mm at 1 day and 13.44 ± 0.88 mm at 1 week. The control group showed 90 ± 6.80 yeast cells/mm(2) at 1 day and 165 ± 7.63 yeast cells/mm(2) at 1 week, whereas the group with origanum oil showed 16 ± 1.15 yeast cells/mm(2) at 1 day and 32 ± 4.00 yeast cells/mm(2) at 1 week. Surface roughness was less with the incorporation of origanum oil. Tensile strength at 1 day was 0.91 ± 0.52 N for the control group, whereas the group with origanum oil showed 0.16 ± 0.05 N. At 1 day, the bond strength of 3.97 ± 0.75 MPa was observed with control specimens, whereas tissue conditioner with origanum oil showed a bond strength of 3.73 ± 0.65 MPa. CONCLUSIONS: Within the limitations of this in vitro study, origanum oil can be used as an additive to tissue conditioner to reduce the adherence of Candida albicans without significantly affecting its bond strength to heat-polymerized acrylic resin. Gómez-Sánchez et al. (2011) evaluated the antifungal activity of Mexican oregano (Lippia berlandieri Schauer) essential oil by gaseous contact on the growth of Aspergillus flavus at selected essential oil concentrations (14.7, 29.4, 58.8, or 117.6 μl of essential oil per liter of air) and temperatures (25, 30, or 35°C) in potato dextrose agar formulated at water activity of 0.98 and pH 4.0. Mold growth curves were adequately fitted (0.984 < R(2) < 0.999) by the modified Gompertz model. The effect of the independent variables (concentration of essential oil and temperature) on the estimated model parameters (reciprocal of growth rate [1/ν(m)] and lag time [λ]) were evaluated through polynomial equations. Both ν(m) and λ were significantly (P < 0.05) affected by the independent variables; ν(m) decreased and λ increased as essential oil concentration increased and temperature decreased, which suggests that Mexican oregano essential oil retards or inhibits mold germination stage. Further, minimum fungistatic and fungicide essential oil concentrations at 30 and 35°C were determined. Mexican oregano essential oil applied in gas phase exerts important antifungal activity on the growth of A. flavus, suggesting its potential to inhibit other food spoilage molds. Chaves-López et al. (2012) evaluated Oregano essential oil (OEO) to determine its effect on the growth of natural contaminating molds on the surface of Spanish fermented sausage, the development of the internal microbial population of the sausage, and the physicochemical properties of the sausage. Results indicated a dramatic reduction in the contaminant molds. At the end of ripening, the main endogenous fungal species in control samples were Mucor racemosus (55%), Aspergillus fumigatus (20.6%), Cladosporium sphaerospermum (11.1%), Acremonium strictum (7.9%), and Aspergillus niger (4.7%). In samples treated with OEO, M. racemosus and A. fumigatus were the only species isolated; the treatment was more effective against A. fumigatus than against M. racemosus. The use of OEO to inhibit surface fungi did not affect the sausage drying process, pH, water activity, or color changes during ripening. These parameters change in a typical pattern for fermented dry-cured sausages during ripening. At the 616 end of ripening, OEO-treated sausages had lower hardness and greater chewiness than the control but showed similar textural properties to sausages treated with potassium sorbate References: 1. Altintas A, Tabanca N, Tyihák E, Ott PG, Móricz AM, Mincsovics E, Wedge DE. Characterization of volatile constituents from Origanum onites and their antifungal and antibacterial activity. J AOAC Int. 2013 Nov-Dec;96(6):1200-8. 2. Chaves-López C1, Martin-Sánchez AM, Fuentes-Zaragoza E, Viuda-Martos M, Fernández-López J, Sendra E, Sayas E, Angel Pérez Alvarez J. Role of Oregano (Origanum vulgare) essential oil as a surface fungus inhibitor on fermented sausages: evaluation of its effect on microbial and physicochemical characteristics. J Food Prot. 2012 Jan;75(1):104-11. 3. Cleff, Marlete Brum et al. In vitro activity of Origanum vulgare essential oil against Candida species. Braz. J. Microbiol. [online]. 2010, vol.41, n.1 [cited 2017-10-24], pp.116-123. 4. Elshafie HS1, Mancini E2, Sakr S1, De Martino L2, Mattia CA2, De Feo V2, Camele I1. Antifungal Activity of Some Constituents of Origanum vulgare L. Essential Oil Against Postharvest Disease of Peach Fruit. J Med Food. 2015 Aug;18(8):929-34. 5. Gómez-Sánchez A1, Palou E, López-Malo A. Antifungal activity evaluation of Mexican oregano (Lippia berlandieri Schauer) essential oil on the growth of Aspergillus flavus by gaseous contact. J Food Prot. 2011 Dec;74(12):2192-8. 6. Santamarina MP1, Roselló J1, Sempere F1, Giménez S1, Blázquez MA2. Commercial Origanum compactum Benth. and Cinnamomum zeylanicum Blume essential oils against natural mycoflora in Valencia rice. Nat Prod Res. 2015;29(23):2215-8. 7. Srivatstava A1, Ginjupalli K, Perampalli NU, Bhat N, Ballal M. Evaluation of the properties of a tissue conditioner containing origanum oil as an antifungaladditive. J Prosthet Dent. 2013 Oct;110(4):313-9. 23. Black pepper essential oil     Black pepper is a common seasoning with tremendous benefits. Black pepper essential oil may range from colorless to a greenish color and has a sharp, spicy, peppery smell. Black pepper essential oil contains over 54 compounds including beta-caryophyllene (which makes up 22% of the oil), limonene (20%), alpha-pinene (15%), beta-pinene (13%), delta-3-carene (12%), beta-myrcene, and sabinene. Black pepper essential oil has antibacterial, it is also antifungal activities. Antifungal activity 617    The main constituents of the oil of Piper divaricatum are methyleugenol (75.0%) and eugenol (10.0%). The oil and these two main constituents were tested individually at concentrations of 0.25 to 2.5 mg/mL against F. solani f. sp. piperis, exhibiting strong antifungal index, from 18.0% to 100.0%. da Silva et al. (2014) Piperine, the pungent bioactive alkaloids accumulate in the skin and seeds of the pepper fruit, showed maximum antifungal activity towards Fusarium oxysporum (14mm) and very least effect against Aspergillus niger (38mm). Rani et al. (2013) Black pepper EO 100% inhibited the mycelial growth of F. graminearum, while the acetone extract 100% inhibited mycelial growth of Penicillium viridcatum and A. ochraceus. Singh et al. ( 2004) Recent reports: da Silva et al. (2014) mentioned that Fusarium disease causes considerable losses in the cultivation of Piper nigrum, the black pepper used in the culinary world. Brazil was the largest producer of black pepper, but in recent years has lost this hegemony, with a significant reduction in its production, due to the ravages produced by the Fusarium solani f. sp. piperis, the fungus which causes this disease. Scientific research seeks new alternatives for the control and the existence of other Piper species in the Brazilian Amazon, resistant to disease, are being considered in this context. The main constituents of the oil of Piper divaricatum are methyleugenol (75.0%) and eugenol (10.0%). The oil and these two main constituents were tested individually at concentrations of 0.25 to 2.5 mg/mL against F. solani f. sp. piperis, exhibiting strong antifungal index, from 18.0% to 100.0%. The 3D structure of the β-glucosidase from Fusarium solani f. sp. piperis, obtained by homology modeling, was used for molecular docking and molecular electrostatic potential calculations in order to determine the binding energy of the natural substrates glucose, methyleugenol and eugenol. The results showed that βglucosidase (Asp45, Arg113, Lys146, Tyr193, Asp225, Trp226 and Leu99) residues play an important role in the interactions that occur between the protein-substrate and the eugenol and methyleugenol inhibitors, justifying the antifungal action of these two phenylpropenes against Fusarium solani f. sp. piperis. Rani et al. (2013) evaluated piperine, the pungent bioactive alkaloids accumulate in the skin and seeds of the pepper fruit, for its antimicrobial activity against Staphylococcus aureus, Bacillus 618 subtilis, Pseudomonas aeruginosa, Escherichia coli, Alternaria alternata, Aspergillus niger, Aspergillus flavus and Fusarium oxysporum. The antibacterial activity was measured by agar well diffusion method and antifungal activity by poisoned food technique. Piperine showed antimicrobial activity against all tested bacteria with zone of inhibition ranged from 8-18mm. maximum zone of inhibition was against Gram positive bacteria Staphylococcus aureus (18mm) and minimum against Gram negative bacteria Escherichia coli (8mm). Piperine showed maximum antifungal activity towards Fusarium oxysporum (14mm) and very least effect against Aspergillus niger (38mm). The results showed significant activity of piperine and suggesting its use as natural antimicrobial agent. Singh et al. ( 2004) performed GC and GC-MS analysis of volatile oil obtained from Piper nigrum L resulted in the identification of 49 components accounting for 99.39% of the total amount, and the major components were β-caryophyllene (24.24%), limonene (16.88%), sabinene (13.01%), β-bisabolene (7.69%) and α-copaene (6.3%). The acetone extract of pepper showed the presence of 18 components accounting for 75.59% of the total amount. Piperine (33.53%), piperolein B (13.73%), piperamide (3.43%) and guineensine (3.23%) were the major components. The oil was found to be 100% effective in controlling the mycelial growth of Fusarium graminearum in inverted petriplate technique. The acetone extract retarded 100% mycelial growth of Penicillium viridcatum and Aspergillus ochraceus in food-poisoning technique. Volatile oil and acetone extract were identified as a better antioxidant for linseed oil, in comparison with butylated hydroxyanisole (BHA) and butylated hydroxytoluene (BHT). References: 1. da Silva JK1, Silva JR2, Nascimento SB3, da Luz SF4, Meireles EN5, Alves CN6, Ramos AR7, Maia JG8. Antifungal activity and computational study of constituents from Piper divaricatum essential oil against Fusarium infection in black pepper. Molecules. 2014 Nov 4;19(11):17926-42. 2. Rani, S.K. Shiva, Neeti Saxena and Udaysree. Antimicrobial Activity of Black Pepper (Piper nigrum L.). Global Journal of Pharmacology 7 (1): 87-90, 2013 3. Singh, G.; Marimuthu, P.; Catalan, C.; DeLampasona, M.P. Chemical, antioxidant and antifungal activities of volatile oil of black pepper and its acetone extract. J. Sci. Food Agric. 2004, 84, 1878–1884. 24. Chili pepper essential oil        Chili peppers are the (typically dried) fruit from plants in the Capsicum genus, and Chili peppers originated in Mexico, Chili peppers essential oil is now available globally Chili peppers essential oil can be used for a vast array of medical conditions, due to its potent antioxidant and anti-inflammatory effects. Chili peppers essential oil is rich in the active ingredient capsaicin, which can have a profound impact on the body. Chili peppers essential oil has trace levels of vitamin C and vitamin A, as well as certain key antioxidants and beneficial fatty acids. Chili peppers essential oil is derived from the steam distillation of hot pepper seeds. 619  Chili peppers essential oil has wonderful therapeutic properties including the ability to stimulate blood circulation making it especially beneficial for healing wounds and aiding in hair growth by delivering vital nutrients to the scalp. Antifungal activity:   The oleoresins of C. frutescens and P. dioica demontrated the best results and only for A. niger (0.10% both). MartinellI, Laira et al. (2017) Capsicum frutescence showed 100% inhibition of colony diameter (cm2 ) at 3000 ppm. Singh et al. (2011) Recent reports: MartinellI, Laira et al. (2017) studied eight species of pepper in order to extract their essential oils and oleoresins, test their antibacterial and antifungal activities and also to identify the compounds present in the most bioactive samples. Results demonstrated that two essential oils [Pimenta dioica (L.) Merr. and Schinus terebinthifolius] and three oleoresins (Schinus terebinthifolius and Piper nigrum white and black) recorded significant antimicrobial activity. The oleoresins of C. frutescens and P. dioica demontrated the best results and only for A. niger (0.10% both).These active essential oils and oleoresins are interesting for use in biotechnological processes employed in food, pharmaceutical and other industries. Singh et al. (2011) tested alcoholic extracts of Capsicum frutescence (Chilly) and Zingiber officinale (Ginger) (ranging between 500 and 3000 ppm) for antifungal activity in vitro on Penicillium digitatum, Aspergillus niger and Fusarium sp isolated from naturally infected citrus fruit. The water extracts served as control and it was observed that the alcoholic extracts concentrations were more effective than the water extract control in showing antifungal activity against the test pathogens. The results also indicated that Capsicum frutescence showed 100% inhibition of colony diameter (cm2 ) at 3000 ppm. Hence, the results of the present investigations indicate the plant extracts posses‘ antifungal activity that can be exploited as an ideal treatment for future plant disease management to eliminate fungal spread. 621 References: 1. Singh, Harbant, Ghassan Fairs and Mohd. Syarhabil. Anti-fungal activity of Capsicum frutescence and Zingiber officinale against key post-harvest pathogens in citrus. 2011 International Conference on Biomedical Engineering and Technology IPCBEE vol.11 (2011) © (2011) IACSIT Press, Singapore 2. MARTINELLI, Laira et al. Antimicrobial activity and chemical constituents of essential oils and oleoresins extracted from eight pepper species. Cienc. Rural [online]. 2017, vol.47, n.5 25. Piper bettle essential oil     Piper betle, Linn belongs to the family Piperaceae. Piper betle is cultivated most parts of South India, Bengal, Sri Lanka, Myanmar and Thailand for its leaves. Piper betle is commonly called tambula in sanskrit, betel leaf pepper in english, betel in french, betel pepper in gennen, pan-tamboli in hindi, pan in panjabi, tambol in persian, naya valli in telungu, vettilai in tamil and, vettila in Malayalam Piper betle leaf contains an aromatic essential oil which contains a phenol, chaviol, which is a powerful antiseptic, five times more powerful than carbolic acid and twice as strong as euginol. To the "betel phenol" is due to the characteristic odour of the leaves and oil. Antifungal activity   The essential oil from the leaves of Piper betle L. Sagar Bangla cultivar has been found in vitro to be highly active against the growth of four keratinophilic fungi, Arthroderma benhamiae, Microsporum gypseum, Trichophyton mentagrophytes, Ctenomyces serratus. Garg &Rajshree (1992) Antifbngal activity of P. betle leaves and of its essential oil has been reported. Chavicol, chavibetol, chavibetol acetate and allylpyrocatechol allylpyrocatechol diacetate isolated form Piper betle were reported to have anti fungal properties. Ueda and Sasaki, 1951, Philip et al., 1984, Supinya et al., 2001) 621 Reports: Astuti et al. (2010) investigated the effect of inclusion complex formation of the Piper betle leaf essential oil in b-cyclodextrin formulated to polyethylene glicol ointment to antifungal candida albicans activity. The essential oil of Piper betle leaf was isolated by destillation. The inclusion complex of the essential oil - β-cyclodextrin was prepared by coprecipitation of the essential oil : β- cyclodextrin 1:1 (w/w). The inclusion complex formation was studied with thin layer chromatography (TLC) and powder X-ray diffraction (XRD). In the TLC, sillica gel was used as solid phase, whereas toluen-ethyl acetate (7:3) and methanol-water (7:3) was used as mobile phase, then the Rf value of the essential oil and inclusion complex was compared. The XRD pattern of β-cyclodextrin, physical mixtures and inclusion complex was compared, too. Then, the polyethylene glicol ointment of the essential oil and inclusion complex was prepared. The physical properties and antifungal activity was compared. The TLC result showed that the essential oil of Piper betle leaf with methanol-water (7:3) as mobile phase had Rf 0,69 and the inclusion complex had Rf 0,81. With toluen-ethyl acetate (7:3), Rf of the essential oil were 0,63; 0,73; 0,85, whereas the inclusion complex were 0,66; 0,80, and 0,91. The powder XRD analysis showed that the pattern of β-cyclodextrin, physical mixture and inclusion complex were different. The differences of Rf from TLC and XRD patterns were showed that the Piper betle leaf essential oil was complexed with β cyclodextrin. The physical properties studies showed that the homogenity of both formulation was good. The inclusion complex ointment had spreading property, adhering property and antifungal activity which better than the essential oil ointment. The potency of antifungal activity of the inclusion complex of the essential oil - β-cyclodextrin was not significant different than miconazol ointment. References: 1. Ika Yuni Astuti(1*), Dwi Hartanti(2), Ani Aminiati. Enhancing antifungal candida albicans activity of piper bettle linn. leaf essential oil ointment through formation of complex with b-cyclodextrin inclusion. Majalah Obat Tradisional (Trad.Med.J) Faculty of Pharmacy Universitas Gadjah Mada, Vol 15, No 3 (2010) 622 2. Muhammed Arif M. ―Isolation, structure elucidation and properties of secondary metabolites in plants‖ Thesis. Department of Chemistry, University of Calicut, 2007 3. S. C. Garg &Rajshree Jain/ Biological Activity of the Essential Oil of Piper betle L. Journal of Essential Oil Research Volume 4, 1992 - Issue 6 4. Philip, H. E., William, S. B. & Evangeline, J. F., J. Agric. Food Chem. 32,1984, 12541256. 5. Supinya, T., Sanan, S., Sopa, K. & Songklanakarin, J. Sci. Technol., 25 12,2003,240-243. 6. Ueda, S., Sasaki, T., J. Pharm. Soc., Jpn., 195 1, 71, 559-561. 26. Peppermint essential oil       Peppermint is native to Europe and is a natural hybrid of the water mint and spearmint plants. Growing to approximately 60 cm tall, peppermint plants bloom from July through August, sprouting tiny, purple flowers in whorls and terminal spikes. Peppermint essential oil is derived from the peppermint plant -- a cross between water mint and spearmint -- that thrives in Europe and North America. Peppermint essential oil is commonly used as flavoring in foods and beverages and as a fragrance in soaps and cosmetics. Peppermint essential oil also is used for a variety of health conditions and can be taken orally in dietary supplements or topically as a skin cream or ointment. Peppermint essential oil likely can help with symptoms of irritable bowel syndrome. Peppermint essential oil may also help indigestion and prevent spasms in the GI tract caused by endoscopy or barium enema. Antifungal activity  Mentha piperita L. essential oil show significant antifungal activity against Alternaria alternaria (38.16 ± 0.10 mm), Fusarium tabacinum (35.24 ± 0.03 mm), Penicillum spp. (34.10 ± 0.02 mm), Fusarium oxyporum (33.44 ± 0.06 mm), and Aspergillus fumigates (30.08 ± 0.08 mm). Strong antifungal activity was noted against A. flavus [(38.02 ± 0.06) mm], while the lowest antifungal activity was recorded against T. mentagrophytes, at (9.56 ± 0.06) mm zone of inhibition (P ≤ 0.01). Maximum and minimum inhibition concentration values were in the range of (9.56 ± 0.06) and (38.02 ± 0.06) μg/mL [(2.50 ± 0.16) and (15.80 ± 0.06) μg/mL] for yeast. Redd,y et al. (2017)  Mentha piperita L. essential oils inhibited both the growth and the activity of C. albicans more efficiently than clotrimazole. Damages induced by essential oils at the cellular level were stronger than those caused by clotrimazole. Bona et al. (2016)  Mentha piperita L. essential oils reduced the population of air, wall, surface and litter fungi in broiler houses, although some exceptions were noted. Aspergillus, Penicillium, Fusarium and Saccharomyces genera were identified 623 most frequently. The effect of essential oils was noticeable in the last two weeks, when the counts of Aspergillus sp. were 46% lower in comparison with the control group. Recent reports: Redd,y et al. (2017) studied the chemical constituents and antibacterial activity of essential oils from the areal parts of Mentha piperita L. essential oil. Essential oil was subjected to hydrodistillation for 4 h using Clevenger apparatus, resulting in nineteen chemical constituents representing 100% of the essential oil, comprising menthol (36.02%), menthone (24.56%), menthyl acetate (8.95%), and menthofuran (6.88%); these are major components, and others are minor components. Essential oil shows significant antibacterial and antifungal activity than principle components. Essential oils show significant antifungal activity against Alternaria alternaria (38.16 ± 0.10 mm), Fusarium tabacinum (35.24 ± 0.03 mm), Penicillum spp. (34.10 ± 0.02 mm), Fusarium oxyporum (33.44 ± 0.06 mm), and Aspergillus fumigates (30.08 ± 0.08 mm). The maximal and minimal inhibition concentration values are in the range of 10.22 ± 0.17 to 38.16 ± 0.10 and 0.50 ± 0.03 to 10.0 ± 0.14 μg/ml, for yeast and fungi respectively. The present study on essential oils deriving from the Mentha piperita L. species could be used in antimicrobial activity as a natural source. Bona et al. (2016) assessed the sensitivity of 30 different vaginal isolated strains of C. albicans to 12 essential oils, compared to the three main used drugs (clotrimazole, fluconazole and itraconazole). Thirty strains of C. albicans were isolated from vaginal swab on CHROMagar™ Candida. The agar disc diffusion method was employed to determine the sensitivity to the essential oils. The antifungal activity of the essential oils and antifungal drugs (clotrimazole, itraconazole and fluconazole) were investigated using a microdilution method. Transmission and scanning electron microscopy analyses were performed to get a deep inside on cellular damages. The results showed MICs between 2 and 4% v/v for laurel, anise, basil, mint, rosemary and tea tree essential oils, with values >4% v/v for some strains. A variable efficacy was observed for lavender essential oil against C. albicans, with MICs ranging from 0·25 to 4% v/v. Candida albicans strains were also rather sensitive to grapefruit essential oil, showing MICs of 0·25 or 0·125% v/v, even if a value of 0·0039% v/v was recorded for a single strain. Mint, basil, lavender, tea tree oil, winter savory and oregano essential oils inhibited both the growth and the activity of C. albicans more efficiently than clotrimazole. Damages induced by essential oils at the cellular level were stronger than those caused by clotrimazole. 624 Witkowska et al. (2016) performed a study to evaluate if essential oils misted in broiler houses reduce environmental fungi counts. The investigation was conducted in three experimental rooms, where broiler chickens were reared between 1 to 42 d of age. Every three days, the rooms were fogged with pure water (control) or with aqueous solutions of peppermint or thyme oils. On the next day, fogging samples from the air, flat surfaces, and litter were collected and quantitatively and qualitatively analysed for fungal contamination. The treatment with essential oils showed promising results. In the room fogged with thyme oil, aerial fungi growth was not as evident as in the control room, and presented the lowest average fungi count. Thyme oil was also the most effective in reducing fungi colonization on drinker surfaces and litter. The use of peppermint oil also reduced the population of air, wall, surface and litter fungi, although some exceptions were noted. Aspergillus, Penicillium, Fusarium and Saccharomyces genera were identified most frequently. The effect of essential oils was noticeable in the last two weeks, when the counts of Aspergillus sp. were 75% (thyme oil) and 46% (peppermint oil) lower in comparison with the control group. The results show that fogging broiler houses with essential oils may be an effective prevention method against fungal aerosol in broiler houses. However, further investigations to determine the synergistic effect of different oils and their compounds, and the best possible doses and methods of application in the field are needed. References: 1. Bona E1, Cantamessa S1, Pavan M1, Novello G1, Massa N1, Rocchetti A2, Berta G1, Gamalero E1. Sensitivity of Candida albicans to essential oils: are they an alternative to antifungal agents? J Appl Microbiol. 2016 Dec;121(6):1530-1545. 2. Redd,y Desam Nagarjuna , Abdul Jabbar Al-Rajab, MukulSharma, Mylabathula Mary Moses, Gowkanapalli Ramachandra Reddy, MohammedAlbratty. Chemical constituents, in vitro antibacterial and antifungal activity of Mentha × Piperita L. (peppermint) essential oils Journal of King Saud University - Science Available online 2 August 2017 3. Witkowska, D; Sowińska, J; ŻEBROWSKA, JP and Mituniewicz, E. The Antifungal Properties of Peppermint and Thyme Essential Oils Misted in Broiler Houses.Rev. Bras. Cienc. Avic. [online]. 2016, vol.18, n.4 [cited 2017-11-04], pp.629-638.. 27. Rosemary essential oil  Rosmarinus officinalis, commonly known as rosemary, is a woody, perennial herb with fragrant, evergreen, needle-like leaves and white, pink, purple, or blue flowers, native to the Mediterranean region.  Rosmarinus officinalis is a member of the mint family Lamiaceae, which includes many other herbs. The name "rosemary" derives from the Latin for "dew" (ros) and "sea" (marinus), or "dew of the sea". 625  Rosmarinus officinalis is also sometimes called anthos, from the ancient Greek word ἄνθος, meaning "flower".[3] Rosemary has a fibrous root system. Antifungal activity   The rosemary essential oils has effective inhibitory activity against the fungus Acremonium sp. Racowski et al. (2016) Rosemary has three chemotypes; CINEOL, CAMPHOR and VERBENON. They derived from a same plant species, but contain different chemical components. The CINEOL, dose-dependently decreased the number of C. albicans in the time-kill assay. Hence it was concluded that the components of rosemary essential oil would have an effect on its antifungal activity. Matsuzaki et al. (2013) Recent reports Racowski et al. (2016) studied the antifungal activity of three different commercial essential oils (oregano, laurel and rosemary) in different treatments against phytopathogenic fungus Acremonium sp. and infusions of fresh leaves at 60°C and 100°C in water and 9% gum arabic. The microorganism was naturally isolated from ―Debora‖ type tomato and identified by fungal slide culture. For GIP (Growth Inhibition Percentage) calculation, agar diffusion inhibition analysis was used. With results obtained, it was observed that the three essential oils have effective inhibitory activity against the fungus, and oregano was the most effective, while infusions with and without the addition of gum arabic were not effective. Therefore, essential oils in this study can be used as natural antimicrobials, but in the case of infusions, they have no inhibitory effect on the growth of Acremonium sp. Soares et al. (2015) assessed the antifungal activity of essential oils obtained from Origanum vulgare (oregano), Cinnamomum zeylanicum (cinnamon), Lippia graveolens (Mexican oregano), Thymus vulgaris (thyme), Salvia officinalis (sage), Rosmarinus officinalis (rosemary), Ocimum basilicum (basil) and Zingiber officinale (ginger) against Candida glabrata isolates. One group contained 30 fluconazole-susceptible C. glabrata isolates, and the second group contained fluconazole-resistant isolates derived from the first group after the in vitro induction of fluconazole-resistance, for a total of 60 tested isolates. The broth microdilution methodology was used. Concentrations of 50μg/mL, 100μg/mL, 200μg/mL, 400μg/mL, 800μg/mL, 1600μg/mL and 3200μg/mL of the essential oils were used, and the minimum inhibitory concentration (MIC) and minimum fungicidal concentration (MFC) were determined. Thyme, sage, rosemary, basil and ginger essential oils showed no antifungal activity at the tested concentrations. Antimicrobial activity less than or equal to 3200μg/mL was observed for oregano, Mexican oregano and cinnamon essential oils. Both the oregano and Mexican oregano essential oils showed high levels of antifungal activity against the fluconazole-susceptible C. glabrata group, whereas the 626 cinnamon essential oil showed the best antifungal activity against the fluconazole-resistant C. glabrata isolates. Matsuzaki et al. (2013) explored antimicrobial activities of essential oils. They evaluated the antifungal activities against C. albicans of essential oils from seven aromatic plants from three manufacturers, and of three chemotype essential oils from rosemary (Rosmarinus officinalis). As a result, they found that the antifungal activity was increased several times by the addition of Tween 80. All the tested essential oils showed stable antifungal activity, however, the variation was observed among the manufacturers of rosemary and eucalyptus. Rosemary has three chemotypes; CINEOL, CAMPHOR and VERBENON. They derived from a same plant species, but contain different chemical components. The CINEOL, dose-dependently decreased the number of C. albicans in the time-kill assay. Hence it was concluded that the components of rosemary essential oil would have an effect on its antifungal activity. A chemotype is the first to consider in measuring antifungal activities of rosemary oil. References: 1. Matsuzaki, Y. , Tsujisawa, T. , Nishihara, T. , Nakamura, M. and Kakinoki, Y. (2013) Antifungal activity of chemotype essential oils from rosemary against Candida albicans. Open Journal of Stomatology, 3, 176-182. doi: 10.4236/ojst.2013.32031. 2. Racowski I. , Foramiglio V. L. , Teodoro J. A. , Freire V. T. , Antifungal Activity of Infusions from Fresh Oregano, Laurel and Rosemary Leaves and Their Commercial Essential Oils against Acremonium sp., Journal of Microbiology Research, Vol. 6 No. 2, 2016, pp. 35-39. doi: 10.5923/j.microbiology.20160602.02. 3. Soares IH1, Loreto ÉS2, Rossato L3, Mario DN4, Venturini TP5, Baldissera F6, Santurio JM7, Alves SH8. In vitro activity of essential oils extracted from condiments against fluconazole-resistant and -sensitive Candida glabrata. J Mycol Med. 2015 Sep;25(3):213-7. 28. Tea Tree essential oil  Tea tree oil is composed of terpene hydrocarbons, mainly monoterpenes, sesquiterpenes, and their associated alcohols. O Terpenes are volatile, aromatic hydrocarbons and may be considered polymers of isoprene O Terpenes has the formula C5H8. Antifungal Activity   Data of several reports show that a range of yeasts, dermatophytes, and other filamentous fungi are susceptible to Tea tree oil (Table) MICs generally range between 0.03 and 0.5%, and fungicidal concentrations generally range from 0.12 to 2%. Susceptibility data for fungi tested against M. alternifolia oil, Carson et al., 2006 627 % (vol/vol) Fungal species Reference(s) MIC MFC 0.016-0.12 0.06-2 Aspergillus flavus 0.31-0.7 2-4 61, 74, 116, 137 A. fumigatus 0.06->2 1-2 74, 148 0.016-0.4 2-8 15, 61, 74 Alternaria spp. A. niger Blastoschizomyces capitatus 0.25 74 117 Candida albicans 0.06-8 0.12-1 C. glabrata 0.03-8 0.12-0.5 13, 52, 59, 77, 111, 117, 148 0.03-0.5 0.12-0.5 52, 77, 111, 117 0.12-2 0.25-0.5 52, 59, 148 Cladosporium spp. 0.008-0.12 0.12-4 Cryptococcus neoformans 0.015-0.06 Epidermophyton flocossum 0.008-0.7 0.12-0.25 Fusarium spp. 0.008-0.25 0.25-2 74 C. parapsilosis C. tropicalis 13, 42, 52, 59, 77, 111, 116, 117, 148 74 111 42, 74 Malassezia furfur 0.03-0.12 0.5-1.0 73 M. sympodialis 0.016-0.12 0.06-0.12 73 0.03-0.5 0.25-0.5 52, 74, 116 M. gypseum 0.016-0.25 0.25-0.5 52 Penicillium spp. 0.03-0.06 0.5-2 74 Rhodotorula rubra 0.06 0.5 71 Saccharomyces cerevisiae 0.25 0.5 71 Trichophyton mentagrophytes 0.11-0.44 0.25-0.5 T. rubrum 0.03-0.6 0.25-1 0.004-0.016 0.12-0.5 0.12-0.22 0.12 Microsporum canis T. tonsurans Trichosporon spp. 52, 61, 116 42, 52, 74, 116 74 71, 116 Mechanism of antifungal action (Carson et al. 2006).  The mechanism of action involves both the loss of membrane integrity accompanied by the release of intracellular material and the inhibition of cellular respiration, with the consequent inability to maintain homeostasis associated to changes in cell morphology o Tea tree oil alters the permeability of C. albicans cells, causes changes or damage to the functioning of fungal membranes. o The respiration rate of Fusarium solani is inhibited by 50% at a concentration of   0.023% Tea tree oil also inhibits glucose-induced medium acidification by C. albicans, C. glabrata, and Saccharomyces cerevisiae The inhibition of this function suggests that the plasma and/or mitochondrial membranes have been adversely affected. Tea tree oil inhibits the formation of germ tubes, or mycelial conversion, in C. albicans . Safety and toxicity 628  Tea tree oil topical use is safe and that adverse events are minor, self-limiting, and infrequent.  Tea tree oil can be toxic if ingested, as evidenced by studies with animals and from o The 50% lethal dose for TTO in a rat model is 1.9 to 2.6 ml/kg, and rats dosed with ≤1.5 g/kg TTO appeared lethargic and ataxic o Incidences of oral poisoning in children and adults have been reported. o No human deaths due to TTO have been reported in the literature.  Tea tree oil can cause both irritant and allergic reactions.  Tea tree oil dermal application of approximately 120 ml of undiluted oil to three cats with shaved but intact skin resulted in symptoms of hypothermia, uncoordination, dehydration, and trembling and in the death of one of the cats. Brands Recent reports: Li et al. (2017) investigated the effects of tea tree oil (TTO) on mitochondrial morphology and function in Botrytis cinerea. Mycelia were treated with TTO at different concentrations. TTO at 2ml/l severely damaged mitochondria, resulting in matrix loss and increased mitochondrial irregularity. Mitochondrial membrane permeability was increased by TTO, as evidenced by a decrease in intracellular adenosine triphosphate (ATP) content and an increase in extracellular ATP content. Increasing concentrations of TTO decreased the activities of enzymes related to mitochondrial function and the tricarboxylic acid (TCA) cycle, affecting malic dehydrogenase, succinate dehydrogenase, ATPase, citrate synthetase, isocitrate dehydrogenase and αketoglutarate dehydrogenase, while sharply increasing the level of reactive oxygen species (ROS). These results suggest that mitochondrial damage, resulting in the disruption of the TCA 629 cycle and accumulation of ROS, is involved in the mechanism of TTO antifungal activity against B. cinerea. Di Vito et al. (2015) evaluated the in vitro microbicidal activity of vaginal suppositories (VS) containing tea tree oil (TTO-VS) towards Candida spp. and vaginal probiotics. A total of 20 Candida spp. strains, taken from patients with vaginitis and from an established type collection, including reference strains, were analysed by using the CLSI microdilution method. To study the action of VS towards the beneficial vaginal microbiota, the sensitivity of Bifidobacterium animalis subsp. lactis (DSM 10140) and Lactobacillus spp. (Lactobacillus casei R-215 and Lactobacillus acidophilus R-52) was tested. Both TTO-VS and TTO showed fungicidal activity against all strains of Candida spp. whereas placebo-VS or the Aloe gel used as controls were ineffective. The study of fractional fungicidal concentrations (FFC) showed synergistic interaction with the association between Amphotericin B and TTO (0.25 to 0.08 µg/ml, respectively) against Candida albicans. Instead, the probiotics were only affected by TTO concentration ≥ 4% v/v, while, at concentrations < 2% v/v, they remained viable. TTO-VS exhibits, in vitro, a selective fungicidal action, slightly affecting only the Bifidobacteriun animalis strain growth belonging to the vaginal microbiota. In vivo studies are needed to confirm the efficacy to prevent acute or recurrent vaginal candidiasis. Homeyer et al. (2015) evaluated the activity of TTO against filamentous fungi associated with IFIs by testing 13 clinical isolates representing nine species via time-kill assay with seven concentrations of TTO (100%, 75%, 50%, 25%, 10%, 5%, and 1%). To ascertain the safety of topical application to wounds, cell viability assays were performed in vitro using human fibroblasts, keratinocytes, osteoblasts, and umbilical vein endothelial cells with 10 concentrations of TTO (75%, 50%, 25%, 10%, 5%, and 10-fold serial dilutions from 1 to 0.0001%) at five time points (5, 15, 30, 60, and 180 min). Compatibility of TTO with explanted porcine tissues was also assessed with eight concentrations of TTO (100%, 75%, 50%, 25%, 10%, 5%, 1%, and 0.1%) at the time points used for cellular assays and at 24 h. The time-kill studies showed that fungicidal activity was variable between isolates. The effect of TTO on cell viability was primarily concentration dependent with significant cytotoxicity at concentrations of ≥ 10% and ≥ 50% for cells lines and whole tissue, respectively. Our findings demonstrate that TTO possesses antifungal activity against filamentous fungi associated with IFIs; furthermore that negligible effects on whole tissues, in contrast to individual cells, were observed following exposure to TTO. Collectively, these findings indicate a potential use of TTO as topical treatment of IFIs. Yu et al. (2015) investigated the antifungal activity and mode of action of tea tree oil (TTO) and its components against B. cinerea. Of the components we tested in contact phase, terpinen-4-ol had the highest antifungal activity, followed by TTO, α-terpineol, terpinolene, then 1,8-cineole. As one of characteristic components of TTO, terpinen-4-ol treatment led to pronounced alterations in mycelial morphology, cellular ultrastructure, membrane permeability under scanning electron microscope, transmission electron microscope and fluorescent microscope, and also reduced the ergosterol content of fungi. As another characteristic component, 1,8-cineole caused serious intracellular damage but only slightly affected B. cinerea otherwise. When terpinen-4-ol and 1,8-cineole were used together, the synergistic antifungal activity was significantly higher than either component by itself. CONCLUSIONS: The results of our study confirmed that terpinen-4-ol and 1,8-cineole act mainly on the cell membranes and organelles of 631 B. cinerea, respectively, and when combined are similar to TTO in antifungal activity due to their differences. Flores et al. (2013) evaluated, for the first time, the antifungal efficacy of nanocapsules and nanoemulsions containing Melaleuca alternifolia essential oil (tea tree oil) in an onychomycosis model. The antifungal activity of nanostructured formulations was evaluated against Trichophyton rubrum in two different in vitro models of dermatophyte nail infection. First, nail powder was infected with T. rubrum in a 96-well plate and then treated with the formulations. After 7 and 14 days, cell viability was verified. The plate counts for the samples were 2.37, 1.45 and 1.0 log CFU mL(-1) (emulsion, nanoemulsion containing tea tree oil and nanocapsules containing tea tree oil, respectively). A second model employed nails fragments which were infected with the microorganism and treated with the formulations. The diameter of fungal colony was measured. The areas obtained were 2.88 ± 2.08 mm(2), 14.59 ± 2.01 mm(2), 40.98 ± 2.76 mm(2) and 38.72 ± 1.22 mm(2) for the nanocapsules containing tea tree oil, nanoemulsion containing tea tree oil, emulsion and untreated nail, respectively. Nail infection models demonstrated the ability of the formulations to reduce T. rubrum growth, with the inclusion of oil in nanocapsules being most efficient. Shao et al. (2013) investigated the effect of tea tree oil tea tree oil (TTO) on the mycelium morphology and ultrastructure, cell wall and membrane, and membrane fatty acid composition of B. cinerea in vitro experiments.Tea tree oil in vapour or contact phase exhibited higher activity against the mycelial growth of B. cinerea. Observations using scanning electron microscope and transmission electron microscope revealed that the mycelial morphology and ultrastructure alternations caused by TTO are the markedly shriveled or flatted empty hyphae, with thick cell walls, ruptured plasmalemma and cytoplasmic coagulation or leakage. Furthermore, TTO caused significantly higher alkaline phosphatase activity after 4-h treatment and markedly higher absorbance at 260 nm and electric conductivity in the external hyphae of fungi after 16-h treatment. Moreover, decreased unsaturated/saturated fatty acid ratio of the fungal membrane was also observed after TTO treatment. CONCLUSIONS: The methodology used in this study confirmed that the cell wall destroyed firstly in the presence of TTO, and then the membrane fatty acid composition changed, which resulted in the increasing of membrane permeability and releasing of cellular material. The above findings may be the main reason for TTO's antifungal ability to B. cinerea. Significance and impact of the study: Understanding the mechanism of TTO antifungal action to B. cinerea is helpful for its commercial application on the preservation of fresh fruit and vegetables. References: 1. Carson CF, Hammer KA, Riley TV. Melaleuca alternifolia (Tea Tree) Oil: a Review of Antimicrobial and Other Medicinal Properties. Clinical Microbiology Reviews. 