Perfect Et Al. 2017 - The Antifungal Pipeline-A Reality Check

REVIEWS
The antifungal pipeline: a reality check

John R. Perfect
Abstract | Invasive fungal infections continue to appear in record numbers as the
immunocompromised population of the world increases, owing partially to the increased number
of individuals who are infected with HIV and partially to the successful treatment of serious
underlying diseases. The effectiveness of current antifungal therapies — polyenes, flucytosine,
azoles and echinocandins (as monotherapies or in combinations for prophylaxis, or as empiric,
pre-emptive or specific therapies) — in the management of these infections has plateaued.
Although these drugs are clinically useful, they have several limitations, such as off-target toxicity,
and drug-resistant fungi are now emerging. New antifungals are therefore needed. In this Review,
I discuss the robust and dynamic antifungal pipeline, including results from preclinical academic
efforts through to pharmaceutical industry products, and describe the targets, strategies,
compounds and potential outcomes.
As modern medicine advances and allows us to manage year of disseminated cryptococcosis, and an estimated
Mycetomas
Chronic fungal infections of
diseases that have previously been refractory to med- 600,000 of these cases resulted in death2. These alarming
skin and soft tissue. ical and surgical intervention, the patient can become figures have decreased with the widespread distribution
vulnerable to invasion by microorganisms. The use of of effective antiretroviral treatments, which has reduced
anticancer chemotherapies, new monoclonal antibodies the spread and disease progression of HIV, but the num-
with immunological properties, immunosuppressive ber of infections still remains very high, particularly in
drugs, broad-spectrum antimicrobials that affect our areas of sub-Saharan Africa. On another medical front,
microbiome and numerous medical devices can dysreg- aggressive chemotherapy to manage life-threatening
ulate or breach the immune surveillance system. Within cancers is increasingly being used in countries with
this opportunistic window during which individuals are limited health-care resources, and the resulting increase
immunocompromised, they are susceptible to invasion in life-threatening complications of invasive mycoses
by certain fungi. will follow, which presents another challenge for these
It has been estimated that there are more than 5 mil- health-care systems. Even highly resourced countries
lion fungal species worldwide; approximately 300 fungal continue to be challenged by the diagnosis and manage
species have been recorded to cause disease in humans, ment of invasive mycoses in the at-risk populations.
but only 20–25 of these do so on a relatively frequent Invasive mycoses can change the landscape of outcomes
basis (TABLE 1). Most of these fungal infections are not for certain underlying diseases.
transmissible from person to person and do not rou- It is important to note that our high mammalian
tinely affect healthy individuals. With the exception body temperature, combined with a powerful immune
of dermatophytic fungal nuisances of the skin and surveillance system, means that we routinely resist fun-
nails, fungal infections are underappreciated by the gal challenges, and primary fungal infections or diseases
general public. However, invasive mycoses are a grow- are an uncommon clinical phenomenon. Furthermore,
ing problem for clinicians to manage in many medical human mycoses generally result from an accidental
settings1. In the clinical climate of an ‘at-risk’ popula- encounter with a fungus — such as inhalation of aero-
tion of immunosuppressed hosts that is increasing in solized spores or direct inoculation with yeasts — and
size owing to modern medical treatment, particularly these fungi, which proliferate within immunocompro-
Duke University Medical
of HIV infections, combined with outbreaks of disfig- mised human hosts, have access to plenty of carbon
Center, 200 Trent Drive,
Durham, North Carolina uring mycetomas in some economically disadvantaged and nitrogen sources. Most sites of the human body
27710, USA. societies, these invasive and superficial mycoses have can potentially provide a safe environment for fungi if
Correspondence to J.R.P. become a major public health problem, with substantial immune surveillance is low.
[email protected] associated morbidities and mortalities. For example, at Clinicians have developed several strategies to meet
doi:10.1038/nrd.2017.46 the peak of the HIV epidemic in the early 2000s, it was this new invasive fungal infection challenge. First, they
Published online 12 May 2017 estimated that there were more than 1 million cases per can categorize patients into certain at-risk groups to
NATURE REVIEWS | DRUG DISCOVERY VOLUME 16 | SEPTEMBER 2017 | 603

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Table 1 | Common invasive fungal diseases

Disease Fungal species Clinical outlook Treatment options (in Areas for improvement
order of preference)
Dimorphic mycoses • Blastomyces dermatitidis • Geographically restricted Azoles > polyenes • A vaccine would be welcomed
• Coccidioides immitis • Infect both immunocompetent and is in development
• Coccidioides posadasii and immunosuppressed • In need of more effective
• Histoplasma capsulatum individuals and oral agents, and better
• Sporothrix spp. diagnostics for earlier
identification
Disseminated • Cryptococcus neoformans • Even with ART, there are still Amphotericin B in Need improved management of
cryptococcosis • Cryptococcus gattii many new cases combination with IRIS and ICP
• No new therapies in more than 5‑flucytosine >
25 years monotherapies
• Cryptococcal antigen levels
are not used to monitor
outcome
• Differences in outcome
correlate with health-care
resource availability
• IRIS and increased ICP have
been associated with this
infection and need to be
managed
Invasive aspergillosis • Aspergillus fumigatus • Increasing resistance to azoles Azoles > polyenes > • Genetic susceptibility needs to
• Aspergillus flavus • Early treatment or prevention echinocandins be defined
• Aspergillus terreus is essential • A biomarker that can be used
• Aspergillus calidoutus for diagnosis and to monitor
treatment outcome would be
very useful
Invasive candidiasis • Candida albicans • High mortality attributable to Echinocandins > • Need better integration of new
• Candida tropicalis infections azoles > polyenes diagnostic tools with specific
• Candida glabrata • Drug resistance develops in treatment strategies
• Candida parapsilosis pathogens • An agent with a new
• Candida krusei • Requires early-stage treatment mechanism of action would be
• Candida auris advantageous for treatment
Mucormycosis • Rhizopus spp. • Control underlying diseases, Polyenes > azoles • Improved diagnostics to ensure
• Mucor spp. initiate polyene therapy and early, accurate diagnosis
• Cunninghamella consider surgery • Empiric therapy is not often
bertholletiae • Poor prognosis successful
ART, antiretroviral therapy; ICP, intracranial pressure; IRIS, immune reconstitution inflammatory syndrome.
allow more focused strategies for diagnosis and prophyl successful management of fungal infections is the con-
actic, empiric and pre-emptive therapies. Second, the tinued development and appropriate use of both new
T2 MRI
diagnostic toolbox for fungal infections has been sub- and old antifungal drugs.
(Magnetic resonance imaging). stantially improved and includes crucial histopathology In the United States, the enthusiasm for antifungal
A testing system from T2 of infected tissues when available. Culture techniques drug development may have been further stimulated
Biosystems that uses advances are validated and robust, and now with matrix- by the GAIN Act, the Orphan Drug Act and the Fast Track
in nanotechnology and
assisted laser desorption/ionization time-of-flight mass designation by the US Food and Drug Administration
molecular biology to detect
microorganisms directly from spectrometry (MALDI–TOF MS), PCR and T2 MRI (FDA), all of which potentially apply to antifungal
body fluids. technology, along with advances in genomic sequenc- agents and thus provide a favourable economic climate
ing, the invading fungus can be rapidly and accurately for investment in newly discovered and developed anti
GAIN Act identified. Furthermore, biomarkers, such as the levels fungal agents9. However, even with these incentives at
The Generating Antibiotic
Incentives Now (GAIN) Act by
of the fungal polysaccharides β‑d‑glucan, galactoman- both the basic and developmental levels of discovery
the US Federal Government is nan and mannan in the blood or other body fluids, have that are discussed in further detail in this Review, there
legislation that aims to been validated as potential surrogates to help prescribe remains some belief that the development of antifungal
stimulate antimicrobial pre-emptive therapy. These biomarkers enable invasive agents will be difficult. A key reason for this scepticism
discovery.
mycoses to be controlled at the early stages of infection is that approximately 80% of antifungal targets in the lit-
Orphan Drug Act when the tissue burden of fungi is low, an important erature turn out to be false positives with little potential
The Orphan Drug Act feature of effective fungal control. Third, there has been to develop target-based inhibitors with desirable features
enables the US Food and a collation of both objective and subjective opinions from them10. Both humans and fungi use similar eukary
Drug Administration (FDA) to into a series of antifungal management guidelines3–8, so otic machinery, and — despite a plethora of potential
designate a treatment as
being developed for a rare
that health-care systems and clinicians have basic stand- targets — there needs to be substantial selectivity and
disease upon request from ards to help initiate and compare successful treatments few or no complicating interactions with host proteins
a sponsor. and strategies. Last, the most important factor for the and the cellular machinery.
604 | SEPTEMBER 2017 | VOLUME 16 www.nature.com/nrd