2006;19(1):50-62. doi:10.1128/CMR.19.1.50-62.2006. 2. Di Vito M1,2, Mattarelli P3, Modesto M3, Girolamo A2, Ballardini M1, Tamburro A1, Meledandri M1, Mondello F2. In Vitro Activity of Tea Tree Oil Vaginal Suppositories against Candida spp. and Probiotic Vaginal Microbiota. Phytother Res. 2015 Oct;29(10):1628-33. 631 3. Flores FC1, de Lima JA, Ribeiro RF, Alves SH, Rolim CM, Beck RC, da Silva CB. Antifungal activity of nanocapsule suspensions containing tea tree oil on the growth of Trichophyton rubrum. Mycopathologia. 2013 Apr;175(3-4):281-6. 4. Homeyer DC1, Sanchez CJ2, Mende K3, Beckius ML4, Murray CK5, Wenke JC2, Akers KS6. In vitro activity of Melaleuca alternifolia (tea tree) oil on filamentous fungi and toxicity to human cells. Med Mycol. 2015 Apr;53(3):285-94. 5. Li Y1, Shao X2, Xu J1, Wei Y1, Xu F1, Wang H1 . Tea tree oil exhibits antifungal activity against Botrytis cinerea by affecting mitochondria. Food Chem. 2017 Nov 1;234:62-67. 6. Shao X1, Cheng S, Wang H, Yu D, Mungai C. The possible mechanism of antifungal action of tea tree oil on Botrytis cinerea. J Appl Microbiol. 2013 Jun;114(6):1642-9. 7. Terzi1, V., C. Morcia1 , P. Faccioli1 , G. Vale` 1 , G. Tacconi1 and M. Malnati. In vitro antifungal activity of the tea tree (Melaleuca alternifolia) essential oil and its major components against plant pathogens Lett Appl Microbiol. 2007 Jun;44(6):613-8. 8. Yu D1, Wang J1, Shao X1, Xu F1, Wang H1. Antifungal modes of action of tea tree oil and its two characteristic components against Botrytis cinerea. J Appl Microbiol. 2015 Nov;119(5):1253-62. 29. Thapsia villosa essential oil   Thapsia L. is a genus of the Apiaceae widely distributed in the Iberian Peninsula and North Africa, with some species used in folk medicine. Thapsia possesses several biological properties such as antioxidant, antimicrobial, antiinflammatory, and anticancer activities. Antifungal activity:   The value of MIC and MBC of Thapsia against C. albicans was (1.25 - 2.5% w/v). The contact time required for 20%w/v extract concentration for inhibiting the growth was (0.75 min). Kusuma et al. (2017) Thapsia villosa essential oil and its main components, limonene and methyleugenol displayed low MIC and MFC (minimum fungicidal concentration) values against Candida spp., Cryptococcus neoformans, dermatophytes, and Aspergillus spp. Regarding Candida species, an inhibition of yeast–mycelium transition was demonstrated at subinhibitory concentrations of the EO (MIC/128; 0.01 _L/mL) and their major compounds. The association of fluconazole with T. villosa oil does not show antagonism, but the combination limonene/fluconazole displays synergism. Pinto et al. (2017) 632 Recent reports: Kusuma et al. (2017) investigated the antimicrobial activities of red piper betel leaf ethanol extracts as natural antiseptics against some airborne pathogens as follows: Staphylococcus aureus, Pseudomonas aeruginosa, Escherichia coli, and Candida albicans. Methods: The extraction of dried piper betel leaves was prepared using a maceration method. The antimicrobial activities of the extract were tested using the agar diffusion method, then followed by the determination of minimal inhibition concentration (MIC) test which was conducted using macrodillution method. Whereas the determination of minimum bactericidal concentration (MBC) was done by subculturing the overnight incubation of MIC result onto Mueller Hinton Agar medium surface. The minimal inhibitory time required of each tested microbial was done by incubating the test medium at the time range of 1.5-6 min, followed by subculturing it onto MHA using the streak plate method. The results showed that the ethanol extract of red piper betel leaves has antibacterial and antifungal activity against all tested microbes. The value of MIC and MBC was ranging as follows: E. coli and P. aeruginosa (2.5-5%w/v), S. aureus (5 10% w /v), C. albicans (1.25 - 2.5% w/v). The contact time required for 20%w/v extract concentration for inhibiting bacterial growth (1.5 min) and C. albicans (0.75 min). Conclusion: It can be concluded that the ethanol extract of red piper betel is highly potent as natural antiseptics against airborne pathogens with an effective time of minimum inhibitory. analysed the composition of the essential oil (EO) of Thapsia villosa (Apiaceae), isolated by hydrodistillation from the plant‘s aerial parts, by GC and GC-MS. Antifungal activity of the EO and its main components, limonene (57.5%) and methyleugenol (35.9%), were evaluated against clinically relevant yeasts (Candida spp., Cryptococcus neoformans and Malassezia furfur) and moulds (Aspergillus spp. and dermatophytes). Minimum inhibitory concentrations (MICs) were measured according to the broth macrodilution protocols by Clinical and Laboratory Standards Institute (CLSI). The EO, limonene and methyleugenol displayed low MIC and MFC (minimum fungicidal concentration) values against Candida spp., Cryptococcus neoformans, dermatophytes, and Aspergillus spp. Regarding Candida species, an inhibition of yeast–mycelium transition was demonstrated at sub-inhibitory concentrations of the EO (MIC/128; 0.01 _L/mL) and their major compounds in Candida albicans. Fluconazole does not show this activity, and the combination with low concentrations of EO could associate a supplementary target for the antifungal activity. The association of fluconazole with T. villosa oil does not show antagonism, but the combination limonene/fluconazole displays synergism. The fungistatic and fungicidal activities revealed by T. villosa EO and its main compounds, Pinto et al. (2017) 633 associated with their low haemolytic activity, confirm their potential antimicrobial interest against fungal species often associated with human mycoses. References: 1. Kusuma, Sri Agung Fitri 1 *, Rini Hendriani2 , Aryo Genta1 Antimicrobial Spectrum of Red Piper Betel Leaf Extract (Piper crocatum Ruiz & Pav) as Natural Antiseptics Against Airborne Pathogens. Sri Agung Fitri Kusuma et al /J. Pharm. Sci. & Res. Vol. 9(5), 2017, 583-587 2. Pinto, E.; Gonçalves, M.-J.; Cavaleiro, C.; Salgueiro, L. Antifungal Activity of Thapsia villosa Essential Oil against Candida, Cryptococcus, Malassezia, Aspergillus and Dermatophyte Species. Molecules 2017, 22, 1595. 30. Thyme essential oil       Oil of thyme, the essential oil of common thyme (Thymus vulgaris), contains 20–54% thymol. Oil of thyme also contains a range of additional compounds, such as p-cymene, myrcene, borneol, and linalool. Thymol (2-isopropyl-5-methylphenol) is a phytoconstituent classified as a monoterpene. Thymol is the majority phytoconstituent in the essential oil of thyme (Thymus vulgaris) Thymol is a major component of the essential oil of oregano (Origanum vulgare). o Thymol was first isolated by the German chemist Caspar Neumann in 1719. o In 1853, the French chemist A. Lallemand named thymol and determined its empirical formula. o Thymol was first synthesized by the Swedish chemist Oskar Widman in 1882. o Alain Thozet and M. Perrin first published the crystal structure analysis with the exact determination of the structural atoms Synonyms include isopropyl-m-cresol, 1-methyl-3-hydroxy-4-isopropylbenzene, 3methyl-6-isopropylphenol, 5-methyl-2-(1-methylethyl)phenol, 5-methyl-2-isopropyl-1phenol, 5-methyl-2-isopropylphenol, 6-isopropyl-3-methylphenol, 6-isopropyl-m-cresol, Apiguard, NSC 11215, NSC 47821, NSC 49142, thyme camphor, m-thymol, and pcymen-3-ol. Chemical synthesis  Thymol is produced from m-cresol and propene in the gas phase:[ C7H8O + C3H6 ⇌ C10H14O 634  Thymol is only slightly soluble in water at neutral pH, but it is extremely soluble in alcohols and other organic solvents. It is also soluble in strongly alkaline aqueous solutions due to deprotonation of the phenol. Antifungal activity  Thymol presented an antifungal effect, with MICs of 39 μg/mL for C. albicans and C. krusei and 78 μg/mL for C. tropicalis. The results of the antifungal test remained unchanged in the presence of sorbitol; however, the MIC value of thymol against C. albicans increased eight times (from 39.0 to 312.5 μg/mL) in presence of exogenous ergosterol. The combination of thymol and nystatin reduced the MIC values of both products by 87.4 %, generating an FIC index of 0.25. De Castro et al. (2015)  Thyme oil as a fumigant at 66.7 lL L1 showed a significant (P < 0.05) inhibition on postharvest pathogens of mango fruits stored at 25 °C for 6 days. Results of our study suggest the possibility of using thyme oil as an alternate natural fungicide to manage postharvest diseases in mango. Perumal et al. (2016)  Thyme essential oil possesses a wide spectrum of fungicidal activity. Klarić et al. (2007), Thyme essential oil presented the strongest inhibitory effect against different pathogenic Candida species, and the inhibitory zone around the colony obtained with amphotericin B by was smaller than that observed with thyme essential oil. Omran and Esmailzadeh (2009) Thyme essential oil showed a strong antifungal activity in comparison with eucalyptus oil, and thyme EO at 50, 75 and 100% concentrations completely inhibited mycelial growth. Katooli et al. (2012 Thyme essential oil is one of the most potent agents against fungi. Riccioni and Orzali (2011) Thyme essential oil isone of the most potent against bacteria and yeasts of veterinary importance. Rusenova and Parvanov (2009) Klarić et al. (2007) demonstrated that the vaporous phase of thyme oil exhibited longlasting suppressive activity on molds from damp dwellings      Mechanism of action  Thymol has antimicrobial activity because of its phenolic structure 635  The antifungal nature of thymol is due to its ability to alter the hyphal morphology and cause hyphal aggregates, resulting in reduced hyphal diameters and lyses of the hyphal wall.  Additionally, thymol is lipophilic, enabling it to interact with the cell membrane of fungus cells, altering cell membrane permeability permitting the loss of macromolecules Brands Recent reports: Perumal et al. (2016) assessed the antifungal effects of five essential oils (thyme, clove, cinnamon, anise and vitex) by disc volatilisation method. Thyme oil vapours at 5 lL per 636 Petriplate, and clove and cinnamon oil at 8 lL per Petriplate showed 100% growth inhibition of mango pathogens in vitro. GC/MS analysis of essential oil showed thymol (23.88), o-cymol (23.88) and terpinolene (23.88) as the major constituents of thyme oil. Clove and cinnamon oils contain 3-allyl-2-methoxyphenol (37.42%) and benzofuran 3-methyl (17.97%), respectively. Thyme oil as a fumigant at 66.7 lL L1 showed a significant (P < 0.05) inhibition on postharvest pathogens of mango fruits stored at 25 °C for 6 days. Results of our study suggest the possibility of using thyme oil as an alternate natural fungicide to manage postharvest diseases in mango. Miroslava Císarová et al. (2016) evaluated the antifungal activity of lemon (Citrus lemon L.), eucalyptus (Eucalyptus globulus LABILL.), thyme (Thymus vulgaris L.), oregano (Origanum vulgare L.) sage (Salvia officinalis L.) and lavender (Lavandula angustifolia MILLER.) EOs against Aspergillus niger and Aspergillus tubingensis isolated from grapes and their ability to affect the growth. It was tested by using the vapor contact with them. At first both tested isolates were identified by using PCR method. Sequence data of 18S rRNA supported the assignment of these isolates to the genus Aspergillus and species A. niger (ITS region: KT824061; RPB2: KT824060) and A. tubingensis (ITS region: KT824062; RPB2: KT824059). Second, EO antifungal activity was evaluated. The effect of the EO volatile phase was confirmed to inhibit growth of A. niger and A tubingensis. EOs were diluted in DMSO (dimethyl sulfoxide) final volume of 100 μL. Only 50 μL this solution was distributed on a round sterile filter paper (1 x 1 cm) by micropipette, and the paper was placed in the center of the lid of Petri dishes. Dishes were kept in an inverted position. The essential oils with the most significant activity were determined by method of graded concentration of oils - minimum inhibitory doses (MIDs). The most effective tested EOs were oregano and thyme oils, which totally inhibited growth of tested isolates for all days of incubation at 0.625 μL.cm-3 (in air) with MFDs 0.125 μL.cm-3 (in air). Lavender EO was less active aginst tested strains (MIDs 0.313 μL.cm-3). The results showed that the tested EOs had antifungal activity, except lemon and eucalyptus. Sage EO was the only one which decelerated the radial growth of colony of both tested strains after all days of cultivation in comparison with a control sets. Our study provides the support that essential oils can be used to control plant pathogens such as A. niger and A. tubingensis. Witkowska et al. (2016) aimed at evaluating if essential oils misted in broiler houses reduce environmental fungi counts. The investigation was conducted in three experimental rooms, where broiler chickens were reared between 1 to 42 d of age. Every three days, the rooms were fogged with pure water (control) or with aqueous solutions of peppermint or thyme oils. On the next day, fogging samples from the air, flat surfaces, and litter were collected and quantitatively and qualitatively analysed for fungal contamination. The treatment with essential oils showed promising results. In the room fogged with thyme oil, aerial fungi growth was not as evident as in the control room, and presented the lowest average fungi count. Thyme oil was also the most effective in reducing fungi colonization on drinker surfaces and litter. The use of peppermint oil also reduced the population of air, wall, surface and litter fungi, although some exceptions were noted. Aspergillus, Penicillium, Fusarium and Saccharomyces genera were identified most frequently. The effect of essential oils was noticeable in the last two weeks, when the counts of Aspergillus sp. were 75% (thyme oil) and 46% (peppermint oil) lower in comparison with the control group. The results show that fogging broiler houses with essential oils may be an effective prevention method against fungal aerosol in broiler houses. However, further investigations to determine the synergistic effect of different oils and their compounds, and the best possible doses and methods of application in the field are needed. 637 De Castro et al. (2015) evaluated the antifungal activity of thymol against Candida albicans, Candida tropicalis and Candida krusei strains and to determine its mode of action and synergistic effect when combined with the synthetic antifungal nystatin. The minimum inhibitory concentration (MIC) was determined using a microdilution technique, and the minimum fungicidal concentration (MFC) was determined via subculture sowing. The mode of action of thymol was established by verifying fungal growth in the presence of sorbitol or ergosterol. The fractional inhibitory concentration index (FIC) was determined using the checkerboard method. Thymol presented an antifungal effect, with MICs of 39 μg/mL for C. albicans and C. krusei and 78 μg/mL for C. tropicalis. The results of the antifungal test remained unchanged in the presence of sorbitol; however, the MIC value of thymol against C. albicans increased eight times (from 39.0 to 312.5 μg/mL) in presence of exogenous ergosterol. The combination of thymol and nystatin reduced the MIC values of both products by 87.4 %, generating an FIC index of 0.25. Conclusions Thymol was found to have a fungicidal effect on Candida species and a synergistic effect when combined with nystatin. References: 1. Anand Babu Perumal,1 Periyar Selvam Sellamuthu,1 * Reshma B. Nambiar1 & Emmanuel Rotimi Sadiku. Antifungal activity of five different essential oils in vapour phase for the control of Colletotrichum gloeosporioides and Lasiodiplodia theobromae in vitro and on mango. International Journal of Food Science and Technology 2016, 51, 411–418 2. De Castro RD, de Souza TMPA, Bezerra LMD, Ferreira GLS, de Brito Costa EMM, Cavalcanti AL. Antifungal activity and mode of action of thymol and its synergism with nystatin against Candida species involved with infections in the oral cavity: an in vitro study. BMC Complementary and Alternative Medicine. 2015;15:417. doi:10.1186/s12906-015-0947-2. 3. Miroslava Císarová, Dana Tančinová, Juraj Medo. Antifungal activity of lemon, eucalyptus, thyme, oregano, sage and lavender essential oils against aspergillus niger and aspergillus tubingensis isolated from grapes. Potravinarstvo, vol. 10, 2016, no. 1, p. 8388 4. M. Šegvić Klarić,I. Kosalec, J. Mastelić, E. Piecková, S. Pepeljnak. Antifungal activity of thyme (Thymus vulgaris L.) essential oil and thymol against moulds from damp dwellings. Lett Appl Microbiol. 2007 Jan;44(1):36-42. 5. Witkowska, D; Sowińska, J; Żebrowska, Jp And Mituniewicz, E. The Antifungal Properties of Peppermint and Thyme Essential Oils Misted in Broiler Houses.Rev. Bras. Cienc. Avic. [online]. 2016, vol.18, n.4 638 31. Zataria multiflora essential oil      Zataria is used for a group of plants belonging to the Labiatae family including 200 genera and 3300 species. Zataria genus has a particular species called multiflora. Zataria multiflora has a limited distribution in the world. Zataria multiflora contains saponins, caffeic acid, resin, tannin, resonates, and finally 2.6% volatile oil referred to as essence. Zataria multiflora oil most important components are thymol and carvacrol; these compounds have antimicrobial properties. Antifungal activity  Zataria multiflora essential oil (ZEO ) and solid lipid nanoparticles (SLNs) containing Zataria multiflora essential oil had 54 and 79% inhibition on the growth of fungal pathogens, respectively. The minimum inhibitory concentration (MIC) under in vitro conditions for the ZEO on the fungal pathogens of Aspergillus ochraceus, Aspergillus niger, Aspergillus flavus, Alternaria solani, Rhizoctonia solani, and Rhizopus stolonifer was 300, 200, 300, 200, 200 and 200 ppm, respectively, for ZE-SLNs, it was 200, 200, 200, 100, 50 and 50 ppm. The antifungal efficacy of ZE-SLNs was significantly more than ZEO. Nasseri et al. (2016)  The superior performance of ZEO when encapsulated by CSNPs under both in vitro and in vivo conditions in comparison with unmodified ZEO against B. cinerea was revealed. The in vivo experiment also showed that the encapsulated oils at 1500 ppm concentration significantly decreased both disease severity and incidence of Botrytisinoculated strawberries during 7 days of storage at 4 °C followed by 2–3 more days at 20 °C. These findings revealed the promising role of CSNPs as a controlled release system for EOs in order to enhance antifungal activities. Mohammadi et al. (2015) 639 Recent reports: Nasseri et al. (2016) prepared, characterized, and evaluated solid lipid nanoparticles (SLNs) containing Zataria multiflora essential oil (ZEO). In this study, Z. multiflora essential oil-loaded solid lipid nanoparticles (ZE-SLNs) were prepared to improve its efficiency in controlling some fungal pathogens. SLNs containing Z. multiflora essential oil were prepared by high shear homogenization and ultra sound technique. ZEO-SLNs contained 0.03% ZEO in 5% of lipid phase (Glyceryl monostearate-GMS and Precirol® ATO 5). Tween 80 and Poloxamer 188 (2.5% w/v) were used as surfactant in the aqueous phase. The antifungal efficacy of ZE-SLNs and ZEO was compared under in vitro conditions. The particle size of ZE-SLNs was around 255.5±3 nm with PDI of 0.369±0.05 and zeta potential was about -37.8±0.8 mV. Encapsulation efficacy of ZE-SLNs in crystalline form was 84±0.92%. The results showed that the ZEO and ZE-SLNs had 54 and 79% inhibition on the growth of fungal pathogens, respectively. The minimum inhibitory concentration (MIC) under in vitro conditions for the ZEO on the fungal pathogens of Aspergillus ochraceus, Aspergillus niger, Aspergillus flavus, Alternaria solani, Rhizoctonia solani, and Rhizopus stolonifer was 300, 200, 300, 200, 200 and 200 ppm, respectively, for ZESLNs, it was 200, 200, 200, 100, 50 and 50 ppm. The antifungal efficacy of ZE-SLNs was significantly more than ZEO. Mohammadi et al. (2015) investigated the nanoencapsulation of Zataria multiflora essential oil (ZEO) in chitosan nanoparticles (CSNPs) in order to enhance antifungal activity and stability of the oils against one isolate of Botrytis cinerea Pers., the causal agent of gray mould disease. ZEO was encapsulated by an ionic gelation technique into CSNPs with an average size of 125–175 nm as observed by transmission electron microscopy (TEM). From UV-vis spectrophotometry results, the drug encapsulation and loading efficiency of ZEO decreased from 45.24% to 3.26% and from 9.05% to 5.22%, respectively, upon increasing initial ZEO content from 0.25 to 1 g/g chitosan. In vitro release studies also demonstrated a controlled and sustained release of ZEO for 40 days. The superior performance of ZEO when encapsulated by CSNPs under both in vitro and in vivo conditions in comparison with unmodified ZEO against B. cinerea was revealed. The in vivo experiment also showed that the encapsulated oils at 1500 ppm concentration significantly decreased both disease severity and incidence of Botrytis-inoculated strawberries during 7 days of storage at 4 °C followed by 2–3 more days at 20 °C. These findings revealed the promising role of CSNPs as a controlled release system for EOs in order to enhance antifungal activities. References: 1. Mohammadi , Ali, Maryam Hashemi Seyed MasoudHosseini. Nanoencapsulation of Zataria multiflora essential oil preparation and characterization with enhanced antifungal activity for controlling Botrytis cinerea, the causal agent of gray mould disease Innovative Food Science & Emerging Technologies Volume 28, March 2015, Pages 7380 2. Nasseri M, Golmohammadzadeh S, Arouiee H, Jaafari MR, Neamati H. Antifungal activity of Zataria multiflora essential oil-loaded solid lipid nanoparticles invitro condition. Iranian Journal of Basic Medical Sciences. 2016;19(11):1231-1237. 641 7.11. Phytoalexins         Phytoalexins are antimicrobial and often antioxidative substances synthesized de novo by plants that accumulate rapidly at areas of pathogen infection. Phytoalexins are broad spectrum inhibitors and are chemically diverse with different types characteristic of particular plant species. Phytoalexins produced in plants act as toxins to the attacking organism. They may puncture the cell wall, delay maturation, disrupt metabolism or prevent reproduction of the pathogen in question. Phytoalexins importance in plant defense is indicated by o An increase in susceptibility of plant tissue to infection when phytoalexin biosynthesis is inhibited. o Mutants incapable of phytoalexin production exhibit more extensive pathogen colonization as compared to wild type. o Host-specific pathogens capable of degrading phytoalexins are more virulent than those unable to do so. Phytoalexins are inducible secondary metabolites possessing antimicrobial activity toward phytopathogens Phytoalexins are "low molecular weight, antimicrobial compounds that are both synthesized and accumulated in plants after exposure to microorganisms or abiotic agents― Phytoalexins are broad spectrum inhibitors and are chemically diverse with different types characteristic of particular plant species. Phytoalexins are terpenoids, glycosteroids or alkaloids Types of phytoalexins:   Ipomoeamarone is an abnormal sesquiterpinoid induced in sweet potato tissue infected with black rot fungus Ceratocystis fimbriata. Ipomoeamarone has a striking inhibitory effect on the fungus even in 0.1% concentrations.   Pisatin has the chromocoumarin ring system , is a phenolic ether Pisatin is produced in pea in response to inoculation with many fungi or injury.   Phaseollin is similar to pisatin in chemistry and function. Phaseollin is fungicidal at high concentrations and fungistatic at low concentrations against S. fructigena.  Glyceollin is produced in soybean plants infected with the fungus Phytophthora megasperma f.sp.glycinea 641   Isocoumarin is isolated from carrot root tissues inoculated with a fungus nonpathogenic to carrot, Ceratocystis fimbriata. Isocoumarin can also be produced in response C. ulmi, Helminthosporium carbonum, Fusarium oxysporum f.sp.lycopersici & Thielaviopsis basicola.   Trifolirhizin is a new glucoside isolated from the roots of red cloves. Trifolirhizin is chemically closely related to pisatin.  Rishitin is isolated from the potato tubers carying the gene R1 for late blight resistance Rishitin is a bicyclic non-sesquiterpine alcohol    Gossypol is an ether soluble phenol . Gossypol is produced in diseases like black spot of rose (Diplocarpon rosa),leaf spot of wheat (Septoria tritici)  Xanthotoxin is isolated from parsnip root discs inoculated with C. fimbriata  Capsidiol is a sequisterpene phytoalexin produced in pepper fruits inoculated with a non – pathogenic fungi. Capsidiol produced concentrations are sufficient to inhibit these fungi in vitro.   Medicarpin is isolated from Alfalfa (Medicago sativa) inoculated with a series of pathogens and non pathogens    Camalexin is an indolic secondary metabolite, Camalexin is a major phytoalexin in Arabidopsis thaliana. Camalexin synthesis is stimulated by a variety of microorganisms, including Pseudomonas syringae, Alternaria brassicicola, and Botrytis cinerea and by some abiotic stresses, such as AgNO3 and amino acid starvation, Camalexin has been shown to inhibit the growth of fungal pathogens.  Recent reports: 642 Hayat et al. (2016) evaluated the genetic diversity among Chinese garlic cultivars for their antifungal potency as well as allicin content distribution and, furthermore; a bioassay was performed to study the bio-stimulation mechanism of aqueous garlic extracts (AGE) in the growth and physiology of cucumber (Cucumis sativus). Initially, 28 garlic cultivars were evaluated against four kinds of phytopathogenic fungi; Fusarium oxysporum, Botrytis cinerea, Verticillium dahliae and Phytophthora capsici, respectively. A capricious antifungal potential among the selected garlic cultivars was observed. HPLC fingerprinting and quantification confirmed diversity in allicin abundance among the selected cultivars. Cultivar G025, G064, and G074 had the highest allicin content of 3.98, 3.7, and 3.66 mg g(-1), respectively, whereas G110 was found to have lowest allicin content of 0.66 mg g(-1). Cluster analysis revealed three groups on the basis of antifungal activity and allicin content among the garlic cultivars. Cultivar G025, G2011-4, and G110 were further evaluated to authenticate the findings through different solvents and shelf life duration and G025 had the strongest antifungal activity in all conditions. minimum inhibitory concentration and minimum fungicidal concentration of Allicin aqueous standard (AAS) and AGE showed significant role of allicin as primary antifungalsubstance of AGE. Leaf disk bioassay against P. capsici and V. dahliae to comparatively study direct action of AGE and AAS during infection process employing eggplant and pepper leaves showed a significant reduction in infection percentage. To study the bioactivity of AGE, a bioassay was performed using cucumber seedlings and results revealed that AGE is biologically active inside cucumber seedlings and alters the defense mechanism of the plant probably activating reactive oxygen species at mild concentrations. However, at higher concentrations, it might cause lipid peroxidation and membrane damage which temper the growth of cucumber seedlings. At the outcome of the study, an argument is advanced that current research findings provide bases for cultivar selection in antifungal effectivity as well as genetic variability of the cultivars. Allicin containing AGE can be used in specialized horticultural situations such as plastic tunnel and organic farming as a bio-stimulant to enhance cucumber growth and attenuate fungal degradation of agricultural produce. Barilli et al. (2015) tackled the changes induced in phytoalexin content by BTH and BABA treatments in the context of the resistance responses to pea rust. Detailed analysis through highperformance liquid chromatography (HPLC) showed qualitative and quantitative differences in the content, as well as in the distribution of phytoalexins. Thus, following BTH treatment, we observed an increase in scopoletin, pisatin and medicarpin contents in all, excreted, soluble and cell wall-bound fraction. This suggests fungal growth impairment by both direct toxic effect as well as plant cell wall reinforcement. The response mediated by BTH was genotype-dependent, since coumarin accumulation was observed only in the resistant genotype whereas treatment by BABA primed phytoalexin accumulation in both genotypes equally. Exogenous application to the leaves of scopoletin, medicarpin and pisatin lead to a reduction of the different fungal growth stages, confirming a role for these phytoalexins in BTH- and BABA-induced resistance against U. pisi hampering pre- and postpenetration fungal stages. Pedras et al. (2015) investigated the metabolites produced in leaves of the crucifers winter cress (Barbarea vulgaris) and upland cress (Barbarea verna) abiotically elicited by analyses of spectroscopic data and confirmed by syntheses. Nasturlexins C and D and their sulfoxides are cruciferous phytoalexins displaying antifungal activity against the crucifer pathogens Alternaria brassicicola, Leptosphaeria maculans and Sclerotinia sclerotiorum. The biosynthesis of these metabolites is proposed based on pathways of cruciferous indolyl phytoalexins. This work 643 indicates that B. vulgaris and B. verna have great potential as sources of defense pathways transferable to agriculturally important crops within the Brassica species. Hasegawa et al. (2014) performed a study to understand the role of the rice flavonoid phytoalexin (PA) sakuranetin for blast resistance, the fungus-responsive characteristics were studied. Young rice leaves in a resistant line exhibited hypersensitive reaction (HR) within 3 days post inoculation (dpi) of a spore suspension, and an increase in sakuranetin was detected at 3 dpi, increasing to 4-fold at 4 dpi. In the susceptible line, increased sakuranetin was detected at 4 dpi, but not at 3 dpi, by which a large fungus mass has accumulated without HR. Induced expression of a PA biosynthesis gene OsNOMT for naringenin 7-O-methyltransferase was found before accumulation of sakuranetin in both cultivars. The antifungal activity of sakuranetin was considerably higher than that of the major rice diterpenoid PA momilactone A in vitro and in vivo under similar experimental conditions. The decrease and detoxification of sakuranetin were detected in both solid and liquid mycelium cultures, and they took place slower than those of momilactone A. Estimated local concentration of sakuranetin at HR lesions was thought to be effective for fungus restriction, while that at enlarged lesions in susceptible rice was insufficient. These results indicate possible involvement of sakuranetin in blast resistance and its specific relation to blast fungus. Houillé et al. (2014) evaluated the candidacidal activities of oligomers (2a, 3-5) of transResveratrol phytoalexin purified from Vitis vinifera grape canes and several analogues (1b-1j) of 1a obtained through semisynthesis using methylation and acetylation. Moreover, trans-εviniferin (2a), a dimer of 1a, was also subjected to methylation (2b) and acetylation (2c) under nonselective conditions. Neither the natural oligomers of 1a (2a, 3-5) nor the derivatives of 2a were active against Candida albicans SC5314. However, the dimethoxy resveratrol derivatives 1d and 1e exhibited antifungal activity against C. albicans with minimum inhibitory concentration (MIC) values of 29-37 μg/mL and against 11 other Candida species. Compound 1e inhibited the yeast-to-hyphae morphogenetic transition of C. albicans at 14 μg/mL. Pedras et al. (2014) identified and quantified by HPLC with photodioarray and electrospray mass detectors the phytoalexins produced by four wild cruciferous species (Brassica tournefortii, Crambe abyssinica (crambe), Diplotaxis tenuifolia (sand rocket), and Diplotaxis tenuisiliqua (wall rocket)). In addition, the production of indole glucosinolates, biosynthetic precursors of cruciferous phytoalexins, was evaluated. Tenualexin, (=2-(1,4-dimethoxy-1H-indol-3yl)acetonitrile), the first cruciferous phytoalexin containing two MeO substituents in the indole ring, was isolated from D. tenuisiliqua, synthesized, and evaluated for antifungal activity. The phytoalexins cyclobrassinin and spirobrassinin were detected in B. tournefortii and C. abyssinica, whereas rutalexin and 4-methoxybrassinin were only found in B. tournefortii. D. tenuifolia, and D. tenuisiliqua produced 2-(1H-indol-3-yl)acetonitriles as phytoalexins. Because tenualexin appears to be one of the broad-range antifungals occurring in crucifers, it is suggested that D. tenuisiliqua may have disease resistance traits important to be incorporated in commercial breeding programs Sun et al. (2014) noted that N. tabacum, young leaves of wild tobacco, N. attenuata, were more resistant to A. alternata than mature leaves, and this was correlated with stronger blue fluorescence induced after infection. However, the nature of the fluorescence-emitting compound, its role in defence, and its regulation were not clear. Silencing feruloyl-CoA 6'hydroxylase 1 (F6'H1), the gene encoding the key enzyme for scopoletin biosynthesis, by virusinduced gene silencing (VIGS) revealed that the blue fluorescence was mainly emitted by 644 scopoletin and its β-glycoside form, scopolin. Further analysis showed that scopoletin exhibited strong antifungal activity against A. alternata in vitro and in vivo. Importantly, jasmonic acid (JA) levels were highly elicited in young leaves but much less in mature leaves after infection; and fungus-elicited scopoletin was absent in JA-deficient plants, but was largely restored with methyl jasmonate treatments. Consistent with this, plants strongly impaired in JA biosynthesis and perception were highly susceptible to A. alternata in the same way scopoletin/scopolindepleted VIGS F6'H1 plants. Furthermore, silencing MYC2, a master regulator of most JA responses, reduced A. alternata-induced NaF6'H1 transcripts and scopoletin. Thus, it is concluded that JA signalling is activated in N. attenuata leaves after infection, which subsequently regulates scopoletin biosynthesis for the defence against A. alternata partly through MYC2, and higher levels of scopoletin accumulated in young leaves account for their strong resistance. References: 1. Barilli E1, Rubiales D2, Amalfitano C3, Evidente A4, Prats E2. BTH and BABA induce resistance in pea against rust (Uromyces pisi) involving differential phytoalexin accumulation. Planta. 2015 Nov;242(5):1095-106. 2. Hasegawa M1, Mitsuhara I2, Seo S3, Okada K4, Yamane H5, Iwai T6, Ohashi Y7. Analysis on blast fungus-responsive characters of a flavonoid phytoalexin sakuranetin; accumulation in infected rice leaves, antifungal activity and detoxification by fungus. Molecules. 2014 Aug 4;19(8):11404-18. 3. Hayat S1, Cheng Z1, Ahmad H1, Ali M1, Chen X2, Wang M1. Garlic, from Remedy to Stimulant: Evaluation of Antifungal Potential Reveals Diversity in Phytoalexin Allicin Content among Garlic Cultivars; Allicin Containing Aqueous Garlic Extracts Trigger Antioxidants in Cucumber. Front Plant Sci. 2016 Aug 25;7:1235. doi: 10.3389/fpls.2016.01235. eCollection 2016 4. Houillé B1, Papon N, Boudesocque L, Bourdeaud E, Besseau S, Courdavault V, Enguehard-Gueiffier C, Delanoue G, Guérin L, Bouchara JP, Clastre M, GiglioliGuivarc'h N, Guillard J, Lanoue A. Antifungal activity of resveratrol derivatives against Candida species. J Nat Prod. 2014 Jul 25;77(7):1658-62. 5. Pedras MS1, Yaya EE. Tenualexin, other phytoalexins and indole glucosinolates from wild cruciferous species. Chem Biodivers. 2014 Jun;11(6):910-8. 6. Pedras MS1, Alavi M2, To QH2. Expanding the nasturlexin family: Nasturlexins C and D and their sulfoxides are phytoalexins of the crucifers Barbarea vulgaris and B. verna. Phytochemistry. 2015 Oct;118:131-8. 7. Sun H1, Wang L1, Zhang B2, Ma J3, Hettenhausen C1, Cao G1, Sun G1, Wu J1, Wu J4. Scopoletin is a phytoalexin against Alternaria alternata in wild tobacco dependent on jasmonate signalling. J Exp Bot. 2014 Aug;65(15):4305-15. 645 7.12. Antiungal Peptides        Antiungal Peptides are naturally occurring molecules that play an important role in the first line of defense against microbial threats. Antiungal Peptides can be isolated from organisms as diverse as humans, plants, insects, and even other microorganisms like bacteria. Antiungal Peptides are produced due to an exposure to infecting microorganisms and act in order to kill or to slow the growth of invading microorganisms and to aid allied mechanisms of natural and adaptive immunity. Antiungal Peptides have a broad spectrum of activity against bacteria, fungi, enveloped viruses, parasites, and even cancerous cells. Antiungal Peptides can act directly on microorganism membranes or other nonspecific cell targets, which is an advantage in avoiding the development of microbial resistance by gene mutation, as it might happen when drugs have specific proteins as targets. Antiungal Peptides can be extremely variable in length, amino acid composition, and structure. Antiungal Peptides are divided into four categories, according to their predominant secondary structure: (a) α-helical, (b) β-sheet, (c) mixed α-helix/β-sheet, and (d) extended. Mechanisms of action, C.G. Freitas and O.L. Franco, 2016   Mechanisms of action involve different membrane interactions. o Membrane disruption can occur through the formation of toroidal pores, composed of loosely associated peptides with interdigitating phospholipid head groups among them. Those peptides are at a critical threshold concentration. o In the ―barrel-stave model,‖ the peptides are not associated with the lipid head groups, but their hydrophobic regions align with the lipid core region of the bilayer, and the hydrophilic peptide regions form the interior region of the pore. o Another type of membrane interaction is through peptide accumulation on the bilayer surface, since they are electronically attracted to the anionic phospholipid head groups at numerous sites, thus covering the surface of the membrane in a carpet-like manner. At high peptide concentrations, these surface-oriented peptides may act like detergents, leading to the formation of micelles. Mechanism of action for the antifungal activity of peptides is generally more complex and often involves entry of the peptide into the cell. o As an example, histatins bind to a receptor in the fungal cell membrane, enter the cytoplasm, and induce the non-lytic loss of ATP from actively respiring cells. Their action can also disrupt the cell cycle and lead to the generation of reactive oxygen species 646 Peptide interaction with the fungal membrane. Schematic representation of the fungal cell wall, compos ed of outer protein layer with carbohydrate residues (dark purple). Peptides with hydrophilic head group and hydrophobic acyl side chain regions (dark green, light green, and orange) interacting with fungal plasma membrane as barrel-stave pore (a), toroidal pore (b), or by membrane translocation (c) and membrane disruption in a carpet-like manner (d), as highlighted for LL-37. These interactions depend on the peptide, its concentration, and lipid composition of the membrane. Some peptides such as histatins , β-defensins, lactoferricins, RK-31, KS-30, and hLF (1-11) can reach internal targets such as the mitochondria (e). Histatin 5 also leads to the generation of (f) reactive oxygen species – ROS (black spindles). The non-lytic release of ATP (pink) (g) by HNP-1, HNP-2, HNP-3a, histatin-5, hLF(1–11), hLF(21–31), and B4010 might activate cell death pathway and (h) induce G1 phase arrest of the nucleus (i) C.G. Freitas and O.L. Franco, 2016 Antifungal peptides. C.G. Freitas and O.L. Franco, 2016 Antifungal peptides Origin Name Species Effective References Insect Alo-3 Acrocinus longimanus Candida albicans, C. albicans ATCC 90030, C. glabrata, C. glabrata ATCC 36082 van der Weerden et al. (2013) and Barbault et al. (2003) Termicin Pseudocanthoterme s spiniger C. albicans, Cryptococcus neoformans Da Silva et al. (2003) and Lamberty et al. (2001) Holotricin-3 Holotrichia diomphalia C. albicans Lee et al. (1995) Tenecin-3 Tenebrio molitor C. albicans Kim et al. (1998) Cecropin A Hyalophora cecropia, Drosophi la Aspergillus fumigatus Steiner et al. (1988) and De Lucca et al. (19972000) ABP-dHCcecropin Hyphantria cunea C. albicans, Neurospora crassa, Rhyzopus, Fusarium, Alter naria, Mucor Zhang et al. (2015) Rondonin Acanthoscurria rondoniae C. albicans, C. krusei, C. glabrata, C. parapsilosis, C. Riciluca et al. (2012) 647 Antifungal peptides Origin Name Species Effective References tropicalis, C. guilliermondii Amphi bian Mamm alian Synthe tic Brevenin1BYa Rana boylii C. aureus Brevenin1Pa, brevenin1Pb, brevenin-1Pc Rana pipiens C. albicans, S. aureus, Escherichia coli Goraya et al. (2000) Marenah et al. (2004) Temporin A Rana temporaria C. albicans Mangoni et al. (2000) Indolicidin Cytoplasmic granules neutrophils of albicans, Staphylococcus C. albicans, C. aureus, E. coli neoformans, S. Conlon et al. (2003), Yeaman and Yount (2003), and Pal et al. (2006) and Selsted et al. (1992), Lee et al. (2003) and Hsu et al. (2005) BMAP-28 Bovine myeloid antimicrobial peptide C. albicans, mammalian tumor cells Risso et al. (2002) SMAP-29 Sheep myeloid antimicrobial peptide C. albicans, Pseudomonas aeruginosa Lee et al. (2002a), Shin et al. (2001) and Dawson and Liu (2011) PMAP-23 Porcine myeloid antimicrobial peptide C. albicans Park et al. (2002b) and Lee et al. (2001, 2002b) Protegrin-1 Porcine cathelicidin C. albicans, C. neoformans Dawson and Liu (2010) LL-37 Human secretions C. albicans, Gram-positive and Gram-negative bacteria den Hertog et al. (2005), Durr et al. (2006), and Oudhoff et al. (2010) HNP1, HNP2, HNP3a Human neutrophils C. albicans, C. neoformans, Coccidioides immitis, Rhizopus oryzae, A. fumigatus Ganz (2003, 2005), Raj and Dentino (2002), and Lehrer et al. (1988) Histatin 5 Human peptide C. albicans, C. fumigatus Xu et al. (1999), Tsai and Bobek (1997), Situ et al. (2000), and Helmerhorst et al. (2001) hLF(1–11), hLF (21–31) Human lactoferrin C. albicans Lupetti et al. (2000) and ViejoDiaz et al. (2004) B4010 Originated from a secondary peptide derived from human β-defensin3 C. albicans Eckert (2011) and Nguyen et al. (2010) Penetratin 1 Cell-penetrate C. albicans, C. neoformans Milletti (2012) and Masman et al. salivary 648 neoformans, A. Antifungal peptides Origin Name Species Effective peptide References (2009) Reference: 1. Camila G., Freitas Octávio L., Franco, Antifungal Peptides with Potential Against Pathogenic Fungi. Springer India 2016 A. Basak et al. (eds.), Recent Trends in Antifungal Agents and Antifungal Therapy, DOI 10.1007/978-81-322-2782-3_3 1. Alo-3     Alo-3 was isolated from the coleopteran Acrocinus longimanus. Alo-3 contains six cysteine residues, forming three disulfide bridges and an antiparallel β-sheet with a long flexible loop connecting the first strand to the second strand and a series of turns. Alo-3 belongs to the knottin-type family of proteins with a cysteine-stabilized, ―knotted‖ topology, defined by two parallel disulfide bonds, threaded by a third one. Alo-3 has no negatively charged residues and displays a cationic pole on its surface that may contribute to its antifungal activity (van der Weerden et al. 2013). Barbault and coworkers (2003) tested two other homologous peptides, Antifungal activity  Alo-3 was the most effective against Candida glabrata and C. albicans, both tested not only against clinical isolates of those pathogens but also against ATCC strains (ATCC90030 and ATCC 36082, respectively). Recent report: Barbault et al. (2003) investigated several classes of peptides, and we have been successful in identifying biologically important classes of peptides and small molecules that will provide a stream of drug candidates for treating severe, life-threatening, hospital-acquired infections and other pathologies of high medical need. They isolated a new class of antifungal peptides from the coleopteran Acrocinus longimanus. Three homologous peptides, Alo-1, Alo-2, and Alo-3, with sequence identity above 80% and active against the Candida glabrata yeast strain were identified. Alo-3 displayed the highest activity against Candida glabrata and was thus chosen for structure determination using NMR spectroscopy and molecular modeling. Alo-3 contains six cysteine residues forming three disulfide bridges. The pairing of the cysteines was assessed using ambiguous disulfide restraints within the ARIA software, allowing us to establish that Alo3 belongs to the inhibitor cystine-knot family. It exhibits all the structural features characteristic of the knottin fold, namely, a triple-stranded antiparallel beta-sheet with a long flexible loop connecting the first strand to the second strand and a series of turns. To our knowledge, Alo-3 is 649 the first peptide from insects with antimicrobial activity adopting the knottin fold. Alo-3 shows a level of activity significantly higher against C. glabrata than Alo-1 or Alo-2. It has no negatively charged residues and displays on its surface a cationic pole that may account for its antifungal activity. This finding is validated by the comparison of the structure of Alo-3 with the structure of other structurally related peptides from other sources also showing antifungal activity. Reference: 1. Barbault F1, Landon C, Guenneugues M, Meyer JP, Schott V, Dimarcq JL, Vovelle F. Solution structure of Alo-3: a new knottin-type antifungal peptide from the insect Acrocinus longimanus. Biochemistry. 2003 Dec 16;42(49):14434-42. 2. Termicin   Termicin was isolated from the fungus-growing termite Pseudocanthotermes spiniger (heterometabole insect, Isoptera). Termicin is a cysteine-rich antifungal peptide with a α-helical segment and two antiparallel β-sheets forming a ―cysteine αβ motif,‖ also found in antibacterial and antifungal defensins and from plants. Antifungal activity  Termicin showed activity against C. albicans and C. neoformans, but was inactive against C. glabrata (Da Silva et al. 2003; Lamberty et al. 2001). Recent reports: Liu et al. (2016) cloned the cDNA by combination of cDNA library construction kit and DNA sequencing. The polypeptide was purified by gel filtration and reversed-phase high performance liquid chromatography (RP-HPLC). Its amino acid sequence was determined by Edman degradation and mass spectrometry. Antimicrobial activity was tested against several bacterial and fungal strains. The minimum inhibitory concentration (MIC) was determined by microdilution tests. A novel termicin-like peptide with primary structure ACDFQQCWVTCQRQYSINFISARCNGDSCVCTFRT was purified from extracts of the cockroach Eupolyphaga sinensis (Insecta: Blattodea). The cDNA encoding Es-termicin was cloned by cDNA library screening. This cDNA encoded a 60 amino acid precursor which included a 25 amino acid signal peptide. Amino acid sequence deduced from the cDNA matched well with the result of protein Edman degradation. Susceptibility test indicated that Estermicin showed strong ability to kill fungi with a MIC of 25 μg/mL against Candida albicans ATCC 90028. It only showed limited potency to affect the growth of Gram-positive bacteria with a MIC of 200 μg/mL against Enterococcus faecalis ATCC 29212. It was inactive against gram-negative bacteria at the highest concentration tested (400 μg/mL). Es-termicin showed high 651 sequence similarity with termicins from many species of termites (Insecta: Isoptera). CONCLUSIONS: This is the first report of a termicin-like peptide isolated from E. sinensis that belongs to the insect order Blattodea. Our results demonstrate the diversity of termicin-like peptides, as well as antimicrobial peptides in insects. Velenovsky et al. (2016) identified the antifungal gene termicin in three species of Cryptocercus woodroaches. Cryptocercus represents the closest living cockroach lineage of termites, which suggests that the antifungal role of termicin evolved prior to the divergence of termites from other cockroaches. An analysis of Cryptocercus termicin and two β-1,3-glucanase genes (GNBP1 and GNBP2), which appear to work synergistically with termicin in termites, revealed evidence of selection in these proteins. We identified the signature of past selective sweeps within GNBP2 from Cryptocercus punctulatus and Cryptocercus wrighti. The signature of past selective sweeps was also found within termicin from Cryptocercus punctulatus and Cryptocercus darwini. Our analysis further suggests a phenotypically identical variant of GNBP2 was maintained within Cryptocercus punctulatus, Cryptocercus wrighti, and Cryptocercus darwini while synonymous sites diverged. Cryptocercus termicin and GNBP2 appear to have experienced similar selective pressure to that of their termite orthologues in Reticulitermes. This selective pressure may be a result of ubiquitous entomopathogenic fungal pathogens such as Metarhizium. This study further reveals the similarities between Cryptocercus woodroaches and termites. References: Liu Z#1, Yuan K#2, Zhang R#3, Ren X#1, Liu X#1, Zhao S4,5, Wang D1,6. Cloning and purification of the first termicin-like peptide from the cockroach Eupolyphaga sinensis. J Venom Anim Toxins Incl Trop Dis. 2016 Jan 28;22:5. Velenovsky JF 4th1, Kalisch J1, Bulmer MS2. Selective sweeps in Cryptocercus woodroach antifungal proteins. Genetica. 2016 Oct;144(5):547-552. Epub 2016 Sep 13. 3. Cecropins     Cecropins are basic 35–39 amino acid residue peptides that can fold into two amphipathic α-helices, separated by a more flexible hinge. Their mode of action against bacteria is based on the formation of either voltage-dependent ion channels or general disruption of the membrane by a ―carpet-like‖ mechanism (Steiner et al. 1988). Cecropin A, a 37 amino acid residue peptide, is complexed with lipopolysaccharide and in germinating cells of Aspergillus fumigatus induces death, whereas binding and cell death were not observed with non-germinating hyphae (De Lucca et al. 1997). De Lucca and coworkers (2000) have proposed the mode of action of this peptide as involving disruption of the plasma membrane. ABP-dHC-cecropin A (antimicrobial peptide drury Hyphantria cunea), a highly cationic peptide isolated from the fat bodies of drury moths (H. cunea), has shown a 651 strong antifungal activity against both C. albicans and Neurospora crassa as well as Rhyzopus, Fusarium, Alternaria, and Mucor species (Zhang et al. 2015) Recent reports: Yun and Lee (2016) investigated cecropin A-induced apoptosis associated with ion balance and redox state of Candida albicans. The antifungal effect of cecropin A, associated with ion movement was verified by significant increase of cell viability following pretreatment of ion channel blockers. Cecropin A induced undesired ion movement such as calcium accumulation and potassium leakage. Furthermore, the reduction of phosphatidyl serine (PS) externalization was detected following pretreatment of ion channel blockers. Based on these results, we confirmed that ion imbalance regulates the apoptotic activity of cecropin A. Moreover, cecropin A decreased NADPH and glutathione levels, which are crucial factors in the intracellular antioxidant defense system. The decreased intracellular antioxidant capacity induced oxidative stress by generating reactive oxygen species (ROS). Moreover, several apoptotic features such as mitochondrial depolarization, caspase activation, and DNA fragmentation were observed in cecropin A-treated cells. In conclusion, disrupted ion balance and intracellular glutathione redox state play a key role in cecropin A-induced apoptosis in C. albicans. Zhang et al. (2015) cloned ABP-dHC-cecropin A into a pSUMO vector and transformed into E. coli, resulting in the production of a pSUMO-ABP-dHC-cecropin A fusion protein. The soluble form of this protein was then purified by Ni-IDA chromatography, yielding a total of 496-mg protein per liter of fermentation culture. The SUMO-ABP-dHC-cecropin A fusion protein was then cleaved using a SUMO protease and re-purified by Ni-IDA chromatography, yielding a total of 158-mg recombinant ABP-dHC-cecropin A per liter of fermentation culture at a purity of ≥94%, the highest yield reported to date. Antifungal activity assays performed using this purified recombinant peptide revealed strong antifungal activity against both Candida albicans and Neurospora crassa, as well as Rhizopus, Fusarium, Alternaria, and Mucor species. Combined with previous analyses demonstrating strong antibacterial activity against a number of important bacterial pathogens, these results confirm the use of ABP-dHC-cecropin A as a broad-spectrum antimicrobial peptide, with significant therapeutic potential. References: Yun J1, Lee DG1. Cecropin A-induced apoptosis is regulated by ion balance and glutathione antioxidant system in Candida albicans. IUBMB Life. 2016 Aug;68(8):652-62. Zhang J1, Movahedi A1, Xu J1, Wang M1, Wu X1, Xu C1, Yin T1, Zhuge Q2. In vitro production and antifungal activity of peptide ABP-dHC-cecropin A. J Biotechnol. 2015 Apr 10;199:47-54. 652 4. Brevinins       Brevinins consist of two families named brevinin-1 (24 residues) and brevinin-2 (33– 34 residues), and they were first described in 1992 by Morikawa et al. (Morikawa et al. 1992), who isolated these peptides from the skin of the Japanese frog Rana brevipoda porsa, demonstrating microbicidal activity against a wide range of Grampositive, Gram-negative bacteria and pathogenic fungi strains. Up to now about 350 types of brevinins have been discovered, sharing common features like linearity, amphipathicity, and cationicity, and some of them have a Cterminal disulfide-bridge cyclic heptapeptide, called a rana box (Novkovic et al. 2012; Savelyeva et al. 2014). Brevinin-1BYa (FLPILASLAAKFGPKLFCLVTKKC) from the norepinephrinestimulated skin secretions from the foothill yellow-legged frog Rana boylii. Brevinin-1BYa was potent against C. albicans and Staphylococcus aureus, but its therapeutic potential is limited due to its strong hemolytic activity. Brevinin-1BYa (FLPILASLAAKFGPKLFSLVTKKS) has eightfold reduced hemolytic activity compared to the native peptide. Antimicrobial activities against C. albicans and Gram-negative bacteria were reduced. Brevinin-1Pa, brevinin-1Pb, and brevinin-1Pc, were also effective against C. albicans, S. aureus, and Escherichia coli (Goraya et al. 2000). ]] temporins. They were initially identified in 1996 in skin secretion of the European red frog Rana temporaria (Simmaco et al. 1996), but they can be isolated from several other frog species as well as from wasp venom (Rollins-Smith et al. 2003). 5. Temporins   Temporins A and B have been reported to be active against C. albicans and Grampositive and Gram-negative bacteria. Temporins A and B permeate both artificial and biological membranes, but they do not lyse human erythrocytes, which suggests there are additional factors involved in the mechanism of action on different cell types (van der Weerden et al. 2013; Mangoni et al. 2000; Wade et al. 2000; Hujakka et al. 2001; Carotenuto et al. 2008). 6. Cathelicidins    Cathelicidins are peptides of approximately 100 amino acid residues, and their sequences are related to cathelin, a cystatin-like protein. Cathelicidins are commonly found in humans and other species such as sheep, pigs, horses, cattle, chickens, rabbits, and some species of fishes, being usually stored in the secretory granules of neutrophils and macrophages. Cathelicidins can also be released extracellularly upon leukocyte activation (Zanetti 2005; Kosciuczuk et al. 2012). 653  Among the cathelicidin peptides, some present antifungal activity and this is stronger against yeast than against filamentous fungi (Benincasa et al. 2006).  Indolicidin is a tryptophan-rich bovine cathelicidin peptide of 13 amino acid residues (ILPWKWPWWPWRR-NH2), purified from the cytoplasmic granules of neutrophils and found in bone marrow cells as a 144-long amino acid precursor (Selsted et al. 1992; Del Sal et al. 1992). Indolicidin showed activity against fungi C. albicans and C. neoformans, as well toward bacteria S. aureus and E. coli(Benincasa et al. 2006). The fungicidal activity involves membrane disruption, DNA binding and topoisomerase 1 inhibition. o In the first situation, the peptide interacts with the lipid bilayers in a salt- and energy-dependent manner. o The DNA interaction occurs by DNA synthesis inhibitors binding DNA or proteins involved in the process. Indolicidins may also interact in other biosynthesis pathways or in cell cycle signal transduction (Lee et al. 2003; Hsu et al. 2005).    BMAP (Bovine myeloid antimicrobial peptides)   (BMAP) of 27 and 38 amino acid residues, BMAP-27 and BMAP-28 BMAP-28 is toxic for mammalian tumor cells, inducing their apoptosis, and it was also demonstrated that it induces mitochondrial permeability, forming transition pores (MPTP), resulting in the release of cytochrome c. SMAP (Sheep myeloid antimicrobial peptides)    SMAP-29 is cathelicidin-like peptide derived from myeloid sheep with α-helical structure in a hydrophobic environment, and its C-terminal hydrophobic domain has a strong membrane permeability (Chen et al. 2011; Skerlavaj et al. 1999). SMAP-29 concentrates on the plasma membrane of treated cells and causes propidium iodide (PI) uptake, provided by the cells that are metabolically active. Lee and coworkers (2002a) suggest that membrane disruption by SMAP-29 occurs via pore formation, due to a direct interaction with the lipid bilayers and irregularly disrupted fungal membranes in an energy- and salt-dependent manner. SMAP-29, however, is strongly hemolytic against human erythrocytes. A variant of SMAP-29, [K22,25,27] SMAP-29, is effective against bacterial and fungal cells in physiological salt concentrations and was not injurious to eukaryotic cells, such as human erythrocytes (Shin et al. 2001; Dawson and Liu 2011). 654 PMAP (Bovine myeloid antimicrobial peptides)    PMAP-23 was identified by cDNA cloning and is 23 residues long, cationic (+7), and amphipathic. In a hydrophobic environment, it forms two α-helices joined by a flexible region when membrane-bound (Roversi et al. 2014; Park et al. 2002b). PMAP-23 is capable of binding to plasma membrane of C. albicans protoplasts, indicating that an interaction with the cell wall is not a requirement for the inhibitory activity of this peptide, which also did not show hemolytic activity (Park et al. 2002b; Lee et al. 2001). Lee and coworkers (2002b) designed several analogs of PMAP-23, with amino acid substitutions in order to increase the net hydrophobicity by Trp (W)substitution at positions 10, 13, or 14 on the hydrophilic face of the peptide. In C. albicans the P6 analog peptide exerted its fungicidal effect on the blastoconidia by disrupting the mycelial forms, causing significant morphological changes. Meanwhile Protegrin (PG)   Protegrin-1 (PG-1), showed activity against clinical isolates of fungi, including those resistant to conventional medicines used in human therapy (Benincasa et al. 2006). These peptides and their variants have a rather rigid antiparallel β-sheet (β-hairpin) structure that is stabilized by two intramolecular disulfide bonds. The linear peptide forms have been reported to be considerably less active than the native form, being sensitive to physiological salt concentrations (Dawson and Liu 2010). PG-1, BMAP-27, BMAP-28, SMAP-29, and indolicidin showed deleterious activity against a number of nosocomial yeast strains, mainly Candida spp. and C. neoformans (Benincasa et al. 2006). Cathelicidin LL-37,      LL-37 is secreted in human sweat and further processed into RK-31 and KS-30, more active peptides that retain their activity even in high salt conditions. Moreover, they are able to enter the cytoplasm of C. albicans cells, suggesting that their increased activity may result from interaction with intracellular targets. In contrast, LL-37 could not be detected in the cytoplasm (den Hertog et al. 2005, 2006; LopezGarcia et al. 2005). LL-37 showed a pH-dependent activity against C. albicans, disrupting its membrane and allowing leakage of proteins of up to 40 kDa into the medium (den Hertog et al. 2005). LL-37 discriminates against phospholipid monolayers containing negatively charged lipids, as SMPA-29 does. However, experiments comparing these two peptides demonstrated that the LL-37 peptide had a more potent effect than the SMAP-29, suggesting that its interaction with monolayers involves other factors, such as hydrophobicity, size, and charge distribution, although SMAP-29 has a higher net positive charge (+10), and it would be expected to be more attracted to the negatively charged lipid monolayers 655 (Neville et al. 2010). When compared to histatin-5, LL-37 induced higher morphological defects, but the efflux of nucleotides is similar in comparable candidacidal concentrations, suggesting that the loss of nucleotides plays an important role in the killing process (den Hertog et al. 2005). LL-37 has been found to have additional activities, such as regulating the inflammatory response and chemo-attracting cells of the adaptive immune system to wound or infection sites, helping to neutralize the microorganism and promoting re-epithelization and wound closure (Durr et al. 2006; Oudhoff et al. 2010). Recent reports: Yu et al. (2016) evaluated the antifungal activities of previously characterized cathelicidins (cathelicidin-BF, Pc-CATH1, Cc-CATH2, Cc-CATH3) against C. albicans in vitro and in vivo using amphotericin B and LL-37 as control. Results showed that all four cathelicidins could eradicate standard and clinically isolated C. albicans strains with most MIC values ranging from 1 to 16 μg/ml, in less than 0.5 h revealed by time-kill kinetic assay. Four peptides only exhibited slight hemolytic activity with most HC50 > 200 μg/ml, and retained potent anti-C. albicans activity at salt concentrations below and beyond physiological level. In animal experiment, 50 mg/kg administration of the four cathelicidins could significantly reduce the fungal counts in a murine oral candidiasis model induced by clinically isolated C. albicans. The antibiofilm activity of cathelicidin-BF, the most potent among the five peptides was evaluated, and result showed that cathelicidin-BF strongly inhibited C. albicans biofilm formation at 20 μg/ml. Furthermore, cathelicidin-BF also exhibited potent anti-C. albicans activity in established biofilms as measured by metabolic and fluorescent viability assays. Structure-function analyses suggest that they mainly adopt an α-helical conformations, which enable them to act as a membrane-active molecule. Altogether, the four cathelicidins display great potential for antifungal agent development against candidiasis. Rapala-Kozik et al. (2015) validated a hypothesis that neutrophils and epithelial cells use the antimicrobial peptide LL-37 to inactivate C. albicans at sites of candidal infection and that C. albicans uses SAPs to effectively degrade LL-37. LL-37 is cleaved into multiple products by SAP1 to -4, SAP8, and SAP9, and this proteolytic processing is correlated with the gradual decrease in the antifungal activity of LL-37. Moreover, a major intermediate of LL-37 cleavagethe LL-25 peptide-is antifungal but devoid of the immunomodulatory properties of LL-37. In contrast to LL-37, LL-25 did not affect the generation of reactive oxygen species by neutrophils upon treatment with phorbol esters. Stimulating neutrophils with LL-25 (rather than LL-37) significantly decreased calcium flux and interleukin-8 production, resulting in lower chemotactic activity of the peptide against neutrophils, which may decrease the recruitment of neutrophils to infection foci. LL-25 also lost the function of LL-37 as an inhibitor of neutrophil apoptosis, thereby reducing the life span of these defense cells. This study indicates that C. albicans can effectively use aspartic proteases to destroy the antimicrobial and immunomodulatory properties of LL-37, thus enabling the pathogen to survive and propagate. Scarsini et al. (2015) investigated the in vitro antifungal activities of the cathelicidin peptides LL-37 and BMAP-28 against pathogenic Candida spp. also including C. albicans, isolated from vaginal infections, and against C. albicans SC5314 as a reference strain. The antimicrobial activity was evaluated against planktonic and biofilm-grown Candida cells by using microdilution susceptibility and XTT [2,3-bis(2-methoxy-4-nitro-5-sulfo-phenyl)-2H656 tetrazolium-5-carboxanilide] reduction assays and, in the case of established biofilms, also by CFU enumeration and fluorescence microscopy. BMAP-28 was effective against planktonically grown yeasts in standard medium (MIC range, 2-32μM), and against isolates of C. albicans and Candida krusei in synthetic vaginal simulated fluid (MIC range 8-32μM, depending on the pH of the medium). Established 48-h old biofilms formed by C. albicans SC5314 and C. albicans and C. krusei isolates were 70-90% inhibited within 24h incubation with 16μM BMAP-28. As shown by propidium dye uptake and CFU enumeration, BMAP-28 at 32μM killed sessile C. albicans SC5314 by membrane permeabilization with a faster killing kinetics compared to 32μM miconazole (80-85% reduced biofilm viability in 90min vs 48h). In addition, BMAP-28 at 16μM prevented Candida biofilm formation on polystyrene and medical grade silicone surfaces by causing a >90% reduction in the viability of planktonic cells in 30min. LL-37 was overall less effective than BMAP-28 against planktonic Candida spp. (MIC range 4-≥64μM), and was ineffective against established Candida biofilms. However, LL-37 at 64μM prevented Candida biofilm development by inhibiting cell adhesion to polystyrene and silicone surfaces. Finally, Candida adhesion was strongly inhibited when silicone was pre-coated with a layer of BMAP-28 or LL-37, encouraging further studies for the development of peptide-based antimicrobial coatings. Ordonez et al. (2014) studied antifungal mechanisms of action of two cathelicidins, chicken CATH-2 and human LL-37 and compared with the mode of action of the salivary peptide histatin 5 (Hst5). Candida albicans was used as a model organism for fungal pathogens. Analysis by live-cell imaging showed that the peptides kill C. albicans rapidly. CATH-2 is the most active peptide and kills C. albicans within 5 min. Both cathelicidins induce cell membrane permeabilization and simultaneous vacuolar expansion. Minimal fungicidal concentrations (MFC) are in the same order of magnitude for all three peptides, but the mechanisms of antifungalactivity are very different. The activity of cathelicidins is independent of the energy status of the fungal cell, unlike Hst5 activity. Live-cell imaging using fluorescently labeled peptides showed that both CATH-2 and LL-37 quickly localize to the C. albicans cell membrane, while Hst5 was mainly directed to the fungal vacuole. Small amounts of cathelicidins internalize at sub-MFCs, suggesting that intracellular activities of the peptide could contribute to the antifungal activity. Analysis by flow cytometry indicated that CATH-2 significantly decreases C. albicans cell size. Finally, electron microscopy showed that CATH-2 affects the integrity of the cell membrane and nuclear envelope. It is concluded that the general mechanisms of action of both cathelicidinsare partially similar (but very different from that of Hst5). CATH-2 has unique features and possesses antifungal potential superior to that of LL-37. References: 1. Ordonez SR1, Amarullah IH, Wubbolts RW, Veldhuizen EJ, Haagsman HP. Fungicidal mechanisms of cathelicidins LL-37 and CATH-2 revealed by live-cell imaging. Antimicrob Agents Chemother. 2014;58(4):2240-8. 2. Rapala-Kozik M1, Bochenska O2, Zawrotniak M2, Wolak N2, Trebacz G2, Gogol M2, Ostrowska D2, Aoki W3, Ueda M4, Kozik A2. Inactivation of the antifungal and immunomodulatory properties of human cathelicidinLL-37 by aspartic proteases produced by the pathogenic yeast Candida albicans. Infect Immun. 2015 Jun;83(6):251830. 657 3. Scarsini M1, Tomasinsig L1, Arzese A2, D'Este F1, Oro D1, Skerlavaj B3. Antifungal activity of cathelicidin peptides against planktonic and biofilm cultures of Candida species isolated from vaginal infections. Peptides. 2015 Sep;71:211-21. 4. Yu H1, Liu X2, Wang C2, Qiao X2, Wu S2, Wang H2, Feng L2, Wang Y3. Assessing the potential of four cathelicidins for the management of mouse candidiasis and Candida albicans biofilms. Biochimie. 2016 Feb;121:268-77. 7. Defensins  Mammalian defensins are a large group of peptides with an important role in the host‘s immune system. They can be divided into the α- and β-defensins based on their structural characteristics and cysteine spacing pattern (van der Weerden et al. 2013). Both defensins were first identified as antimicrobial compounds involved in innate immunity. Human defensins     In humans, α- and β-defensins are expressed mainly in different sites: o the α-defensins are mostly expressed in neutrophils (known as human neutrophil peptides (HNP), or human defensins (HP) when expressed in natural killer cells) and o the β-defensins are secreted by the epithelial cells of the skin and mucosae and known as HβD (Suarez-Carmona et al. 2014). The human defensins present activity against a wide range of microorganisms, including fungal pathogens. o HNP 1–3 are identical apart from one N-terminal amino acid, which makes HNP 3 completely inactive against C. albicans, o HNP 1–2 is candidacidal. o HNP 4 is also toxic to C. albicans cells, the mechanism of action of human defensins on fungal cells has been proposed to be by membrane permeabilization (Ganz and Lehrer 1995; Ganz 2005). o HNP-1 causes C. albicans to release ATP, just as histatin 5 does, but in contrast, it did not seem to lyse cells. o HNP-1, NP2, and NP3a were highly effective against C. albicans, and o HNP-1 was effective against C. neoformans, Coccidioides immitis, and hyphae and germinating conidia of Rhizopus oryzaeand Aspergillus fumigatus (van der Weerden et al. 2013; Raj and Dentino 2002; Lehrer et al. 1988). β-defensins, HβD 2 and HβD 3, are potent inhibitors of C. albicans. o Exposure to this microorganism and to Trichophyton rubrum and A. fumigatus stimulates HβD 2 expression. A. fumigatus also induces the expression of HβD 9. 658 Recent reports: Mathew and Nagaraj (2015) investigated the antimicrobial activity of HD6 analogs. A linear analog of HD6, in which the distribution of arginine residues was similar to active α-defensins, shows broad-spectrum antimicrobial activity, indicating that atypical distribution of arginine residues contributes to the inactivity of HD6. Peptides spanning the N-terminal cationic segment were active against a wide range of organisms. Antimicrobial potency of these shorter analogs was further enhanced when myristic acid was conjugated at the N-terminus. Cytoplasmic localization of the analogs without fatty acylation was observed to be necessary for bacterial killing, while they exhibited fungicidal activity by permeabilizing Candida albicans membranes. Myristoylated analogs and the linear full-length arginine analog exhibited activity by permeabilizing bacterial and fungal membranes. Our study provides insights into the lack of bactericidal activity of HD6 against aerobic bacteria. Mith et al. (2015) renowned plant defensins for their antifungal activity but various side activities have also been described. Usually, a new biological role is reported along with the discovery of a new defensin and it is thus not clear if this multifunctionality exists at the family level or at the peptide level. We previously showed that the plant defensin AhPDF1.1b exhibits an unexpected role by conferring zinc tolerance to yeast and plant cells. In this paper, we further explored this activity using different yeast genetic backgrounds: especially the zrc1 mutant and an UPRE-GFP reporter yeast strain. We showed that AhPDF1.1b interferes with adaptive cell response in the endoplasmic reticulum to confer cellular zinc tolerance. We thus highlighted that, depending on its cellular localization, AhPDF1.1b exerts quite separate activities: when it is applied exogenously, it is a toxin against fungal and also root cells, but when it is expressed in yeast cells, it is a peptide that modulates the cellular adaptive response to zinc overload. Oddepally and Guruprasad (2015) isolated a novel defensin-like antifungal peptide (Tf-AFP) with molecular mass of 10.3 kDa from seeds of Trigonella foenum-graecum (fenugreek) by ammonium sulfate precipitation, cation-exchange, gel-filtration, hydrophobic chromatography, and RP-HPLC. Mass spectroscopic analysis revealed the intact mass of the purified antifungal peptide as 10321.5 Da and high similarity to plant defensins and other antifungal proteins in database search. 2D-PAGE showed pI value to be 8.8 and absence of isoforms. Isolated Tf-AFP inhibited growth of fungal species such as Fusarium oxysporum, Fusarium solani, and Rhizoctonia solani. The antifungal activity was inhibited in the presence of 50 mM NaCl. Circular dichroism analysis demonstrated that the protein is rich in β-sheet structure and highly stable over a wide range of temperatures. Surprisingly, reduction of disulfide bridges and chemical denaturation did not produce large changes in secondary structure as judged by circular dichroism as well as by fluorescence spectroscopy. Dracatos et al. (2014) reported the isolation and characterization of a class I secreted defensin (NaD2) from the flowers of Nicotiana alata, and compares its antifungal activity with the class II defensin (NaD1) from N. alata flowers, which is stored in the vacuole. NaD2, like all other class I defensins, lacks the C-terminal pro-peptide (CTPP) characteristic of class II defensins. NaD2 is most closely related to Nt-thionin from N. tabacum (96% identical) and shares 81% identity with MtDef4 from alfalfa. The concentration required to inhibit in vitro fungal growth by 50% (IC50 ) was assessed for both NaD1 and NaD2 for the biotrophic basidiomycete fungi Puccinia coronata f. sp. avenae (Pca) and P. sorghi (Ps), the necrotrophic pathogenic ascomycetes Fusarium oxysporum f. sp. vasinfectum (Fov), F. 659 graminearum (Fgr), Verticillium dahliae (Vd) and Thielaviopsis basicola (Tb), and the saprobe Aspergillus nidulans. NaD1 was a more potent antifungal molecule than NaD2 against both the biotrophic and necrotrophic fungal pathogens tested. NaD2 was 5-10 times less effective at killing necrotrophs, but only two-fold less effective on Puccinia species. A new procedure for testing antifungal proteins is described in this study which is applicable to pathogens with spores that are not amenable to liquid culture, such as rust pathogens. Rusts are the most damaging fungal pathogens of many agronomically important crop species (wheat, barley, oats and soybean). NaD1 and NaD2 inhibited urediniospore germination, germ tube growth and germ tube differentiation (appressoria induction) of both Puccinia species tested. NaD1 and NaD2 were fungicidal on Puccinia species and produced stunted germ tubes with a granular cytoplasm. When NaD1 and NaD2 were sprayed onto susceptible oat plants prior to the plants being inoculated with crown rust, they reduced the number of pustules per leaf area, as well as the amount of chlorosis induced by infection. Similar to observations in vitro, NaD1 was more effective as an antifungalcontrol agent than NaD2. Further investigation revealed that both NaD1 and NaD2 permeabilized the plasma membranes of Puccinia spp. This study provides evidence that both secreted (NaD2) and nonsecreted (NaD1) defensins may be useful for broad-spectrum resistance to pathogens. References: 1. Dracatos PM1, van der Weerden NL, Carroll KT, Johnson ED, Plummer KM, Anderson MA. Inhibition of cereal rust fungi by both class I and II defensins derived from the flowers of Nicotiana alata. Mol Plant Pathol. 