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Fast Track What issues and needs are specific to antifungal new antifungal drugs. Despite the importance of and
Fast Track is a US Food and drug development 11? First, mortality that is attributa- need for new antifungal agents, successful clinical drug
Drug Administration (FDA) ble to fungal infections simply remains too high with development has a series of roadblocks that need to be
designation for expedited current antifungal agents. Second, there needs to be overcome (BOX 2). All of these specific issues or difficul-
review of drugs to fill unmet
medical needs, as requested
a greater emphasis on more rapid fungicidal activity ties can be managed, but it takes an experienced team
by a drug company. by new antifungal agents. For improved clinical out- with insightful protocols and careful management of the
comes, drugs must kill yeasts or moulds rapidly and trial to carry out and complete these licensing studies.
completely. Currently, the general treatment course for It is truly an appropriate time to review antifungal
common antifungal agents is too long and thus intro- drug development, and to discuss its current leads and
duces the potential for poor immediate-term fungicidal directions, so that this important antifungal pipeline can
activity, reduced patient compliance and/or tolerabil- be re-evaluated14–16. In this Review, I examine the cur-
ity, or even the emergence of direct antifungal drug rently available antifungal agents and provide an over-
resistance12 (BOX 1). Third, there is a need to widen the view of the ongoing efforts to develop completely new
spectrum of antifungal activity against some emerg- classes of drugs, which includes strategies to repurpose
ing, highly drug-resistant fungi (such as Lomentospora existing drugs, develop new drugs from current antifun-
(Scedosporium) prolificans and Candida auris) that are gal classes and create new biological antifungal agents.
increasingly observed in patients who are being immu-
nosuppressed for other severe underlying diseases and Currently available antifungal drugs
are thus admitted to hospitals. There are simply no For many of the superficial mycoses, there have been
antifungal agents that can adequately treat infections a series of topical drugs used over the past century that
caused by certain fungal strains. Fourth, it is important have had moderate success in controlling common
to have an optimized combination of therapeutic agents and irritating infections. By contrast, for the invasive
or classes to increase potency and reduce the emergence mycoses, which require systemic antifungal therapy,
of drug resistance. Fifth, resistant strains are increasing there have been only four major classes of antifungal
in number for some antifungal agent classes, particu- agents (polyenes, flucytosine, azoles and echinocandins)
larly for the azoles and the echinocandins13. Sixth, safety (FIG. 1).
remains a very important issue for antifungal drug use. A central feature of antifungal agents is the require-
Invasive mycoses occur in very fragile patients who can- ment for the eukaryotic machinery to be differentially
not tolerate much additional organ toxicity from other blocked or destroyed in the fungus but do limited or no
treatments. Furthermore, these patients are frequently damage to host cellular functions17. The lineage of suc-
taking multiple other therapeutic agents, so drug–drug cessful systemic antifungal drugs started in the 1950s
interactions need to be carefully considered. Last, there with the approval of the polyene amphotericin B deoxy-
are multiple issues around the clinical development of cholate. Despite its substantial toxicities, amphotericin B,
in formulation with deoxycholate or other solubilizing
agents, remains the most potent fungicide and has the
Box 1 | Resistance to current antifungal agents
broadest antifungal spectrum of the systemic antifun-
The mechanisms that have been acquired by fungi to become resistant to current gal agents in clinical use today. The polyenes interact
antifungal agents are fairly well understood. It is important to note that, unlike bacteria, with ergosterol-containing fungal membranes and
there are no known plasmid- or transposon-mediated mechanisms for drug resistance. disrupt them by puncturing these membranes (FIG. 2),
For instance, polyene resistance is rarely acquired; most resistance to polyenes is but they can also interact with cholesterol-containing
primary and thus observed in fungal species that have ergosterol membranes that are
membranes and thus injure host cells, so host toxicity
not susceptible to or only mildly affected by polyenes. However, polyenes can lose their
fungicidal activity during prolonged exposure of the fungus to the drug, which leads to
has always been an issue. In the mid‑1990s, the formu-
reduced efficacy or clinical resistance144. lation of amphotericin B was vastly improved with the
Azoles, by contrast, have multiple mechanisms for the development of both primary creation of lipid formulations of amphotericin B, such
and acquired resistance, including mutations in the gene encoding lanosterol as AmBisome and amphotericin B lipid complex, that
14α‑demethylase (ERG11), so that azoles can no longer block its catalytic activity, and reduced host toxicity, especially the occurrence of renal
amplification of ERG11, so that Erg11 molecules overwhelm the inhibitory capacity of dysfunction.
the azole145. Also, some fungal species have amplified or induced efflux pumps to Flucytosine is a pyrimidine analogue that was
remove azoles from the fungal cell and therefore from the target. This rise in azole approved in the 1960s and is generally used in limited
resistance has been observed consistently in hospitals for years and has even been circumstances, such as in combination with a polyene
linked, in certain cases, to the environmental use of fungicides in agriculture146.
for cryptococcal meningitis. Flucytosine is rarely used
Over the past 5–6 years and with the widespread use of echinocandins in hospitals,
there has clearly been an increase in the identification of yeasts that have become
alone because of the rapid development of drug resist-
resistant to echinocandins, through the development of mutations in FKS1, which ance that occurs during monotherapy. Flucytosine is
encodes the 1,3‑β‑d‑glucan enzyme that helps in the formation of the fungal cell wall. converted by a cytosine deaminase that is not present
This echinocandin resistance mechanism has been most prominently observed in the in humans to the toxic compound 5‑fluorouracil, which
haploid yeast, Candida glabrata147. interferes with RNA and DNA metabolism.
Recently, mutations in MSH1, a mismatch repair gene, have also been observed to In the late 1970s, the systemic azoles started their
cause multiple drug-resistant phenotypes (to azoles and echinocandins) in yeast ascension to become a first-line choice for the treat-
strains148. Finally, drug-resistant mutations in the pyrimidine pathway occur at the rate ment of invasive fungal infections. The azoles primar-
of 1 in every 106–107 yeast cells, so 5‑flucytosine is very vulnerable to the development ily block ergosterol synthesis by inhibiting lanosterol
of drug resistance if used as a monotherapy in high fungal burden infections149.
14α‑demethylase (Erg11), a primary target in the fungal

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Box 2 | Antifungal drug development considerations reduced drug–drug interactions and their improved
safety. This antifungal class has become the first line of
A number of hurdles to antifungal drug development must be overcome and will treatment for the deadly and relatively common nosoco-
determine the clinical utility of these compounds and the development path: mial candidaemia and invasive candidiasis4.
• The value of limited- versus broad-spectrum antifungal activity must be balanced. Finally, the squalene epoxidase (also known as
For instance, a drug with antifungal activity only against particular yeasts or moulds squalene monooxygenase) inhibitor terbinafine is used,
will rely heavily on diagnostic acumen albeit uncommonly, as a combination agent in inva-
• For eukaryotic targets, the toxicity data will always be crucial sive fungal infections, and aerosolized pentamidine is
• Biomarkers should be accepted as validated primary end points instead of relying infrequently used in prophylaxis against pneumocystis
exclusively on death: these patents have too many other comorbidities, so efficacy infections.
signals will require large number of patients There have been several excellent detailed discussions
• Although there are substantial numbers of invasive fungal infections, many patients of the mechanisms of the antifungal agents in use at
will often need to be screened to get a single patient enrolled. This is particularly true present 18–22. Each currently used class has both strengths
for candidaemia studies
and weaknesses in terms of efficacy and safety. These
• The use of compounds for prophylaxis or for treatment should be considered as an weaknesses are clearly emphasized by the mortality rates
initial focus for the development of safe and broad-spectrum compounds
attributable to invasive mycoses, which remain substan-
• Although more rapid fungicidal activity and shorter treatment courses are needed, tial. For instance, in invasive candidiasis, the mortality
initial studies will probably require prolonged treatment duration
rate has been estimated to be around 40%23; the mortal-
• Invasive fungal infections classically occur in patients with the most severe illnesses, ity rate among individuals with disseminated cryptococ-
so both underlying diseases and tolerability can frequently affect the outcome
cosis is 20–30% in well-resourced health-care systems24,
assessment of the antifungal drug
and this rate is substantially higher in resource-limited
• Many of the scoring systems use radiographic results, and this is simply too imprecise areas (50% or greater)25. By contrast, the mortality rate
• Success should include disease control, rather than disease eradication, in many among individuals with invasive aspergillosis has been
circumstances reduced over the past decade but has now plateaued at
• The clinical studies are particularly expensive. These patients are fragile and require approximately 20%26. In many other invasive mould
close monitoring as well as detailed records. Furthermore, there may be interruptions infections, the reported mortality rates are much higher
of assessments due to decisions by the clinical care team
(≥50%). Although a new azole, isavuconazole, was
approved for treatment of aspergillosis and mucormy-
cosis in 2015, it has been more than a decade since a
membrane that is not present on the host cell mem- new class of antifungal agents has been introduced into
brane. The first azole-based therapies were an intrave- the clinic.
nous miconazole preparation and an oral ketoconazole
tablet. The second generation, the extended-spectrum Novel pathways and targets
azoles, improved on the spectrum of antifungal activ- Over the past two decades — during the fungal genomic
ity, safety and pharmacokinetics, and were available in era — there has been substantial progress in antifungal
new formulations. For instance, fluconazole and itra- drug development for a multitude of potential drug tar-
conazole have both intravenous and oral formulations. gets27 and inhibitors28,29. Notably, antifungal molecules
Following further discovery and development, there are frequently discovered in phenotypic screens for anti-
are now third-generation extended-spectrum azoles: fungal inhibitors, and these strategies require live fungus
voriconazole, posaconazole and isavuconazole. The readouts, natural products as sources of molecules and
merits of these newer azoles are substantial as they have pharmaceutical insights to move identified molecules
improved antifungal activity, safety, pharmacokinetics forward30–34. This Review focuses on several examples of
and formulations. They are a key component of the promising pathways and specific targets (TABLE 2, FIG. 1)
current clinical management of invasive mycoses as but is not comprehensive. These specific pathways were
wide-spectrum antifungal agents for use in prophylaxis chosen as prime examples of the mechanistic approach
(to prevent infection), and pre-emptive (to prevent dis- to block important fungal molecules. The following spe-
ease manifestations), empiric and therapeutic strategies. cific target studies illustrate the depth and the potential
The azoles have been shown to reduce mortality and for the detailed, mechanistic approaches to antifungal
allow clinicians to practise aggressive medical and sur- target development at an early exploratory stage as
gical management of many serious underlying diseases18. a foundation for the future antifungal drug pipeline.
The development and marketing of the fourth class
of antifungal agents, the echinocandins, began in the Calcineurin. The calcineurin pathway is important in
early 2000s. The echinocandins block 1,3‑β-glucan eukaryotes and is potentially a target of selective inhib-
synthase, which helps to form the cell wall (a unique itors that could become antifungal drugs35,36. The ser-
structure of the fungus that is not present in mammals). ine/threonine phosphatase calcineurin (also known as
Indeed, the echinocandins have very little host toxicity, protein phosphatase 3; a heterodimer that is composed
and this is one factor that contributes to their frequent of the subunits calcineurin A and calcineurin B) is the
use in the hospital setting. Three echinocandins (caspo- target for the most commonly used transplant anti-
fungin, micafungin and anidulafungin) have had much rejection drugs: tacrolimus and cyclosporine. Cyclo
Nosocomial success over the past decade in the clinic owing to their sporine was initially discovered in a screen as an anti-
Hospital-based. broad-spectrum fungicidal activity against yeasts, their Candida molecule, and calcineurin is central to the stress

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REVIEWS
in discovering potent antifungal, anti-calcineurin mol-