2014 Jan;15(1):67-79. 2. Mathew B1, Nagaraj R1. Antimicrobial activity of human α-defensin 6 analogs: insights into the physico-chemical reasons behind weak bactericidal activity of HD6 in vitro. J Pept Sci. 2015 Nov;21(11):811-8. 3. Mith O1, Benhamdi A1, Castillo T1, Bergé M1, MacDiarmid CW2, Steffen J2, Eide DJ2, Perrier V3, Subileau M3, Gosti F1, Berthomieu P1, Marquès L1.The antifungal plant defensin AhPDF1.1b is a beneficial factor involved in adaptive response to zinc overload when it is expressed in yeast cells. Microbiologyopen. 2015 Jun;4(3):409-22. 4. Oddepally R1, Guruprasad L. Isolation, purification, and characterization of a stable defensin-like antifungal peptide from Trigonella foenum-graecum (fenugreek) seeds. Biochemistry (Mosc). 2015 Mar;80(3):332-42. 8. Histatins  The histatin family consists of 12 members of histidine-rich peptides from which histatins 1 and 3 (the full-length proteins and gene products) and histatin 5 (a cleavage product of histatin 3) are the main ones and constitute 70–80 % of the total amount (Xu et al. 1999). The other nine members are proteolytic cleavage products of these peptides (Fitzgerald et al. 2003). 661      The histatins are named due to a high number of histidine residues, however, other amino acids including lysines (Lys 5 and Lys13) rather than histidines have key importance for fungicidal activity (Kumar et al. 2011; Rothstein et al. 2001). Studies demonstrate that histatins have a number of biological activities in vitro, such as the maintenance of tooth surface integrity, histamine release induction, and potentiation of rabbit chondrocyte growth (Hay 1975; Oppenheim et al. 1986; Sugiyama et al. 1985; Murakami et al. 1994). The histatins are encoded by two closely related genes (HIS1 and HIS2), with histatin 1 and histatin 3 as primary products of HISI and HIS2, respectively (Sabatini and Azen 1989). Histatin 5 was obtained from histatin 3 (Raj et al. 1998) and has the strongest antimicrobial activity against pathogenic fungi C. albicans, C. neoformans, and A. fumigatus (Kavanagh and Dowd 2004). This \ Histatin 5 is 24-amino acid residues long with seven histidines, four arginines, and three lysines, and its fungicidal activity resides in a region of 11–24 residues at the Cterminal, referred to as the functional domain or dh-5 (Driscoll et al. 1995). Histatin 5 antifungal mechanisms against C. albicans involve     binding to a specific receptor, translocation across the membrane, and interaction with internal targets such as mitochondria and non-lytic release of cellular ATP (Fitzgerald et al. 2003; Helmerhorst et al. 1999b; Koshlukova et al. 1999, 2000). Histatins do not display lytic activities to lipid membranes, measured by release and dequenching of the fluorescent dye calcein (Edgerton et al. 1998). Histatin interaction with the cell wall and its uptake by the cell are two independent events, since the fungal cell wall binding itself does not result in uptake of histidines. Internalization of histatin 5 occurs by translocation, and its uptake is dependent on two polyamine transporters, Dur3 and Dur31 (which usually function in spermidine uptake), since C. albicans showed a reduced intracellular transport of histatin 5 upon growth in a medium rich in spermidine, implicating polyamine transporters in uptake of this peptide (van der Weerden et al. 2013; Kumar et al. 2011). Recent reports: Han et al. (2016) designed six hybrid peptides by conjugating histatin 5 and halocidin. A comparative approach was established to study the activity, salt tolerance, cell wall glucan binding assay, cytotoxicity, generation of ROS and killing kinetics. CD spectrometry was conducted to evaluate secondary structures of these hybrid peptides. Furthermore the cellular localization of hybrid peptides was investigated by confocal fluorescence microscopy. Of the six hybrid congeners, di-PH2, di-WP2 and HHP1 had stronger activities than other hybrid peptides against all tested Candida strains. The MIC values of these peptides were 1-2, 2-4 and 2-4 μg/ml, respectively. Moreover, none of the hybrid peptides was cytotoxic in the hemolytic assay and cell-based cytotoxicity assay. Confocal laser microscopy showed that di-PH2 and HHP1 were translocated into cytoplasm whereas di-WP2 was accumulated on surface of C. albicans to exert their candidacidal activity. All translocated peptides (Hst 5, P113, di-PH2) were capable of generating 661 intracellular ROS except HHP1. Additionally, the KFH residues at C-terminal end of these peptides were assumed for core sequence for active translocation. Moffa et al. (2015) evaluated the potential of histatin 5 to protect the Human Oral Epithelium against C. albicans adhesion. Human Oral Epithelial Tissues (HOET) were incubated with PBS containing histatin 5 for 2 h, followed by incubation with C. albicans for 1 h at 37°C. The tissues were then washed several times in PBS, transferred to fresh RPMI and incubated for 16 h at 37°C at 5% CO2. HOET were then prepared for histopathological analysis using light microscopy. In addition, the TUNEL assay was employed to evaluate the apoptosis of epithelial cells using fluorescent microscopy. HOET pre-incubated with histatin 5 showed a lower rate of C. albicans growth and cell apoptosis when compared to the control groups (HOET alone and HOET incubated with C. albicans). The data suggest that the coating with histatin 5 is able to reduce C. albicans colonization on epithelial cell surfaces and also protect the basal cell layers from undergoing apoptosis. Scaria et al. (2014) evaluated ligand targeting of bHK peptides to fungal surface integrins by determining whether a cyclic RGD (cRGD) peptide with a large PEG linker could enhance bHK peptide antifungal activity. Whereas conjugates containing only the PEG linker reduced bHK peptide activity, conjugates with the cRGD-PEG ligand resulted in marked enhancement of activity against Candida albicans. This study provides the first demonstration of benefit from ligand targeting of antifungal agents to fungal surface receptors. Tati et al. (2014) constructed a conjugate peptide using spermidine (Spd) linked to the active fragment of Hst 5 (Hst 54-15), based upon our findings that C. albicans spermidine transporters are required for Hst 5 uptake and fungicidal activity. We found that Hst 54-15-Spd was significantly more effective in killing C. albicans and Candida glabrata than Hst 5 alone in both planktonic and biofilm growth and that Hst 54-15-Spd retained high activity in both serum and saliva. Hst 54-15Spd was not bactericidal against streptococcal oral commensal bacteria and had no hemolytic activity. We tested the effectiveness of Hst 54-15-Spd in vivo by topical application to tongue surfaces of immunocompromised mice with OPC. Mice treated with Hst 54-15-Spd had significant clearance of candidal tongue lesions macroscopically, which was confirmed by a 3- to 5-log fold reduction of C. albicans colonies recovered from tongue tissues. Hst 54-15-Spd conjugates are a new class of peptide-based drugs with high selectivity for fungi and potential as topical therapeutic agents for oral candidiasis. References: 1. Han J1, Jyoti MA1, Song HY1,2, Jang WS2. Antifungal Activity and Action Mechanism of Histatin 5-Halocidin Hybrid Peptides against Candida ssp. PLoS One. 2016 Feb 26;11(2):e0150196. doi: 10.1371/journal.pone.0150196. eCollection 2016. 2. Moffa EB1, Mussi MC2, Xiao Y3, Garrido SS4, Machado MA5, Giampaolo ET6, Siqueira WL3. Histatin 5 inhibits adhesion of C. albicans to Reconstructed Human Oral Epithelium. Front Microbiol. 2015 Aug 28;6:885. 3. Scaria PV1, Liu Y, Leng Q, Chou ST, Mixson AJ, Woodle MC. Enhancement of antifungal activity by integrin-targeting of branched histidine rich peptides. J Drug Target. 2014 Jul;22(6):536-42. 662 4. Tati S1, Li R, Puri S, Kumar R, Davidow P, Edgerton M. Histatin 5-spermidine conjugates have enhanced fungicidal activity and efficacy as a topical therapeutic for oral candidiasis. Antimicrob Agents Chemother. 2014;58(2):756-66. 9. Lactoferrin       Lactoferrin (Lf) is a multifunctional protein (80 kDa), a member of the transferrin family of non-heme iron-binding glycoproteins that is expressed and secreted by granular epithelial cells and secreted into mucosal fluids that bathe the body surface; it is found in the secondary granules of neutrophils during the myelocyte stage of maturation (Ward et al. 2005; Levay and Viljoen 1995). Lactoferrin was first isolated from bovine milk and later identified in mice, pigs, and humans (van der Weerden et al. 2013). On the mucosal surface, this peptide works as a component of the first line of host defense, being released from neutrophils during infection, inflammation, tumor development, and iron overload (Levay and Viljoen 1995; Legrand et al. 2008). Lactoferrin also acts in the regulation of iron homeostasis, cellular growth, and differentiation and protection against cancer development and metastasis (Ward et al. 2005; Shimamura et al. 2004). Lactoferrin proteolytic cleavages revealed some peptides (lactoferricins) with better antifungal activity than that of the whole protein, such as the first and second cationic domains derived from human lactoferrin (hLF) hLF (1–11) and hLF (21–31), respectively (Lupetti et al. 2000). A study using those synthetic peptides revealed a dose-dependent release of ATP by C. albicans upon exposure to hLF (1–11). o The same study demonstrated that a metabolic active cell is necessary for the hLF (1–11) mode of action, since cells incubated with sodium azide had a reduced candidacidal activity and a lower PI uptake. o The use of the fluorescent dye rhodamine 123 showed an accumulation inside the mitochondria and later was released into the cytoplasm when cells were treated with hLF (1–11), which indicates that the peptide triggers the energized mitochondrion (Lupetti et al. 2000). Another study showed that cell wall interaction and therefore membrane binding with hLF are not the major mode of action, thus demonstrating a slight efflux of K + from C. albicans cells, but this did not allow Na + release or membrane disruption (Viejo-Diaz et al. 2004). Recent reports: Bruni et al. 2016) mentioned that antimicrobial peptides (AMPs) represent a vast array of molecules produced by virtually all living organisms as natural barriers against infection. Among AMP sources, an interesting class regards the food-derived bioactive agents. The whey protein lactoferrin (Lf) is an iron-binding glycoprotein that plays a significant role in the innate 663 immune system, and is considered as an important host defense molecule. In search for novel antimicrobial agents, Lf offers a new source with potential pharmaceutical applications. The Lfderived peptides Lf(1-11), lactoferricin (Lfcin) and lactoferrampin exhibit interesting and more potent antimicrobial actions than intact protein. Particularly, Lfcin has demonstrated strong antibacterial, anti-fungal and antiparasitic activity with promising applications both in human and veterinary diseases (from ocular infections to osteo-articular, gastrointestinal and dermatological diseases). Morici et al. (2016) evaluated the in vitro activity of the synthetic peptide hLF1-11 against biofilm produced by clinical isolates of Candida albicans with different fluconazole susceptibility. The antibiofilm activity of the peptide hLF1-11 was assessed in terms of reduction of biofilm cellular density, metabolic activity and sessile cell viability. The extent of morphogenesis in hLF1-11 treated and untreated biofilms was also investigated microscopically. Transcription levels of genes related to cell adhesion, hyphal development and extracellular matrix production were analysed by qRT-PCR in hLF1-11 treated and untreated biofilms. Exogenous dibutyryl-cAMP (db-cAMP) was used to rescue morphogenesis in cells exposed to the peptide. The results revealed that hLF1-11 exhibited an inhibitory effect on biofilm formation by all C. albicans isolates tested in a dose-dependent manner, regardless of their fluconazole susceptibility. Visual inspection of treated or untreated biofilm cells with an inverted microscope revealed a significant reduction in hyphal formation by hLF1-11 treated cells, as early as 3 hours of incubation. Moreover, hLF1-11 showed a reduced activity on preadherent cells. hLF1-11 induced the down-regulation of biofilm and hyphal-associated genes, which were predominantly regulated via the Ras1-cAMP-Efg1 pathway. Indeed, exogenous db-cAMP restored morphogenesis in hLF1-11 treated cells. The hLF1-11 peptide significantly inhibited biofilm formation by C. albicans mainly at early stages, interfering with biofilm cellular density and metabolic activity, and affected morphogenesis through the Ras1-cAMP-Efg1 pathway. Our findings provide the first evidence that hLF1-11 could represent a potential candidate for the prevention of biofilm formation by C. albicans. Rastogi et al. (2014) been bovine lactoferrin hydrolyzed by trypsin, the major enzyme present in the gut, to produce three functional molecules of sizes approximately 21 kDa, 38 kDa and 45 kDa. The molecules have been purified using ion exchange and gel filtration chromatography and identified using N-terminal sequencing, which reveals that while the 21 kDa molecule corresponds to the N2 domain (21LF), the 38 kDa represents the whole C-lobe (38LF) and the 45 kDa is a portion of N1 domain of N-lobe attached to the C-lobe (45LF). The iron binding and release properties of 21LF, 38LF and 45LF have been studied and compared. The sequence and structure analysis of the portions of the excision sites of LF from various species have been done. The antibacterial properties of these three molecules against bacterial strains, Streptococcus pyogenes, Escherichia coli, Yersinia enterocolitica and Listeria monocytogenes were investigated. The antifungal action of the molecules was also evaluated against Candida albicans. This is the first report on the antimicrobial actions of the trypsin cleaved functional molecules of lactoferrin from any species. References: 1. Bruni N1, Capucchio MT2, Biasibetti E3, Pessione E4, Cirrincione S5, Giraudo L6, Corona A7, Dosio F8. Antimicrobial Activity of Lactoferrin-Related Peptides and Applications in 664 Human and Veterinary Medicine. Molecules. 2016 Jun 11;21(6). pii: E752. doi: 10.3390/molecules21060752. 2. Rastogi N1, Nagpal N2, Alam H3, Pandey S1, Gautam L1, Sinha M1, Shin K4, Manzoor N3, Virdi JS2, Kaur P1, Sharma S1, Singh TP1. Preparation and antimicrobial action of three tryptic digested functional molecules of bovine lactoferrin. PLoS One. 2014 Mar 3;9(3):e90011. doi: 10.1371/journal.pone.0090011. eCollection 2014. 3. Morici P1, Fais R1, Rizzato C1, Tavanti A2, Lupetti A1. Inhibition of Candida albicans Biofilm Formation by the Synthetic Lactoferricin Derived Peptide hLF1-11. PLoS One. 2016 Nov 30;11(11):e0167470. doi: 10.1371/journal.pone.0167470. eCollection 2016. 10. Synthetic Antifungal Peptides B4010     B4010 is a synthetic peptide originated from a 10-residue peptide (RGRKVVRRKK), which in turn is a synthetic analogue of human β-defensin-3 (HβD-3). B4010 properties have been previously reported by Lakshminarayanan and coworkers (2014) as showing potent activity against Pseudomonas aeruginosa, but poor activity against fungi (Bai et al. 2009). B4010 presented deleterious activity against C. albicans strains (Lakshminarayanan et al. 2014). B4010 MIC values (0.37 μM) for two clinical isolates of C. albicans were lower when compared to the MIC values for amphotericin B (1.4 μM) and natamycin (15 μM). CPPs (Cell-penetrating peptides)      CPPs are part of a group of synthetic peptides with up to 30 peptides and are able to enter cells in an energy-independent manner, translocating across the membrane (Milletti 2012). Penetratin 1 is a 16 amino acid long CPP from the third helix of the Antennapedia homeodomain of Drosophila. Penetratin 1 can be classified as a cationic amphipathic peptide, and its proposed mechanism of action is by ―inverted micelle‖ pathway. Penetratin 1 was synthetized and had its fungicidal activity evaluated by Masman and coworkers (2009). Penetratin 1 displayed the most potent inhibitory effect against against C. albicans and C. neoformans (Garibotto et al. 2010; Masman et al. 2009). Recent reports: Ciociola et al. (2016) presented a brief overview on antifungal natural peptides of animals, plants, micro-organisms, peptide fragments derived by proteolytic cleavage of physiological 665 proteins (cryptides), synthetic unnatural peptides and peptide derivatives. Antifungal peptides are schematically reported based on their structure, antifungal spectrum and reported effects. Natural or synthetic peptides and their modified derivatives may represent the basis for new compounds active against fungal infections. Neelabh et al. (2016) explored antifungal peptides naturally produced by prokaryotes as well as eukaryotes. They are components of innate immune system providing first line of defence against microbial attacks, especially in eukaryotes. The present article concentrates on types, structures, sources and mode of action of gene-encoded antifungal peptides such as mammalian defensins, protegrins, tritrpticins, histatins, lactoferricins, antifungalpeptides derived from birds, amphibians, insects, fungi, bacteria and their synthetic analogues such as pexiganan, omiganan, echinocandins and Novexatin. In silico drug designing, a major revolution in the area of therapeutics, facilitates drug development by exploiting different bioinformatics tools. With this view, bioinformatics tools were used to visualize the structural details of antifungal peptides and to predict their level of similarity. Current practices and recent developments in this area have also been discussed briefly. Stensen et al. (2016) evaluated five syntheticcationic antimicrobial tripeptides as antifungal therapeutics against 24 pathogenic strains of fungi. Three of the peptidesdisplayed strong general antifungal properties at low micromolar inhibitory concentrations. The most promising peptide, compound 5, was selected and evaluated as an antifungal remedy for Candida albicans candidiasis in a human skin model and for the treatment of Trichophyton rubrum induced onychomycosis in an infected human nail model. Compound 5 was shown to display antifungal properties and a rapid mode of action superior to those of both the commercial comparators Loceryl and Lamisil. Compound 5 was also active against a clinical isolate of Candida albicans with acquired fluconazole resistance. Lum et al. (2015) used two peptides, KABT-AMP and uperin 3.6 as templates to develop novel antifungal peptides. Their anticandidal activity was assessed using a combination of MIC, time-killing assay and biofilm reduction assay. Hybrid peptides, KU2 and KU3 containing a mixed backbone of KABT-AMP and Uperin 3.6 demonstrated the most potent anticandidal activity with MIC values ranging from 8-16 mg/L. The number of Trp residues and the amphipathic structure of peptidesprobably enhanced the anticandidal activity of peptides. Increasing the cationicity of the uperin 3.6 analogues resulted in reduced MIC from the range of 64-128 mg/L to 16-64 mg/L and this was also correlated with the antibiofilm activity and killing kinetics of the peptides. Peptidesshowed synergistic effects when used in combination with conventional antifungals. Peptides demonstrated low haemolytic activity but significant toxicity on two normal human epithelial cell lines. This study provides us with a better understanding on the structure-activity relationship and the balance between cationicity and hydrophobicity of the peptides although the therapeutic application of the peptides is limited. Mora-Navarro et al. (2015) reported for the first time the inhibition achieved in Candida albicans when treated with a mixture of a β-peptide model and fluconazole or ketoconazole. This combination treatment enhanced the biological activity of these azoles in planktonic and biofilm Candida, and also in a fluconazole-resistant strain. Furthermore, the in vitro cytotoxicity of the dual treatment was evaluated towards the human hepatoma cell line, HepG2, a widely used model derived from liver tissue, which is primarily affected by azoles. Analyses based on the LA-based method and the mass-action law principle, using a microtiter 666 checkerboard approach, revealed synergism of the combination treatment in the inhibition of planktonic C. albicans. The dual treatment proved to be fungicidal at 48 and 72 h. Interestingly, it was also found that the viability of HepG2 was not significantly affected by the dual treatments. Finally, a remarkable enhancement in the inhibition of the highly azole-resistant biofilms and fluconazole resistant C. albicans strain was obtained. Lakshminarayanan et al. (2014) described antifungal activity and possible mechanism of action of tetravalent peptide (B4010) which carries 4 copies of the sequence RGRKVVRR through a branched lysine core. B4010 displayed better antifungal properties than natamycin and amphotericin B. The peptide retained significant activity in the presence of monovalent/divalent cations, trypsin and serum and tear fluid. Moreover, B4010 is non-haemolytic and non-toxic to mice by intraperitoneal (200 mg/kg) or intravenous (100 mg/kg) routes. S. cerevisiae mutant strains with altered membrane sterol structures and composition showed hyper senstivity to B4010. The peptide had no affinity for cell wall polysaccharides and caused rapid dissipation of membrane potential and release of vital ions and ATP when treated with C. albicans. We demonstrate that additives which alter the membrane potential or membrane rigidity protect C. albicans from B4010-induced lethality. References: Ciociola T1, Giovati L1, Conti S1, Magliani W1, Santinoli C1, Polonelli L1. Natural and synthetic peptides with antifungal activity. Future Med Chem. 2016 Aug;8(12):141333. Lakshminarayanan R1, Liu S1, Li J2, Nandhakumar M3, Aung TT3, Goh E3, Chang JY3, Saraswathi P3, Tang C4, Safie SR3, Lin LY3, Riezman H5, Lei Z1, Verma CS6, Beuerman RW7. Synthetic multivalent antifungal peptides effective against fungi. PLoS One. 2014 Feb 3;9(2):e87730 Lum KY1, Tay ST1, Le CF2, Lee VS3, Sabri NH3, Velayuthan RD1, Hassan H1, Sekaran SD1. Activity of Novel Synthetic Peptides against Candida albicans. Sci Rep. 2015 May 12;5:9657. doi: 10.1038/srep09657. Mora-Navarro C1, Caraballo-León J1, Torres-Lugo M1, Ortiz-Bermúdez P1. Synthetic antimicrobial β-peptide in dual-treatment with fluconazole or ketoconazole enhances the in vitro inhibition of planktonic and biofilm Candida albicans. J Pept Sci. 2015 Dec;21(12):853-61. Neelabh1, Singh K2, Rani J1 . Sequential and Structural Aspects of Antifungal Peptides from Animals, Bacteria and Fungi Based on Bioinformatics Tools. Probiotics Antimicrob Proteins. 2016 Jun;8(2):85-101. Stensen W1,2, Turner R3, Brown M3,4, Kondori N5, Svendsen JS1,2, Svenson J6. Short Cationic Antimicrobial Peptides Display Superior Antifungal Activities toward Candidiasis and Onychomycosis in Comparison with Terbinafine and Amorolfine. Mol Pharm. 2016 Oct 3;13(10):3595-3600. Epub 2016 Sep 6. 667 7.13. Boric Acid: Alternative Names: Acidum boricum, boracic acid, hydrogen borate, orthoboric acid.    Boric acid is a weak acid derived from minerals that has mild antiseptic and antifungal properties. Boric acid, derived from boron, is actually an antifungal cure-all of sorts. Boric acid is the key ingredient in a variety of effective and affordable home remedies for some of the most common fungal infections, including athlete‘s foot and vaginal yeast infections.  Formula: H3BO3 Uses       Boric acid is used topically Boric acid is available in powder and/or suppository form from many pharmacies Boric acid actually work as a natural and effective treatment for a vaginal yeast infection. Some experts now recommend vaginal BA capsules as a treatment option for vaginal yeast infections, particularly infections that can‘t be cured by antifungal yeast infection medicines. Boric acid is used as a suppository before bed for one to two weeks. The CDC reports that this regimen has clinical and mycologic eradication rates of approximately 70 percent. Boric acid power can also treat fungal infections, such as athlete‘s foot and toenail fungus. Just a few sprinkles of the BA powder in socks or stockings can help clear mild infections and ease the itching associated with athlete‘s foot. Several cases using boric acid for the treatment of azole-refractory candidal vaginitis have been reported. . Mechanism of action    Boric acid is a weak, topical, bacteriostatic, and fungistatic agent; however, the exact mechanism of action is unclear. Boric acid antifungal properties can be explained by its ability to prevent the yeast-tohyphae transition of C. albicans at doses that are not fully inhibitory to growth (De Seta et al., 2009). The cytoskeleton appears to be a direct or indirect target of BA action in yeast. In the model yeast Saccharomyces cerevisiae, it has been demonstrated that BA destabilizes the cytoskeleton at the bud neck, causing a cytokinesis defect (Schmidt et al., 2010). 668   Boric acid fungistatic activity may be mediated by vaginal acidification, resulting in fungal cell wall penetration and disruption of the fungal cell membrane. Conversely, studies evaluating the minimum inhibitory concentration of boric acid indicated that boric acid works at a pH similar to that of the untreated vaginal tract, and, therefore, the action may not be simply due to an increase in acidity. Spectrum of activity     Boric acid is most often associated with antifungal activity, although further elucidation is necessary. In vitro studies of boric acid concentrations ranging from 0.4-5.0% have been demonstrated to inhibit clinical isolates of Candida albicans and 500 mg of boric acid has reportedly killed 50-90% of C. albicans isolates in 48 hours. Boric acid may also possess antifungal activity against Saccharomyces cerevisiae, Other non-C, albicans species against which boric acid may possess activity include Candida parapsilosis, Candida krusei, Candida tropicalis, and Trichosporon beigelii. Pharmacokinetics         Boric acid is rapidly and completely absorbed following oral ingestion and is well absorbed through denuded and abraded skin in solution or as a dry powder. Boric acid absorption has been reported to be negligible through intact skin in the presence of alkaline salts. Boric acid, once absorbed, is widely distributed throughout body water and accumulates in the brain, liver, and kidneys. Boric acid is not appreciably metabolized and is primarily excreted unchanged by the kidneys, with about 50% excreted within twelve hours of administration1 and 90% of excretion occurring within 96 hours, Minimal amounts are excreted in feces, sweat, and saliva In a study evaluating vaginal absorption of boric acid following the intravaginal administration of one to two 600-mg boric acid capsules for one to two weeks in eight healthy volunteers, daily blood boron concentrations of less than lag/mL during use (mean level, 42 pg/mL) were reported Blood boron analysis following vaginal insertion of a single 600-mg boric acid capsule in one healthy volunteer revealed systemic boric acid absorption of approximately 6% from the vagina and a serum half-life of about 10.5 hours. A half life of 21 hours has been reported following administration of a 600-mg intravenous bolus to eight healthy males. Metabolism  Boric acid is not metabolized in either animals or humans, owing to the high energy level required (523 kJ/mol) to break the B–O bond (Emsley, 1989). Other inorganic borates convert to boric acid at physiological pH in the aqueous layer overlying the mucosal surfaces prior to absorption. Additional support for this derives from studies in which more than 90% of administered doses of inorganic borates are excreted in the urine as boric acid. 669  Boric acid is a very weak and exclusively monobasic acid that is believed to act, not as a proton donor, but as a Lewis acid, i.e., it accepts OH−. Because of the high pKa, regardless of the form of inorganic borate ingested (e.g., boric acid, disodium tetraborate decahydrate or boron associated with animal or plant tissues), uptake is almost exclusively (>98%) as undissociated boric acid. Clinical applications   Boric acid may be considered as an alternative in azole-resistant Candida strains or refractory cases of chronic, recurrent vulvovaginal candidiasis. Boric acid should not be used in pregnant women due the risk of teratogenic effects and the lack of data demonstrating safety, Side effects and interactions                Short courses of intravaginal boric acid are generally well tolerated. The adverse effects reported most frequently are mild and include watery discharge, erythema, and a burning sensation; also, a partner reported a gritty sensation with intercourse during the treatment period. The risk of systemic toxicity depends on the concentration used, route of administration, age of the patient, skin condition, and duration of exposure. The fatal adult dose is thought to be about 20 grams or 0.1-0.5 mg/kg taken orally. Boric acid poisoning affects multiple organ systems including the gastrointestinal tract, central nervous system (CNS), skin, liver, and kidneys. Vomiting, diarrhea, and abdominal pain are the most common symptoms. Excitement of the CNS followed by malaise, lethargy, headache, seizures, coma, and hyperpyrexia also occurs. Additionally, an erythematous, vesicular, or papular rash with desquamatization, referred to as boiled lobster syndrome, may be observed. The kidneys are probably the most seriously affected of all the organs involved, resulting in renal tubular necrosis, anuria, and albuminuria. Death resulting from cardiovascular collapse, shock, or respiratory failure may occur within 3-5 days of acute poisoning. The risk of systemic toxicity due to vaginal administration of boric acid is minimal. Symptoms of chronic intoxication include anorexia, gastrointestinal disturbances, weakness, confusion, dermatitis, menstrual disorders, anemia, seizures, and alopecia. No drug-drug interactions have been reported involving boric acid. Boric acid vaginal suppositories may include vaginal burning and irritation. Boric acid is poisonous if taken internally or inhaled in large quantities Boric acid should NOT be placed on wounds. Boric acid shouldn't be used for a prolonged period of time, or in amounts greater than recommended. Boric acid should not be used by pregnant women or applied to the skin of infants or children. Boric acid solutions used as an eye wash or on abraded skin are known to be especially toxic to infants. 671 Brands Recent reports: Schmidt (2017) investigated the effect of BA on growth and morphology of T. rubrum. This is of particular interest since BA facilitates wound healing, raising the possibility that treating athlete‘s foot with BA, either alone or in combination with other antifungal drugs, would combine the benefits of antimicrobial activity and tissue regeneration to accelerate healing of infected skin. The data presented here show that BA represses T. rubrum growth at a concentration reported to be beneficial for host tissue regeneration. Oxygen exposure increases BA toxicity, and mycelia growing under BA stress avoid colonizing the surface of the growth surface, which leads to a suppression of aerial mycelium growth and surface conidia formation. BA penetrates into solid agar matrices, but the relative lack of oxygen below the substrate surface limits the effectiveness of BA in suppressing growth of embedded T. rubrum cells. Romsaithong et al. (2016) compared the clinical effectiveness and adverse events for 3 per cent boric acid in 70 per cent alcohol versus 1 per cent clotrimazole solution in the treatment of 671 otomycosi A total of 120 otomycosis patients were randomly assigned to receive either 1 per cent clotrimazole solution (intervention group) or 3 per cent boric acid in 70 per cent alcohol (control group) at the Khon Kaen Hospital ENT out-patient department. Treatment effectiveness was determined based on the otomicroscopic absence of fungus one week after therapy, following a single application of treatment. After 1 week of treatment, there were data for 109 participants, 54 in the clotrimazole group and 55 in the boric acid group. The absolute difference in cure rates between 1 per cent clotrimazole solution and 3 per cent boric acid in 70 per cent alcohol was 17.9 per cent (95 per cent confidence interval, 2.3 to 33.5; p = 0.028) and the number needed to treat was 6 (95 per cent confidence interval, 3.0 to 43.4). Adverse events for the two agents were comparable. CONCLUSION: One per cent clotrimazole solution is more effective than 3 per cent boric acid in 70 per cent alcohol for otomycosis treatment. Pointer et al. (2015) proved that exposure of Candida albicans to sub-lethal concentrations of boric acid (BA) restricts the dimorphic fungus to its yeast morphology and prevents the formation of invasive hyphae on solid substrates. Exposure to BA causes a rapid and reversible disappearance of polarisome and Spitzenkörper in growing hyphae. In BA-treated hyphae of C. albicans, actin quickly reorganizes from cytoplasmic cables to cortical patches and cell wall growth switches from an apical to an isotropic pattern. As a result of the cytoskeletal changes, the hyphal tips broaden and directional growth of hyphae ceases in the presence of BA. An analysis of homozygous deletion strains showed that mutants with constitutive or enhanced hyphal growth (tup1, nrg1, ssn6, rbf1) are BA-sensitive, demonstrating that cellular morphology is a major determinant of BA tolerance. The screening of deletion mutants also showed that deficiencies of the main activator of hyphal gene expression, Efg1, and the Rim101-signalling cascade, leading to Efg1 activation, cause BA resistance. Taken together, the data presented show that the selective inhibitory effect on BA on C. albicans hyphae is rooted in a disruption of apical cytoskeletal elements of growing hyphae. Khameneie et al. (2014) studied the efficiency of Fluconazole and boric acid in preventing recurrence of vaginal candidiasis. Seventy five patients out of total 150 patients with signs and symptoms related to vulvo vaginal candidiasis were treated with boric acid powder everynight for a week and the remaining 75 patients received Fluconazole. The cure rate in first group was 46.7% but the cure rate in second group was 37.3%. The difference was not statistically significant (P>0.3). Difference between the efficacy of the two drugs was not significant either (P=0.47). The recurrence rate among patients in first group was 35% while it was 32% in second group. Their difference was not statistically significant (P=0.54). CONCLUSION: According to our findings, treatment of vaginal candidiasis with boric acid is as effective as fluconazole. The availability of boric acid and its relatively low cost suggests it as a safe and effective drug for treatment of candidiasis Saindane et al. (2013) mentioned that Boric acid is naturally occurring compound containing the elements boron, oxygen, and hydrogen (H3BO3). In nature, the element boron does not exist by itself. Boron is combined with other common elements, such as sodium to make salts like borax and with oxygen to make boric acid. The main cause of vaginal diseases is Yeasts. Yeast is a fungus scientifically referred to as Candida. The specific type of fungus most commonly responsible for vaginitis is Candida albicans. The Fungal strains used to assess the study are Candida species, Candida albicans, Candida parapsilosis, Candida tropicalis. The method used for investigate the boric acid effect is of agar well diffusion. The zone of inhibition was 672 measured and calculated. The zone of inhibition observed for the three strains varied for different concentration. The maximum zone of inhibition for candida albicans was 2.5 cm or 25 mm for 3 mg in 1ml dilution was observed in candida albicans compared to the other strains. Supporting to the results obtained we aim to further screen the pathogens study there biochemical and characteristic properties of boric acid and work on the dilutions and its composition to prepare a suitable and effective remedy against the pathogens responsible for vaginal infections because Boric Acid treatment mainly causes cells to form irregular septa and leads to the synthesis of irregular cell wall protuberances that extend far into the cytoplasm. Kalkanci et al. (2012) tested 207 vaginal yeast isolates recovered from pregnant women for susceptibility to 13 antifungal drugs and boric acid and through these studies four virulence factors were also determined. The isolates were recovered from vaginal samples of patients with acute VVC [AVVC, (n = 73)], symptomatic recurrent VVC [RVVC, (n = 89)], asymptomatic RVVC (n = 27), and those without signs and symptoms (n = 18). Candida albicans was the most common species found (59.9%), followed by C. glabrata (19.8%), other Candida spp., (19.8%), and Saccharomyces cerevisiae (0.5%). Antifungal susceptibility testing was performed as described in CLSI document M27-A3. Additionally, we examined phospholipase and proteinase production, adhesion to vaginal epithelial cells and hemolytic activity. Notably, the MIC values of Candida spp. isolates derived from patients with VVC were no different from those of the controls (P > 0.05). In addition, Candida isolates derived from patients with AVVC or RVVC produced significantly higher amounts of phospholipase and proteinase compared with the controls (P < 0.05). Antifungal testing and the determination of virulence factors may lead to the effective and prompt treatment of VVC, particularly in pregnant women. Iavazzo et al. (2011) searched PubMed and Scopus for studies that reported clinical evidence on the intravaginal use of boric acid for vulvovaginal candidiasis. They identified 14 studies (2 randomized clinical trials [RCTs], 9 case series, and 4 case reports) as eligible for inclusion in this review. Boric acid was compared with nystatin, terconazole, flucytosine, itraconazole, clotrimazole, ketoconazole, fluconazole, buconazole, and miconazole; as monotherapy, boric acid was studied in 7 studies. The mycologic cure rates varied from 40% to 100% in patients treated with boric acid; 4 of the 9 included case series reported statistically significant outcomes regarding cure (both mycologic and clinical) rates. None of the included studies reported statistically significant differences in recurrence rates. Regarding the adverse effects caused by boric acid use, vaginal burning sensation (<10% of cases), water discharge during treatment, and vaginal erythema were identified in 7 studies. The findings suggest that boric acid is a safe, alternative, economic option for women with recurrent and chronic symptoms of vaginitis when conventional treatment fails because of the involvement of non-albicans Candida spp. or azoleresistant strains. De Seta et al. (2009) used in vitro methods to understand the spectrum and mechanism of boric acid as a potential treatment for vaginal infection. Yeast and bacterial isolates were tested by agar dilution to determine the intrinsic antimicrobial activity of boric acid. Established microbial physiology methods illuminated the mechanism of the action of boric acid against Candida albicans. C. albicans strains (including fluconazole-resistant strains) were inhibited at concentrations attainable intravaginally; as were bacteria. Broth dilution MICs were between 1563 and 6250 mg/L and boric acid proved fungistatic (also reflected by a decrease in CO(2) generation); prolonged culture at 50,000 mg/L was fungicidal. Several organic acids in yeast 673 nitrogen broth yielded a lower pH than equimolar boric acid and sodium borate but were less inhibitory. Cold or anaerobic incubation protected yeast at high boric acid concentrations. Cells maintained integrity for 6 h in boric acid at 37 degrees C, but after 24 h modest intrusion of propidium iodide occurred; loss of plate count viability preceded uptake of vital stain. Growth at sub-MIC concentrations of boric acid decreased cellular ergosterol. The drug efflux pump CDR1 did not protect Candida as CDR1 expression was abrogated by boric acid. Boric acid interfered with the development of biofilm and hyphal transformation. CONCLUSIONS: Boric acid is fungistatic to fungicidal depending on concentration and temperature. Inhibition of oxidative metabolism appears to be a key antifungal mechanism, but inhibition of virulence probably contributes to therapeutic efficacy in vivo. Recent references: 1. De Seta F1, Schmidt M, Vu B, Essmann M, Larsen B. Antifungal mechanisms supporting boric acid therapy of Candida vaginitis. J Antimicrob Chemother. 