Future generations ecules with reduced immunosuppressive activity; these
are currently being tested in animal models40.
• Oral formulations
• Nanoparticles
• Polysaccharide Polyenes Sphingolipid synthesis and RAS. Two pathways (RAS41
conjugation Flucytosine and sphingolipid synthesis42) have been active areas in
Azoles
Echinocandins the search for new anticancer agents. However, genetic
• VT-1161 etc.
(reduced toxicity, and structural studies have also shown that both of
increased half-life) these signalling pathways are important for fungi
• SCY078 (oral) to efficiently produce disease. Fungal sphingolipids
• CD101 (increased have emerged as a potential target for new antifungal
stability) agents because the biosynthesis of these molecules in
fungi is structurally different from that in mammals.
Second and third generation
Sphingolipids are important in cellular metabolism
• Lipid formulations but can also be important in the regulation of the fun-
(reduced toxicity) gal virulence composite. There are now diverse strat-
• Structural changes to improve egies that could be used to block the synthesis and/or
activity, safety, pharmacokinetics, etc. function of sphingolipids43. Several new compounds
(Nʹ‑(3‑bromo‑4‑hydroxybenzylidene)-2‑methyl ben-
First generation
zohydrazide and its derivative, 3‑bromo-Nʹ‑(3‑bromo‑
4‑hydroxybenzylidene) benzohydrazide) have been
• Nystatin found to selectively decrease levels of fungal glycosphin-
• Amphotericin B golipids relative to the mammalian ones. These com-
• Flucytosine pounds are anticipated to go into clinical trials (see the
American Society for Microbiology press release). In the
• Miconazole (intravenous)
• Ketoconazole (oral)
RAS pathway, there are several antifungal targets within
the protein farnesylation and prenylation processes that
• Anidulafungin could be of interest, as the structures differ between the
• Micafungin
• Caspofungin fungal and mammalian proteins41. With these observa-
tions and the ability to design and/or discover molecules
that would inhibit the actively growing fungi but have no
Figure 1 | Currently available antifungal compounds and future derivatives
or little effect on human cells, a potent antifungal agent
thereof. There are currently four classes of antifungals available: polyenes, flucytosine,
azoles and echinocandins. Improvements have been made Nature Reviews
to three | Drugclasses
of these Discovery
to
could emerge. Similarly to the calcineurin inhibitors,
increase efficacy or reduce toxicity. Future generations of these classes of compounds these targets have been validated with inhibitors for the
are in development. human enzymes during the development of potential
anticancer agents. Therefore, the focus will be on finding
inhibitors with selectivity for the fungal over the human
homologues and, importantly, on getting the molecules
responses of many pathogenic fungi. For instance, cal- to the site of action within the intact fungal cells.
cineurin has been shown to be essential for the virulence
composite of the major fungal pathogens (Aspergillus Trehalose. The trehalose pathway comprises several
fumigatus, Candida albicans and Cryptococcus neofor- enzymes that are connected to glycolysis and creates
mans) and thus for fungal survival and fitness in the the regulatory molecule trehalose‑6‑phosphate and the
host 37. Furthermore, calcineurin can be linked to other disaccharide sugar trehalose44. Relative to compounds
well-studied stress signalling pathways, including the targeting the RAS and calcineurin pathways, molecules
heat shock protein 90 (Hsp90)38 pathway. Hsp90 has targeting this pathway are at a much earlier developmen-
also become an excellent target for antifungal inhibi- tal stage, and few inhibitors have been discovered thus far.
tors, and an antibody against Hsp90 (efungumab; also Despite this lack of development, many targets within the
known as Mycograb; NeuTec Pharma/Novartis) in com- trehalose pathway possess attractive features of antifungal
bination with amphotericin B made it into a substantial, agents. First, unlike many of the fungal stress pathways
comparative clinical trial and demonstrated therapeutic that are currently being studied, this pathway is present in
efficacy in invasive candidiasis39. The potential to make fungi, bacteria, plants and invertebrates, but is not found
calcineurin a viable target for antifungal drug discovery in the mammalian biochemical machinery. Therefore, the
has been contingent on finding specific inhibitors that potential for inhibitor toxicity should be minimal, unless
have the differential ability to block fungal over mam- there are off-target issues. Second, this pathway, which
malian calcineurin. In this respect, the inhibitors must contains two primary synthesizing enzymes (treha-
be fungicidal with minimal or no immunosuppressive lose‑6‑phosphate synthase (Tps1) and trehalose‑6‑phos-
activity. It has been helpful that the fungal and human phate phosphatase (Tps2)), has been validated as essential
Virulence composite
The genetic and phenotypic
homologues of calcineurin are well understood from a to tolerating stress in all of the major fungal pathogens44.
traits that encompass structural perspective36. It is with this knowledge and a Third, genetically blocking this pathway kills pathogenic
pathogenicity. concerted chemistry effort that progress is being made fungi, which clearly demonstrates that this pathway is a

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REVIEWS
Glycolipid inhibitors Terbinafine Cloudbreak molecule

(e.g. BHBM,
aureobasidin A Azoles Polyenes
analogues)
Gepinacin
APX001
Aminocandins
Ras
Farnesylation Nikkomycin Z
or prenylation
inhibitors
SCY078
Echinocandins
Pdk1 inhibitors
Icofungipen (e.g. UCN-01)
Endoplasmic
Sordarins reticulum
AR-12 Acs1
Mohangamide A Icl MGCD290
Mohangamide B
Rifampin
Metabolism
5-flucytosine Cell wall
Cell membrane
F901318 Dhodh Pyrimidines Nucleus
?
Pentamidine Sertraline
?
Tamoxifen Ergosterol
Mitochondria 1,6-β-glucans
Stress
response ASP2397
1,3-β-glucans
T-2307 UDP-glucose
Calcineurin Hsp90 inhibitors Chitin
inhibitors (e.g. efungumab
(e.g. tacrolimus) and geldanamycin) Fungus-specific Mannoproteins
transporters
HOG pathway inhibitors Trehalose PMN cell
(e.g. fludioxonil, ambruticins) inhibitors 1,3-β-glucan synthase
Figure 2 | 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 areNature
indicated in light blue boxes,
Reviews | Drug Discovery
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.
fungicidal target45,46. Recently, the crystal structures of the A. fumigatus invasion but not C. neoformans inva-
C. albicans proteins Tps1 and Tps2 have been solved47, so sion, and has been a target of some potent inhibitors,
molecules that specifically bind to active catalytic com- such as mohangamide A and mohangamide B, which
ponents to inhibit the enzymes could be found compu- inhibit the enzyme in C. albicans 48. The mitogen-
tationally or in compound libraries47. activated protein (MAP) kinase and the high-osmolarity
glycerol (HOG) pathways, which are required for adap-
Other targets. Several other pathways have been iden- tation to environmental signals, have also been attrac-
tified as potential antifungal targets. For instance, the tive targets. The HOG pathway was identified as the
metabolic glyoxylate cycle, specifically the enzyme target for the antifungal action of fludioxonil49–51. New
isocitrate lyase, is important for C. albicans and targets and inhibitors also include the cell wall target

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3‑phosphoinositide-dependent protein kinase 1 (Pdk1) compound for the treatment of systemic fungal diseases65.
and an inhibitor, VCN‑01 (REF. 29), of calcium signalling. Therefore, these compounds are not emphasized in this
The sphingosine‑1‑phosphate receptor modulator, fin- Review. The focus of this section is on the targets and
golimod hydrochloride (also known as FTY720), also mechanisms of action of the compounds, the general
has broad-spectrum antifungal activity 52. Finally, even antifungal susceptibility pattern of the compound and its
altering gene expression through the manipulation of preliminary in vivo activities (TABLE 2).
transcription factors has emerged as an attractive anti-
fungal approach: a prime example of this strategy has ASP2397. A new antifungal compound, ASP2397
been the successful identification of compounds that (Vical), produces its antifungal effects by disrupting
block the transcription factor sterol uptake control the intracellular fungal biochemical machinery. Its pre-
protein 2 (Upc2)53. cise target inside the fungal cell remains uncertain, but
The above pathways are examples of potential anti- ASP2397 localizes within fungi such as A. fumigatus,
fungal targets but do not constitute an exhaustive list. as it is taken up by the specific siderophore iron trans-
However, they are clear examples of how academic porter 1 (Sit1)66. As mammalian cells do not have this
research can provide the framework to discover and transporter, it is hypothesized that the compound will
validate antifungal targets and thus provide a platform have excellent selective fungal toxicity. In both in vitro
to identify and develop antifungal molecules. From these and in vivo studies, ASP2397 has very potent fungicidal
robust scientific platforms for targets and inhibitors, the activity against A. fumigatus67. Along with potent activity
pharmaceutical industry can then use their chemistry against both azole-susceptible and azole-resistant strains
infrastructure, formulation expertise and molecule of Aspergillus spp., it also has in vitro antifungal activity
libraries to identify and/or further develop antifungal against a few Candida spp. and some rare moulds and
drugs. To target these ubiquitous and highly linked yeasts, such as the Fusarium spp. and Trichosporon spp.66.
pathways, the ideal compounds should have a broad
antifungal spectrum, not overlap with existing drug- T-2307. The allylamine T-2307 (Tokuyama Corporation)
resistant mechanisms and potentially synergize with has been in development for several years. It has inter-
either new or old antifungal drugs. The main focus of esting and unusual mechanisms for selectivity and activ-
these studies must remain on the identification of pow- ity. First, the compound is selectively transported and
erful fungicidal targets that will work within the host, as accumulates in fungal cells through a specific polyam-
the final goal is to identify and develop new drugs that ine transporter 68. Once inside the yeast cell, it specif-
are clinically useful. ically inhibits the mitochondrial membrane potential,
There also remains a robust platform for the dis- and this has profound fungicidal activity, as the fungal
covery of natural products with antifungal activity, and strains that cause human disease are primarily res-
many natural antifungal compounds have been reported. piratory fungi69. This compound has broad-spectrum
For instance, psoriasin (also known as S100A7), a mam- and potent antifungal activity against Candida spp.,
malian protein that is commonly found in psoriatic Cryptococcus spp. and Aspergillus spp., with extremely
lesions, has antifungal activity, particularly against low minimum inhibitory concentrations for yeasts and
Trichophyton rubrum54. Other products such as humi- moulds70. Furthermore, the in vitro antifungal activity
dimycin (also known as MDN‑0010), a bacterial nat- is corroborated by impressive antifungal activity in the
ural product, potentiate known antifungal agents by treatment of animal models of mycoses. In some models,
targeting an echinocandin salvage pathway 55. Although T-2307 is more potent than standard azoles and polyenes
nature can help to select antifungal compounds, we must for the treatment of mycoses71. However, for unclear rea-
then make them into drugs. From impressive antifungal sons, it has yet to be advanced into clinical trials.
scaffolds56 and screening of natural products57 to finding
natural products such as carvacrol58 and the antibacterial AR‑12. The celecoxib derivative AR‑12 (Arno Thera
quinolone analogues that are active leads against mem- peutics) is a repurposed compound in some respects.
bers of the fungal kingdom59, the strategies for antifungal It was first used in phase I oncology trials, so safety has
compound discovery from natural products are diverse been determined in humans (ClinicalTrials.gov iden-
and robust. tifier: NCT00978523). However, it was shown to have
consistent antifungal activity against yeasts, such as
New agents in development C. neoformans and C. albicans, and moulds, including
Multiple types of antifungal molecules are in clinical those from the Mucorales order and the hyalohypho-
development and currently have substantial support from mycosis group, such as Fusarium spp. and Scedosporium
pharmaceutical companies. For a variety of reasons, three spp.72,73. In animal models, AR‑12 potentiates the activ-
groups of antifungal compounds — the aminocandins60,61, ity of fluconazole against C. neoformans infection72. The
sordarins (which inhibit protein synthesis by stabilizing mechanism of action of this compound is not precisely
the ribosome–elongation factor 2 (Ef2) complex)62 and known. AR‑12 seems to act via two mechanisms: by
icofungipen (which is an isoleucyl-tRNA synthesis inhib- blocking acetyl-CoA synthetase 1 in fungal metabolism
itor)63 — have received little recent developmental atten- and by downregulating host chaperone proteins, such
tion, and a broad-spectrum triazole, albaconazole64, is as 78 kDa glucose-regulated protein (GRP78), HSP90
now only studied for its use in treating superficial fungal and HSP27 (REF. 73), which reduces the host immune
infections, whereas before it was considered a potential response. Targeting the host immune response may

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Table 2 | Antifungal compounds with novel targets in development

Compound Molecular target Target species or relevant disease Development stage ClinicalTrials.gov
identifier or ref.
Unapproved compounds with novel structures
APX001 Glycosyl phosphatidylin- • Broad-spectrum potency against Phase I; phase II planned NCT02957929 and
ositol synthesis (prevents pathogens, including Mucorales NCT02956499
attachment of mannose order, Candida spp., Aspergillus spp.,
proteins to the outer cell wall) Fusarium spp. and Scedosporium
spp.
• Synergizes with approved
antifungals
AR‑12 • Probably blocks fungal • Cryptococcus neoformans Completed phase I for NCT00978523
acetyl-CoA synthetase 1 • Candida albicans oncology indications
• Increases host immune • Mucorales order moulds
response by downregulating • Hyalohyphomycosis, including
host chaperone proteins those caused by Fusarium spp. and
Scedosporium spp.
ASP2397 Unknown, but taken up by • Aspergillus fumigatus Preclinical but potentially –
Sit1 • Some Candida spp. approaching clinical
• Fusarium spp. studies
• Trichosporon spp.
Aureobasidin A Inositol phosphorylceramide Broad spectrum Preclinical –
synthase
Cloudbreak Binds to granulocytes and Could have focused or Preclinical –
molecules (bispecific thereby concentrates the broad-spectrum antifungal activity
antibodies) antifungal at the infection
Efungumab (also Hsp90 Candida spp. Phase II NCT00324025 and
known as Mycograb) NCT00847678
F901318 Dihydroorotate • Aspergillosis spp. Phase II NCT02856178
dehydrogenase • Scedosporidium spp.
Geldanamycin-like Hsp90 Broad spectrum Completed phase I for 148
agents oncology indications
MGCD290 Hos2 • Broad spectrum Phase II NCT01497223
antifungals
Nikkomycin Z Chitin synthase • Coccidioidomycosis, histoplasmosis Phase I NCT00834184
and blastomycosis
antifungals
T-2307 Mitochondrial membrane • Candida spp. Phase I (see Further –
potential • Cryptococcus spp. information for details)
• Aspergillus spp.
Compounds that could be repurposed
Cyclosporine, mTOR or calcineurin • Broad spectrum Approved for –
tacrolimus or • To be used alongside existing post-transplant
rapamycin antifungals immunosuppression
Rifampin RNA polymerase • Broad spectrum Approved for bacterial –
• To be used alongside existing infections
antifungals
Sertraline Serotonin reuptake • Cryptococcal meningitis Approved for depression –
• To be used alongside existing
antifungals
Tamoxifen Oestrogen receptor • Cryptococcosis Approved for oestrogen –
• To be used alongside existing receptor‑positive breast
antifungals cancer
Verapamil Calcium channel • Broad spectrum Approved for cardiac –
• To be used alongside existing conditions (including
antifungals hypertension and
arrhythmias)
Hos2, histone deacetylase 2; Hsp90, heat shock protein 90; mTOR, mechanistic target of rapamycin; Sit1, siderophore iron transporter 1.

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provide a high genetic barrier to the development of Nikkomycin Z. Nikkomycin Z has a protracted history,
resistance compared with the direct antifungal activity and its development might have been delayed by its poor
of most agents used for the treatment of invasive fungal antifungal activity as a stand-alone agent against yeasts
infections. such as Candida spp.. It was first discovered in the 1970s
by Bayer. Shaman Pharmaceuticals held the rights to its
F901318. F901318 (F2G) is a member of the new oroto- development during the 1990s, but the University of
mide class of antifungal agents. It is currently in phase II Arizona, which still has this compound in development,
development as an intravenous and oral agent for use in obtained those rights in 2005 (REF. 80). Nikkomycin Z
systemic mould infections, with a particular emphasis resembles uridine diphosphate (UDP)‑N‑acetyl glu-
on aspergillosis and scedosporiosis (NCT02856178)8. cosamine, which is a precursor of a major component
The mechanism of action is very well described. It is of the fungal cell wall, chitin. Nikkomycin Z is a com-
a potent inhibitor of Aspergillus spp. dihydroorotate petitive inhibitor of chitin synthase. It has been a very
dehydrogenase, which is crucially involved in fun- potent fungicidal agent for the treatment of murine
gal pyrimidine biosynthesis8. Humans also have this coccidioidomycosis, histoplasmosis and blastomycosis81,
enzyme, but F901318 is a 2,000‑fold more potent inhib- and as its target is a component of the cell wall, it has
itor of the fungal enzyme than the mammalian enzyme additive or synergistic in vitro and in vivo activity with
homologue and, with this differential inhibitory activ- the 1,3‑β-glucan synthase inhibitors (echinocandins)82.
ity, its toxicity towards mammalian cells is anticipated As nikkomycin Z targets the fungal cell wall, it is likely
to be very low 8. A similar phenomenon had previously to be safe for clinical use. Its ability to potentiate the anti-
been observed with an antibacterial compound, tri- fungal activity of echinocandins makes nikkomycin Z
methoprim, which inhibits dihydrofolate reductase in plus an echinochandin an ideal broad-spectrum drug
both bacteria and humans with substantially different combination to attack the fungal cell wall in both yeasts
kinetics. F901318 has potent anti-Aspergillus activity and moulds. Furthermore, new chemistry studies of the
in treatment of animal models8. Although it has poor peptidyl nucleoside antibiotics, which includes nikko-
activity against yeasts in vitro, it does possess fungicidal mycins and polyoxins, may enable further development
activity against a series of moulds and most endemic of this class of compounds83.
(dimorphic) mycoses8.
MGCD290. The histone deacetylase 2 (Hos2) inhibitor
APX001. The first-in-class compound APX001 (also MGCD290 (Mirati Therapeutics) is effective in com-
known as E1211; Eisai) is an antifungal compound that bination with both azoles and echinocandins in vitro
has been transferred to Amplyx Pharmaceuticals for fur- and in animal models84,85. Histone deacetylases remove
ther development. APX001 is a prodrug that is converted acetyl groups from lysines on core histones, HSP90 and
to the active moiety E1210 in the presence of alkaline other cellular proteins, and thus have important roles in
phosphatase in vivo. This compound is an inhibitor of the regulation of gene transcription and control other
glycosyl phosphatidylinositol (GPI) synthesis and thus cellular functions, such as cell proliferation and death.
hinders the attachment of essential adhesion proteins Hsp90 is a molecular chaperone that regulates crucial cell
(such as mannoproteins) to the outer fungal cell wall, responses to both cell membrane and cell wall stresses86,
a process that is mediated by GPI-anchored wall transfer so inhibiting Hsp90 could help to block the cellular stress
protein 1 (Gwt1)74,75. Another GPI inhibitor (gepinacin) responses and thus potentiate standard cell wall or mem-
that also blocks Gwt1 has recently been discovered76. brane inhibitors. The stress response in the fungal cell is
These GPI-anchored proteins provide cell wall integrity mediated by both Hsp90 and its client protein calcineu-
and are involved in membrane homeostasis, and fun- rin. Therefore, blockade of either of these targets could
gal mannoproteins promote adhesion, pathogenicity be synergistic with other inhibitors, such as azoles or
and immune evasion. APX001 specifically inhibits the echinocandins. Much work has been carried out to inves-
conversion of glucosaminylphosphatidylinositol to its tigate HSP90 inhibitors, such as the geldanamycin-like
acrylate form, glucosaminyl(acyl)phosphatidylinositol, agents38,87 and the monoclonal antibody efungumab39,88,89.
an essential step in GPI synthesis 75. Furthermore, Notably, the capacity of MGCD290 to synergize with
APX001 has excellent, broad-spectrum potency with known antifungals is retained even when there is some
antifungal activity in vitro against Candida spp. and apparent resistance to the primary, established drug 84.
Aspergillus spp., and can provide antifungal activity This compound has the potential to be a potent enabler
against some drug-resistant yeasts and moulds 77,78. to increase fungicidal activity, overcome resistance and
It even has potent antifungal activity in vitro against broaden the activity of other antifungal drugs. However,
moulds that are difficult to treat, such as Fusarium in the first human trial in severe vulvovaginal candid-
spp. and Scedosporium spp.79. Finally, APX001 has iasis, combining MGCD290 with fluconazole did not
some direct antifungal activity against the Mucorales give better results than fluconazole treatment alone (see
in vitro 79. In animal models, APX001 has potent and MethylGene press release). Recapitulating the positive
consistent fungicidal activity, and can be additive or syn- results observed during testing in vitro and in animal
ergistic with other antifungal agents, such as the azoles models can be challenging in the human host for a vari-
or echinocandins77. At present, APX001 is in phase I ety of reasons, including differing pharmacokinetics, bur-
(NCT02956499 and NCT02957929), and phase II clinical den of fungus at the site of infection and host immune
trials are planned. responses.

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Aureobasidin A. Aureobasidin A is a very potent natu- (Matinas BioPharma) has shown in vivo activity in ani-
ral product inhibitor of an essential and unique enzyme, mals and is now in clinical trials (NCT02971007 and
inositol phosphorylceramide synthase, which catalyses NCT02629419)100.
a pivotal step in fungal sphingolipid biosynthesis90. In regard to 1,3‑β-glucan synthase inhibitors, there
This enzyme has been a broad-spectrum antifungal are two areas of investigation. First, the echinocandin
target, and potent antifungal aureobasidin A analogues CD101 (Cidara Therapeutics) has a chemical modifica-
have been generated through medicinal chemistry 90,91. tion on the echinocandin backbone that makes the com-
AureoGen Biosciences has recently signed a licensing pound more stable, and phase II trials (NCT02733432
agreement with Merck & Co. for novel derivatives of and NCT02734862) have been initiated for this long-
aureobasidin A that are made with AureoGen’s chemis- acting echinocandin101,102. The improved stability of the
try platform, and these have improved antifungal activity molecule has created two new features for the echino-
against yeasts and moulds. Inositol phosphorylceramide candins: this drug can now be used as a topical agent
synthase and its natural product inhibitors have attracted for skin and vaginal infections, and the substantially
renewed therapeutic interest. longer half-life in the blood may allow for treatment with
weekly dosing. The second area of investigation involves
Targeted delivery approaches. A very new and evolving another 1,3‑β-glucan synthase inhibitor, SCY078 (also
concept in cancer therapies has been adopted by the anti- known as enfumafungin; Scynexis), which is in phase II
fungal discovery field: targeting a drug to the relevant trials for treatment of yeast infections (NCT02679456).
site. Small bispecific molecules have been made using This is a triterpene 1,3‑β-glucan synthase inhibitor, and
Cloudbreak technology (Cidara Therapeutics). These its primary advantage is its oral bioavailability. SCY078
compounds comprise an effector moiety that attaches has similar activity against yeasts to that of the echi-
to host cells (such as granulocytes), which enables the nocandins103 but has some in vitro antifungal activity
compound to accumulate at the site of infection, and an against echinocandin-resistant yeasts. It should be a safe
echinocandin moiety that attaches to fungal cell walls compound, as it targets the fungal cell wall, a feature that
and exerts antifungal activity. Therefore, this bispecific is not present in mammalian cells, and SCY078 also has
molecule attaches to granulocytes and is taken to the site some antifungal activity against certain moulds87.
of infection, where it accumulates in high concentrations In addition, even the widely used and developed
near the fungus and exerts direct antifungal effects. In a azole class of antifungal agents has been further mod-
related approach, T cells have been engineered to express ified with a new chemistry approach, which might have
chimeric T cell receptors that contain extracellular dectin exciting implications for the clinic. The ‘Achilles heel’
1 (also known as CLEC7A) domains and thus become of currently available triazoles is that polypharmacy
activated upon interaction with the fungal cell wall, is common in patients with serious illnesses, so many
thereby localizing cytotoxic immune activity to fun- individuals experience negative side effects through
gus-infected sites. Infusion of these dectin 1–chimeric drug–drug interactions. The Viamet Pharmaceutical
antigen receptor (D–CAR) T cells reduces fungal bur- platform uses the metal-binding group of the standard
den and mortality in mouse models of aspergillosis92. azole compounds. Following proprietary manipulation
Directing or concentrating antifungals or host immune of this part of the molecule, compounds have now been
cells to infection sites, either with bispecific molecules or developed that have substantially reduced interactions
targeting specific effector host cells, is an area that could with cytochrome P450 and thus fewer potential drug–
identify a potent and creative future fungicidal solution. drug interactions. This platform has yielded several
new compounds: VT‑1161 (REFS 104,105), which is in
Improving existing antifungals phase II clinical trials for onychomycosis106 and vaginal
There are four promising initiatives to improve on exist- candidiasis (NCT02267356 and NCT02267382), and
ing antifungal compounds (FIG. 1). First, for the class of a very potent anti-cryptococcal compound, VT‑1129,
polyenes (for example, amphotericin B and nystatin)93, which has outstanding efficacy in vitro and in animal
safer and more effective broad-spectrum drugs are under models107. Finally, in their portfolio is VT-1598, which
development. These include changing the structure of is a potent azole, with activity against endemic mycosis
amphotericin B from ‘molecular umbrella conjugates’ (see the Business Wire press release) and cryptococcosis.
(REF. 94) to alternative structures, such as nanoparticles95 Viamet’s platform has also generally increased the half-
and conjugated polysaccharides96,97, that may be able lives of the newly created azoles by chemical optimiza-
to penetrate certain body compartments and reduce tion of the active antifungal backbone of the triazole,
membrane toxicity 97,98. One proposed mechanism for thereby generating potent and broad-spectrum com-
this reduced toxicity is that the aggregated forms of pounds. Through this creative chemical modification of
amphotericin B have very different activities (specifi- an old class of molecules, a fourth generation of effective
cally toxicities) compared with monomers: aggregates antifungal azoles could emerge.
target host cells and thereby increase toxicity, whereas
the monomers should target fungi preferentially over the Repurposing old drugs
host cells99. Another considerable advance in this area The discovery of new therapies for fungal infections can
has been to produce an oral formulation for polyene be enriched by the ability to identify antifungal activ-
treatment. An oral drug delivery formulation consisting ity in approved drugs and to direct them to the anti-
of amphotericin B cochleate lipid–crystal nanoparticles fungal pipeline108. There is an ample history of using