2009 Feb;63(2):325-36. 2. Iavazzo C1, Gkegkes ID, Zarkada IM, Falagas ME. Boric acid for recurrent vulvovaginal candidiasis: the clinical evidence. J Womens Health (Larchmt). 2011 Aug;20(8):1245-55. 3. Kalkanci A1, Güzel AB, Khalil II, Aydin M, Ilkit M, Kuştimur S. Yeast vaginitis during pregnancy: susceptibility testing of 13 antifungal drugs and boric acid and the detection of four virulence factors. Med Mycol. 2012 Aug;50(6):585-93. 4. Khameneie KM1, Arianpour N, Roozegar R, Aklamli M, Amiri MM. Fluconazole and boric acid for treatment of vaginal candidiasis--new words about old issue. East Afr Med J. 2013 Apr;90(4):117-23. 5. Pointer, B.R., Michael P. Boyer, Martin Schmidt. Boric acid destabilizes the hyphal cytoskeleton and inhibits invasive growth of Candida albicans. Yeast. Apr 2015, Vol. 32, No. 4: 389-398 6. Romsaithong S1, Tomanakan K2, Tangsawad W1, Thanaviratananich S3. Effectiveness of 3 per cent boric acid in 70 per cent alcohol versus 1 per cent clotrimazole solution in otomycosis patients: a randomised, controlled trial. J Laryngol Otol. 2016 Sep;130(9):811-5. 7. Saindane Dinesh, Pabal Ajit, Purane Madhav, Patil Chetan and Pandit Prachi Study of antifungal activity of boric acid on vaginal pathogens. International Journal of Advanced Biotechnology and Research ISSN 0976-2612, Online ISSN 2278–599X, Vol 4, Issue 3, 2013, pp 319-323 8. Schmidt.M. Boric Acid Inhibition of Trichophyton rubrum Growth and Conidia Formation 9. Biol Trace Elem Res. 2017 Apr 8. doi: 10.1007/s12011-017-1019-x 674 7.14. Ciclopirox    Ciclopirox olamine (used in preparations called Batrafen, Loprox, Mycoster, Penlac and Stieprox) Ciclopirox is a synthetic antifungal agent for topical dermatologic treatment of superficial mycoses. Ciclopirox is most useful against Tinea versicolor. Chemical Names: CICLOPIROX; 29342-05-0; Loprox; Penlac; Ciclopiroxum; Batrafen Molecular Formula: C12H17NO2 Pharmacodynamics  Ciclopirox is a broad-spectrum antifungal medication that also has antibacterial and antiinflammatory properties.  Ciclopirox is thought to have high affinity for trivalent cations, which inhibit essential co-factors in enzymes.  Ciclopirox exhibits either fungistatic or fungicidal activity in vitro against a broad spectrum of fungal organisms, such as dermatophytes, yeasts, dimorphic fungi, eumycetes, and actinomycetes.  Ciclopirox also exerts antibacterial activity against many Gram-positive and Gramnegative bacteria.  Ciclopirox inhibitsed the synthesis of prostaglandin and leukotriene.  Ciclopirox can also exhibit its anti-inflammatory effects by inhibiting the formation of 5lipoxygenase and cyclooxygenase. Mechanism of action  Ciclopirox is thought to act through the chelation of polyvalent metal cations, such as Fe3+ and Al3+.  These cations inhibit many enzymes, including cytochromes, thus disrupting cellular activities such as mitochondrial electron transport processes and energy production.  Ciclopirox also appears to modify the plasma membrane of fungi, resulting in the disorganization of internal structures.  Ciclopirox anti-inflammatory action is most likely due to inhibition of 5-lipoxygenase and cyclooxygenase. 675  Ciclopirox may exert its effect by disrupting DNA repair, cell division signals and structures (mitotic spindles) as well as some elements of intracellular transport Absorption  Ciclopirox is rapidly absorbed after oral administration.  Ciclopirox mean absorption after application to nails of all twenty digits and adjacent 5 millimeters of skin once daily for 6 months in patients with dermatophytic onychomycoses was less than 5% of the applied dose.  Ciclopirox olamine also penetrates into hair and through the epidermis and hair follicles into sebaceous glands and dermis. Protein binding  Protein binding is 94-97% following topical administration Route of elimination  Most of the compound is excreted either unchanged or as glucuronide.  After oral administration of 10 mg of radiolabeled drug (14C-ciclopirox) to healthy volunteers, approximately 96% of the radioactivity was excreted renally within 12 hours of administration.  Ninety-four percent of the renally excreted radioactivity was in the form of glucuronides. Toxicity  Oral LD50 in rat is >10 ml/kg. Symptoms of overexposure include drowsiness and headache. Generic Name: Ciclopirox olamine Dosage Form: cream For Dermatologic Use Only Not For Use In Eyes Rx Only Ciclopirox Description Ciclopirox Olamine Cream USP, 0.77% is for topical use. Each gram of Ciclopirox Olamine Cream USP, 0.77% contains 7.70 mg of Ciclopirox (as Ciclopirox olamine) in a water miscible 676 Recent reports: Lukášová et al. (2017) evaluated the pharmacokinetic parameters of ciclopirox olamine after the buccal application of mucoadhesive film prepared by the solvent casting method. A chromatographic method using an internal standard was developed and validated for evaluation of ciclopirox olamine plasma concentrations. Method accuracy was 88.5-104.6% and 89.599.7% for interday and intraday assays, respectively. The pharmacokinetic properties of ciclopirox olamine were studied in New Zealand White rabbits. The mucoadhesive films containing ciclopirox olamine in a total dose of 34.4 (33.0; 35.9) mg kg-1 were applied to all the rabbits. Plasma ciclopirox olamine concentrations were determined during the 12 h following application. The time taken to reach maximum plasma concentration was 1.7 (1.1; 2.2) h after the drug administration with cmax 5.73 (4.18; 7.28) μg mL-1. Overall elimination half-life was 3.8 (1.9; 10.8) h. Iorizzo et al. (2016) reported a randomized, controlled, parallel-group clinical trial with a blinded evaluator, designed to compare the efficacy and safety of the nail lacquer P-3051 with amorolfine 5% in the treatment of mild-to-moderate toenail onychomycosis. Patients were treated for 48 weeks with P-3051 daily, or twice weekly with amorolfine 5%. Out of 120 677 evaluable patients, 60 (50.0%) received P-3051 and 60 (50.0%) amorolfine 5%. At baseline, the two groups were homogeneous in terms of race, pathogens, number of affected toenails and severity of the infected target nail area. The statistical superiority of P-3051 versus amorolfine was achieved after 48 weeks (treatment success: 58.3% for P-3051 vs. 26.7% for amorolfine, p < 0.001; complete cure: 35.0% for P-3051 vs. 11.7% for amorolfine, p < 0.001). Mycological cure at week 48 was achieved in all patients treated with P-3051 compared to 81.7% of patients treated with amorolfine (p < 0.001). Moreover, fungal eradication by P-3051 was statistically superior at week 24. The results of this study, and of a previous pivotal study versus the insoluble formulation of ciclopirox8%, led to consider P-3051 as the gold standard for the topical treatment of mild-to-moderate onychomycosis. Urbanova et al. (2016) demonstrated he structural diversity of these complex multicomponent and mostly multiphase systems as well as an experimental strategy for their structural characterization at molecular scale with atomic resolution using MBFs of ciclopirox olamine (CPX) in a poly(ethylene oxide) (PEO) matrix as a case study. A detailed description of each component of the CPX/PEO films was followed by an analysis of the relationships between each component and the physicochemical properties of the MBFs. Two distinct MBFs were identified by solid-state NMR spectroscopy: (i) at low API (active pharmaceutical ingredient) loading, a nanoheterogeneous solid solution of CPX molecularly dispersed in an amorphous PEO matrix was created; and (ii) at high API loading, a pseudoco-crystalline system containing CPX-2aminoethanol nanocrystals incorporated into the interlamellar space of a crystalline PEO matrix was revealed. Tabara et al. (2015) mentioned that Amorolfine 5% and ciclopirox 8% nail lacquers are commonly used in topical treatment of onychomycosis. These formulations may be used alone or in combination with oral antifungal agents. Amorolfine and ciclopirox are valuable therapeutic options, however, their usage in monotherapy should be limited. Proper amorolfine and ciclopirox penetration through the nail plate is provided by transungual drug delivery systems. Although amorolfine and ciclopirox have a different mode of action, they both exhibit a broad antifungal activity. The use of antifungal nail lacquers in combination with oral agents, such as terbinafine and itraconazole, improves efficacy of antifungal therapy References: 1. Iorizzo M1, Hartmane I2, Derveniece A2, Mikazans I2. Ciclopirox 8% HPCH Nail Lacquer in the Treatment of Mild-to-Moderate Onychomycosis: A Randomized, DoubleBlind Amorolfine Controlled Study Using a Blinded Evaluator. Skin Appendage Disord. 2016 Feb;1(3):134-40. 2. Lukášová I, Muselík J1, Vetchý D, Gajdziok J, Gajdošová M, Juřica J, Knotek Z, Hauptman K, Jekl V. Pharmacokinetics of Ciclopirox Olamine after Buccal Administration in Rabbits. Curr Drug Deliv. 2017;14(1):99-108. 3. Tabara K1, Szewczyk AE1, Bienias W1, Wojciechowska A1, Pastuszka M1, Oszukowska M1, Kaszuba A1. Amorolfine vs. ciclopirox - lacquers for the treatment of onychomycosis. Postepy Dermatol Alergol. 2015 Feb;32(1):40-5. 4. Urbanova M1, Gajdosova M2, Steinhart M1, Vetchy D2, Brus J1. Molecular-Level Control of Ciclopirox Olamine Release from Poly(ethylene oxide)-Based Mucoadhesive Buccal Films: Exploration of Structure-Property Relationships with Solid-State NMR. Mol Pharm. 2016 May 2;13(5):1551-63. 678 7.15. Antifungal Metals       Metals, such as copper and silver, can be extremely toxic to bacteria at exceptionally low concentrations. Metals have been widely used as antimicrobial agents in a multitude of applications related with agriculture, healthcare, and the industry in general. Metals are stable under conditions currently found in the industry allowing their use as additives. Today these metal based additives are found as: o particles, o ions absorbed/exchanged in different carriers, o salts, o hybrid structures, etc. One recent route to further extend the antimicrobial applications of these metals is by their incorporation as nanoparticles into polymer matrices. These polymer/metal nanocomposites can be prepared by several routes such as in situ synthesis of the nanoparticle within a hydrogel or direct addition of the metal nanofiller into a thermoplastic matrix. Humberto Palza, 2014 Metal oxide particles  Metal oxide particles have immense commercial applications and are being studied for their antimicrobial behaviour.  Some metal oxides such as copper oxides, titanium dioxide, zinc oxide and recently tungsten oxides and molybdenum oxides are receiving substantial attention as antimicrobials and additives in textiles, food packaging, medical devices, health related and industrial products.  Copper oxides nanoparticles have a broad antimicrobial spectrum against several pathogens. They are increasingly used in production surfaces and packaging materials in the food industry and as water filtration for treatment of secondary or tertiary waste water.  Titanium dioxide nanoparticles are used in cosmetics and food contact materials and as a self cleaning or self disinfecting material for surface coatings.  Zinc oxides are applied in the wallpapers of hospitals and for dermatological applications in creams, lotions and ointments due to their antimicrobial property.  Molybdenum oxides and tungsten oxides currently have been developed to permanently prevent growth of infectious agents on various materials surfaces. Metal oxides as antimicrobial agents  Metal oxide particles represent an increasingly important class of materials as antimicrobial active agents for numerous applications.  Metal oxide particles have been of particular interest as antimicrobial agents as they can be prepared with extremely high surface areas and different crystal morphologies that have a high number of edges, corners and other potentially reactive sites.  Metal oxide particles has the great advantage over organic-based antimicrobial agents in their much higher stability. 679   Metal oxide particles is possible to incorporate into the polymers by typical extrusion processing at elevated temperatures. Metal oxide particles including Al2O3, MoO3, WO3, TiO2, ZnO, CuO, Co3O4, In2O3, MgO, SiO2, ZrO2, Cr2O3, Ni2O3, Mn2O3 and CoO have toxicity toward several microorganisms Metal Nanoparticles as antimicrobial agents  Metal nanoparticles are synthesized highly biologically active nanoparticles.  Metal nanoparticles can be either immobilized or coated onto surfaces towards application in several fields such as medical instruments and devices, water treatment, and food processing, among others.  Metal nanoparticles combination with polymers forming composites is stressed for a better, and easier, utilization of the antimicrobial activity of these nanoparticles.  Metal nanoparticles can dissolve faster in a given solution volume as compared with larger particles releasing therefore a higher amount of metal ions. Mode of action of Silver Nanoparticles  Silver is generally used in the nitrate form to induce antimicrobial effects, but when silver nanoparticles are used, there is a huge increase in the surface area available opening new approaches.  The most pronounced effect of silver nanoparticles is on the cellular metabolic activity and the membrane inflicting damage to the cells and potentially resulting in a myriad of secondary effects, such as generation of ROS and DNA damage.  The potency of silver nanoparticles to induce cell damage compared to silver ions is cell type and size-dependent.  Silver nanoparticles have the ability to anchor to the bacterial cell wall and subsequently penetrate it, causing structural changes in the cell membrane such as in permeability, and afterward cell death.  There is also a formation of ―pits‖ on the cell surfaceincreasing the accumulation of silver nanoparticles on the cell surface.  The formation of free radicals by silver nanoparticles may also be considered to explain cell death.  These radicals can damage the cell membrane and make it porous leading to cell death . Polymer/Metal Composites as antimicrobial agents     One of the best methods to further extend the range of applications of antimicrobial metals is by their addition into a polymer obtaining a composite material. Metals can be either incorporated on the surface of a polymer or embedded into the matrix. Copper has been impregnated on the surface of cotton fibers, latex, and other polymeric materials. These materials present broad-spectrum antimicrobial (i.e., antibacterial, antiviral, and antifungal) and antimite activities. 681    Copper can further be incorporated by plasma immersion ion implantation producing antibacterial polyethylene surface. The production of copper alginate-cotton cellulose (CACC) composite fibers by immersing cotton fibers in aqueous solution of sodium alginate is another approach producing biocidal materials. The process includes the ionic crosslinking of alginate chains within the cotton cellulose fibers with Cu2+ ions. Metal chelation     Chelation is a type of bonding of ions and molecules to metal ions. It involves the formation or presence of two or more separate coordinate bonds between a polydentate ligand and a single central atom. Thiosemicarbazones represent a very attractive class of metal-chelating ligands for their coordinating versatility and the possibility to easily modify the molecular backbone and tuning their physical and chemical properties. Metal chelation could improve lipophilicity, facilitating the penetration of the complexes into lipid membranes, and, in this way, metal complexes should restrict proliferation of the microorganisms. They have a great variety of biological properties both as free ligands and as metal complexes. Metal Complex Derivatives of Azoles      Antifungal activity of azoles is related to their ability to bind readily to enzymes and receptors in biological systems Azoles bind to the heme cofactor that is located in the active site of cytochrome P450 14α-demethylase, and they inhibit the conversion pathway from lanosterol to ergosterol, an essential step in the synthesis of the fungal cell membrane. Azole ligands coordinated to metals as Cobalt (II) , Cupper (II) Nickel (II) and Iron (II) and Zinc (II) have higher antimicrobial activity than the free ligand, and in some cases, they exceed that of standard test substances. The increased antimicrobial activity is likely related to azole‘s better solubility, bioavailability and interaction with DNA (deoxyribonucleic acid) through intermolecular associations. Increased lipophilicity in the complexes reduces the permeability barrier of cells and slows normal cellular processes in microorganisms, resulting in increased antimicrobial activity 681 1. Aluminium   Aluminium or aluminum is a chemical element Aluminium a silvery-white, soft, nonmagnetic, ductile metal in the boron group. Wikipedia Symbol: Al Melting point: 660.3 °C Atomic mass: 26.981539 u ± 8 × 10^-7 u Atomic number: 13 Electron configuration: [Ne] 3s23p1 Atomic radius: 143 pm Aluminium and health         Food is the most important source of aluminium for the human body, with medicines that contains aluminium. Most of the intake of aluminium from food comes from the natural content of aluminium in fruit and vegetables. This is because plants absorb aluminium from the soil. Some foods contain added aluminium salts. In Europe, the daily aluminium intake from food is estimated at 3-10 milligrams. Aluminium is a natural component in surface and ground water. It is also common to use aluminium sulfate or ―alum‖ for efficient purification of water supplies. Aluminium in medicine goes back to ancient Greek and Rome, where aluminium compounds were used as an astringent, for example to stop bleedings. Nowadays, the main aluminium compound in medicine is aluminium hydroxide. This is used to treat stomach ulcers and kidney failure. Some vaccines contain aluminium compounds to make them more efficient. Aluminium salts are used in cosmetic products like deodorants. The aluminium salts block sweat ducts and reduce the amount of sweat on the surface of the skin. Antifungal activity    Mesoporous alumina sphere (MAS) nanoparticles showed a high antifungal efficacy against F. oxysporium. MAS nanoparticles presented an antifungal potential similar to that of tolclofos-methyl and much greater than that of the control under both laboratory and greenhouse conditions. The highest growth parameters were recorded in tomato plants treated with MAS nanoparticles, followed by those treated with tolclofos-methyl. Shenashen et al. (2017) Aluminium nanoparticles showed aluminium nanoparticles against C. albicans against C. albicans Chidambaranathan et al. (2016) Aluminium-containing salts provided strong inhibition of all the tested pathogens (Alternaria solani, Botrytis cinerea, F. sambucinum, P. sulcatum and Rhizopus stolonifer) with minimal inhibitory concentration of 1–10 mM. Aluminium chloride and 682 aluminium sulphate were generally the most effective, inhibiting mycelial growth of pathogens by as much as 47% and 100%, respectively, at a salt concentration of 1 mM. Applied at 5 mM, aluminium sulphate also provided 28% and 100% inhibition of dry rot and cavity spot, respectively. Aluminium chloride (5 mM) reduced dry rot by 25% whereas aluminium lactate (5 mM) decreased cavity spot lesions by 86%. Kolaei et al. (2013) v Recent reports: Shenashen et al. (2017) to evaluate the antifungal activity of mesoporous alumina sphere (MAS) nanoparticles against tomato root rot caused by Fusarium oxysporium, as compared with the recommended fungicide, tolclofos-methyl, under laboratory and greenhouse conditions. The effects of MAS nanoparticles on the growth of tomato plants were also evaluated and compared with those of tolclofos-methyl. The physical characteristics and structural features of MAS nanoparticles, such as their large surface-area-to-volume ratio, active surface sites and open channel pores, caused high antifungal efficacy against F. oxysporium. MAS nanoparticles presented an antifungal potential similar to that of tolclofos-methyl and much greater than that of the control under both laboratory and greenhouse conditions. The highest growth parameters were recorded in tomato plants treated with MAS nanoparticles, followed by those treated with tolclofos-methyl. Conclusions:The study demonstrated the possible use of cylindrically cubic MAS nanoparticles as an effective alternative for the control of Fusarium root rot in tomato. Chidambaranathan et al. (2016) evaluated the anticandidal effect of titanium, zirconium and aluminium nanoparticles against C. albicans at 24 hours, 72 hours and one week time interval. 683 The samples were prepared with the dimension of 20mm diameter and 1mm thickness in grade IV titanium. A total of 40 samples were made and the samples were divided into four groups. The samples without coating were Group-A (control), samples coated with titanium nano particles were Group-B, samples coated with zirconium nano particles were Group-C and samples coated with aluminium nano particles were Group-D. The samples were cleaned by sonicating in acetone and subsequently in water three times for 15 min. Then they were treated with TiO2, ZrO2 and Al2O3nanoparticles. The discs were sterilized under uv radiation and placed in SDA for C.albicans. The colonies were counted in 24, 72 hours and one week intervals. The values were statistically analyzed using one-way ANOVA and Tukey HSD Test. Significance pvalue was < .001, which showed that significant difference in C.F.U among the groups in titanium coated samples at 24 hours, 72 hours and one week time intervals. Conclusion TiO2 nanoparticles coated titanium plates showed significant anticandidal effect compared to ZrO2 and Al2O3 nanoparticles at 24, 72 hours and one week time interval. Kolaei et al. (2013) evaluated aluminium-containing salts for their effects on the mycelial growth of various fungal or fungus-like pathogens and their ability to control carrot cavity spot (Pythium sulcatum) and potato dry rot (Fusarium sambucinum). Results showed that various aluminium-containing salts provided strong inhibition of all the tested pathogens (Alternaria solani, Botrytis cinerea, F. sambucinum, P. sulcatum and Rhizopus stolonifer) with minimal inhibitory concentration of 1–10 mM. Aluminium chloride and aluminium sulphate were generally the most effective, inhibiting mycelial growth of pathogens by as much as 47% and 100%, respectively, at a salt concentration of 1 mM. Applied at 5 mM, aluminium sulphate also provided 28% and 100% inhibition of dry rot and cavity spot, respectively. Aluminium chloride (5 mM) reduced dry rot by 25% whereas aluminium lactate (5 mM) decreased cavity spot lesions by 86%. These results indicate that various aluminium-containing salts may provide an alternative to the use of synthetic fungicides to control these pathogens. References: 1. Chidambaranathan AS, Mohandoss K, Balasubramaniam MK. Comparative Evaluation of Antifungal of Titanium, Zirconium and Aluminium Nanoparticles Coated Titanium Plates Against C. albicans. Journal of Clinical and Diagnostic Research : JCDR. 2016;10(1):ZC56-ZC59. doi:10.7860/JCDR/2016/15473.7114. 2. E.A. Kolaei, C. Cenatus, R.J. Tweddell, T.J. Avis. Antifungal activity of aluminiumcontaining salts against the development of carrot cavity spot and potato dry rot. Ann. Appl. Biol. Volume 163, Issue 2 September 2013 Pages 311–317 3. Shenashen M1,2, Derbalah A1,3, Hamza A3, Mohamed A4, El Safty S1,5. Antifungal activity of fabricated mesoporous alumina nanoparticles against root rot disease of tomato caused by Fusarium oxysporium. Pest Manag Sci. 2017 Jun;73(6):1121-1126. 684 2. Bismuth   Bismuth is a chemical Bismuth, a pentavalent post-transition metal and one of the pnictogens, chemically resembles its lighter homologs arsenic and antimony. Symbol: Bi Electron configuration: [Xe] 4f145d106s26p3 Atomic number: 83 Melting point: 271.4 Uses    Bismuth medication is used to treat occasional upset stomach, heartburn, and nausea. It is also used to treat diarrhea and help prevent travelers' diarrhea. Bismuth works by helping to slow the growth of bacteria that might be causing the diarrhea. This product should not be used to self-treat diarrhea Bismuth medication is used with other medication to treat stomach ulcers caused by a certain bacteria (Helicobacter pylori). Antifungal activity   Organobismuth(III) compounds derived from alkyl aryl ketones [XBi(5-R'C6H3-2COR)(Ar)] showed antifungal activity against the yeast Saccharomyces cerevisiae. Murafuji et al. (2014) Aqueous colloidal bismuth oxide nanoparticles displayed antimicrobial activity against C. albicans growth (reducing colony size by 85%) and a complete inhibition of biofilm formation. Hernandez-Delgadillo et al. (2013) Recent reports: 685 Murafuji et al. (2014) synthesized a series of hypervalent organobismuth(III) compounds derived from alkyl aryl ketones [XBi(5-R'C6H3-2-COR)(Ar)] to investigate the effect of the compounds' structural features on their antifungal activity against the yeast Saccharomyces cerevisiae. In contrast to bismuth heterocycles [XBi(5-RC6H3-2-SO2C6H4-1'-)] derived from diphenyl sulfones, a systematic quantitative structure-activity relationship study was possible. The activity depended on the Ar group and increased for heavier X atoms, whereas lengthening the alkyl chain (R) or introducing a substituent (R') reduced the activity. IBi(C6H4-2COCH3)(4-FC6H4) was the most active. Its activity was superior to that of the related acyclic analogues ClBi[C6H4-2-CH2N(CH3)2](Ar) and ClBi(C6H4-2-SO2 tert-Bu)(Ar) and also comparable to that of heterocyclic ClBi(C6H4-2-SO2C6H4-1'-), which was the most active compound in our previous studies. Density function theory calculations suggested that hypervalent bismuthanes undergo nucleophilic addition with a biomolecule at the bismuth atom to give an intermediate ate complex. For higher antifungal activity, adjusting the lipophilicityhydrophilicity balance, modeling the three-dimensional molecular structure around the bismuth atom, and stabilizing the ate complex appear to be more important than tuning the Lewis acidity at the bismuth atom. Hernandez-Delgadillo et al. (2013) analyzed the fungicidal activity of bismuth oxide nanoparticles against Candida albicans, and their antibiofilm capabilities. The results showed that aqueous colloidal bismuth oxide nanoparticles displayed antimicrobial activity against C. albicans growth (reducing colony size by 85%) and a complete inhibition of biofilm formation. These results are better than those obtained with chlorhexidine, nystatin, and terbinafine, the most effective oral antiseptic and commercial antifungal agents. In this work, they also compared the antimycotic activities of bulk bismuth oxide and bismuth nitrate, the precursor metallic salt. These results suggest that bismuth oxide colloidal nanoparticles could be a very interesting candidate as a fungicidal agent to be incorporated into an oral antiseptic. Additionally, they determined the minimum inhibitory concentration for the synthesized aqueous colloidal Bi2O3 nanoparticles. Murafuji et al. (2013) synthesized series of heterocyclic organobismuth(III) carboxylates 4 and 5 [RCO2Bi(C6H4-2-SO2C6H4-1'-)] derived from diphenyl sulfone to determine the influence of the carboxylate ligand structure on the lipophilicity and antifungal activity against the yeast Saccharomyces cerevisiae. In contrast to the clear structure-activity relationship between the size of the inhibition zone and the value of ClogP for specific substitution on diphenyl sulfone scaffold 1 [ClBi(5-RC6H3-2-SO2C6H4-1'-)], scaffolds 4 and 5 showed similar inhibition activities irrespective of the ClogP value. This suggests that these molecules function inside the yeast cell by separating into the cationic heterocyclic bismuth scaffold and the anionic carboxylate moiety, and that the bismuth scaffold plays an important role in the inhibition activity. Murafuji et al. (2011) synthesized a series of heterocyclic organobismuth(III) compounds 2 [ClBi(5-R-C6H(3)-2-SO2C6H(4)-1'-): R=Me, Ph, MeO, Cl, H, t-Bu, CF3, F, Me2N] in order to study the relative importance of structure and specific substitutions in relation to their lipophilicity and antifungal activity against the yeast Saccharomyces cerevisiae. A clear structure-activity relationship between the size of the inhibition zone and the value of ClogP was 686 found for 2. These results suggest that the higher the lipophilicity, the lower the antifungal activity. Thus, 2e (R=H) and 2h (R=F), which had ClogP values of 1.18 and 1.45, respectively, were most active. In contrast, 2b (R=Ph) and 2f (R=t-Bu) had ClogP values of 3.06 and 3.00, respectively, and exhibited no antifungal activity. Compound 6b ClBi[5-(OH)C6H(3)2-SO(2)-5'-(OH)C6H(3)-1'-] had an estimated ClogP value of 0.81 but exhibited only low activity in spite of its low ClogP value, suggesting that such a considerable decrease in lipophilicity lowers inhibition activity. Bismuth carboxylate 7b derived from p-nitrobenzoic acid and 2e exhibited inhibition activity comparable to those of 2e and 2h despite its higher lipophilicity (ClogP=2.68). References: 1. Hernandez-Delgadillo R1, Velasco-Arias D, Martinez-Sanmiguel JJ, Diaz D, Zumeta-Dube I, Arevalo-Niño K, Cabral-Romero C. Bismuth oxide aqueous colloidal nanoparticles inhibit Candida albicans growth and biofilm formation. Int J Nanomedicine. 2013;8:1645-52. 2. Murafuji T1, Fujiwara Y, Yoshimatsu D, Miyakawa I, Migita K, Mikata Y. Bismuth heterocycles based on a diphenyl sulfone scaffold: synthesis and substituent effect on the antifungal activity against Saccharomyces cerevisiae. Eur J Med Chem. 2011 Feb;46(2):519-25. 3. Murafuji T1, Tomura M2, Ishiguro K3, Miyakawa I3. Activity of antifungal organobismuth(III) compounds derived from alkyl aryl ketones against S. cerevisiae: comparison with a heterocyclic bismuth scaffold consisting of a diphenyl sulfone. Molecules. 2014 Jul 29;19(8):11077-95. 4. Murafuji T1, Kitagawa K, Yoshimatsu D, Kondo K, Ishiguro K, Tsunashima R, Miyakawa I, Mikata Y. Heterocyclic bismuth carboxylates based on a diphenyl sulfone scaffold: synthesis and antifungal activity against Saccharomyces cerevisiae. Eur J Med Chem. 2013 May;63:531-5. 3. Cadmium  Cadmium is a chemical element with symbol Cd and atomic number 48. This soft, bluish-white metal is chemically similar to the two other stable metals in group 12, zinc and mercury.  cadmium is used in Ni-Cd batteries, pigments, coatings and plating, and as stabilizers for plastics. Cadium has been used particularly to electroplate steel where a film of cadmium only 0.05 mm thick will provide complete protection against the sea. Cadmium has the ability to absorb neutrons, so it is used as a barrier to control nuclear fission.  Symbol: Cd Electron configuration: [Kr] 4d105s2 Atomic number: 48 Atomic mass: 112.411 u ± 0.008 u Melting point: 321.1 °C 687 Discovered: 1817 Antifungal activity   Cadmium chelates were shown to possess more antimicrobial activity than the free Schiff-base chelate and their nano-sized metal oxides have the highest activity. Abdel-Rahman et al. (2016) Cadmium growth inhibiting activity of the ligands and complexes against bacteria and fungi were compared with the standard antibiotic ampicillin and commercially important antifungal agent, griseofulvin respectively. Among them some of the macrocyclic complexes were found to be more fungitoxic and antibacterial than the reference antifungal drug griseofulvin and antibacterial drug ampicillin respectively Health effects of cadmium   Cadmium uptake of takes place mainly through food. Foodstuffs that are rich in cadmium can greatly increase the cadmium concentration in human bodies. Examples are liver, mushrooms, shellfish, mussels, cocoa powder and dried seaweed Cadmium is first transported to the liver through the blood. There, it is bond to proteins to form complexes that are transported to the kidneys. Cadmium accumulates in kidneys, where it damages filtering mechanisms. Biswas et al. (2014) Vegetables are subjected to pollution A fisherman shows fish killed by the cadmium pollution in Hechi, the Guangxi Zhuang autonomous region. Jiang Dong / China Daily Recent reports: 688 Abdel-Rahman et al. (2016) prepared the complexes of Fe(II), Cd(II) and Zn(II) with Schiff base derived from 2-amino-3-hydroxypyridine and 3-methoxysalicylaldehyde. Melting points, decomposition temperatures, Elemental analyses, TGA, conductance measurements, infrared (IR) and UV-Visible spectrophotometric studies were utilized in characterizing the compounds. The UV-Visible spectrophotometric analysis revealed 1:1 (metal-ligand) stoichiometry for the three complexes. In addition to, the prepared complexes have been used as precursors for preparing their corresponding metal oxides nanoparticles via thermal decomposition. The structures of the nano-sized complexes and their metal oxides were characterized by X-ray powder diffraction and transmittance electron microscopy. Moreover, the prepared Schiff base ligand, its complexes and their corresponding nano-sized metal oxides have been screened in vitro for their antibacterial activity against three bacteria, Gram-positive (Microccus luteus) and Gram-negative (Escherichia coli, Serratia marcescence) and three strains of fungus. The metal chelates were shown to possess more antimicrobial activity than the free Schiff-base chelate and their nano-sized metal oxides have the highest activity. The binding behaviors of the complexes to calf thymus DNA have been investigated by absorption spectra, viscosity mensuration and gel electrophoresis. The DNA binding constants reveal that all these complexes interact with DNA through intercalative binding mode. Furthermore, the cytotoxic activity of the prepared Schiff base complexes on human colon carcinoma cells, (HCT-116 cell line) and hepatic cellular carcinoma cells, (HepG-2) showed potent cytotoxicity effect against growth of carcinoma cells compared to the clinically used Vinblastine standard. Biswas et al. (2014) evaluated the antibacterial and antifungal effects of cadmium(II) complexes with hexamethyltetraazacyclotetradecadiene ligands. Five coordinated square pyramidal cadmium(II) complexes and six coordinated square octahedral cadmium(II) complexes have been synthesized by interaction of 5,7,7,12,14,14-hexamethyl-1,4,8,11tetraazacyclotetradeca-4,11-diene (denoted by L.2HClO4) and C-chiral isomers of its saturated analogue (denoted by 'teta' and 'tetb') with different salts of Cd(2+) ion [e.g. CdI2, Cd(NO3)2·6H2O, CdCl2·2H2O and Cd(ClO4)2·6H2O] in methanolic solution. Complexes of the ligands were investigated for antibacterial activity by disc diffusion method and antifungal effect by poisoned food technique. The newly synthesized cadmium(II) complexes of the ligands were screened as potential antimicrobial agent against a number of medically important bacteria (Staphylococcus aureus, Bacillus cereus, Salmonella typhi, Shigella dysenteriae and Escherichia coli) and against two fungi (Candida albicans and Aspergillus aculeatus). The growth inhibiting activity of the ligands and complexes against bacteria and fungi were compared with the standard antibiotic ampicillin and commercially important antifungal agent, griseofulvin respectively. Among them some of the macrocyclic complexes were found to be more fungitoxic and antibacterial than the reference antifungal drug griseofulvin and antibacterial drug ampicillin respectively. CONCLUSIONS: Hexamethyltetraazacyclotetradecadiene ligands and its complexes could be considered as very potential antibacterial and antifungal agent with further investigation. References: 1. Abdel-Rahman LH1, Abu-Dief AM2, El-Khatib RM1, Abdel-Fatah SM1. Some new nano-sized Fe(II), Cd(II) and Zn(II) Schiff base complexes as precursor for metal oxides: Sonochemical synthesis, characterization, DNA interaction, in vitro antimicrobial and anticancer activities. Bioorg Chem. 2016 Dec;69:140-152. 689 2. Biswas FB1, Roy TG2, Rahman MA3, Emran TB4. An in vitro antibacterial and antifungal effects of cadmium(II) complexes of hexamethyltetraazacyclotetradecadiene and isomers of its saturated analogue. Asian Pac J Trop Med. 2014 Sep;7S1:S534-9. 