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established drugs, including antibacterial agents, for reduce the toxicity of these drugs while preserving their
fungal infections. For example, although not used in anticellular or antifungal activity 120,121. In a serendipitous
standard clinical practice, the addition of a known anti- way, anticancer compounds, which often cause immu-
bacterial agent, such as the RNA polymerase inhibitor nosuppression and thus increase the incidence of fungal
rifampin, has been examined and shown to enhance infections, could be chemically manipulated to produce
the antifungal activity of established antifungal agents congeners that effectively treat these opportunistic fun-
in vitro109. Calcium channel blockers, such as verapa- gal infections. For example, miltefosine is an alkyl phos-
mil110, also amplify antifungal drug potency. Possibly phocholine compound that was initially developed as an
owing to drug–drug interactions, increased toxicity or anticancer agent but now has indications for treatment
a lack of funding for clinical trials, most of these repur- of protozoan infections, such as Leishmania infections,
posing agents have not had much clinical success, so in some countries. Miltefosine had been shown to have
most remain intriguing hypothetical tools for further antifungal activities in vitro and in animal models122.
antifungal drug development and discovery. However, studies have also demonstrated little in vivo
Since the introduction of the fungistatic azole flucona- activity against cryptococcosis123, which makes its use as
zole more than 25 years ago, the treatment of crypto an antifungal less certain and demonstrates how robust
coccosis has not advanced substantially 111. There have the preliminary studies must be to advance repurposed
been at least three attempts to repurpose old drugs for drugs. On a similar note, a new oral preparation of itra-
cryptococcosis infections. First, as previously noted, cal- conazole (also known as ‘super bioavailability’ (SUBA)-
cineurin inhibitors have anti-cryptococcal activity both itraconazole; Mayne Pharma) is under investigation for
individually and in combination with other compounds112. the treatment of patients with basal cell carcinoma nevus
They are, however, immunosuppressive agents, and cryp- syndrome (NCT02354261). The anticancer properties of
tococcosis can occur while patients are receiving them. itraconazole come from its inhibition of both angiogenesis
Nonetheless, upon closer inspection of clinical outcomes, and Hedgehog signalling 124. However, the new nanosus-
patients receiving the calcineurin inhibitor tacrolimus had pension formulation has improved bioavailability 125, so it
more skin infections than internal infections with cryp- might be co‑opted again by clinicians for its antifungal
tococcosis113, which is consistent with reduced survival of activity, and Mayne Pharma could direct efforts towards
cryptococci at high body temperatures upon blockade of its development in the antifungal arena. Finally, antifungal
calcineurin function. Clearly, these immunosuppressive agents and basic antiseptic chemicals have been altered
compounds (cyclosporine, tacrolimus and rapamycin) to make formulations that can be aerosolized for delivery
will need to be manipulated to reduce immunosuppres- into the lungs126, including new powder formulations127,
sion, but if this group of drugs could be modified to be or incorporated into formulations that can attack yeast
more fungicidal and less immunosuppressive, an effective biofilms on foreign bodies and could therefore be used as
antifungal drug could be generated. antifungal solutions or coatings to preserve catheters128.
Second, studies carried out more than 50 years ago
showed that an oestrogen, diethylstilbestrol, had in vitro Host immune cell-targeted approaches
anti-cryptococcal activity. Attempts have been made to The increased focus on immune diseases and immuno-
show in vivo activity, but it was not clear whether this oncology has also been helpful for developing strategies
hormonal approach would work114,115. However, recent for the antifungal pipeline. For example, there have been
studies have demonstrated that a compound used to promising results using adoptive transfer of activated
treat breast cancer, the oestrogen receptor-targeting immune cells in infections with Candida spp., Aspergillus
drug, tamoxifen, has anti-cryptococcal activity and spp. and Mucorales in animal models129. Another fascinat-
could be combined with fluconazole as an all-oral treating example of work in immune cell antifungals is in tar-
ment option to enhance anti-cryptococcal activity 116,117. geting JUN amino-terminal kinase 1 (JNK1; also known
Third, the most advanced repurposing attempt is the as MAPK8), which has an important role in T cell activa-
adjunctive use of sertraline in cryptococcal meningitis. tion and T helper cell differentiation. JNK1 negatively reg-
Sertraline is a selective serotonin reuptake inhibitor that is ulates the host antifungal innate immune response, and
primarily used to manage depression. However, sertraline JNK1 inhibitors exert potent antifungal therapeutic effects
has been shown to potentiate the anti-cryptococcal activ- both in mice and in human cells130. Finally, unlike for viral
ity of azoles118. After a successful exploratory phase II and bacterial infections, currently there is no commercial
study with the use of sertraline as adjunctive therapy for fungal vaccine for humans. There is, however, a substan-
cryptococcal meningitis119, the investigators are approxi- tial infrastructure of work in this area for proof of prin-
mately half-way through a phase III study to determine ciple131–137. In fact, there is fundamental knowledge that
the value of adding this compound to a standard induc- vaccines can prevent fungal infections in model systems,
tion therapy for cryptococcal meningitis (NCT01802385). but very little data on therapeutic fungal vaccines exist.
This randomized, comparative study is a structural para- Preliminary human fungal vaccine studies have been
digm for how to get these established drugs repurposed. carried out in coccidioidomycosis and candidiasis138,139.
For many decades, antineoplastic agents have been A Candida spp. vaccine (NovaDigm Therapeutics) has
used to treat eukaryotic hyperproliferation in the form been used in phase I and phase II studies (NCT01447407
of cancer, although they might not be direct antifungals. and NCT01926028). Understanding the potential of these
Many of these anticancer agents have antifungal activity, vaccines will require clinical studies in carefully identified
and their clinical history can be used by investigators to at-risk groups to assess outcomes and the development of

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a financial plan for their implementation. Prevention is an Summary

important goal in the management of fungal infections. The current antifungal tools that are available to tackle
As host immunity is crucial for the long-term manage- the invasive fungal epidemic occurring in the clinics
ment of fungal infections, protection given by vaccines and hospitals have improved, but are still inadequate
and/or immune cell-targeted approaches should receive for use in all patient groups. In response to this need
high priority in the antifungal pipeline. for more and better antifungal agents, this Review has
focused on four areas that could bolster and refine the
Antifungal biological agents antifungal pipeline: basic pursuits to identify fungal
Although there are few primary antifungal therapy rec- pathways, targets and mechanisms of action that could
ommendations for the use of biological agents in the lead to new antifungal inhibitors; antifungal compounds
Infectious Diseases Society of America guidelines3–7, the and immune strategies currently in development that
area has received some attention and could be further could become new antifungal therapies; improved for-
developed. The use of monoclonal antibodies to attack mulations of existing compounds; and the repurposing
fungi88,140 or even carry potent antifungal material, such as of drugs approved for other indications that have the
radiation (radioimmunotherapy), to the fungus has been potential to be antifungal agents.
validated in animal models141 as a potential treatment Invasive fungal infections will not go away anytime
strategy. However, it should be noted how carefully these soon. Therefore, we need to circumvent resistance to
antibodies need to be tested. For instance, when the efun- treatment by continued discovery and development
gumab formulation was changed to an efungumab‑C28Y of new antifungal agents and strategies. Hopefully,
variant, it lost its anti-Candida spp. activity 89. The adju- these new fungicidal agents will meet the management
vant therapeutic use of cytokines has been explored, and challenges of an enlarging population of susceptible
these molecules could be useful142,143, but precise control ‘human Petri dishes’ as we attempt to manage serious
of immune reconstitution might need some fine-tuning. underlying diseases.
1. Brown, G. D., Denning, D. W. & Levitz, S. M. Tackling 14. Denning, D. W. & Bromley, M. J. Infectious disease. 27. Perfect, J. R. Fungal virulence genes as targets for
human fungal infections. Science 336, 647 (2012). How to bolster the antifungal pipeline. Science 347, antifungal chemotherapy. Antimicrob. Agents
This work reviews the current magnitude of 1414–1416 (2015). Chemother. 40, 1577–1583 (1996).
issues relating to invasive fungal infections. This insightful discussion describes the potential 28. Kitamura, A., Someya, K., Hata, M., Nakajima, R. &
2. Park, B. J. et al. Estimation of the current global needs and barriers to antifungal development. Takemura, M. Discovery of a small-molecule inhibitor
burden of cryptococcal meningitis among persons 15. Ostrosky-Zeichner, L., Casadevall, A., Galgiani, J. N., of β-1,6‑glucan synthesis. Antimicrob. Agents
living with HIV/AIDS. AIDS 23, 525–530 (2009). Odds, F. C. & Rex, J. H. An insight into the antifungal Chemother. 53, 670–677 (2009).
3. Patterson, T. F. et al. Practice guidelines for the pipeline: selected new molecules and beyond. Nat. 29. Baxter, B. K., DiDone, L., Ogu, D., Schor, S. &
diagnosis and management of aspergillosis: 2016 Rev. Drug Discov. 9, 719–727 (2010). Krysan, D. J. Identification, in vitro activity and mode
update by the Infectious Diseases Society of America. By comparing reference 15 and this Review, the of action of phosphoinositide-dependent‑1 kinase
Clin. Infect. Dis. 63, e1–e60 (2016). progress that has been made in the antifungal inhibitors as antifungal molecules. ACS Chem. Biol. 6,
4. Pappas, P. G. et al. Clinical practice guideline for the pipeline in the past decade can be determined. 502–510 (2011).
management of candidiasis: 2016 update by the 16. Osherov, N. & Kontoyiannis, D. P. The anti-Aspergillus 30. Breger, J. et al. Antifungal chemical compounds
Infectious Diseases Society of America. Clin. Infect. drug pipeline: is the glass half full or empty? Med. identified using a C. elegans pathogenicity assay. PLoS
Dis. 62, e1–e50 (2016). Mycol. 55, 118–124 (2017). Pathog. 3, e18 (2007).
5. Galgiani, J. N. et al. 2016 Infectious Diseases Society 17. Odds, F. C., Brown, A. J. & Gow, N. A. Antifungal 31. Spitzer, M. et al. Cross-species discovery of syncretic
of America (IDSA) clinical practice guideline for the agents: mechanisms of action. Trends Microbiol. 11, drug combinations that potentiate the antifungal
treatment of coccidioidomycosis. Clin. Infect. Dis. 63, 272–279 (2003). fluconazole. Mol. Syst. Biol. 7, 499 (2011).
e112–e146 (2016). 18. Allen, D., Wilson, D., Drew, R. & Perfect, J. Azole 32. Roemer, T. et al. Confronting the challenges of natural
6. Perfect, J. R. et al. Clinical practice guidelines for the antifungals: 35 years of invasive fungal infection product-based antifungal discovery. Chem. Biol. 18,
management of cryptococcal disease: 2010 update by management. Expert Rev. Anti Infect. Ther. 13, 148–164 (2011).
the Infectious Diseases Society of America. Clin. Infect. 787–798 (2015). 33. Tebbets, B. et al. Identification and characterization of
Dis. 50, 291–322 (2010). 19. Hamill, R. J. Amphotericin B formulations: antifungal compounds using a Saccharomyces
7. Kauffman, C. A., Hajjeh, R. & Chapman, S. W. Practice a comparative review of efficacy and toxicity. Drugs cerevisiae reporter bioassay. PLoS ONE 7, e36021
guidelines for the management of patients with 73, 919–934 (2013). (2012).
sporotrichosis. For the Mycoses Study Group. 20. Holt, S. L. & Drew, R. H. Echinocandins: addressing 34. Krysan, D. J. & Didone, L. A high-throughput
Infectious Diseases Society of America. Clin. Infect. outstanding questions surrounding treatment of screening assay for small molecules that disrupt yeast
Dis. 30, 684–687 (2000). invasive fungal infections. Am. J. Health Syst. Pharm. cell integrity. J. Biomol. Screen. 13, 657–664 (2008).
8. Oliver, J. D. et al. F901318 represents a novel class of 68, 1207–1220 (2011). 35. Lamoth, F., Juvvadi, P. R. & Steinbach, W. J. Editorial:
antifungal drug that inhibits dihydroorotate 21. Peyton, L. R., Gallagher, S. & Hashemzadeh, M. advances in Aspergillus fumigatus pathobiology.
dehydrogenase. Proc. Natl Acad. Sci. USA 113, Triazole antifungals: a review. Drugs Today (Barc.) 51, Front. Microbiol. 7, 43 (2016).
12809–12814 (2016). 705–718 (2015). 36. Juvvadi, P. R., Lee, S. C., Heitman, J. &
9. Shahid, S. K. Newer patents in antimycotic therapy. 22. Nett, J. E. & Andes, D. R. Antifungal agents: Steinbach, W. J. Calcineurin in fungal virulence and
Pharm. Pat. Anal. 5, 115–134 (2016). spectrum of activity, pharmacology, and clinical drug resistance: prospects for harnessing targeted
10. Pouliot, M. & Jeanmart, S. Pan assay interference indications. Infect. Dis. Clin. North Am. 30, 51–83 inhibition of calcineurin for an antifungal therapeutic
compounds (PAINS) and other promiscuous (2016). approach. Virulence 8, 186–197 (2017).
compounds in antifungal research. J. Med. Chem. 59, 23. Andes, D. R. et al. Impact of treatment strategy on 37. Blankenship, J. R., Steinbach, W. J., Perfect, J. R. &
497–503 (2016). outcomes in patients with candidemia and other forms Heitman, J. Teaching old drugs new tricks:
11. Pitman, S. K., Drew, R. H. & Perfect, J. R. Addressing of invasive candidiasis: a patient-level quantitative reincarnation immunosuppressants as antifungal
current medical needs in invasive fungal infection review of randomized trials. Clin. Infect. Dis. 54, drugs. Curr. Opin. Investig. Drugs 4, 192–199
prevention and treatment with new antifungal agents, 1110–1122 (2012). (2003).
strategies and formulations. Expert Opin. Emerg. 24. Bratton, E. W. et al. Comparison and temporal trends 38. Cowen, L. E. et al. Harnessing Hsp90 function as
Drugs 16, 559–586 (2011). of three groups with cryptococcosis: HIV-infected, solid a powerful, broadly effective therapeutic strategy for
This study is an extensive review of the available organ transplant, and HIV-negative/non-transplant. fungal infectious disease. Proc. Natl Acad. Sci. USA
antifungal agents and discusses how they are PLoS ONE 7, e43582 (2012). 106, 2818–2823 (2009).
optimally used today. 25. Nyazika, T. K. et al. Cryptococcus neoformans 39. Pachl, J. et al. A randomized, blinded, multicenter
12. Cuenca-Estrella, M. Antifungal drug resistance population diversity and clinical outcomes of HIV- trial of lipid-associated Amphotericin B alone versus
mechanisms in pathogenic fungi: from bench to bedside. associated cryptococcal meningitis patients in in combination with an antibody-based inhibitor of
Clin. Microbiol. Infect. 20 (Suppl. 6), 54–59 (2014). Zimbabwe. J. Med. Microbiol. 65, 1281–1288 heat shock protein 90 in patients with invasive
13. Smith, K. D. et al. Increased antifungal drug (2016). candidiasis. Clin. Infect. Dis. 42, 1404–1413 (2006).
resistance in clinical isolates of Cryptococcus 26. Marr, K. A. et al. Combination antifungal therapy for 40. Nambu, M. et al. A calcineurin antifungal strategy with
neoformans in Uganda. Antimicrob. Agents invasive aspergillosis: a randomized trial. Ann. Intern. analogs of FK506. Bioorg. Med. Chem. Lett. http://dx.
Chemother. 59, 7197–7204 (2015). Med. 162, 81–89 (2015). doi.org/10.1016/j.bmcl.2017.04.004 (2011).