4. Cobalt   Cobalt is a chemical element with symbol Co and atomic number 27. Like nickel, cobalt is found in the Earth's crust only in chemically combined form, save for small deposits found in alloys of natural meteoric Cobalt is silver-colored cobalt metal is brittle, has a high melting point and is valued for its wear resistance and ability to retain its strength at high temperatures. Symbol: Co Electron configuration: [Ar] 3d74s2 Atomic number: 27 Atomic mass: 58.933195 u ± 0.000005 u Melting point: 1,495 °C Discovered: 1735 Antifungal activity:   Antifungal activity of complexes of Co(II), Cu(II), and Zn(II).was screened against eight pathogenic yeasts: Candida albicans (DMic 972576), Candida krusei, Candida glabrata, Candida tropicalis, Candida dubliniensis, Candida guilliermondii, Cryptococcus neoformans, and Cryptococcus gattii. These compounds demonstrated to be effective against the assayed yeasts. The maximum zones of inhibition for TBZA, its Co(II), Cu(II), and Zn(II) complexes were observed against Cryptococcus neoformans (18 ± 3, 20 ± 3, 15 ± 1, and 22 ± 3 mm, respectively) Diaz et al. (2016) Cobalt complex were screened on Candida albicans (ATCC 10231), Aspergillus fumigatus (ATCC 1022), Trichophyton mentagrophytes (ATCC 9533) and Pencillium marneffei by determining MICs and inhibition zones. The activity of complexes was 691    found to be in the order: CuL ˃ CoL ≈ NiL ˃ L. Detection of DNA damage at the level of the individual eukaryotic cell was observed by commet assay. Singh et al. (2016) The polymer-cobalt(III) complex with x = 0.365 shows antimicrobial activity against several human pathogens. Vignesh et al. (2016) The antifungal effect of cobalt(II) complex of uniconazole is more pronounced than the effect of fungicide uniconazole for Botryosphaeria ribis Zhang et al. (2016) Co(II) complex of diniconazole showed a higher antifungal activity for Botryosphaeria ribis and Botryosphaeria berengriana than diniconazole, but a lower antifungal activity for Gibberella nicotiancola and Alternaria solani. Xi et al. (2015) Recent reports: Diaz et al. (2016) synthesized a sulfonamide 1-tosyl-1-H-benzo(d)imidazol-2-amine (TBZA) and three new complexes of Co(II), Cu(II), and Zn(II). The compounds have been characterized by elemental analyses, FTIR, 1H, and 13C-NMR spectroscopy. The structure of the TBZA, and its Co(II) and Cu(II) complexes, was determined by X-ray diffraction methods. TBZA and its Co(II) complex crystallize in the triclinic P-1 space group, while the Cu(II) complex crystallizes in the monoclinic P21/c space group. Antifungal activity was screened against eight pathogenic yeasts: Candida albicans (DMic 972576), Candida krusei (DMic 951705), Candida glabrata (DMic 982882), Candida tropicalis (DMic 982884), Candida dubliniensis (DMic 93695), Candida guilliermondii (DMic 021150), Cryptococcus neoformans (ATCC 24067), and Cryptococcus gattii (ATCC MYA-4561). These compounds demonstrated to be effective against the assayed yeasts. The maximum zones of inhibition for TBZA, its Co(II), Cu(II), and Zn(II) complexes were observed against Cryptococcus neoformans (18 ± 3, 20 ± 3, 15 ± 1, and 22 ± 3 mm, respectively) compared with the other yeasts investigated in the present study. Singh et al. (2016) synthesized Porphyrin core dendrimeric ligand (L) by Rothemund synthetic route in which p-hydroxy benzaldehyde and pyrrole were fused together. The prepared ligand was complexed with Ni(II), Cu(II) and Co(II) ions, separately. Both the ligand and its complexes were characterized by elemental analysis and spectroscopic studies (FT-IR, UV-Vis, (1)HNMR). Square planar geometries were proposed for Cu(II), Ni(II) and Co(II) ions in cobalt, Nickel and copper complexes, respectively on the basis of UV-Vis spectroscopic data. The ligand and its complex were screened on Candida albicans (ATCC 10231), Aspergillus fumigatus (ATCC 1022), Trichophyton mentagrophytes (ATCC 9533) and Pencillium marneffei by determining MICs and inhibition zones. The activity of the ligand and its complexes was found to be in the order: CuL ˃ CoL ≈ NiL ˃ L. Detection of DNA damage at the level of the individual eukaryotic cell was observed by commet assay. Molecular docking technique was used to understand the ligand-DNA interactions. From docking experiment, we conclude that copper complex interacts more strongly than rest two. Vignesh et al. (2016) synthesized and characterized the polymer-cobalt(III) complexes, [Co(bpy)(dien)BPEI]Cl3 · 4H2O (bpy = 2,2'-bipyridine, dien = diethylentriamine, BPEI = branched polyethyleneimine) The interaction of these complexes with human serum albumin (HSA) and bovine serum albumin (BSA) was investigated under physiological conditions using various physico-chemical techniques. The results reveal that the fluorescence quenching of serum albumins by polymer-cobalt(III) complexes took place through static 691 quenching. The binding of these complexes changed the molecular conformation of the protein considerably. The polymer-cobalt(III) complex with x = 0.365 shows antimicrobial activity against several human pathogens. This complex also induces cytotoxicity against MCF-7 through apoptotic induction. However, further studies are needed to decipher the molecular mode of action of polymer-cobalt(III) complex and for its possible utilization in anticancer therapy.= Zhang et al. (2016) synthesized and structurally characterized a new cobalt(II) complex of uniconazole, namely dichloridotetrakis[1-(4-chlorophenyl)-4,4-dimethyl-2-(1H-1,2,4-triazol-1yl-κN(4))pent-1-en-3-ol]cobalt(II), [CoCl2(C15H18ClN3O)4], by element analysis, IR spectrometry and X-ray single-crystal diffraction. The crystal structural analysis shows that the Co(II) atom is located on the inversion centre and is coordinated by four uniconazole and two chloride ligands, forming a distorted octahedral geometry. The hydroxy groups of an uniconazole ligands of adjacent molecules form hydrogen bonds with the axial chloride ligands, resulting in one-dimensional chains parallel to the a axis. The complex was analysed for its antifungal activity by the mycelial growth rate method. It was revealed that the antifungal effect of the title complex is more pronounced than the effect of fungicide uniconazole for Botryosphaeria ribis, Wheat gibberellic and Grape anthracnose. Xi et al. (2015) synthesized and characterized new Co(II) complex of diniconazole, namely diaqua[(E)-(RS)-1-(2,4-dichlorophenyl)-4,4-dimethyl-2-(1H-1,2,4-triazol-1-yl-κN(4))pent-1-en3-ol]cobalt(II) dinitrate dihydrate, [Co(C15H17Cl2N3O)3(H2O)2](NO3)2·2H2O, by elemental analysis, IR spectroscopy and single-crystal X-ray diffraction. Crystal structural analysis shows that the centrosymmetric Co(II) cation is coordinated by four diniconazole ligands and two water molecules, forming a six-coordinated octahedral structure. There are also two free nitrate counter-anions and two additional solvent water molecules in the structure. Intermolecular OH...O hydrogen bonds link the complex cations into a one-dimensional chain. In addition, the antifungal activity of the complex against Botryosphaeria ribis, Gibberella nicotiancola, Botryosphaeria berengriana and Alternaria solani was studied. The results indicate that the complex shows a higher antifungal activity for Botryosphaeria ribis and Botryosphaeria berengriana than diniconazole, but a lower antifungal activity for Gibberella nicotiancola and Alternaria solani. References: Diaz JR1, Fernández Baldo M2, Echeverría G3, Baldoni H4, Vullo D5, Soria DB6, Supuran CT5, Camí GE1. A substituted sulfonamide and its Co (II), Cu (II), and Zn (II) complexes as potential antifungal agents. J Enzyme Inhib Med Chem. 2016;31(sup2):51-62. Singh U1, Malla AM2, Bhat IA3, Ahmad A4, Bukhari MN1, Bhat S1, Anayutullah S1, Hashmi AA5. Synthesis, molecular docking and evaluation of antifungal activity of Ni(II), Co(II) and Cu(II) complexes of porphyrin core macromolecular ligand. Microb Pathog. 2016 Apr;93:172-9. Vignesh G1, Pradeep I1, Arunachalam S1, Vignesh S2, Arthur James R2, Arun R3, Premkumar K3. Biological and protein-binding studies of newly synthesized polymer-cobalt(III) complexes. Luminescence. 2016 Mar;31(2):533-43. Xi T1, Li J1, Yan B1, Yang M2, Song J1, Ma H1. A new Co(II) complex of diniconazole: synthesis, crystal structure and antifungalactivity. Acta Crystallogr C Struct Chem. 2015 Oct;71(Pt 10):889-93.. 692 Zhang Y1, Li J1, Ren G1, Qin B2, Ma H1. Synthesis, crystal structure and antifungal activity of a divalent cobalt(II) complex with uniconazole. Acta Crystallogr C Struct Chem. 2016 Jun 1;72(Pt 6):485-90. 5. Copper   Copper is a chemical element Copper is a soft, malleable, and ductile metal with very high thermal and electrical conductivity. A freshly exposed surface of pure copper has a reddish-orange color. Symbol: Cu Atomic mass: 63.546 u ± 0.003 u Melting point: 1,085 °C Electron configuration: [Ar] 3d104s1 Atomic number: 29 Boiling point: 2,562 °C  Copper is an essential mineral required by the body for bone and connective tissue production, and for coding specific enzymes that range in function from eliminating free radicals to producing melanin. Top 10 High Copper Foods by Nutrient Density (Copper per Gram) #1: Liver (Veal, cooked) 15.1mg (753% DV) per 100 grams 10.1mg (504% DV) per slice (67 grams) #2: Seafood (Oysters, cooked) 5.71mg (285% DV) per 100 grams 4.85mg (243% DV) per 3oz (85 grams) #3: Sesame Seeds 4.08mg (204% DV) per 100 grams 1.14mg (57% DV) per ounce (28 grams) #4: Cocoa & Dark Chocolate (Cocoa) 3.79mg (189% DV) per 100 grams 0.19mg (9% DV) per tablespoon (5 grams) #5: Spices (Mace) 2.47mg (123% DV) per 100 grams 0.05mg (2% DV) per teaspoon (2 grams) #6: Cashew Nuts 2.22mg (111% DV) per 100 grams 0.62mg (31% DV) per ounce (28 grams) #7: Sun Dried Tomatoes 1.42mg (71% DV) per 100 grams 0.77mg (38% DV) per cup (54 grams) #8: Lean Ham (Cooked) 1.20mg (60% DV) per 100 grams 1.02mg (51% DV) per 3oz (85 grams) #9: Roasted Soybeans (Edamame) 1.08mg (54% DV) per 100 grams 1.0mg (50% DV) per cup (93 grams) #10: Wheat Bran 1.0mg (50% DV) per 100 grams 0.58mg (29% DV) per cup (58 grams) Health hazard  A deficiency in copper can lead to osteoporosis, joint pain, lowered immunity, and since copper is essential for the absorption of iron, anemia. 693   Over-consumption of copper will lead to cramps, diarrhea, and vomiting in the short term, and can lead to depression, schizophrenia, hypertension, senility, and insomnia in the long term. Copper in large amounts can even be poisonous. The stomach needs to be acidic in order to absorb copper and thus antacids interfere with the absorption of copper, as do milk and egg proteins. The current DV for copper is 2mg. Cupper tee Copper Rich Foods Antifungal activity  Porphyrin core dendrimeric ligand (L) complexed with Cu(II) inhibited the growth of Candida albicans (ATCC 10231), Aspergillus fumigatus (ATCC 1022), Trichophyton mentagrophytes (ATCC 9533) and Pencillium marneffei. Singh et al. (2016)  Copper nanoparticles had high activity against Gram-positive bacteria and Candida species. Kruk et al. (2015)  The antifungal activity against Candida albicans strains was higher for the Copper metal complexes than for free ligand. Pahontu et al. (2015)  Cu2O@OAm NPs exhibited the most prominent antifungal activity with 3.73 μg/mL IC(50viability) value. Giannousi et al. 2014)  There was an Increased antifungal activity of the AmB-Cu(2+) complex against Candida albicans in comparison with the pure AmB and Fungizone. Additionally, it was stated that the increased antifungal activity of the AmB-Cu(2+) complex is not the sum of the toxic effects of AmB and Cu(2+) ions, but is a result of the unique structure of this compound. Chudzik et al. (2013) Recent reports: Jie et al. (2017) synthesized and determined the structures of 2 transition metal complexes, [CoL4Cl2]·4MeOH 1 and [NiL4Cl2]·4MeOH 2 (L = (RS)-1-(4-chloro-phenyl)-4,4-dimethyl-3(1,2,4-triazole-1-ylmethyl)pentane-3-ol), tebuconazole using single crystal X-ray diffraction (XRD). Crystal structural analysis shows that complexes 1 and 2have similar structures, both with the metal cation lying on a crystallographic inversion center and coordinated with four triazole groups and two chloride anions. The antifungal activities of L and its complexes against four selected plant pathogenic fungi were evaluated. The results show that both complexes have stronger bioactivities than the ligand L and that complex 2 has slightly higher bioactivities than complex 1. To elucidate the mechanisms behind the increased antifungal activities of the title complexes in comparison with L, cumulative release studies in static water and theoretical investigations of the complexes were carried out. The results indicate that there are three factors 694 contributing to the enhanced bioactivities: attractive controlled release properties, synergic interaction between metal cations and L, and improved penetration into the lipid membranes Diaz et al. (2016) synthesized a sulfonamide 1-tosyl-1-H-benzo(d)imidazol-2-amine (TBZA) and three new complexes of Co(II), Cu(II), and Zn(II). The compounds have been characterized by elemental analyses, FTIR, 1H, and 13C-NMR spectroscopy. The structure of the TBZA, and its Co(II) and Cu(II) complexes, was determined by X-ray diffraction methods. TBZA and its Co(II) complex crystallize in the triclinic P-1 space group, while the Cu(II) complex crystallizes in the monoclinic P21/c space group. Antifungal activity was screened against eight pathogenic yeasts: Candida albicans (DMic 972576), Candida krusei (DMic 951705), Candida glabrata (DMic 982882), Candida tropicalis (DMic 982884), Candida dubliniensis (DMic 93695), Candida guilliermondii (DMic 021150), Cryptococcus neoformans (ATCC 24067), and Cryptococcus gattii (ATCC MYA-4561). Results on the inhibition of various human (h) CAs, hCA I, II, IV, VII, IX, and XII, and pathogenic beta and gamma CAs are also reported. Singh et al. (2016) synthesized Porphyrin core dendrimeric ligand (L) by Rothemund synthetic route in which p-hydroxy benzaldehyde and pyrrole were fused together. The prepared ligand was complexed with Ni(II), Cu(II) and Co(II) ions, separately. Both the ligand and its complexes were characterized by elemental analysis and spectroscopic studies (FT-IR, UV-Vis, (1)HNMR). Square planar geometries were proposed for Cu(II), Ni(II) and Co(II) ions in cobalt, Nickel and copper complexes, respectively on the basis of UV-Vis spectroscopic data. The ligand and its complex were screened on Candida albicans (ATCC 10231), Aspergillus fumigatus (ATCC 1022), Trichophyton mentagrophytes (ATCC 9533) and Pencillium marneffei by determining MICs and inhibition zones. The activity of the ligand and its complexes was found to be in the order: CuL ˃ CoL ≈ NiL ˃ L. Detection of DNA damage at the level of the individual eukaryotic cell was observed by commet assay. Molecular docking technique was used to understand the ligand-DNA interactions. From docking experiment, it is concluded that copper complex interacts more strongly than rest two. Kruk et al. (2015) synthesized metallic monodisperse copper nanoparticles at a relatively high concentration (300 ppm CuNPs) by the reduction of copper salt with hydrazine in the aqueous SDS solution. The average particles size and the distribution size were characterized by Dynamic Light Scattering (DLS), Nanosight-Nanoparticle Tracking Analysis (NTA). The morphology and structure of nanoparticles were investigated using Scanning Electron Microscopy (SEM). The chemical composition of the copper nanoparticles was determined by X-ray Photoelectron Spectroscopy (XPS). Monodisperse copper nanoparticles with average diameter 50 nm were received. UV/vis absorption spectra confirmed the formation of the nanoparticles with the characteristic peak 550 nm. The antimicrobial studies showed that the copper nanoparticles had high activity against Gram-positive bacteria, standard and clinical strains, including methicillinresistant Staphylococcus aureus, comparable to silver nanoparticles and some antibiotics. They also exhibited antifungal activity against Candida species. Pahontu et al. (2015) synthesized and characterized 1-phenyl-3-methyl-4-benzoyl-5-pyrazolone 4-ethyl-thiosemicarbazone (HL) and its copper(II), vanadium(V) and nickel(II) complexes: [Cu(L)(Cl)]·C₂H₅OH·(1), [Cu(L)₂]·H₂O (2), [Cu(L)(Br)]·H₂O·CH₃OH (3), [Cu(L)(NO₃)]·2C₂H₅OH (4), [VO₂(L)]·2H₂O (5), [Ni(L)₂]·H₂O (6),. The ligand has been characterized by elemental analyses, IR, (1) H NMR and (13) C NMR spectroscopy. The tridentate nature of the ligand is evident from the IR spectra. The copper(II), vanadium(V) and 695 nickel(II) complexes have been characterized by different physico-chemical techniques such as molar conductivity, magnetic susceptibility measurements and electronic, infrared and electron paramagnetic resonance spectral studies. The structures of the ligand and its copper(II) (2, 4), and vanadium(V) (5) complexes have been determined by single-crystal X-ray diffraction. The composition of the coordination polyhedron of the central atom in 2, 4 and 5 is different. The tetrahedral coordination geometry of Cu was found in complex 2 while in complex 4, it is square planar, in complex 5 the coordination polyhedron of the central ion is distorted square pyramid. The in vitro antibacterial activity of the complexes against Escherichia coli, Salmonella abony, Staphylococcus aureus, Bacillus cereus and the antifungal activity against Candida albicans strains was higher for the metal complexes than for free ligand. The effect of the free ligand and its metal complexes on the proliferation of HL-60 cells was tested. Giannousi et al. 2014) achieved a facile selective synthesis of Cu2O and heterogeneous Cu/Cu2O nanoparticles (NPs) through a solvothermal approach by Cu(NO3)2 in proportion of three different surfactants, namely, tetraethylene glycol (TEG), oleylamine (OAm) and polyoxyethylene (20) sorbitan laurate (Tween 20). Formation aspects for the spherical Cu2O@OAm (30 nm) and Cu2O@Tween (12 nm) as well as for the core-shell and semishell Cu/Cu2O@TEG NPs (7 nm) and the Cu/Cu2O@OAm (170 nm) nanorods have been proposed. The fungistatic and fungicidal activity of the newly synthesized NPs was studied in vitro against the yeast Saccharomyces cerevisiae, which constitutes a unicellular eukaryotic model microorganism in molecular and cell biology. The antifungal results, based on optical density and fluorescence measurements, clearly indicate that the composition, size, and amount of surfactant are of key importance in the antifungal properties of the NPs. Cu2O@OAm NPs exhibited the most prominent antifungal activity with 3.73 μg/mL IC(50viability) value. The isolated DNA of S. cerevisiae cells after exposure to the NPs was investigated, and binding and/or degradation phenomena were recorded that are correlated to the size and concentration of the NPs. Their activity pathway was further explored, and reactive oxygen species production and lipid peroxidation were verified mainly for Cu2O NPs. Chudzik et al. (2013) prepared and evaluated the utility of the AmB-Cu(2+) complex as a potential compound with a high fungicidal activity at lower concentrations, compared with conventional AmB. It was hypothesized that insertion of copper ions into fungal cell membranes, together with the AmB-Cu(2+) complex bypassing the natural homeostatic mechanisms of this element, may contribute to the increased fungicidal activity of AmB. The analysis of results indicates the increased antifungal activity of the AmB-Cu(2+) complex against Candida albicans in comparison with the pure AmB and Fungizone. Additionally, it was stated that the increased antifungal activity of the AmB-Cu(2+) complex is not the sum of the toxic effects of AmB and Cu(2+) ions, but is a result of the unique structure of this compound. References: 1. Chudzik B1, Tracz IB, Czernel G, Fiołka MJ, Borsuk G, Gagoś M. Amphotericin Bcopper(II) complex as a potential agent with higher antifungal activityagainst Candida albicans. Eur J Pharm Sci. 2013 Aug 16;49(5):850-7. 2. Diaz JR1, Fernández Baldo M2, Echeverría G3, Baldoni H4, Vullo D5, Soria DB6, Supuran CT5, Camí GE1. A substituted sulfonamide and its Co (II), Cu (II), and Zn (II) complexes as potential antifungal agents. J Enzyme Inhib Med Chem. 2016;31(sup2):51-62. 696 3. Giannousi K1, Sarafidis G, Mourdikoudis S, Pantazaki A, Dendrinou-Samara C. Selective synthesis of Cu₂O and Cu/Cu₂O NPs: antifungal activity to yeast Saccharomyces cerevisiae and DNA interaction. Inorg Chem. 2014 Sep 15;53(18):9657-66. 4. Kruk T1, Szczepanowicz K2, Stefańska J3, Socha RP2, Warszyński P2. Synthesis and antimicrobial activity of monodisperse copper nanoparticles. Colloids Surf B Biointerfaces. 2015 Apr 1;128:17-22. 5. Pahontu E1, Julea F, Rosu T, Purcarea V, Chumakov Y, Petrenco P, Gulea A. Antibacterial, antifungal and in vitro antileukaemia activity of metal complexes with thiosemicarbazones. J Cell Mol Med. 2015 Apr;19(4):865-78. 6. Singh U1, Malla AM2, Bhat IA3, Ahmad A4, Bukhari MN1, Bhat S1, Anayutullah S1, Hashmi AA5. Synthesis, molecular docking and evaluation of antifungal activity of Ni(II), Co(II) and Cu(II) complexes of porphyrin core macromolecular ligand. Microb Pathog. 2016 Apr;93:172-9. 6. Gold    Gold is a chemical element. In its purest form, it is a bright, slightly reddish yellow, dense, soft, malleable, and ductile metal. Chemically, gold is a transition metal and a group 11 element. Symbol: Au Melting point: 1,064 °C Atomic number: 79 Atomic mass: 196.96657 u ± 0.000004 u Electron configuration: [Xe] 4f145d106s1 Boiling point: 2,700 °C Antifungal activity  AuNPs. showed a strong    anticandidal activity (10.09-15.47 mm inhibition zones) when combined with amphotericin B against five pathogenic Candida species. Patra and Baek (2016) Gold nanocubes had higher antifungal properties against Candida albicans, C. glabrata and C. tropicalis than nanospheres and nanowires Jebali et al. (2014a) Naked triangular gold nanoparticle and all conjugated triangular gold nanoparticles had high antifungal activity, against thirty clinical isolates of C. albicansP Jebali et al. (2014b) The synthesized nanoparticles were active against Aspergillus niger and Fusarium oxysporum Smitha et al. (2013) Toxicity  Pure metallic (elemental) gold is non-toxic and non-irritating when ingested and is sometimes used as a food decoration in the form of gold leaf. 697       Metallic gold is also a component of the alcoholic drinks Goldschläger, Gold Strike, and Goldwasser. Metallic gold is approved as a food additive in the EU (E175 in the Codex Alimentarius). Gold ion is toxic, the acceptance of metallic gold as a food additive is due to its relative chemical inertness, and resistance to being corroded or transformed into soluble salts (gold compounds) by any known chemical process which would be encountered in the human body. Soluble compounds (gold salts) such as gold chloride are toxic to the liver and kidneys. Common cyanide salts of gold such as potassium gold cyanide, used in gold electroplating, are toxic by virtue of both their cyanide and gold content. There are rare cases of lethal gold poisoning from potassium gold cyanide. Gold toxicity can be ameliorated with chelation therapy with an agent such as dimercaprol. Recent reports: Patra and Baek (2016) compared the biological synthesis of gold nanoparticles (AuNPs) generated using the aqueous extracts of outer oriental melon peel (OMP) and peach. The synthesized OMP-AuNPs and peach extract (PE)-AuNPs were characterized by ultravioletvisible spectroscopy, field emission scanning electron microscopy, energy dispersive X-ray analysis, X-ray powder diffraction, Fourier transform infrared spectroscopy, and thermogravimetric analysis. The surface plasmon resonance spectra were obtained at 545 nm and 540 nm for OMP-AuNPs and PE-AuNPs, respectively. The estimated absolute crystallite size of the synthesized AuNPs was calculated to be 78.11 nm for OMP-AuNPs and 39.90 nm for PEAuNPs based on the Scherer equation of the X-ray powder diffraction peaks. Fourier transform infrared spectroscopy results revealed the involvement of bioactive compounds present in OMP and peach extracts in the synthesis and stabilization of synthesized AuNPs. Both the OMPAuNPs and PE-AuNPs showed a strong antibacterial synergistic activity when combined with kanamycin (9.38-20.45 mm inhibition zones) and rifampicin (9.52-25.23 mm inhibition zones), and they also exerted a strong synergistic anticandidal activity (10.09-15.47 mm inhibition zones) when combined with amphotericin B against five pathogenic Candida species. Both the OMP-AuNPs and PE-AuNPs exhibited a strong antioxidant potential in terms of 1,1-diphenyl-2picrylhydraxyl radical scavenging, nitric oxide scavenging, 2,2'-azino-bis(3ethylbenzothiazoline-6-sulphonic acid) radical scavenging, and a reducing power, along with a strong proteasome inhibitory potential that could be useful in cancer drug delivery and cancer treatments. The PE-AuNPs showed comparatively higher activity than OMP-AuNPs, which could be attributed to the presence of rich bioactive compounds in the PE that acted as reducing and capping agents in the synthesis of PE-AuNPs. Overall, the results of the current investigation highlighted a novel green technology for the synthesis of AuNPs using food waste materials and their potential applications in the biomedical, pharmaceutical, and cosmetic industries. 698 Jebali et al. (2014a) evaluated the in vitro antifungal activities of three different shapes of silver and gold nanostructures, including nanocubes, nanospheres, and nanowires, on Candida albicans, C. glabrata and C. tropicalis, using the microdilution and disk diffusion methods as per the guidelines of the Clinical and Laboratory Standards Institute. They found that silver and gold nanocubes had higher antifungal properties against the test species than nanospheres and nanowires. While some isolates were resistant to silver and gold nanospheres and nanowires, none of the isolates were resistant to silver and gold nanocubes. The occurrence of resistance is a new finding which should be further explored. Jebali et al. (2014b) performed a study to find the peptide ligands to inhibit Candida albicans secreted aspartyl proteinase 2 (Sap2). First, a ligand library, containing 300 different peptides, was constructed, and their interaction with Sap2 was separately calculated by molecular dynamic software. Second, 10 peptide ligands with the lowest intermolecular energy were selected. Then, triangular gold nanoparticles were synthesized, and separately conjugated with the peptide ligands. After synthesis, antifungal property and Sap inactivation of conjugated triangular goldnanoparticles, peptide ligands, and naked triangular gold nanoparticle were separately assessed, against thirty clinical isolates of C. albicans. In this study, they measured the uptake of conjugated and naked nanoparticles by atomic adsorption spectroscopy. This study showed that naked triangular gold nanoparticle and all conjugated triangular gold nanoparticles had high antifungal activity, but no peptide ligands had such activity. Of 300 peptide ligands, the peptide containing N-Cys-Lys-Lys-Arg-Met-Met-Lys-Ser-Met-Cys-C and its conjugate had the highest capability to inhibit Sap. Moreover, the uptake assay demonstrated that triangular gold nanoparticles conjugated with the peptide ligand had the highest uptake. Smitha et al. (2013) reported on the surface enhanced Raman scattering (SERS) activity of Cinnamomum zeylanicum leaf broth reduced gold nanoparticles consisting of triangular and spherical like particles, using 2-aminothiophenol (2-ATP) and crystal violet (CV) as probe molecules. Nanoparticles prepared with a minimum leaf broth concentration, having a greater number of triangular like particles exhibit a SERS activity of the order of 10(7). The synthesized nanoparticles exhibit efficient antibacterial activity against the tested gram negative bacterium Escherichia coli and Gram positive bacterium Staphylococcus aureus. Investigations on the antifungal activity of the synthesized nanoparticles against Aspergillus niger and Fusarium oxysporum positive is also discussed. References: Fatima F1, Bajpai P2, Pathak N3, Singh S4, Priya S5, Verma SR6. Antimicrobial and immunomodulatory efficacy of extracellularly synthesized silver and gold nanoparticles by a novel phosphate solubilizing fungus Bipolaris tetramera. BMC Microbiol. 2015 Feb 27;15:52. Jebali A1, Hajjar FH, Pourdanesh F, Hekmatimoghaddam S, Kazemi B, Masoudi A, Daliri K, Sedighi N. Silver and gold nanostructures: antifungal property of different shapes of these nanostructures on Candida species. Med Mycol. 2014a Jan;52(1):65-72. Jebali A1, Hajjar FH2, Hekmatimoghaddam S3, Kazemi B4, De La Fuente JM5, Rashidi M6. Triangular gold nanoparticles conjugated with peptide ligands: a new class of inhibitor for Candida albicans secreted aspartyl proteinase. Biochem Pharmacol. 2014b Aug 15;90(4):34955. 699 Patra JK1, Baek KH2. Comparative study of proteasome inhibitory, synergistic antibacterial, synergistic anticandidal, and antioxidant activities of gold nanoparticles biosynthesized using fruit waste materials. Int J Nanomedicine. 2016 Sep 14;11:4691-4705. eCollection 2016. Smitha SL1, Gopchandran KG. Surface enhanced Raman scattering, antibacterial and antifungal active triangular gold nanoparticles. Spectrochim Acta A Mol Biomol Spectrosc. 2013 Feb;102:114-9. 7. Iron   Iron is a metal in the first transition series. Iron is by mass the most common element on Earth, forming much of Earth's outer and inner core. Symbol: Fe Atomic mass: 55.845 u ± 0.002 u Melting point: 1,538 °C Atomic number: 26 Electron configuration: [Ar] 3d64s2 Electrons per shell: 2, 8, 14, 2 Uses     Iron is a mineral. Most of the iron in the body is found in the hemoglobin of red blood cells and in the myoglobin of muscle cells. Iron is needed for transporting oxygen and carbon dioxide. People take iron supplements for preventing and treating low levels of iron (iron deficiency) and the resulting iron deficiency anemia. In people with iron deficiency anemia, the red blood cells can't carry enough oxygen to the body because they don't have enough iron. People with this condition often feel very tired. Iron is also used for improving athletic performance and treating attention deficithyperactivity disorder (ADHD) and canker sores. Some people also use iron for Crohn's disease, depression, fatigue, and the inability to get pregnant. Women sometimes take iron supplements to make up for iron lost in heavy menstrual periods. Iron-rich foods, such as pork, ham, chicken, fish, beans, and especially beef, liver, and lamb are also used. Antifungal activity  Mean diameter of inhibition zone of synthesised chitosan coated Fe3O4NPs was in the range 14.5 to 18.5 mm. The effect of chitosan coated Iron oxide nanoparticles was F. solani/A. niger < C. albicans < E. coli/B. subtilis (p < 0.001). Conclusions: Chitosan coated Fe3O4 NPs are effective antimicrobial agents and so may be developed as a microbial resistant coating for biomedical devices. Nehra et al. (2017) 711     Iron-oxide nanoparticles possessed antifungal potential against pathogenic Candida spp. and could inhibit the growth of all the tested Candida spp. Seddighi et al. (2017) Fe2O3 nanoparticles inhibited the growth of A. ochraceus and A. niger strains at a concentration of 25 ug/ml and more. Aliaa et al. (2015) Fe2O3 NPs had an inhibitory effect against the growth of T. verrecosum at concentrations of 3 mg /ml. in case of T. mentagrophytes, iron oxide NPs revealed an inhibitory effect at concentration of 3- 5 mg/ml. Hassan et al. (2015) The aflatoxigenic strains required higher concentration of , iron oxide NPs than nonaflatoxigenic strains where the zone diameter of growth inhibition increased when the concentration increased and it was larger in non-aflatoxigenic than aflatoxigenic strains. The concentrations of metal nanoparticles below 25 ug/ml didn't affect the growth of all A. flavus strains. Nabawy et al. (2014) Potential health risks of consuming iron     The tolerable upper intake level for iron is between 40-45 milligrams. Adults with a healthy functional gastrointestinal system have a very low risk of iron overload from dietary sources. People with a genetic disorder called hemochromatosis are at a high risk of iron overload as they absorb three to four times more iron from food compared to people without the condition. This can lead to a build-up of iron in the liver and other organs, and the creation of free radicals that damage cells and tissues including the liver, heart and pancreas, in addition to increasing the risk of cancer. In severe cases, iron overdoses can lead to organ failure, coma, seizure, and even death. It is important to keep iron supplements out of reach of children so as to reduce the risk of fatal overdose. Accidental ingestion of iron supplements were responsible for about a third of poisoning deaths among children in the US between 1983 and 1991, and some 43 deaths between 1983 and 2000. 711 Rercent reports: Nehra et al. (2017) determined the antibacterial and antifungal activity of bare and chitosan coated Fe3O4 nanoparticles (NPs) against five organisms, Escherichia coli (E. coli), Bacillus subtilis (B. subtilis), Candida albicans (C. albicans), Aspergillus niger (A. niger) and Fusarium solani (F. solani). Fe3O4 NPs were synthesised by coprecipitation and surface coating was done by chitosan polymer to avoid agglomeration. The antimicrobial property of NPs was tested by agar well diffusion and analysed by measuring the diameter of the inhibition zone. Average particle size of Fe3O4 and chitosan coated Fe3O4 NPs was 10.4 ± 4.9 and 11.4 ± 5.2 nm, respectively. Mean diameter of inhibition zone of synthesised chitosan coated Fe3O4NPs was in the range 14.5 to 18.5 mm. The effect of chitosan coated Iron oxide nanoparticles was F. solani/A. niger < C. albicans < E. coli/B. subtilis (p < 0.001). Conclusions: Chitosan coated Fe3O4 NPs are effective antimicrobial agents and so may be developed as a microbial resistant coating for biomedical devices. Seddighi et al. (2017) characterised Iron-oxide nanoparticles (IONPs) by scanning electron microscopy, X-ray diffraction, Fourier transform infrared spectroscopy and vibrating sample magnetometer. The goal of this study was to evaluate the antifungal activity of IONPs against different Candida spp. compared with fluconazole (FLC). IONPs were spherical with the size of 30-40 nm. The minimum inhibitory concentration (MIC) and minimum fungicidal concentration (MFC) values of IONPs ranged from 62.5 to 500 μg/ml and 500 to 1000 μg/ml, respectively. The MIC and MFC of FLC were in range of 16-128 μg/ml and 64-512 μg/ml, respectively. The growth inhibition value indicated that Candida tropicalis, Candida albicans and Candida glabrata spp. were most susceptible to IONPs. The finding showed that the IONPs possessed antifungal potential against pathogenic Candida spp. and could inhibit the growth of all the tested Candida spp. Further studies, both in vitro and in vivo (including susceptibility, toxicity, Probability of kill (PK) and efficacy studies) are needed to determine whether IONPs are suitable for medicinal purposes. Aliaa et al. (2015) evaluated the antifungal potential of ZnO and Fe2O3 nanoparticles in comparison with some commercial antifungal feed additives (probiotic, propionic acid and clove oil) in inhibiting the growth of A. ochraceus and A. niger strains that were isolated from animal and poultry feeds using well and disc diffusion tests. The diameters of inhibition zones induced by metal nanoparticles for non-ochratoxigenic strains were larger than that of ochratoxigenic strains and the zone diameters increased when the concentration increased. The concentrations of metal nanoparticles 20 ug/ml did not affect the growth of all A. ochraceus and A. niger strains, 712 whereas the zones of inhibition produced by the metal nanoparticles required lower concentration (25 ug/ml and more) than that produced by the commercial antifungal feed additives (50 ug/ml and more). The ochratoxin A production by ochratoxigenic strains in liquid medium (YES) or on yellow corn was significantly diminished in parallel with the decline parameters in colony count of the treated ochratoxigenic strains. The field application of the used nanoparticles and other drugs on commercial animal feed evidenced the availability to use ZnO and Fe2O3 nanoparticles only as antifungal but their antimycotoxins effect was limited to their use as feed additives during manufacture and before exposure of feeds to fungal contamination. The significance of the present results was fully discussed. It is concluded that further studies are required for investigating the synergistic effects of combined antioxidant metal nanoparticles and other commercial antimycotoxins to obtain dual synergistic actions in order to decrease the amount of used chemicals in the feed manufacture and to study the availability of its use in vivo. Hassan et al. (2015) investigated biosynthesis and characterization of iron oxide nanoparticles and evaluation of its antimicrobial potential against isolated bacterial and fungal causes of skin affection in cattle. Out of 120 cases of cattle suffering from obvious skin lesions, samples of skin scrapings and hairs from animals were collected. The recovered fungal species from samples included Trichophyton verucosum and T. mentagrophytes and bacterial species of Dermatophilus congolensis. The biological synthesis of Fe2O3 NPs was done using Candida albicans and the particles were identified and characterized by UV –visible spectrophotometer and scanning by electron microscopy (SEM) for detection of their particle size and the purity of the prepared powder. The antimicrobial effect of prepared Fe2O3 NPs against isolated Dermatophytes and Dermatophilus species that recovered from skin affection of cattle was studied. The Fe2O3 NPs had an inhibitory effect against the growth of T. verrecosum at concentrations of 3 mg /ml and 4 mg /ml which yielded inhibitory zone diameter of (10 ±0.5mm and 14±0.7mm), respectively (using well diffusion test). Whereas, the concentration of 5 mg/ml of Fe2O3 NPs showed an inhibitory zone diameter of (10±0.1 mm and 20±0.5 mm) using disc and well diffusion tests, respectively. On the other hand, in case of T. mentagrophytes, iron oxide NPs revealed an inhibitory effect at concentration of 1, 2, 3, 4 and 5 mg/ml by well diffusion test and at concentration of 3, 4 and 5 mg/ml by disc diffusion test. The treatment by Fe2O3 NPs had no effect on the growth of Dermatophilus sp. at the concentration ranged from 1- 3 mg/ml using disc diffusion test. While, the treatment by 4 mg/ml or more resulted in inhibition of bacterial growth. But in case of well diffusion test, lower concentrations of Fe2O3 NPs were required ( 2 mg/ml or more) for inhibition of Dermatophilus sp. growth. When the treated fungi or bacteria were subjected to SEM, the damage and rupture of their cell wall were detected in the area surrounding growth leading to leakage of the cell contents and finally cell death. Further studies are needed to investigate the efficacy of preparations of Fe2O3 NPs as ointments, skin lotions and synergistic effects of nanoparticles in combination with other antibiotics in the treatment of animal diseases. Nabawy et al. (2014) evaluated the antifungal potential of ZnO and Fe2O3 nanoparticles in comparison with some commercial antifungal feed additives (probiotic, propionic acid and clove oil) in inhibiting the growth of A. flavus strains that were isolated from feeds using well and disc diffusion tests. The aflatoxigenic strains required higher concentration of metal nanoparticles than non-aflatoxigenic strains where the zone diameter of growth inhibition increased when the concentration increased and it was larger in non-aflatoxigenic than aflatoxigenic strains. The concentrations of metal nanoparticles below 25 ug/ml didn't affect the growth of all A. flavus strains. The zones of inhibition produced by the metal nanoparticles were larger than that 713 produced by the commercial antifungal feed additives. The aflatoxin B1 production by aflatoxigenic strains in liquid medium (YES) or on yellow corn was significantly diminished in parallel with the decline parameters in colony count of the treated aflatoxigenic strains. The field application of the above used nanoparticles and other drugs on commercial poultry feed evidenced the availability to use ZnO and Fe2O3 nanoparticles only as antifungal but their antimycotoxins effect was limited to their use as feed additives during manufacture and before exposure of feeds to fungal contamination. The significance of the present results was fully discussed. It is concluded that further studies are required for investigating the effect of combination of antioxidant metal nanoparticles with othe References: 1. Aliaa E. Mouhamed, Atef A. Hassanb , Manal, A. Hassanb , Mahmoud El Hariria , Mohamed Refai. Effect of Metal Nanoparticles on the Growth of Ochratoxigenic Moulds and Ochratoxin A Production Isolated From Food and Feed. International Journal of Research Studies in Biosciences (IJRSB) Volume 3, Issue 9, September 2015, PP 1-14 2. Hassan, A. Atef 1; Noha H. Oraby1; El-Dahshan, E.M. E.2 and Ali, M.A. Antimicrobial Potential of Iron Oxide Nanoparticles in Control of Some Causes of Microbial Skin Affection in Cattle. European Journal of Academic Essays 2(6): 20-31, 2015 3. Nabawy, Gehan A. Nabawy1, Atef A. Hassan2, Rasha H. Sayed El-Ahl2 and Mohamed K. Refai3. Effect of metal nanoparticles in comparison with commercial antifungal feed additives on the growth of aspergillus flavus and aflatoxin b1 production. Journal of Global Biosciences. ISSN 2320-1355Volume 3, Number 6, 2014, pp. 954-971 4. P Nehra, RP Chauhan,N Garg &K Verma. Antibacterial and antifungal activity of chitosan coated iron oxide nanoparticles. 