©
2
0
1
7
M
a
c
m
i
l
l
a
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P
u
b
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i
s
h
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i
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e
d
,
p
a
r
t
o
f
S
p
r
i
n
g
e
r
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a
t
u
r
e
.
A
l
l
r
i
g
h
t
s
r
e
s
e
r
v
e
d
.
REVIEWS
41. Hast, M. A. et al. Structures of Cryptococcus 64. Sigurgeirsson, B., van Rossem, K., Malahias, S. & 85. Pfaller, M. A., Rhomberg, P. R., Messer, S. A. &
neoformans protein farnesyltransferase reveal Raterink, K. A phase II, randomized, double-blind, Castanheira, M. In vitro activity of a Hos2 deacetylase
strategies for developing inhibitors that target fungal placebo-controlled, parallel group, dose-ranging study inhibitor, MGCD290, in combination with echinocandins
pathogens. J. Biol. Chem. 286, 35149–35162 to investigate the efficacy and safety of 4 dose against echinocandin-resistant Candida species. Diagn.
(2011). regimens of oral albaconazole in patients with distal Microbiol. Infect. Dis. 81, 259–263 (2015).
42. Mor, V. et al. Identification of a new class of subungual onychomycosis. J. Am. Acad. Dermatol. 69, 86. Cowen, L. E. The fungal Achilles’ heel: targeting Hsp90
antifungals targeting the synthesis of fungal 416–425 (2013). to cripple fungal pathogens. Curr. Opin. Microbiol. 16,
sphingolipids. mBio 6, e00647 (2015). 65. Miller, J. L. et al. In vitro and in vivo efficacies of the 377–384 (2013).
43. Rollin-Pinheiro, R., Singh, A., Barreto-Bergter, E. & new triazole albaconazole against Cryptococcus 87. Lamoth, F., Alexander, B. D., Juvvadi, P. R. &
Del Poeta, M. Sphingolipids as targets for treatment neoformans. Antimicrob. Agents Chemother. 48, Steinbach, W. J. Antifungal activity of compounds
of fungal infections. Future Med. Chem. 8, 384–387 (2004). targeting the Hsp90‑calcineurin pathway against
1469–1484 (2016). 66. Nakamura, I. et al. ASP2397: a novel antifungal agent various mould species. J. Antimicrob. Chemother. 70,
44. Perfect, J. R., Tenor, J. L., Miao, Y. & Brennan, R. G. produced by Acremonium persicinum MF‑347833. 1408–1411 (2015).
Trehalose pathway as an antifungal target. Virulence J. Antibiot. (Tokyo) 70, 45–51 (2017). 88. Bugli, F. et al. Human monoclonal antibody-based
8, 143–149 (2016). 67. Nakamura, I. et al. Discovery of a new antifungal agent therapy in the treatment of invasive candidiasis. Clin.
45. Petzold, E. W. et al. Characterization and regulation of ASP2397 using a silkworm model of Aspergillus Dev. Immunol. 2013, 403121 (2013).
the trehalose synthesis pathway and its importance in fumigatus infection. J. Antibiot. (Tokyo) 70, 41–44 89. Louie, A. et al. Dose range evaluation of Mycograb
the pathogenicity of Cryptococcus neoformans. Infect. (2017). C28Y variant, a human recombinant antibody
Immun. 74, 5877–5887 (2006). 68. Nishikawa, H. et al. T-2307, a novel arylamidine, is fragment to heat shock protein 90, in combination
46. Ngamskulrungroj, P. et al. The trehalose pathway: an transported into Candida albicans by a high-affinity with amphotericin B‑desoxycholate for treatment of
integral part of virulence composite for Cryptococcus spermine and spermidine carrier regulated by murine systemic candidiasis. Antimicrob. Agents
gattii. Infect. Immun. 77, 4584–4596 (2009). Agp2. J. Antimicrob. Chemother. 71, 1845–1855 Chemother. 55, 3295–3304 (2011).
47. Miao, Y. et al. Structures of trehalose‑6‑phosphate (2016). 90. Aeed, P. A. Young, C. L., Nagiec, M. M. &
phosphatase from pathogenic fungi reveal the 69. Shibata, T. et al. T-2307 causes collapse of Elhammer, A. P. Inhibition of inositol
mechanisms of substrate recognition and catalysis. mitochondrial membrane potential in yeast. Antimicrob. phosphorylceramide synthase by the cyclic peptide
Proc. Natl Acad. Sci. USA 113, 7148–7153 (2016). Agents Chemother. 56, 5892–5897 (2012). aureobasidin A. Antimicrob. Agents Chemother. 53,
48. Cheah, H. L., Lim, V. & Sandai, D. Inhibitors of the 70. Mitsuyama, J. et al. In vitro and in vivo antifungal 496–504 (2009).
glyoxylate cycle enzyme ICL1 in Candida albicans for activities of T-2307, a novel arylamidine. Antimicrob. 91. Kurome, T., Inoue, T., Takesako, K. & Kato, I. Syntheses
potential use as antifungal agents. PLoS ONE 9, Agents Chemother. 52, 1318–1324 (2008). of antifungal aureobasidin A analogs with alkyl chains
e95951 (2014). 71. Yamada, E., Nishikawa, H., Nomura, N. & for structure-activity relationship. J. Antibiot. 51,
49. Knauth, P. & Reichenbach, H. On the mechanism of Mitsuyama, J. T-2307 shows efficacy in a murine 359–367 (1998).
action of the myxobacterial fungicide ambruticin. model of Candida glabrata infection despite in vitro 92. Kumaresan, P. R. et al. Bioengineering T cells to target
J. Antibiot. (Tokyo) 53, 1182–1190 (2000). trailing growth phenomena. Antimicrob. Agents carbohydrate to treat opportunistic fungal infection.
50. Levine, H. B., Ringel, S. M. & Cobb, J. M. Therapeutic Chemother. 54, 3630–3634 (2010). Proc. Natl Acad. Sci. USA 111, 10660–10665 (2014).
properties of oral ambruticin (W7783) in experimental 72. Koselny, K. et al. The celecoxib derivative AR‑12 has 93. Arikan, S. & Rex, J. H. Nystatin LF (Aronex/Abbott).
pulmonary coccidioidomycosis of mice. Chest 73, broad spectrum antifungal activity in vitro and Curr. Opin. Investig. Drugs 2, 488–495 (2001).
202–206 (1978). improves the activity of fluconazole in a murine model 94. Janout, V., Bienvenu, C., Schell, W., Perfect, J. R. &
51. Shubitz, L. F. et al. Efficacy of ambruticin analogs in of cryptococcosis. Antimicrob. Agents Chemother. 60, Regen, S. L. Molecular umbrella-amphotericin B
a murine model of coccidioidomycosis. Antimicrob. 7115–7127 (2016). conjugates. Bioconjug. Chem. 25, 1408–1411 (2014).
Agents Chemother. 50, 3467–3469 (2006). 73. Koselny, K. et al. Antitumor/antifungal celecoxib 95. Yang, Z. et al. Development and characterization of
52. Hagihara, K. et al. Fingolimod (FTY720) stimulates derivative AR‑12 is a non-nucleoside inhibitor of the amphotericin B nanosuspensions for oral
Ca2+/calcineurin signaling in fission yeast. PLoS ONE ANL-family adenylating enzyme acetyl CoA administration through a simple top-down method.
8, e81907 (2013). synthetase. ACS Infect. Dis. 2, 268–280 (2016). Curr. Pharm. Biotechnol. 15, 569–576 (2014).
53. Gallo-Ebert, C. et al. Novel antifungal drug discovery 74. Richard, M. L. & Plaine, A. Comprehensive analysis 96. Halperin, A. et al. Novel water-soluble amphotericin
based on targeting pathways regulating the fungus- of glycosylphosphatidylinositol-anchored proteins in B‑PEG conjugates with low toxicity and potent in vivo
conserved Upc2 transcription factor. Antimicrob. Candida albicans. Eukaryot. Cell 6, 119–133 efficacy. J. Med. Chem. 59, 1197–1206 (2016).
Agents Chemother. 58, 258–266 (2014). (2007). 97. Ickowicz, D. E. et al. Activity, reduced toxicity, and
54. Hein, K. Z. et al. Disulphide-reduced psoriasin is 75. Watanabe, N. A. et al. E1210, a new broad-spectrum scale‑up synthesis of amphotericin B‑conjugated
a human apoptosis-inducing broad-spectrum antifungal, suppresses Candida albicans hyphal polysaccharide. Biomacromolecules 15, 2079–2089
fungicide. Proc. Natl Acad. Sci. USA 112, growth through inhibition of (2014).
13039–13044 (2015). glycosylphosphatidylinositol biosynthesis. Antimicrob. 98. Jung, S. H. et al. Amphotericin B‑entrapping lipid
55. Valiante, V. et al. Hitting the caspofungin salvage Agents Chemother. 56, 960–971 (2012). nanoparticles and their in vitro and in vivo
pathway of human-pathogenic fungi with the novel 76. McLellan, C. A. et al. Inhibiting GPI anchor characteristics. Eur. J. Pharm. Sci. 37, 313–320
lasso peptide humidimycin (MDN‑0010). Antimicrob. biosynthesis in fungi stresses the endoplasmic (2009).
Agents Chemother. 59, 5145–5153 (2015). reticulum and enhances immunogenicity. ACS Chem. 99. Janout, V. et al. Taming amphotericin B. Bioconjug.
56. Liu, N., Wang, C., Su, H., Zhang, W. & Sheng, C. Biol. 7, 1520–1528 (2012). Chem. 26, 2021–2024 (2015).
Strategies in the discovery of novel antifungal 77. Hata, K. et al. Efficacy of oral E1210, a new broad- 100. Delmas, G. et al. Efficacy of orally delivered cochleates
scaffolds. Future Med. Chem. 8, 1435–1454 (2016). spectrum antifungal with a novel mechanism of containing amphotericin B in a murine model of
57. Scorzoni, L. et al. Searching new antifungals: the use action, in murine models of candidiasis, aspergillosis, aspergillosis. Antimicrob. Agents Chemother. 46,
of in vitro and in vivo methods for evaluation of and fusariosis. Antimicrob. Agents Chemother. 55, 2704–2707 (2002).
natural compounds. J. Microbiol. Methods 123, 4543–4551 (2011). 101. Ong, V. et al. Preclinical evaluation of the stability,
68–78 (2016). 78. Wiederhold, N. P. et al. The investigational agent safety and efficacy of CD101, a novel echinocandin.
58. Nobrega, R. O., Teixeira, A. P., Oliveira, W. A., E1210 is effective in treatment of experimental Antimicrob. Agents Chemother. 60, 6872–6879
Lima, E. O. & Lima, I. O. Investigation of the antifungal invasive candidiasis caused by resistant Candida (2016).
activity of carvacrol against strains of Cryptococcus albicans. Antimicrob. Agents Chemother. 59, 102. Pfaller, M. A., Messer, S. A., Rhomberg, P. R.,
neoformans. Pharm. Biol. 54, 2591–2596 (2016). 690–692 (2015). Jones, R. N. & Castanheira, M. Activity of a long-
59. Zuo, R. et al. In vitro antifungal and antibiofilm 79. Miyazaki, M. et al. In vitro activity of E1210, a novel acting echinocandin, CD101, determined using CLSI
activities of halogenated quinoline analogues against antifungal, against clinically important yeasts and and EUCAST reference methods, against Candida and
Candida albicans and Cryptococcus neoformans. Int. molds. Antimicrob. Agents Chemother. 55, 4652–4658 Aspergillus spp., including echinocandin- and azole-
J. Antimicrob. Agents 48, 208–211 (2016). (2011). resistant isolates. J. Antimicrob. Chemother. 71,
60. Ghannoum, M. A., Kim, H. G. & Long, L. Efficacy of 80. Shubitz, L. F. et al. Modeling nikkomycin Z dosing and 2868–2873 (2016).
aminocandin in the treatment of immunocompetent pharmacology in murine pulmonary 103. Walker, S. S. et al. Discovery of a novel class of orally
mice with haematogenously disseminated fluconazole- coccidioidomycosis preparatory to phase 2 clinical active antifungal β‑1,3-d‑glucan synthase inhibitors.
resistant candidiasis. J. Antimicrob. Chemother. 59, trials. J. Infect. Dis. 209, 1949–1954 (2014). Antimicrob. Agents Chemother. 55, 5099–5106
556–559 (2007). 81. Hector, R. F., Zimmer, B. L. & Pappagianis, D. (2011).
61. Warn, P. A., Sharp, A., Morrissey, G. & Denning, D. W. Evaluation of nikkomycins X and Z in murine models of 104. Gebremariam, T. et al. VT‑1161 protects
Activity of aminocandin (IP960; HMR3270) compared coccidioidomycosis, histoplasmosis, and immunosuppressed mice from Rhizopus arrhizus var.
with amphotericin B, itraconazole, caspofungin and blastomycosis. Antimicrob. Agents Chemother. 34, arrhizus infection. Antimicrob. Agents Chemother. 59,
micafungin in neutropenic murine models of 587–593 (1990). 7815–7817 (2015).
disseminated infection caused by itraconazole- 82. Fortwendel, J. R. et al. Differential effects of 105. Warrilow, A. G. et al. The clinical candidate VT‑1161 is
susceptible and -resistant strains of Aspergillus inhibiting chitin and 1,3‑β-D‑glucan synthesis in ras a highly potent inhibitor of Candida albicans CYP51
fumigatus. Int. J. Antimicrob. Agents 35, 146–151 and calcineurin mutants of Aspergillus fumigatus. but fails to bind the human enzyme. Antimicrob.
(2010). Antimicrob. Agents Chemother. 53, 476–482 Agents Chemother. 58, 7121–7127 (2014).
62. Hanadate, T. et al. FR290581, a novel sordarin (2009). 106. Gupta, A. K. & Studholme, C. Novel investigational
derivative: synthesis and antifungal activity. Bioorg. 83. Lilla, E. A. & Yokoyama, K. Carbon extension in therapies for onychomycosis: an update. Expert Opin.
Med. Chem. Lett. 19, 1465–1468 (2009). peptidylnucleoside biosynthesis by radical SAM Investig. Drugs 25, 297–305 (2016).
63. Hasenoehrl, A. et al. In vitro activity and in vivo enzymes. Nat. Chem. Biol. 12, 905–907 (2016). 107. Lockhart, S. R. et al. The investigational fungal Cyp51
efficacy of icofungipen (PLD‑118), a novel oral 84. Pfaller, M. A. et al. Activity of MGCD290, a Hos2 inhibitor VT‑1129 demonstrates potent in vitro
antifungal agent, against the pathogenic yeast histone deacetylase inhibitor, in combination with activity against Cryptococcus neoformans and
Candida albicans. Antimicrob. Agents Chemother. 50, azole antifungals against opportunistic fungal Cryptococcus gattii. Antimicrob. Agents Chemother.
3011–3018 (2006). pathogens. J. Clin. Microbiol. 47, 3797–3804 (2009). 60, 2528–2531 (2016).

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2
0
1
7
M
a
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i
l
l
a
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s
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s
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i
m
i
t
e
d
,
p
a
r
t
o
f
S
p
r
i
n
g
e
r
N
a
t
u
r
e
.
A
l
l
r
i
g
h
t
s
r
e
s
e
r
v
e
d
.
REVIEWS
108. Butts, A. & Krysan, D. J. Antifungal drug discovery: 124. Pace, J. R. et al. Repurposing the clinically efficacious 141. Bryan, R. A. et al. Toward developing a universal
something old and something new. PLoS Pathog. 8, antifungal agent itraconazole as an anticancer treatment for fungal disease using
e1002870 (2012). chemotherapeutic. J. Med. Chem. 59, 3635–3649 radioimmunotherapy targeting common fungal
109. Christenson, J. C., Shalit, I., Welch, D. F., Guruswamy, A. (2016). antigens. Mycopathologia 173, 463–471 (2012).
& Marks, M. I. Synergistic action of amphotericin B and 125. Abuhelwa, A. Y., Foster, D. J., Mudge, S., Hayes, D. & 142. Jarvis, J. et al. Adjunctive interferon‑γ immnotherapy
rifampin against Rhizopus species. Antimicrob. Agents Upton, R. N. Population pharmacokinetic modeling of for the treatment of HIV-associated cryptococcal
Chemother. 31, 1775–1778 (1987). itraconazole and hydroxyitraconazole for oral SUBA- meningitis: a randomized controlled trial. AIDS 26,
110. Liu, S. et al. Synergistic effect of fluconazole and itraconazole and sporanox capsule formulations in 1105–1113 (2012).
calcium channel blockers against resistant Candida healthy subjects in fed and fasted states. Antimicrob. 143. Pappas, P. G. et al. Recombinant interferon-γ 1b as
albicans. PLoS ONE 11, e0150859 (2016). Agents Chemother. 59, 5681–5696 (2015). adjunctive therapy for AIDS-related acute
111. Coelho, C. & Casadevall, A. Cryptococcal therapies 126. Le, J. & Schiller, D. S. Aerosolized delivery of cryptococcal meningitis. J. Infect. Dis. 189,
and drug targets: the old, the new and the promising. antifungal agents. Curr. Fungal Infect. Rep. 4, 96–102 2185–2191 (2004).
Cell. Microbiol. 18, 792–799 (2016). (2010). 144. Rodero, L. et al. In vitro susceptibility studies of
112. Shirazi, F. & Kontoyiannis, D. P. The calcineurin 127. Pornputtapitak, W., El‑Gendy, N. & Berkland, C. Cryptococcus neoformans isolated from patients
pathway inhibitor tacrolimus enhances the in vitro NanoCluster itraconazole formulations provide with no clinical response to amphotericin B therapy.
activity of azoles against Mucorales via apoptosis. a potential engineered drug particle approach to J. Antimicrob. Chemother. 45, 239–242 (2000).
Eukaryot. Cell 12, 1225–1234 (2013). generate effective dry powder aerosols. J. Aerosol 145. Sanglard, D. & Odds, F. C. Resistance of Candida species
113. Husain, S., Wagner, M. & Singh, N. Cryptococcus Med. Pulm. Drug Deliv. 28, 341–352 (2015). to antifungal agents: molecular mechanisms and clinical
neoformans infection in organ transplant recipients: 128. Walraven, C. J. & Lee, S. A. Antifungal lock therapy. consequences. Lancet Infect. Dis. 2, 73–85 (2002).
variables influencing clinical characteristics and Antimicrob. Agents Chemother. 57, 1–8 (2013). 146. Verweij, P. E., Chowdhary, A., Melchers, W. J. &
outcome. Emerg. Infect. Dis. 7, 375–381 (2001). 129. Tramsen, L. et al. Clinical-scale generation of multi- Meis, J. F. Azole resistance in Aspergillus fumigatus:
114. Duke, S. S. & Fromtling, R. A. Effects of diethyl- specific anti-fungal T cells targeting Candida, can we retain the clinical use of mold-active antifungal
stilbestrol and cyclophosphamide on the pathogenesis Aspergillus and mucormycetes. Cytotherapy 15, azoles? Clin. Infect. Dis. 62, 362–368 (2016).
of experimental Cryptococcus neoformans infections. 344–351 (2013). 147. Alexander, B. D. et al. Increasing echinocandin
Sabouraudia 22, 125–135 (1984). 130. Zhao, X. et al. JNK1 negatively controls antifungal resistance in Candida glabrata: clinical failure
115. Mohr, J. A., Tatem, B. A., Long, H., Muchmore, H. G. & innate immunity by suppressing CD23 expression. correlates with presence of FKS mutations and
Felton, F. G. Increased susceptibility of Cryptococcus Nat. Med. 23, 337–346 (2017). elevated minimum inhibitory concentrations. Clin.
neoformans to amphotericin B in the presence of 131. Galgiani, J. N. Vaccines to prevent systemic mycoses: Infect. Dis. 56, 1724–1732 (2013).
steroids. Sabouraudia 11, 140–142 (1973). holy grails meet translational realities. J. Infect. Dis. 148. Healey, K. R. et al. Prevalent mutator genotype identified
116. Butts, A. et al. Estrogen receptor antagonists are anti- 197, 938–940 (2008). in fungal pathogen Candida glabrata promotes multi-
cryptococcal agents that directly bind EF hand This article discusses the potential for antifungal drug resistance. Nat. Commun. 7, 11128 (2016).
proteins and synergize with fluconazole in vivo. mBio vaccines. 149. Edlind, T. D. & Katiyar, S. K. Mutational analysis of
5, e00765‑13 (2014). 132. Casadevall, A. & Pirofski, L. A. Feasibility and flucytosine resistance in Candida glabrata. Antimicrob.
117. Dolan, K. et al. Antifungal activity of tamoxifen: prospects for a vaccine to prevent cryptococcosis. Agents Chemother. 54, 4733–4738 (2010).
in vitro and in vivo activities and mechanistic Med. Mycol. 43, 667–680 (2005).
characterization. Antimicrob. Agents Chemother. 53, 133. Cutler, J. E., Deepe, G. S. Jr & Klein, B. S. Advances in Acknowledgements
3337–3346 (2009). combating fungal diseases: vaccines on the threshold. The author has research support from Public Health Service
118. Zhai, B., Wu, C., Wang, L., Sachs, M. S. & Lin, X. The Nat. Rev. Microbiol. 5, 13–28 (2007). Grants (AI73896, AI04533, AI93257).
antidepressant sertraline provides a promising 134. Levitz, S. M. Aspergillus vaccines: hardly worth
Competing interests statement
therapeutic option for neurotropic cryptococcal studying or worthy of hard study? Med. Mycol. 55,
The author declares competing interests: see Web version
infections. Antimicrob. Agents Chemother. 56, 103–108 (2017).
for details.
3758–3766 (2012). 135. Upadhya, R. et al. Induction of protective immunity to
119. Rhein, J. et al. Efficacy of adjunctive sertraline for the cryptococcal infection in mice by a heat-killed,
treatment of HIV-associated cryptococcal meningitis: chitosan-deficient strain of Cryptococcus neoformans. DATABASES
an open-label dose-ranging study. Lancet Infect. Dis. mBio 7, e00547‑16 (2016). ClinicalTrials.gov: https://clinicaltrials.gov/
16, 809–818 (2016). 136. Mor, V. et al. Glucosylceramide administration as
120. Del Poeta, M. et al. Comparison of in vitro activities of a vaccination strategy in mouse models of FURTHER INFORMATION
camptothecin and nitidine derivatives against fungal cryptococcosis. PLoS ONE 11, e0153853 (2016). Cloudbreak technology: https://www.cidara.com/cloudbreak/
and cancer cells. Antimicrob. Agents Chemother. 43, 137. Wormley, F. L. Jr, Perfect, J. R., Steele, C. & Cox, G. M. MethylGene reports results of phase II trial of MGCD290:
2862–2868 (1999). Protection against cryptococcosis by using a murine http://www.advfn.com/news_MethylGene-Reports-Results-
121. Cardenas, M. E. et al. Antifungal activities of gamma interferon-producing Cryptococcus neoformans of-Phase-II-Trial-of-MG_56785808.html
antineoplastic agents: Saccharomyces cerevisiae as strain. Infect. Immun. 75, 1453–1462 (2007). Researchers identify new class of antifungal agents:
a model system to study drug action. Clin. Microbiol. 138. Pappagianis, D. Evaluation of the protective efficacy of http://www.asm.org/index.php/journal-press-releases/93560-
Rev. 12, 583–611 (1999). the killed Coccidioides immitis spherule vaccine in reserachers-identify-new-class-of-antifungal-agents
122. Widmer, F. et al. Hexadecylphosphocholine humans. The Valley Fever Vaccine Study Group. Am. (SUBA)-itraconazole: https://www.maynepharma.com/
(miltefosine) has broad-spectrum fungicidal activity Rev. Respir. Dis. 148, 656–660 (1993). T-2307 developmental pipeline: http://www.toyama-
and is efficacious in a mouse model of cryptococcosis. 139. Edwards, J. E. Jr. Fungal cell wall vaccines: an update. chemical.co.jp/en/rd/pipeline/index.html
Antimicrob. Agents Chemother. 50, 414–421 J. Med. Microbiol. 61, 895–903 (2012). Viamet receives Orphan Drug Designation from the FDA for
(2006). 140. Larsen, R. A. et al. Phase I evaluation of the safety VT‑1598 for the treatment of coccidioidomycosis: http://
123. Wiederhold, N. P. et al. Limited activity of miltefosine and pharmacokinetics of murine-derived www.businesswire.com/news/home/20160525005794/en/
in murine models of cryptococcal meningoencephalitis anticryptococcal antibody 18B7 in subjects with Viamet-recives-orphen-drug-designation-FDA-VT-1598.2016
and disseminated cryptococcosis. Antimicrob. Agents treated cryptococcal meningitis. Antimicrob. Agents
ALL LINKS ARE ACTIVE IN THE ONLINE PDF
Chemother. 57, 745–750 (2013). Chemother. 49, 952–958 (2005).

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REVIEWS

The antifungal pipeline: a reality check

NATURE REVIEWS | DRUG DISCOVERY VOLUME 16 | SEPTEMBER 2017 | 603

Table 1 | Common invasive fungal diseases

604 | SEPTEMBER 2017 | VOLUME 16 www.nature.com/nrd

NATURE REVIEWS | DRUG DISCOVERY VOLUME 16 | SEPTEMBER 2017 | 605

606 | SEPTEMBER 2017 | VOLUME 16 www.nature.com/nrd

in discovering potent antifungal, anti-calcineurin mol-

NATURE REVIEWS | DRUG DISCOVERY VOLUME 16 | SEPTEMBER 2017 | 607

Glycolipid inhibitors Terbinaﬁne Cloudbreak molecule

F901318 Dhodh Pyrimidines Nucleus

608 | SEPTEMBER 2017 | VOLUME 16 www.nature.com/nrd

NATURE REVIEWS | DRUG DISCOVERY VOLUME 16 | SEPTEMBER 2017 | 609

Table 2 | Antifungal compounds with novel targets in development

610 | SEPTEMBER 2017 | VOLUME 16 www.nature.com/nrd

NATURE REVIEWS | DRUG DISCOVERY VOLUME 16 | SEPTEMBER 2017 | 611

612 | SEPTEMBER 2017 | VOLUME 16 www.nature.com/nrd

NATURE REVIEWS | DRUG DISCOVERY VOLUME 16 | SEPTEMBER 2017 | 613

a financial plan for their implementation. Prevention is an Summary

614 | SEPTEMBER 2017 | VOLUME 16 www.nature.com/nrd

NATURE REVIEWS | DRUG DISCOVERY VOLUME 16 | SEPTEMBER 2017 | 615

616 | SEPTEMBER 2017 | VOLUME 16 www.nature.com/nrd

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