8. Magnesium Magnesium is a chemical element with symbol Mg and atomic number 12. It is a shiny gray solid which bears a close physical resemblance to the other five elements in the second column of the periodic ... Wikipedia Symbol: Mg Atomic mass: 24.305 u ± 0.0006 u Atomic number: 12 Electron configuration: [Ne] 3s2 Melting point: 650 °C Antifungal activity  The antifungal effect of magnesium oxide nanoparticles on ―oxysporum f. sp. Lycopersic‖ increased with an increase in the administered dosage of nanoparticles, and, there existed a direct correlation between the administered dosage and controlling effect such that the concentration of 2% had the greatest effect in both liquid and solid growth media. The results are in accordance with other researches concerning effect of nanoparticles on microorganisms, and, it can be also interpreted that the cells are 714 decomposed at a higher rate in presence of nanoparticles. Heidari Soureshjan ,Mina Heidari (2017).   MgO and CaO powders exhibited the antimicrobial activities against Candida albicans NBRC1060, Saccharomyces cerevisiae NBRC1950, Aspergillus niger NBRC4067 and Rhizopus stolonifer NBRC4781 and showed little differences between types of fungi. J. Sawai and T. Yoshikawa, 2004 MIC of nano-MgO against Candida albicans was greater than 3200 µg/mL Karimiyan et al. (2015) Functions of magnesium     Magnesium, an abundant mineral in the body, is naturally present in many foods, added to other food products, available as a dietary supplement, and present in some medicines (such as antacids). Magnesium is a cofactor in more than 300 enzyme systems that regulate diverse biochemical reactions in the body, including protein synthesis, muscle and nerve function, blood glucose control, and blood pressure regulation. Magnesium is required for energy production, oxidative phosphorylation, and glycolysis. It contributes to the structural development of bone and is required for the synthesis of DNA, RNA, and the antioxidant glutathione. Magnesium also plays a role in the active transport of calcium and potassium ions across cell membranes, a process that is important to nerve impulse conduction, muscle contraction, and normal heart rhythm Magnesium Deficiency  Symptomatic magnesium deficiency due to low dietary intake in otherwise-healthy people is uncommon because the kidneys limit urinary excretion of this mineral.  Habitually low intakes or excessive losses of magnesium due to certain health conditions, chronic alcoholism, and/or the use of certain medications can lead to magnesium deficiency.  Early signs of magnesium deficiency include loss of appetite, nausea, vomiting, fatigue, and weakness. As magnesium deficiency worsens, numbness, tingling, muscle contractions and cramps, seizures, personality changes, abnormal heart rhythms, and coronary spasms can occur.  Severe magnesium deficiency can result in hypocalcemia or hypokalemia (low serum calcium or potassium levels, respectively) because mineral homeostasis is disrupted 715 Recent report: Heidari Soureshjan ,Mina Heidari (2017) assessed the antifungal effect of magnesium oxide nanoparticles on ―oxysporum f. sp. Lycopersic‖. The nanoparticles used in the current research were chemically synthesized and its physical-chemical properties were measured and confirmed using double-beam visible-ultraviolet spectrophotometer (Model: TU-1901), X-ray diffraction device (Model: D/Max-RA) under CuKα emission, and transmission electron microscope (Model: TEM-200CX). Concentrations of 0.5%, 1%, and 2% of magnesium oxide nanoparticles were prepared with deionized water and their effect on the respective fungus was studied in liquid and solid growth media; the results were analyzed by means of Student t-test software at p-value<0.05. The results indicated that controlling effect increases with an increase in the administered dosage of nanoparticles, and, there exists a direct correlation between the administered dosage and controlling effect such that the concentration of 2% had the greatest effect in both liquid and solid growth media. The results are in accordance with other researches 716 concerning effect of nanoparticles on microorganisms, and, it can be also interpreted that the cells are decomposed at a higher rate in presence of nanoparticles. Karimiyan et al. (2015) investigated the antifungal effects of 4 nano-metal oxides; magnesium oxide, zinc oxide, silicon oxide and copper oxide (MgO, SiO2, ZnO and CuO) in vitro against Candida albicans and compared with amphotericin B. Solution acetic acid was used for preparing nanoparticles suspensions. Minimum inhibitory concentration (MIC) and minimum fungicidal concentration (MFC) of these nano-particles were evaluated. The results showed that MIC of nano-MgO and nano SiO2 was greater than 3200 µg/mL, but MIC and MFC of nanoZnO was recorded 200 µg/mL and 400 µg/mL, respectively. The MIC and MFC of nano-CuO was 400 µg/mL. The MIC and MFC of amphotericin B was 0.5 µg/mL and 2 µg/mL, respectively. Conclusions: It is concluded that, ZnO and CuO nanoparticles have anti C. albicans properties and may be used in treatment of infections caused by this fungus that should be investigated in vivo. Reference: 1. Ehsan Heidari Soureshjan1,*,Mina Heidari. Assessing Antifungal Effects of Magnesium Oxide Nanoparticles on †œ Oxysporum f. sp. Lycopersic †•, Pathogenic Agent of Tomato. Electronic Journal of Biology, 2017: Volume 13, Issue 3 2. Karimiyan A, Najafzadeh H, Ghorbanpour M, Hekmati-Moghaddam S H. Antifungal Effect of Magnesium Oxide, Zinc Oxide, Silicon Oxide and Copper Oxide Nanoparticles Against Candida albicans, Zahedan J Res Med Sci. 2015 ;17(10):e2179 3. J. Sawai and T. Yoshikawa. Quantitative evaluation of antifungal activity of metallic oxide powders (MgO, CaO and ZnO) by an indirect conductimetric assay Journal of Applied Microbiology 2004, 96, 803–809 9. Nickel     Nickel is a chemical element. Nickel is a silvery-white lustrous metal with a slight golden tinge. Nickel belongs to the transition metals and is hard and ductile. Nickel is a naturally occurring, lustrous, silvery-white metallic element. It is the fifth most common element on earth and occurs extensively in the earth's crust. Symbol: Ni Atomic mass: 58.6934 u ± 0.0002 u Electron configuration: [Ar] 3d84s2 Atomic number: 28 Melting point: 1,455 °C Antifungal activity 717    Nickel showed inhibitory effect on the growth of Candida albicans (ATCC 10231), Aspergillus fumigatus (ATCC 1022), Trichophyton mentagrophytes (ATCC 9533) and Pencillium marneffei Singh et al. (2016) Nickel antifungal activity against Aspergillus niger, Aspergillus flavus was reported Chandra et al. (2015) Nickel antifungal activity against Candida, Aspergillus niger and Rhizopus Patil et al. (2015) Recent reports: Singh et al. (2016) synthesized Porphyrin core dendrimeric ligand (L) by Rothemund synthetic route in which p-hydroxy benzaldehyde and pyrrole were fused together. The prepared ligand was complexed with Ni(II), Cu(II) and Co(II) ions, separately. Both the ligand and its complexes were characterized by elemental analysis and spectroscopic studies (FT-IR, UV-Vis, (1)HNMR). Square planar geometries were proposed for Cu(II), Ni(II) and Co(II) ions in cobalt, Nickel and copper complexes, respectively on the basis of UV-Vis spectroscopic data. The ligand and its complex were screened on Candida albicans (ATCC 10231), Aspergillus fumigatus (ATCC 1022), Trichophyton mentagrophytes (ATCC 9533) and Pencillium marneffei by determining MICs and inhibition zones. The activity of the ligand and its complexes was found to be in the order: CuL ˃ CoL ≈ NiL ˃ L. Detection of DNA damage at the level of the individual eukaryotic cell was observed by commet assay. Molecular docking technique was used to understand the ligand-DNA interactions. From docking experiment, we conclude that copper complex interacts more strongly than rest two. Chandra et al. (2015) synthesized and characterized Schiff's base ligand(L) hydrazine carboxamide, 2-[3-methyl-2-thienyl methylene] and its metal complexes by elemental analysis, molar conductance, various spectroscopic techniques such as electronic, IR, (1)H NMR, mass, EPR. Molar conductance of complexes in DMF solution corresponds to non-electrolyte. Complexes have general composition [M(L)2X2], where M=Ni(II) and Cu(II), X=Cl(-), NO3(-), CH3COO(-) and ½SO4(2-). On the basis of above spectral studies, an octahedral geometry has been assigned for Ni(II) complexes and tetragonal geometry for Cu(II) complexes except [Cu(L)2SO4] which possesses five coordinated trigonal bipyramidal geometry. These metal complexes were also tested for their anticancer, antibacterial and antifungal activities to assess their inhibition potential. Anticancer activity of ligand and its metal complexes were evaluated using SRB fluorometric assay and Adriamycin (ADR) was applied as positive control. Schiff's base ligand and its metal complexes were screened for their antibacterial and antifungal activity against Escherichia coli, Bacillus cereus and Aspergillus niger, Aspergillus flavus, respectively. Kirby-Bauer single disk susceptibility test was used for antibacterial activity and well diffusion method for antifungal activity of the compounds on the used fungi. 718 Patil et al. (2015) synthesized the metal complexes of Co(II), Ni(II) and Cu(II) from 6-formyl7,8-dihydroxy-4-methylcoumarin with o-toluidine/3-aminobenzotrifluoride. The synthesized Schiff bases and their metal complexes were structurally characterized based on IR, (1)H NMR, (13)C NMR, UV-visible, ESR, magnetic, thermal, fluorescence, mass and ESI-MS studies. The molar conductance values indicate that complexes are non-electrolytic in nature. Elemental analysis reveals ML2·2H2O [M = Co(II), Ni(II) and Cu(II)] stoichiometry, where 'L' stands for a singly deprotonated ligand. The presence of co-ordinated water molecules were confirmed by thermal studies. The spectroscopic studies suggest the octahedral geometry. Redox behavior of the complexes were confirmed by cyclic voltammetry. All the synthesized compounds were screened for their antibacterial (Escherichia coli, Pseudomonas auregenosa, klebsiella, Proteus, Staphylococcus aureus and salmonella) antifungal (Candida, Aspergillus niger and Rhizopus), anthelmintic (Pheretima posthuma) and DNA cleavage (Calf Thymus DNA) activity. References: 1. Chandra S1, Vandana2, Kumar S3. Synthesis, spectroscopic, anticancer, antibacterial and antifungal studies of Ni(II) and Cu(II) complexes with hydrazine carboxamide, 2[3-methyl-2-thienyl methylene]. Spectrochim Acta A Mol Biomol Spectrosc. 2015 Jan 25;135:356-63. 2. Patil SA1, Prabhakara CT2, Halasangi BM2, Toragalmath SS2, Badami PS3. DNA cleavage, antibacterial, antifungal and anthelmintic studies of Co(II), Ni(II) and Cu(II) complexes of coumarin Schiff bases: synthesis and spectral approach. Spectrochim Acta A Mol Biomol Spectrosc. 2015 Feb 25;137:641-51. 3. Singh U1, Malla AM2, Bhat IA3, Ahmad A4, Bukhari MN1, Bhat S1, Anayutullah S1, Hashmi AA5. Synthesis, molecular docking and evaluation of antifungal activity of Ni(II), Co(II) and Cu(II) complexes of porphyrin core macromolecular ligand. Microb Pathog. 2016 Apr;93:172-9. 10. Silicon  Silicon is a chemical element. A hard and brittle crystalline solid with a blue-grey metallic lustre, it is a tetravalent metalloid and semiconductor. Symbol: Si Atomic number: 14 Electron configuration: [Ne] 3s23p2 Atomic mass: 28.0855 u ± 0.0003 u Melting point: 1,414 °C Electrons per shell: 2, 8, 4 Antifungal activity  Soluble silicon (Si) has been shown to induce resistance in a number of plant species. In Si-treated wheat (Triticum aestivum) infected with powdery mildew (Blumeria 719  graminis f.sp. tritici(Bgt)), microscopic and ultrastructural observations highlighted the presence of phenolic-like material associated with degraded powdery mildew haustoria. Rémus-Borel et al., 2005 Silicon incorporated morpholine antifungals exhibited potent antifungal activity against different human fungal pathogens such as Candida albicans, Candida glabrata, Candida tropicalis, Cryptococcus neoformans, and Aspergillus niger. Sila-analogue (fenpropimorph analogue) was the best as it showed superior fungicidal potential than fenpropidin, fenpropimorph, and amorolfine. The mode of action of sila-analogues was similar to morpholines, i.e., inhibition of sterol reductase and sterol isomerase enzymes of ergosterol synthesis pathway. Recent reports: Fu et al. (2017) introduced the first example of octahedral silicon complexes, which can very well serve as an efficient antimicrobial agent. The typical silicon arenediolate complex 1 {[(phen)₂Si(OO)](PF₆)₂, with phen = 1,10-phenanthroline, OO = 9,10phenanthrenediolate} exhibited significant inhibition towards the growth of Cryptococcus neoformans with MIC and MFC values of 4.5 and 11.3 μM, respectively. Moreover, it was fungicidal against both proliferative and quiescent Cryptococcus cells. This work may set the stage for the development of novel antifungal drugs based upon hexacoodinate silicon scaffolds. References: 1. Fu C1, Fu B2, Peng X3, Liao G4. Discovery of an Octahedral Silicon Complex as a Potent Antifungal Agent. Molecules. 2017 Apr 15;22(4). pii: E637. doi: 10.3390/molecules22040637. 2. Jachak GR, Ramesh R, Sant DG, et al. Silicon Incorporated Morpholine Antifungals: Design, Synthesis, and Biological Evaluation. ACS Medicinal Chemistry Letters. 2015;6(11):1111-1116. doi:10.1021/acsmedchemlett.5b00245. 3. Wilfried Rémus-BorelaJames G.MenziesbRichard R.Bélanger. Silicon induces antifungal compounds in powdery mildew-infected wheat. Physiological and Molecular Plant Pathology 4. Volume 66, Issue 3, March 2005, Pages 108-115 711 11. Silver  Silver is a chemical element with symbol Ag and atomic number 47. A soft, white, lustrous transition metal, it exhibits the highest electrical conductivity, thermal conductivity, and reflectivity of any metal. Symbol: Ag Melting point: 961.8 °C Atomic mass: 107.8682 u Electron configuration: [Kr] 4d105s1 Atomic number: 47 Boiling point: 2,162 °C Antifungal properties   The inhibitory effect of the silver nanoparticles on the growth of Candida albicans was proved. The diameter of growth inhibition zone of AgNPs for C. albicans was 12±1.0 mm using well diffusion test (WD) at the concentration of 400 μg/ml. However, the diameter of inhibition zone reached to 26±2 mm, when the concentration was increased to 1000 μg/ml. The results of the control drugs showed that C. albicans was sensitive to fluconazole with inhibition zone diameters of 22.0 mm. Refai et al. (2017) Biosynthesized AgNPs showed considerable activity against the tested fungal strains, including Candida spp., Aspergillus spp., and Fusarium spp., especially Candida spp. Xue et al. (2016)  Nanosilver values of MIC50 were 0.1 µg ml(-1) AgNPs and MFC were 0.25 and 0.5 µg ml(-1) for C. glabrata and C. krusei, respectively. Mallmann et al. (2015)  Nanosilver values of MIC50 were 0.1 µg ml(-1) and MFC were 0.25 and 0.5 µg ml(-1) for C. glabrata and C. krusei, respectively. Artunduaga Bonilla et al. (2015)  Nanosilver is an effective antifungal agent against a broad spectrum of common fungi. Nano-Ag showed potent activity against clinical isolates and ATCC strains of Trichophyton mentagrophytes and Candida species (IC80, 1-7 microg/ml). The activity of nano-Ag was comparable to that of amphotericin B, but superior to that of fluconazole (amphotericin B IC80, 1-5 microg/ml; fluconazole IC80, 10- 30 microg/ml). The nanoparticles also inhibited the growth of Candida albicans, Candida glabrata, Candida parapsilosis, Candida krusei. Kim et al., 2008 711 Recent reports: Refai et al. (2017) evaluated the antifungal efficiency of locally biologically-prepared silver nanoparticles. The inhibitory effect of the silver nanoparticles on the growth of Candida albicans was proved. The diameter of growth inhibition zone of AgNPs for C. albicans was 12±1.0 mm using well diffusion test (WD) at the concentration of 400 μg/ml. However, the diameter of inhibition zone reached to 26±2 mm, when the concentration was increased to 1000 μg/ml. The results of the control drugs showed that C. albicans was sensitive to fluconazole with inhibition zone diameters of 22.0mm. Balashanmugam et al. (2016) made an attempt to synthesis of biocompatible silver nanoparticles from ten different Cassia spp. Among them, Cassia roxburghii aqueous leaf extract supported the synthesis of highly efficient and stable AgNPs. The synthesis of AgNPs was optimized at different physico-chemical condition and highly stable AgNPs were synthesized with 1.0mL of C. roxburghii leaf extract, pH 7.0, 1.0mM AgNO3 and at 37°C. The synthesized AgNPs were characterized by XPS, DLS and ZETA potential. DLS and ZETA potential analysis, the average AgNPs size was 35nm and the zeta potential was -18.3mV. The AgNPs exhibit higher antifungal activity when compared with the conventional antifungal drug amphotericin B against all the tested human fungal pathogens such as Aspergillus niger, Aspergillus fumigatus, Aspergillus flavus, Penicillium sp., Candida albicans and the plant pathogens such as Rhizoctonia solani, Fusarium oxysporum and Curvularia sp. Scanning electron microscope (SEM) analysis showed distinct structural changes in the cell membranes of C. albicans upon AgNPs treatment. These results suggest that phytosynthesized AgNPs could be used as effective growth inhibitors in controlling various human and plant diseases caused by fungi. Xue et al. (2016) performed a study was to find one or more fungal strains that could be utilized to biosynthesize antifungal silver nanoparticles (AgNPs). Using morphological and molecular methods, Arthroderma fulvum was identified as the most effective fungal strain for synthesizing AgNPs. The UV-visible range showed a single peak at 420 nm, which corresponded to the surface plasmon absorbance of AgNPs. X-ray diffraction and transmission electron microscopy demonstrated that the biosynthesized AgNPs were crystalline in nature with an average diameter of 15.5±2.5 nm. Numerous factors could potentially affect the process of biosynthesis, and the main factors are discussed here. Optimization results showed that substrate concentration of 1.5 mM, alkaline pH, reaction temperature of 55°C, and reaction time of 10 hours were the optimum conditions for AgNP biosynthesis. Biosynthesized AgNPs showed considerable activity against 712 the tested fungal strains, including Candida spp., Aspergillus spp., and Fusarium spp., especially Candida spp. Artunduaga Bonilla et al. (2015) synthesized AgNPs by eco-friendly method, using cysteine as a reducing agent. Also, antifungal activity against Candida species with resistance to fluconazole was evaluated through determination of Minimum Inhibitory Concentration (MIC50) according to protocol M27-A3 of Clinical and Laboratory Standards Institute (CLSI) and Minimum Fungicide Concentration (MFC). This study was carried out with strains Candida krusei and Candida glabrata. As a result, the formation of spherical nanoparticles was obtained with mean sizes of 19 nm and positive surface charge. Values of MIC50 were 0.1 µg ml(-1) AgNPs for the studied species, and MFC were 0.25 and 0.5 µg ml(-1) for C. glabrata and C. krusei, respectively. The AgNPs synthesized showed cytotoxic effect in 50% of Murine Fibroblast Cells (CC50) at a mean concentrations of 10 µg ml(-1) (100 times higher than MIC50). Consequently, AgNPs could be considered as an alternative potential in the development of new antifungal agents with minimum cytotoxicity in fibroblasts and lethal action on Candida species with resistance to conventional antifungal compounds. Mallmann et al. (2015) synthesized AgNPs using ribose as a reducing agent and sodium dodecyl sulfate (SDS) as a stabilizer. The antifungal activity of these particles against C. albicans and C. tropicalis was also evaluated. Stable nanoparticles 12.5 ± 4.9 nm (mean ± SD) in size were obtained, which showed high activity against Candida spp. and could represent an alternative for fungal infection treatment. References: 1. Artunduaga Bonilla JJ1, Paredes Guerrero DJ2, Sánchez Suárez CI1, Ortiz López CC3, Torres Sáez RG2. In vitro antifungal activity of silver nanoparticles against fluconazole-resistant Candida species. World J Microbiol Biotechnol. 2015 Nov;31(11):1801-9. 2. Balashanmugam P1, Balakumaran MD2, Murugan R2, Dhanapal K3, Kalaichelvan PT2. Phytogenic synthesis of silver nanoparticles, optimization and evaluation of in vitro antifungalactivity against human and plant pathogens. Microbiol Res. 2016 Nov;192:52-64. 3. Refai, H.1; Badawy, M. 2; Hassan, A. 3; Sakr, H2 and Baraka. Antimicrobial Effect of Biologically Prepared Silver Nanoparticles (AgNPs) on Two Different Obturator's Soft Linings in Maxillectomy Patients, European Journal of Academic Essays 4(1): 15-25, 2017 4. Kim KJ, Sung WS, Moon SK, Choi JS, Kim JG, Lee DG. Antifungal effect of silver nanoparticles on dermatophytes. J Microbiol Biotechnol. 2008;18(8):1482–1484. 5. Mallmann EJ1, Cunha FA1, Castro BN2, Maciel AM1, Menezes EA2, Fechine PB1. Antifungal activity of silver nanoparticles obtained by green synthesis. Rev Inst Med Trop Sao Paulo. 2015 Mar-Apr;57(2):165-7. 6. Xue B1, He D1, Gao S1, Wang D1, Yokoyama K2, Wang L1. Biosynthesis of silver nanoparticles by the fungus Arthroderma fulvum and its antifungal activityagainst genera of Candida, Aspergillus and Fusarium. Int J Nanomedicine. 2016 May 4;11:1899-906. 713 12. Titanium  Titanium is a chemical element . It is a lustrous transition metal with a silver color, low density, and high strength.  Titanium is resistant to corrosion in sea water, aqua regia, and chlorine.  Titanium metal and its alloys oxidize immediately upon exposure to air. Titanium readily reacts with oxygen at 1,200 °C (2,190 °F) in air, and at 610 °C (1,130 °F) in pure oxygen, forming titanium dioxide Symbol :Ti Atomic number (Z): 22 Group, period: group 4, period 4 Block: d-block Element category: transition metal Electron configuration: [Ar] 3d2 4s2 Medical uses  Titanium is biocompatible (non-toxic and not rejected by the body), it has many medical uses, including surgical implements and implants, such as hip balls and sockets (joint replacement) and dental implants that can stay in place for up to 20 years.  Titanium dioxide nanoparticles are widely used in the delivery of pharmaceuticals and cosmetics Antifungal activity    Amorphous titanium dioxide (TiO2) nanotubes (NTs) significantly reduced Candida albicans adhesion and viability. Cross-sectioning of the fungal cells revealed promoted nano-contact bonds with superior fungal spread on the control alloy interface; meanwhile NTs evidenced decreased tendency along time; suggesting, down-regulation by the nanostructured morphology Beltrán-Partida et al. (2017) TiO2 nanoparticles coated titanium plates showed significant anticandidal effect against Candida albicans compared to ZrO2 and Al2O3 nanoparticles at 24, 72 hours and one week time interval. Chidambaranathan et al. (2016) Anti-fungal activity of Titanium dioxide nano-particles against eight fungal cultures Aspergillus niger, Trichophyton, Fonsecaea, Aspergillus flavus, Rhizopus oryzae, Fusarium, Ramichloridium schulzeri and Cladosporium, isolated from infected skin and dandruff flakes almost equally efficient as Amphotericin-B. George et al. (2014) 714 Recent reports: Beltrán-Partida et al. (2017) isolated and tested the effects of Candida albicans (C. albicans) on disinfected, wetter and nanoroughness NTs compared to a non-modified control. Moreover, they elucidated part of the fungal adhesion mechanism by studying and relating the mycotic adhesion kinetics and the formation of fungal nanoadhesion bonds among the experimental materials, to gain new insight of the fungal-material-interface. NTs significantly reduced the yeasts adhesion and viability with non-outcomes of biofilm than the non-modified surface. Cross-sectioning of the fungal cells revealed promoted nano-contact bonds with superior fungal spread on the control alloy interface; meanwhile NTs evidenced decreased tendency along time; suggesting, downregulation by the nanostructured morphology and the SOW treatment. Importantly, the initial performance of HAOb demonstrated strikingly promoted anchorage with effects of filopodia formation and increased vital cell on NTs with SOW. The present study proposes SOW treatment as an active protocol for synthesis and disinfection of NTs with potent antifungal capability, acting in part by the reduction of nano-adhesion bonds at the surface-fungal interface; opening up a novel route for the investigation of mycotic-adhesion processes at the nanoscale for bone implants applications Chidambaranathan et al. (2016) evaluated the anticandidal effect of titanium, zirconium and aluminium nanoparticles against C. albicans at 24 hours, 72 hours and one week time interval. Samples were prepared with the dimension of 20mm diameter and 1mm thickness in grade IV titanium. A total of 40 samples were made and the samples were divided into four groups. The samples without coating were Group-A (control), samples coated with titanium nano particles were Group-B, samples coated with zirconium nano particles were Group-C and samples coated with aluminium nano particles were Group-D. The samples were cleaned by sonicating in acetone and subsequently in water three times for 15 min. Then they were treated with TiO 2, ZrO2 and Al2O3nanoparticles. The discs were sterilized under uv radiation and placed in SDA for C.albicans. The colonies were counted in 24, 72 hours and one week intervals. The values were statistically analyzed using one-way ANOVA and Tukey HSD Test. Significance p-value was < .001, which showed that significant difference in C.F.U among the groups in titanium coated samples at 24 hours, 72 hours and one week time intervals. Conclusion TiO2 nanoparticles coated titanium plates showed significant anticandidal effect compared to ZrO2 and Al2O3 nanoparticles at 24, 72 hours and one week time interval. George et al. (2014) assessed the anti-fungal activity of Zinc oxide and Titanium dioxide nanoparticles by treating eight fungal cultures - Aspergillus niger, Trichophyton, Fonsecaea, Aspergillus flavus, Rhizopus oryzae, Fusarium, Ramichloridium schulzeri and Cladosporium, 715 isolated from infected skin and dandruff flakes with the nanoparticles and analysing the extent of growth inhibition on agar and in broth media. The anti-fungal activity of these nano-particles was also compared to that of their respective bulk-particular forms, as well as to two commonly used anti-fungals, namely Amphotericin-B and Miconazole. The nano-particles were found to be more effective than the bulk-particles and almost equally efficient as Amphotericin-B, however Miconazole was found to be a better anti-fungal at an equal concentration. Zinc oxide nanoparticles were better anti-fungals than Titanium dioxide, thus its anti-fungal activity at different concentrations was assessed to identify the concentration that shows similar anti-fungal activity as 3μg/ml of Miconazole. The reason for performing this study was to investigate the possibility of replacing presently used anti-fungal drugs with nano-particles in topical applications to treat mycosis. References: 1. Beltrán-Partida E1, Valdez-Salas B2, Curiel-Álvarez M3, Castillo-Uribe S4, Escamilla A3, Nedev N3. Enhanced antifungal activity by disinfected titanium dioxide nanotubes via reduced nano-adhesion bonds. Mater Sci Eng C Mater Biol Appl. 2017 Jul 1;76:59-65 2. Chidambaranathan AS, Mohandoss K, Balasubramaniam MK. Comparative Evaluation of Antifungal Effect of Titanium, Zirconium and Aluminium Nanoparticles Coated Titanium Plates Against C. albicans. Journal of Clinical and Diagnostic Research : JCDR. 2016;10(1):ZC56-ZC59. doi:10.7860/JCDR/2016/15473.7114. 3. Sara A George, M Shailaja Raj*, Diana Solomon, and Roselin P. A Comparative Study of the Anti-Fungal Activity of Zinc Oxide and Titanium Dioxide Nano and Bulk Particles with Anti-Fungals against Fungi Isolated from Infected Skin and Dandruff Flakes. Research & Reviews: Journal of Microbiology and Biotechnology. 25 June 2014 13. Zirconia  Zirconium is a chemical element. The name zirconium is taken from the name of the mineral zircon, the most important source of zirconium. Symbol: Zr Electron configuration: [Kr] 4d25s2 Atomic number: 40 Atomic mass: 91.224 u ± 0.002 u Melting point: 1,855 °C Discovered: 1789 Uses  Zirconium is o used in dentistry in the manufacture of 1) subframes for the construction of dental restorations such as crowns and bridges, which are then veneered with a conventional feldspathic porcelain for aesthetic reasons, or of 2) strong, extremely 716 durable dental prostheses constructed entirely from monolithic zirconia, with limited but constantly improving aesthetics Antifungal activity  The addition of zirconia nanoparticles to cold-cured acrylic resin is an effective method for reducing Candida adhesion to repaired polymethyl methacrylate (PMMA) denture bases and cold-cured removable prosthesis. Based on the results of the current study, zirconia nanoparticles have an antifungal effect, which could be incorporated in the repair material for repairing denture bases and in PMMA removable prostheses as a possible approach for denture stomatitis prevention. Gad et al. (2017)  The antifungal properties of Ag@ZrO2 core-shell nanoparticles against against Candida albicans, Candida glabrata, Aspergillus niger and Aspergillus flavus were reported. Dhanalekshmi Iand Meena (2016)  The zirconium Zr(IV) complexes are found to possess significant antifungal activity against A. niger. Jangra et al. (2012) Recent reports: Gad et al. (2017) evaluated the effect of zirconia nanoparticles added to cold-cured acrylic resin on Candida albicans adhesion. A total of 120 acrylic resin specimens with dimensions measuring 22×10×2.5 mm3 were prepared and divided into two equal groups. One group (repair) comprised heat-polymerized specimens that were sectioned at the center and prepared to create a 2 mm repair area that was repaired with cold-cured resin reinforced with 0% wt, 2.5% wt, 5% wt, and 7.5% wt zirconia nanoparticles. The second group contained intact cold-cured acrylic resin specimens reinforced with 0% wt, 2.5% wt, 5% wt, and 7.5% wt zirconia nanoparticles. Specimens were incubated at 37°C in artificial saliva containing C. albicans, and the effect of zirconia nanoparticles on C. albicans was assessed using two methods: 1) a slide count method and 2) a direct culture test. Variations in the number of living Candida were observed in relation to the different concentrations of zirconia nanoparticles. Analysis of variance (ANOVA) and post hoc Tukey‘s tests were performed for data analysis. If the P-value was ≤0.05, then the difference was considered as statistically significant. It was found that C. albicans adhesion to repaired specimens was significantly decreased by the addition of zirconia nanoparticles (P<0.00001) in comparison with the control group. Intact cold-cured groups and groups repaired with cold-cured resin reinforced with 7.5% wt zirconia nanoparticles showed the 717 lowest Candida count. Tukey‘s test showed a significant difference between the repaired group and the intact cold-cured group, while the later demonstrated a lower Candidacount. Conclusion: The addition of zirconia nanoparticles to cold-cured acrylic resin is an effective method for reducing Candida adhesion to repaired polymethyl methacrylate (PMMA) denture bases and cold-cured removable prosthesis. Based on the results of the current study, zirconia nanoparticles have an antifungal effect, which could be incorporated in the repair material for repairing denture bases and in PMMA removable prostheses as a possible approach for denture stomatitis prevention. Chidambaranathan et al. (2016) evaluated the anticandidal effect of titanium, zirconium and aluminium nanoparticles against C. albicansat 24 hours, 72 hours and one week time interval. Samples were prepared with the dimension of 20mm diameter and 1mm thickness in grade IV titanium. A total of 40 samples were made and the samples were divided into four groups. The samples without coating were Group-A (control), samples coated with titanium nano particles were Group-B, samples coated with zirconium nano particles were Group-C and samples coated with aluminium nano particles were Group-D. The samples were cleaned by sonicating in acetone and subsequently in water three times for 15 min. Then they were treated with TiO 2, ZrO2 and Al2O3nanoparticles. The discs were sterilized under uv radiation and placed in SDA for C.albicans. The colonies were counted in 24, 72 hours and one week intervals. The values were statistically analyzed using one-way ANOVA and Tukey HSD Test. Significance p-value was < .001, which showed that significant difference in C.F.U among the groups in titanium coated samples at 24 hours, 72 hours and one week time intervals. TiO2 nanoparticles coated titanium plates showed significant anticandidal effect compared to ZrO2 and Al2O3 nanoparticles at 24, 72 hours and one week time interval. Dhanalekshmi et al. (2016) prepared Ag@ZrO2 core-shell nanoparticles by one pot simultaneous reduction of AgNO3 and hydrolysis of zirconium (IV) isopropoxide. The formation of core-shell nanoparticles was confirmed by absorption, XRD, and HR-TEM techniques. The antibacterial activity of Ag@ZrO2 core-shell nanoparticles against Escherichia coli and Staphylococcus aureus and the antifungal properties against Candida albicans, Candida glabrata, Aspergillus niger and Aspergillus flavus were examined by the agar diffusion method. DNA intercalation studies were carried out in CT-DNA. As a result ZrO2 supported on the surface of AgNPs not only prevented aggregation, but also proved to have enhanced antimicrobial activity and DNA intercalation than the Ag nanoparticles. Jangra et al. (2012) studied the antimicrobial activities of zirconia (ZrO2) nanoparticles and zirconium mixed ligand complexes on bacterial strains of E. coli, S. aureus and fungal strain of A. niger. The nanoparticles of zirconia and Zr(IV) complexes with different amino acids as ligands were synthesized by hydrothermal method. X-ray diffraction (XRD) and HRTEM confirmed the crystalline nature and morphology of the synthesized products. The antimicrobial studies revealed that the zirconia exhibits activity only against the E. coli, whereas, the Zr(IV) complexes exhibits activity against both the bacteria: Gram -ve E. coli and Gram +ve S. aureus as well as fungal strains. The Zr(IV) complexes are found to possess significant antifungal activity against A. niger. The results are indicative of crystal planedependent antimicrobial activity of zirconia nanoparticles and complexes. The observed difference in the antibacterial activity of ZrO2 crystals and Zr(IV) complexes may be ascribed to the atomic arrangements of different exposed surfaces. On the basis of the study, it could be 718 speculated that the ZrO2 nanoparticles with the same surface areas but with different shapes i.e., different active facets will show different antimicrobial activity. References: 1. Chidambaranathan AS, Mohandoss K, Balasubramaniam MK. Comparative Evaluation of Antifungal Effect of Titanium, Zirconium and Aluminium Nanoparticles Coated Titanium Plates Against C. albicans. Journal of Clinical and Diagnostic Research : JCDR. 2016;10(1):ZC56-ZC59. doi:10.7860/JCDR/2016/15473.7114 2. Dhanalekshmi KI1, Meena KS2. DNA intercalation studies and antimicrobial activity of Ag@ZrO2 core-shell nanoparticles in vitro. Mater Sci Eng C Mater Biol Appl. 2016 Feb;59:1063-1068. 3. Gad MM, Al-Thobity AM, Shahin SY, Alsaqer BT, Ali AA. Inhibitory effect of zirconium oxide nanoparticles on Candida albicans adhesion to repaired polymethyl methacrylate denture bases and interim removable prostheses: a new approach for denture stomatitis prevention. International Journal of Nanomedicine.28 July 2017 Volume 2017:12 Pages 5409—5419 4. Jangra SL1, Stalin K, Dilbaghi N, Kumar S, Tawale J, Singh SP, Pasricha R. Antimicrobial activity of zirconia (ZrO2) nanoparticles and zirconium complexes. J Nanosci Nanotechnol. 2012 Sep;12(9):7105-12. 14. Zinc   Zinc is a metal. It is called an ―essential trace element‖ because very small amounts of zinc are necessary for human health. Zinc is the first element in group 12 of the periodic table. Other Names: Acétate de Zinc, Acexamate de Zinc, Aspartate de Zinc, Atomic Number 30, Chlorure de Zinc, Citrate de Zinc, Gluconate de Zinc, Méthionine de Zinc, Monométhionine de Zinc, Numéro Atomique 30, Orotate de Zinc, Oxyde de Zinc, Picolinate de Zinc, P Symbol: Zn Electron configuration: [Ar] 3d104s2 Atomic mass: 65.38 u ± 0.002 u Melting point: 419.5 °C Atomic number: 30 Electronegativity: 1.65 Uses:  Zinc is used for treatment and prevention of zinc deficiency and its consequences, including stunted growth and acute diarrhea in children, and slow wound healing.  Zinc is also used for boosting the immune system, treating the common cold and recurrent ear infections, and preventing lower respiratory infections. 719          Zinc is also used for malariaand other diseases caused by parasites. Zinc is also used for an eye disease called macular degeneration, for night blindness, and for cataracts. Zinc is also used for asthma; diabetes; high blood pressure; acquired immunodeficiency syndrome (AIDS); and skin conditions such as psoriasis, eczema, and acne. Other uses include treating attention deficit-hyperactivity disorder (ADHD), blunted sense of taste (hypogeusia), ringing in the ears (tinnitus), severe head injuries, Crohn‘s disease, Alzheimer‘s disease, Down syndrome, Hansen‘s disease, ulcerative colitis, peptic ulcers and promoting weight gain in people with eating disorders such as anorexia nervosa. Some people use zinc for benign prostatic hyperplasia (BPH), male infertility, erectile dysfunction (ED), weak bones (osteoporosis), rheumatoid arthritis, and muscle crampsassociated with liver disease. Zinc is also applied to the skin for treating acne, aging skin, herpes simplex infections, and to speed wound healing. There is a zinc preparation that can be sprayed in the nostrils for treating the common cold. Zinc sulfate is used in products for eye irritation. Zinc citrate is used in toothpaste and mouthwash to prevent dental plaque formation and gingivitis. Antifungal activity  A concentration of 9 mmol L−1 for the sample obtained from the 0.15 M and at 12 mmol L−1 for the 0.1 M system significantly inhibited growth of E. salmonicolor. In the HROM images a deformation was observed in the growth pattern: notable thinning of the fibers of the hyphae and a clumping tendency. The TEM images showed a liquefaction of the cytoplasmic content, making it less electron-dense, with the presence of a number of vacuoles and significant detachment of the cell wall. ArciniegasGrijalba et al. (2017)  Antifungal activity of Zn(II) was reported against eight pathogenic yeasts: Candida albicans (DMic 972576), Candida krusei (DMic 951705), Candida glabrata (DMic 982882), Candida tropicalis (DMic 982884), Candida dubliniensis (DMic 93695), Candida guilliermondii (DMic 021150), Cryptococcus neoformans (ATCC 24067), and Cryptococcus gattii (ATCC MYA-4561). Diaz et al. (2016)  The IC90 value of the cationic α-mono-substituted ZnPc against C. albicans cells is as low as 3.3 μM with a light dose of 27 J cm(-2), meaning that 6a is a promising candidate as the antifungal photosensitizer for future investigations. Zheng et al. (2016)  ZnO NPs at concentrations greater than 3 mmol l(-1) can significantly inhibit the growth of B. cinerea and P. expansum. P. expansum was more sensitive to the treatment with ZnO NPs than B. cinerea. SEM images and Raman spectra indicate two different antifungal activities of ZnO NPs against B. cinerea and P. expansum. ZnO NPs inhibited the growth of B. cinerea by affecting cellular functions, which caused deformation in fungal hyphae. In comparison, ZnO NPs prevented the development of 721 conidiophores and conidia of P. expansum, which eventually led to the death of fungal hyphae. These results suggest that ZnO NPs could be used as an effective fungicide in agricultural and food safety applications. He et al. (2011) Recent reports: Arciniegas-Grijalba et al. (2017) designed a methodology of synthesis to obtain ZnO nanoparticles (ZnO NPs) in a controlled and reproducible manner. The nanoparticles obtained were characterized using infrared spectroscopy, X-ray diffraction, and transmission electron microscopy (TEM). Also, we determined the antifungal capacity in vitro of zinc oxide nanoparticles synthesized, examining their action on Erythricium salmonicolor fungy causal of pink disease. To determine the effect of the quantity of zinc precursor used during ZnO NPs synthesis on the antifungal capacity, 0.1 and 0.15 M concentrations of zinc acetate were examined. To study the inactivation of the mycelial growth of the fungus, different concentrations of ZnO NPs of the two types of synthesized samples were used. The inhibitory effect on the growth of the fungus was determined by measuring the growth area as a function of time. The morphological change was observed with high-resolution optical microscopy (HROM), while TEM was used to observe changes in its ultrastructure. The results showed that a concentration of 9 mmol L−1 for the sample obtained from the 0.15 M and at 12 mmol L−1 for the 0.1 M system significantly inhibited growth of E. salmonicolor. In the HROM images a deformation was observed in the growth pattern: notable thinning of the fibers of the hyphae and a clumping tendency. The TEM images showed a liquefaction of the cytoplasmic content, 721 making it less electron-dense, with the presence of a number of vacuoles and significant detachment of the cell wall. Diaz et al. (2016) synthesized a sulfonamide 1-tosyl-1-H-benzo(d)imidazol-2-amine (TBZA) and three new complexes of Co(II), Cu(II), and Zn(II). The compounds have been characterized by elemental analyses, FTIR, 1H, and 13C-NMR spectroscopy. The structure of the TBZA, and its Co(II) and Cu(II) complexes, was determined by X-ray diffraction methods. TBZA and its Co(II) complex crystallize in the triclinic P-1 space group, while the Cu(II) complex crystallizes in the monoclinic P21/c space group. Antifungal activity was screened against eight pathogenic yeasts: Candida albicans (DMic 972576), Candida krusei (DMic 951705), Candida glabrata (DMic 982882), Candida tropicalis (DMic 982884), Candida dubliniensis (DMic 93695), Candida guilliermondii (DMic 021150), Cryptococcus neoformans (ATCC 24067), and Cryptococcus gattii (ATCC MYA-4561). Zheng et al. (2016) synthesized and evaluated series of zinc(II) phthalocyanines (ZnPcs) monosubstituted and tetra-substituted with morpholinyl moieties and their quaternized derivatives for their antifungal photodynamic activities toward Candida albicans. The α-substituted, quaternized, and mono-substituted ZnPcs are found to have higher antifungal photoactivity than β-substituted, neutral, and tetra-substituted counterparts. The cationic α-mono-substituted ZnPc (6a) exhibits the highest photocytotoxicity. Moreover, it is more potent than axially disubstituted analogue. Janaki et al. (2015) synthesized the ZnO nano crystallites of average size range of 23-26 nm by rapid, simple and eco friendly method. Zinc oxide nano particles were characterized by using X-ray diffraction (XRD), Scanning Electron Microscope (SEM), Energy Dispersive X-ray spectroscopy (EDX). FTIR spectra confirmed the adsorption of surfactant molecules at the surface of ZnO nanoparticles and the presence of ZnO bonding. Antimicrobial activity of ZnO nano particles was done by well diffusion method against pathogenic organisms like Klebsiella pneumonia, Staphylococcus aureus and Candida albicans and Penicillium notatum. It is observed that the ZnO synthesized in the process has the efficient antimicrobial activity. References: 1. P. A. Arciniegas-Grijalba, M. C. Patiño-Portela, L. P. Mosquera-Sánchez, J. A. GuerreroVargas, J. E. Rodríguez-Páe. ZnO nanoparticles (ZnO-NPs) and their antifungal activity against coffee fungus Erythricium salmonicolor Applied Nanoscience June 2017, Volume 7, Issue 5, pp 225–241 2. Diaz JR1, Fernández Baldo M2, Echeverría G3, Baldoni H4, Vullo D5, Soria DB6, Supuran CT5, Camí GE1. A substituted sulfonamide and its Co (II), Cu (II), and Zn (II) complexes as potential antifungal agents. J Enzyme Inhib Med Chem. 2016;31(sup2):51-62. 3. He L1, Liu Y, Mustapha A, Lin M. Antifungal activity of zinc oxide nanoparticles against Botrytis cinerea and Penicillium expansum. Microbiol Res. 2011 Mar 20;166(3):207-15. 4. Janaki AC1, Sailatha E2, Gunasekaran S3. Synthesis, characteristics and antimicrobial activity of ZnO nanoparticles. Spectrochim Acta A Mol Biomol Spectrosc. 2015 Jun 5;144:17-22. 722 5. Zheng BY1, Ke MR1, Lan WL1, Hou L1, Guo J1, Wan DH1, Cheong LZ2, Huang JD3. Mono- and tetra-substituted zinc(II) phthalocyanines containing morpholinyl moieties: Synthesis, antifungal photodynamic activities, and structure-activity relationships. 15. Metal complexes of coumarin derivatives      Metal complexes of coumarin derivatives have antimicrobial activity. It is due to the chelation property of these compounds. Metal complexes of coumarin salts are more potent than the parent drug. These complexes have many other applications such as antifungal, antibacterial, and anti-tumor. Synthesis of Schiff base coumarin derivatives is achieved by condensation of substituted acetyl coumarins with different aliphatic and aromatic amines. The transition metal (II) ions such as Co(II), Ni(II), Cu(II), Zn(II), Pd(II) and Cd(II) complexes are prepared by refluxing metal salt solution and the alcoholic solution of these ligands. This will gives organic compound with solubility in variety of solvents. The product formed will have O, N-donor functional groups; will behave as a good chelating ligand. Recent reports: Sahoo and Paidesetty (2017) synthesized new transitional metal complexes derived from 3aryl-azo-4-hydroxy coumarin analogues and evaluated their antimicrobial activities.The syntheses of complexes of coumarin analogues were accomplished by mixing a hydro-alcoholic solution of 3-aryl-azo-4-hydroxy coumarin analogues with transition metal chlorides. The structural environment of the synthesized molecules was characterized using different instrumental methods. The antimicrobial activity of the compounds was determined by the agar well diffusion method. The cobalt complexes of (E)-3-((4-chlorophenyl) diazenyl)-4-hydroxy2H-chromen-2-one (HL1): (4a) and (E)-3-((4-methoxyphenyl) diazenyl)-4-hydroxy-2Hchromen-2-one (HL2): (4e) significant antimicrobial activity in comparison to standard drugs (p < 0.05) against E. coli, K. pneumonia, S. aureus, C. albicans and C. neoformans compared with their ligands. Elhusseiny et al. (2014) synthesized a series of metal complexes of zinc(II), cadmium(II), copper(II), nickel(II) and palladium(II) from coumarin-imine ligand, 8-[(1E)-1-(2aminophenyliminio)ethyl]-2-oxo-2H-chromen-7-olate, [HL]. The structures of the complexes were proposed in the light of their spectroscopic, molar conductance, magnetic and thermal studies. The ligand coordinated in a tridentate manner through the azomethine nitrogen, the phenolic oxygen and the amine nitrogen and all complexes were non-electrolytes with different geometrical arrangements around the central metal ion. Photoluminescence data unambiguously showed remarkable fluorescence enhancement to Zn(2+) over other cations. The antimicrobial screening tests revealed that copper(II) complex exhibited the highest potency and its minimum inhibitory concentration on the enzymatic activities of the tested microbial species was determined. No toxin productivity was detected for all tested toxigenic species upon the exposure of copper complex. 723 References: 1. Elhusseiny AF1, Aazam ES2, Al-Amri HM2. Synthesis of new microbial pesticide metal complexes derived from coumarin-imine ligand. Spectrochim Acta A Mol Biomol Spectrosc. 2014 Jul 15;128:852-63. 2. Jyotirmaya Sahoo .aSudhir K. Paidesetty . Antimicrobial activity of novel synthesized coumarin based transitional metal complexes. Journal of Taibah University Medical Sciences 3. Volume 12, Issue 2, April 2017, Pages 115-124 16. Metal ions loading inorganic carrier      Special attention has been paid to metal ions loading inorganic carrier, which are superior in terms of safety, and long-term antibacterial effectiveness when compared with conventional metal. Clay minerals as supports for synthesis of various inorganic antimicrobial materials has attracted considerable interest, owing to their nontoxic, environmentally friendly characteristic, and easy preparation. Heavy metal (silver, Cu, Zn, and so on) exchanged clay minerals can serve as an antimicrobial reagent in vitro. Until recently, Cu or Zn exchanged clay minerals has been added to the animal feed as an antibiotic alternative, with the additive amount of Cu and Zn being quite lower than that in conventional animal diet. Loading two metal ions onto montmorillonite (Mt) displayed obvious synergistic antimicrobial effect in vitro. Recent report Jiao et al. (2017) prepared a series of modified montmorillonites (Mt) including zinc-loaded Mt (Zn-Mt), copper-loaded Mt (Cu-Mt), copper/zinc-loaded Mt with different Cu/Zn ratio (Cu/ZnMt-1, Cu/Zn-Mt-2, Cu/Zn-Mt-3) by an ion-exchange reaction, and characterized using X-ray diffraction (XRD), fourier transformed infrared spectroscopy (FTIR) and transmission electron microscopy (TEM). The specific surface areas, antimicrobial activity and cytotoxicity of the modified Mt were investigated. In the modified Mt, hydrated Cu ions and Zn ions were exchanged in the interlayer space of Mt and the particles were irregular shapes. The results showed that Cu/Zn-Mt enhanced antibacterial and antifungal activity compared with Zn-Mt and Cu-Mt possibly due to the synergistic effect between Cu and Zn. References: 1. Jiao L1, Lin F1, Cao S1, Wang C1, Wu H1, Shu M1, Hu C2. Preparation, characterization, antimicrobial and cytotoxicity studies of copper/zincloaded montmorillonite. J Anim Sci Biotechnol. 2017 Mar 21;8:27. 724 17. Thiosemicarbazones derivatives complex with metal ions     Thiosemicarbazones derivatives are able to complex with metal ions, and their biological activity is modulated by the structure of the ligand and the nature of the metal Thiosemicarbazones complex possess a range of biological applications that include antitumor (Antholine et al. 1977), antifungal (Mittal et al. 1981), antiviral (Shipman et al. 1981), antibacterial (Dobek et al. 1980), antifilarial (Klayman et al. 1991) and antimalarial activities (Klayman et al. 1979). Thiosemicarbazones exercise their biological activity in mamalian cells by inhibiting ribonucleotide reductase, a necessary enzyme in the synthesis of DNA precursors (Frence et al. 1970). o This inhibitory action is thought to be due to coordination of iron via a heterocyclic thiosemicarbazone's N-N-S tridentate ligating system, either by a preformed iron complex binding to the enzyme or by the free ligand complexing with the iron-charged enzyme (Sartorelli et al. 1977). o Studies of iron and copper complexes have shown that they can be more active in the inhibition of DNA synthesis than the uncomplexed parent thiosemicarbazone (Saryan et al. 1981). o Evidence has also been presented that a thiosemicarbazone may cause lesions in DNA, suggesting a second site of action (Karon & Benedict 1972 Thiosemicarbazones complex show antifungal activities against Aspergillus spp. A. parasiticus, Candida albicans, A. niger, Trichophyton mentagrophites, Rizocthonia solani and Stemphylium solani Recent reports: de Araújo Neto et al. (2017) evaluated the in vitro cytotoxic and antifungal activities of 12 Nsubstituted 2-(5-nitro-thiophene)-thiosemicarbazones derivatives (L1-12) against Candida sp. and Cryptococcus neoformans. The probable mechanisms of action have been investigated by sorbitol and ergosterol assays. Additionally, ultrastructural study by Scanning Electron Microscopy was performed with the L10 compound. All compounds were obtained in good yield and their chemical structures were characterized on basis of their physico-chemical and Nuclear Magnetic Resonance - NMR, Spectrophotometric Absorption in the Infrared - IR and Highresolution Mass Spectrometry - HRMS data. The results showed that all strains were more sensitive to the compound L10 except Candida tropicalis URM 6551. On the other hand, the cytotoxicity assay by incorporation of tritiated thymidine showed moderate cytotoxic activity on L8 of the 50 μg/mLat which had the best MIC-cytotoxicity relationship. Concerning the study of the possible mechanism of action, the compounds were not able to bind to ergosterol in the membrane, do not act by inhibiting the synthesis of fungal cell wall (sorbitol assay). Kovač et al. (2017) studied the antifungal and antiaflatoxigenic effects of two series of coumarinyl thiosemicarbazides on Aspergillus flavus NRRL 3251. Fungi were grown in YES medium for 72 h at 29 °C in the presence of 0, 0.1, 1, and 10 µg mL-1 of coumarinyl thiosemicarbazides: one series with substitution in position 7 and another with substitution in position 4 of the coumarin core. Dry mycelia weight determination was used for antifungal activity estimation, while the aflatoxin B1 content in YES media, determined by the dilute and 725 shoot LC-MS/MS technique, was used for the antiaflatoxigenic effect estimation. Standard biochemical assays were used for oxidative status marker (TBARS, SOD, CAT, and GPX) determination in A. flavus NRRL 3251 mycelia. Results show that 7-substituted-coumarinyl thiosemicarbazides possess a better antifungal and antiaflatoxigenic activity than 4-substituted ones. The most prominent substituted compound was the compound 3, N-(4-chlorophenyl)-2-(2((4-methyl-2-oxo-2H-chromen-7-yl)oxy)acetyl)hydrazine-1-carbothioamide, which completely inhibited aflatoxin production at the concentration of 10 µg mL-1. Oxidative stress response of A. flavus exposed to the selected compounds points to the modulation of oxidative stress as a possible reason of aflatoxin production inhibition. Rogolino et al. (2017) present the synthesis of a series of chelating ligands based on the thiosemicarbazone scaffold, to be evaluated for their antifungal and antiaflatoxigenic effects. Starting from molecules of natural origin of known antifungal properties, we introduced the thiogroup and then the corresponding copper complexes were synthesised. Some molecules highlighted aflatoxin inhibition in the range 67-92% at 100 μM. The most active compounds were evaluated for their cytotoxic effects on human cells. While all the copper complexes showed high cytotoxicity in the micromolar range, one of the ligand has no effect on cell proliferation. This hit was chosen for further analysis of mutagenicity and genotoxicity on bacteria, plants and human cells. Altıntop et al. (2016) obtained new thiosemicarbazone derivatives (1-10) via the reaction of 4(naphthalen-1-yl) thiosemicarbazide with fluoro-substituted aromatic aldehydes. The synthesized compounds were evaluated for their in vitro antifungal effects against pathogenic yeasts and molds using broth microdilution assay. Ames and umuC assays were carried out to determine the genotoxicity of the most effective antifungal derivatives. Among these derivatives, 4(naphthalen-1-yl)-1-(2,3-difluorobenzylidene)thiosemicarbazide (1) and 4-(naphthalen-1-yl)-1(2,5-difluorobenzylidene)thiosemicarbazide (3) can be identified as the most promising antifungal derivatives due to their notable inhibitory effects on Candida species and no cytotoxicity against NIH/3T3 mouse embryonic fibroblast cell line. Thanh et al. (2016) synthesized some new isatin N-(2,3,4,6-tetra-O-acetyl-β-dglucopyranosyl)thiosemicarbazones 4a-t with different substituents at 1-, 5- and 7-positions of isatin ring by reaction of N-(2,3,4,6-tetra-O-acetyl-β-d-glucopyranosyl)thiosemicarbazide 2 with corresponding isatins 3a-t. Compounds 4a-t were evaluated in vivo for antioxidant activity and in vitro for anti-microorganism activities. The MIC values were found for Gram positive bacteria (MIC = 1.56-6.25 μM), for Gram negative bacteria (MIC = 12.5 μM), and for fungi Aspergillus niger (MIC = 3.12-12.5 μM), Fusarium oxysporum (MIC = 6.25-12.5 μM) and Saccharomyces cerevisiae (MIC = 6.25-12.5 μM). Regarding the antioxidant activity, the SOD, GHS-Px and catalase activities of 4c-i and 4m-r were MIC = 10.57-10.85, 0.27-0.93 and 345.45-399.75 unit/mg protein, respectively. Compounds 4e-h had MIC values of 0.78, 1.56, and 3.12 μM for three clinical MRSA isolates. Compound 4e showed the selective cytotoxic effects against some cancer (LU-1, HepG2, MCF7, P338, SW480, KB) cell lines and normal fibroblast cell line NIH/3T3. References: 1. Altıntop MD1, Atlı Ö2, Ilgın S2, Demirel R3, Özdemir A1, Kaplancıklı ZA4. Synthesis and biological evaluation of new naphthalene substituted thiosemicarbazone derivatives 726 as potent antifungal and anticancer agents. Eur J Med Chem. 2016 Jan 27;108:406414. 2. de Araújo Neto LN1, do Carmo Alves de Lima M2, de Oliveira JF1, de Souza ER1, Buonafina MDS3, Vitor Anjos MN4, Brayner FA5, Alves LC6, Neves RP3, Mendonça-Junior FJB7. Synthesis, cytotoxicity and antifungal activity of 5-nitrothiophene-thiosemicarbazonesderivatives. Chem Biol Interact. 2017 Jun 25;272:172181. 3. Kovač T. et al. Antifungal and antiaflatoxigenic activity of coumarinyl thiosemicarbazides against Aspergillus flavus NRRL 3251 Arh Hig Rada Toksikol 2017;68:9-15 4. Rogolino D1, Gatti A2, Carcelli M2, Pelosi G2, Bisceglie F2, Restivo FM2, Degola F2, Buschini A2, Montalbano S2, Feretti D3, Zani C3. Thiosemicarbazone scaffold for the design of antifungal and antiaflatoxigenic agents: evaluation of ligands and related copper complexes. Sci Rep. 2017 Sep 11;7(1):11214. doi: Sci Rep. 2017 Sep 11;7(1):11214. 5. Thanh ND1, Giang NTK2, Quyen TH3, Huong DT3, Toan VN4. Synthesis and evaluation of in vivo antioxidant, in vitro antibacterial, MRSA and antifungal activity of novel substituted isatin N-(2,3,4,6-tetra-O-acetyl-β-d-glucopyranosyl) thiosemicarbazones. Eur J Med Chem. 2016 Nov 10;123:532-543. 18. Metal Complex Derivatives of Azole  Aromatic nitrogen heterocycles represent an important class of compounds which can act as ligands towards metal ions.  Azoles belong to this class and are five-membered heterocyclic ligands containing two or more heteroatoms, one of which must be nitrogen.    When azole ligands are coordinated to metal ions such as Co2+, Cu2+ and Zn2+, they have higher antimicrobial activity than the free ligand, and in some cases, they exceed that of standard test substances. The increased antimicrobial activity is likely related to azole‘s better solubility, bioavailability and interaction with DNA (deoxyribonucleic acid) through intermolecular associations. Increased lipophilicity in the complexes reduces the permeability barrier of cells and slows normal cellular processes in microorganisms, resulting in increased antimicrobial activity Recent reports: Castillo et al. (2016) synthesized 4 new zinc complex derivatives of azoles and ligands and isolated as white air-stable solids and characterized by elemental analyses, thermogravimetric analysis (TGA), infrared spectroscopy, nuclear magnetic resonance (NMR) and mass spectra. The elemental analysis, theoretical calculations and NMR show that the complexes likely have a 1:1 (M:L) stoichiometry and tetrahedral geometry. To evaluate the biological activity of the complexes and to discuss the role of metal ions and structural properties, the ligands and their 727 metal complexes have been studied. Their antimicrobial activity was determined in vitro by agarwell diffusion and broth microdilution against nine bacterial strains and seven fungal strains with clinical relevance. In vitro assays showed that the complexes exhibited moderate antibacterial and/or antifungal activities. The antimicrobial activity was found to be more active for the metal complexes than the ligands. The metal complexes that contained copper and cobalt, respectively, displayed notable antibacterial and antifungal effects against all the tested bacterial strains. The minimum inhibitory concentration 50 (MIC50) values were in the range 2454-0.7 μg mL-1. Metal complexes were more effective at inhibiting bacteria than fungi. The results could provide a high-potential solution for antimicrobial growth resistance, for both bacteria and fungi. Palza (2014) mentioned that metals, such as copper and silver, can be extremely toxic to bacteria at exceptionally low concentrations. Because of this biocidal activity, metals have been widely used as antimicrobial agents in a multitude of applications related with agriculture, healthcare, and the industry in general. Unlike other antimicrobial agents, metals are stable under conditions currently found in the industry allowing their use as additives. Today these metal based additives are found as: particles, ions absorbed/exchanged in different carriers, salts, hybrid structures, etc. Nfor et al. (2913) synthesized 2 new complexes of nickel (II) with 4-amino-3, 5-bis(pyridyl)-1, 2, 4-triazole (abpt) and iron (II) with 2-(3-phenyl-1H-pyrazole-5-yl) pyridine (phpzpy) and characterized by elemental analysis and IR spectroscopy. The crystal structures of the complexes have been determined by single crystal X-ray diffraction techniques. In the nickel and iron complexes, the ligands are coordinated through nitrogen atoms in bidentate manner. The ligands and their respective complexes have been tested for their antifungal activity against Aspergillus niger, Aspergillus flavus, and Candida albicans. From the study, the complexes showed enhanced activities against the tested organisms compared to the ligands. References: 1. Emmanuel N. Nfor, Peter F. Asobo, Justin Nenwa, et al., ―Nickel (II) and Iron (II) Complexes with Azole Derivatives: Synthesis, Crystal Structures and Antifungal Activities,‖ International Journal of Inorganic Chemistry, vol. 2013, Article ID 987574, 6 pages, 2013. doi:10.1155/2013/987574 2. Keshia F. Castillo,a,# Nestor J. Bello-Vieda,b,# Nelson G. Nuñez-Dallos,b Homero F. Pastrana,c Adriana M. Celis,a Silvia Restrepo,a John J. Hurtado*,b and Alba G. Ávilac Metal Complex Derivatives of Azole: a Study on Their Synthesis, Characterization, and Antibacterial and Antifungal Activities, J. Braz. Chem. Soc., Vol. 27, No. 12, 23342347, 2016. 3. Palza,H. 2014. Antimicrobial Polymers with Metal Nanoparticles. Int. J. Mol. Sci. 2015, 16, 2099-2116; doi:10.3390/ijms16012099 728 7.16. Miscellaneous antifungal chemicals       Alcohols are membrane-active microbicides whose antimicrobial efficacy is universally acknowledged. o Butanol vapours eliminate the fungi on concentrations between 80 and 96%, and isopropanol and ethanol are effective on a range between 30 and 90%. o Ethanol acts on fungi by affecting the permeability of their cytoplasmic membrane, causing the leakage of cytosol constituents and ultimately leading to the disintegration of the cell. o Ethylene oxide microbiologic inactivation properties are related to its powerful alkylation reaction of cellular constituents of organisms, like nucleic acids and functional proteins, causing their denaturation. This process affects the normal cellular metabolism, leading to non viable microbes. Formaldehyde is an electrophilically active microbicide with the ability to react with several different amino acids present in the microbial cell, including purine and pyrimidine groups of both DNA and RNA, a unique characteristic of this compound. Phenol Derivatives are membraneactive antifungals, causing mainly damages in the plasma membrane of fungi. o Dichlorophen (4-chloro-2-[(5-chloro-2- hydroxyphenyl)methyl]phenol), also known by the trade names Preventol GD or Panacide, is used as a fungicide for paper, cardboard, textiles, adhesives, and is also used for treating fungal infections of the skin, as a germicide in soaps and cosmetics. It is strongly effective against yeast and filamentous fungi. o Ortho-phenylphenol (C12H10O), also known by the trade names Preventol O, Topane or Dowicide, is a membrane-active microbicide with a broad spectrum of activity, covering bacteria, yeasts and fungi. o Pentachlorophenol (C6HCl5O), with the trade names Dowicide 7, G, EC-7 or Preventol P, is a highly lipophilic weak acid and is considered a broad-spectrum microbicide widely used as a fungicide for books, textiles and wood. o Thymol (2-Isopropyl-5-methylphenol) is a natural monoterpene phenol. Already used in the ancient Egypt for the preservation of mummies. Photocatalysts has been used to decompose several pollutants and biological contaminations. o Titanium dioxide (TiO2) irradiated with UV can only act as a fungistatic and do not affect the conidia Quaternary ammonium compounds are considered sporistatic microbicides, since they inhibit spore germination and outgrowth without actually killing the spore. o Dimethyl-lauryl-benzyl ammonium bromide is used in medicine as a low-level disinfectant with no sporicidal activity o Lauryl-dimethyl-carbethoxymethyl ammonium bromide. is used in archives and libraries for elimination of mould. Salts and esters of acids o Calcium propionate [Ca(C2H5COO)2] has been commonly used as a food preservative since the late 1930‘s due to its ability to inhibit 729 activity    o Esters of p-hydroxybenzoic acid are mainly fungistatic and bacteriostatic, being more effective against yeast and moulds than bacteria. Salicylaldehyde hydrazones and hydrazides are potent inhibitors of fungal growth with little to no mammalian cell toxicity, making these analogs promising new targets for future therapeutic development. Iodine has an antifungal effect. o Iodine is such a good antifungal and antibacterial, the Center for Disease Control (CDC) recommends Iodine for the disinfection and sterilization of medical facilities. o Iodine is also used for water purification. NASA also uses Iodine to disinfect their water from harmful organisms such as mold. o Iodine can penetrate the cell wall of microorganisms quickly, and the lethal effects are believed to result from disruption of protein and nucleic acid structure and synthesis. o Povidone iodine is an effective antifungal in the treatment of otomycosis. Gentian violet was shown to not only have direct fungicidal action, but also disrupt the adherence of Candida to catheters. o Gentian violet has also been used extensively for oral candidasis (thrush). Painting the mouth of an infant with oral thrush with GV has for more than 90 years been a safe and effective treatment. o Gentian violet has been used to treat oral candidasis in human immunodeficiency virus (HIV) infected individuals, especially in developing countries where treatment with fluconazole is impractical due to availability, cost of treatment and the development of resistance. o Gentian violet has also been found to inhibit biofilms of Candida isolates taken from HIV infected patients in vitro.  against yeast and dermatophytes, respectively C. albicans was the most susceptible among yeast, while Epidermophyton floccosum and Trichophyton rubrum were the most susceptible among dermatophytes. o Phlorotannins mechanism of action was approached. C. nodicaulis and C. usneoides seem to act by affecting the ergosterol composition of the cell membrane of yeast and dermatophyte, respectively. F. spiralis influenced the dermatophyte cell wall composition by reducing the levels of chitin. o Phlorotannins also seem to affect the respiratory chain function, as all species significantly increased the activity of mitochondrial dehydrogenases and increased the incorporation of rhodamine 123 by yeast cells. o Phlorotannins from F. spiralisi inhibited the dimorphic transition of Candida albicans, leading to the formation of pseudohyphae with diminished capacity to adhere to epithelial cells.  Chlorine (1%) causesd a rapid inactivation of A. ochraceus strains and C. albicans, C. krusei and C. parapsilosis. strains. o Chlorine (1%) was high level disinfectants bringing about a rapid inactivation of conidia Trichophyton mentagrophytes, T. raubitschekii and T. tonsurans. 731            Phenol (5%) is equally effective against Candida species; however, a number of A. ochraceus conidia were able to survive this treatment for up to 1 h. o Phenol was equally effective against T. raubitschekii and T. tonsurans; however, T. mentagrophytes cells were able to survive for up to 1 h in 5% phenol. Benzalkonium chloride (0.5%) and cetrimide (0.5%) are able to disinfect the three Candida species rapidly; however, these two quaternary ammonium compounds were relatively ineffective against A. ochraceus. Quaternary ammonium compounds were less rapid in their action against dermatophytes and were needed at a level of about 0¢5% to be completely fungicidal. Three commercial spray formulations with a range of 0¢1 to 0¢3% quaternary ammonium salts were fungistatic against T. mentagrophytes strains. o spray experiments, quaternary ammonium compounds has a fungicidal activity against Candida species and were fungistatic against A. ochraceus conidia. Formaldehyde 8% with activity against 74.8% of fungi, was effective disinfectant at 30 min. Glutaraldehyde 8% and formaldehyde 8% with 100% prevention of growth were effective disinfectants at 60 min. 4% formalin, 10% Dettol®, 0.5% NaClO, 70% Ethanol alcohol, 1% Iodine and 10% Potassium permanganate against Aspergillus flvus ,Candida albicans The results showed that o formalin was his effectiveness on all microbes used, o Dettol®has been more effective than formalin in their effect on fungus . o Iodine, Sodium Hypochlorite, Ethanol alcohol, Potassium Permanganate) were least effective in comparison with Formalin and Dettol® on microbes used Polyhexamethylene biguanide MIC90 (minimum inhibitory concentration for 90% of the organisms) values were 4 and 16 μg/mL for F. solani and A. flavus, respectively. Thimerosal MIC90 values of were 0.0313 and 0.0625 μg/mL for F. solani and A. flavus, respectively. Cetylpyridinium chloride MIC90 values were 2 and 2 μg/mL for F. solani and A. flavus, respectively. Chlorhexidine MIC90 values of were 32 and 32 μg/mL for F. solani and A. flavus, respectively. Tea tree oil demonstrated the greatest inhibitory effect on the growth of Aspergillus fumigatus and Penicillium chrysogenum, applied in either a liquid or vapour form.  Cavicide® and Virkon® demonstrated similar, although less, growth inhibition of both genera.  A 2.4% sodium hypochlorite (NaOCl) treatment was tested on Alternaria alternate, Aspergillus niger, Cladosporium herbarum, Penicillium chrysogenum, Stachybotrys chartarum and Trichophyton mentagrophytes and found to inactivate all the spores of the stock cultures to undetectable levels after 5 min contact time on non-porous surfaces and after 10 min contact time on porous surfaces. . 731         Elemental sulphur was highly toxic (ED50 1–3 μg ml−1) to many fungal pathogens representing ascomycetes, basidiomycetes, and deuteromycetes, but not to an oomycete, Phytophthora, or to bacteria. o Elemental sulphur levels in cocoa and tomato xylem and Arabidopsis leaves were potentially inhibitory, but in other interactions were below theoretically toxic concentrations. o Elemental sulphur accumulation is highly localized, suggesting that the element is produced in sufficient amounts, at the right time and place to be effective. SEM-EDX revealed S in tomato and cocoa xylem walls, xylem parenchyma, and vascular gels and tyloses, all sites appropriate to counter vascular pathogenic Verticillium dahliae. Transient increases in sulphate, glutathione and cysteine occurred in tomato xylem. o The sulphate may reflect the over-expression of sulphate transporters, but the thiols might be possible precursors. o There are many S-containing compounds, which have been linked, directly or indirectly, with the defence of plants against microbial pathogens; these include thionins, defensins, glucosinolates, crucifer phytoalexins, alliin, and glutathione. Zinc pyrithione (ZPT) inhibits fungal growth through increased cellular levels of copper, damaging iron-sulphur clusters of proteins essential for fungal metabolism. Viscosinamide produced by Pseudomonas fluorescens DR54 showed antagonistic properties against plant pathogenic fungi like Pythium ultimum and Rhizoctonia solani. Tolaasin is a lipodepsipeptide, found to be produced by a pathogen of mushroom species. o Tolaasin causes disruption of the A. bisporus plasma membrane and vacuole membranes by tolaasin. Tensin is an antifungal cyclic lipopeptide produced by P. fluorescens strain 96.578. Syringotoxin is produced by P. syringae pv. syringae which is a known pathogen of various species of citrus trees. Syringopeptin, another major phytotoxic antibiotic produced by P. syringae pv. syringae, is also a lipodepsipeptide. The pseudophomins are also cyclic lipodepsipeptides grouped into pseudophomins A and B. o The pseudophomins are isolated from P. fluorescens strain BRG100, a bacterium with potential application as a biocontrol agent for plant pathogens and agricultural weeds. o Pseudophomin B showed higher antifungal activity against the phytopathogens such as Phoma lingam/Leptosphaeria maculans and Sclerotinia sclerotiorum. o Pseudophomin A showed stronger inhibition toward green foxtail (Setaria viridis) and induced root germination than pseudophomin B (Segre et al. 1989; Galonić et al. 2007). o Pseudomycins are peptide antimycotics that are isolated from P. syringae, another plant-associated bacterium. o Pseudomycins contain three analogs classified as A–C that contain amino acids hydroxyl aspartic acid, aspartic acid, serine, arginine, lysine, and diaminobutyric acid. 732         o Pseudomycin A is the predominant peptide of the pseudomycin family that possesses selective phytotoxicity and is effective against human pathogen Candida albicans Massetolide A is isolated from P. fluorescens SS101, identified as a biocontrol agent. P. fluorescens SS101 was effective in preventing infection of tomato (Lycopersicon esculentum) leaves by P. infestans and significantly reduced the expansion of existing late blight lesions. o Massetolide A displayed significant control of P. infestans both locally and systemically via induced resistance. Chlorine (1%) was high level disinfectants bringing about a rapid inactivation of conidia Trichophyton mentagrophytes, T. raubitschekii and T. tonsurans. Phenol was equally effective against T. raubitschekii and T. tonsurans; however, T. mentagrophytes cells were able to survive for up to 1 h in 5% phenol. Quaternary ammonium compounds were less rapid in their action against dermatophytes and were needed at a level of about 0¢5% to be completely fungicidal. Three commercial spray formulations with a range of 0¢1 to 0¢3% quaternary ammonium salts were fungistatic against T. mentagrophytes strains. Formaldehyde 8% with activity against 63.6% of fungi including Aspergillus spp, Penicillium spp, Fusarium spp, Rhizopus, Alternaria and Circinella were effective disinfectants at 15 min. Formaldehyde 8% with activity against 74.8% of fungi, was effective disinfectant at 30 min. Glutaraldehyde 8% and formaldehyde 8% with 100% prevention of growth were effective disinfectants at 60 min. 4% formalin, 10% Dettol®, 0.5% NaClO, 70% Ethanol alcohol, 1% Iodine and 10% Potassium permanganate against Aspergillus flvus ,Candida albicans The results showed that o formalin was his effectiveness on all microbes used, o Dettol®has been more effective than formalin in their effect on fungus . o Iodine, Sodium Hypochlorite, Ethanol alcohol, Potassium Permanganate) were least effective in comparison with Formalin and Dettol® on microbes used References: 1. Abbas Razzaq Abed, Ibtisam Mohammed Hussein. 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Shreaz S1, Wani WA2, Behbehani JM3, Raja V4, Irshad M3, Karched M3, Ali I5, Siddiqi WA4, Hun LT2. Cinnamaldehyde and its derivatives, a novel class of antifungal agents. Fitoterapia. 2016 Jul;112:116-31. 11. Xu Y1, He Y, Zhou L, Gao C, Sun S, Wang X, Pang G. Effects of contact lens solution disinfectants against filamentous fungi. Optom Vis Sci. 2014 Dec;91(12):14405. 12. Yildirim-Bicer A Z. ,1 I. Peker,2 G. Akca,3 and I. Celik3 In Vitro Antifungal Evaluation of Seven Different Disinfectants on Acrylic Resins. BioMed Research International. Volume 2014 (2014), Article ID 519098 734