The mortality rates of fungal infections that affect the central nervous system are high in consequence of the absence of effective antifungal drugs with good penetration across the blood-brain barrier and the blood-cerebrospinal fluid barrier. In the present work in vitro antifungal activities of three good penetrating non-antifungal drugs (amantadine hydrochloride, R-(-)-deprenyl hydrochloride, valproic acid sodium salt) and their combinations with three antifungal agents (amphotericin B, itraconazole, terbinafine) were tested with broth microdilution method against eight fungal isolates belonging to Zygomycetes (Lichtheimia corymbifera, Rhizomucor miehei, Rhizopus microsporus var. rhizopodiformis, Saksenaeavasiformis) and Aspergillus genus (A. flavus, A. fumigatus, A. nidulans, A. terreus). These are known to be possible agents of central nervous fungal infections (CNFI). When used alone, the investigated nonantifungal drugs exerted slight antifungal effects. In their combinations with antifungal agents they acted antagonistically, additively and synergistically against zygomyceteous isolates. Primarily antagonistic interactions were revealed between the investigated drugs in case of Aspergilli, but additive and synergistic interactions were also observed. The additive and synergistic combinations allowed the usage of reduced concentrations of antifungal agents to inhibit the fungal growth in our study. These combinations would be a basis of an effective, less toxic therapy for treatment of CNFI.
Abraham, O. C., Manavathu, E. K., Cutright, J. L., Chandrasekar, P. H. (1999) In vitro susceptibilities of Aspergillus species to voriconazole, itraconazole, and amphotericin B. Diagn. Microbiol. Infect. Dis. 33, 7–11.
Chandrasekar P. H. , 'In vitro susceptibilities of Aspergillus species to voriconazole, itraconazole, and amphotericin B ' (1999 ) 33 Diagn. Microbiol. Infect. Dis. : 7 -11 .
Afeltra, J., Verweij, P. E. (2003) Antifungal activity of nonantifungal drugs. Eur. J. Clin. Microbiol. Infect. Dis. 22, 397–407.
Verweij P. E. , 'Antifungal activity of nonantifungal drugs ' (2003 ) 22 Eur. J. Clin. Microbiol. Infect. Dis. : 397 -407 .
Azzaro, A. J., Ziemniak, J., Kemper, E., Campbell, B. J., Van Den Berg, C. (2007) Pharmacokinetics and absolute bioavailability of selegiline following treatment of healthy subjects with the selegiline transdermal system (6 mg/24 h): a comparison with oral selegiline capsules. J. Clin. Pharmacol. 47, 1256–1267.
Berg C. , 'Pharmacokinetics and absolute bioavailability of selegiline following treatment of healthy subjects with the selegiline transdermal system (6 mg/24 h): a comparison with oral selegiline capsules ' (2007 ) 47 J. Clin. Pharmacol. : 1256 -1267 .
Baddley, J. W., Salzman, D., Pappas, P. G. (2002) Fungal brain abscess in transplant recipients: epidemiologic, microbiologic, and clinical features. Clin. Transplant. 16, 419–424.
Pappas P. G. , 'Fungal brain abscess in transplant recipients: epidemiologic, microbiologic, and clinical features ' (2002 ) 16 Clin. Transplant. : 419 -424 .
Bazinet, R. P., Weis, M. T., Rapoport, S. I., Rosenberger, T. A. (2006) Valproic acid selectively inhibits conversion of arachidonic acid to arachidonoyl-CoA by brain microsomal long-chain fatty acyl-CoA synthetases: relevance to bipolar disorder. Psychopharmacology (Berl.) 184, 122–129.
Rosenberger T. A. , 'Valproic acid selectively inhibits conversion of arachidonic acid to arachidonoyl-CoA by brain microsomal long-chain fatty acyl-CoA synthetases: relevance to bipolar disorder ' (2006 ) 184 Psychopharmacology (Berl.) : 122 -129 .
Blum, G., Perkhofer, S., Haas, H., Schrettl, M., Würzner, R., Dierich, M. P., Lass-Flörl, C. (2008) Potential basis for amphotericin B resistance in Aspergillus terreus. Antimicrob. Agents. Chemother. 52, 1553–1555.
Lass-Flörl C. , 'Potential basis for amphotericin B resistance in Aspergillus terreus ' (2008 ) 52 Antimicrob. Agents. Chemother. : 1553 -1555 .
Chakrabarti, A., Marak, R. S. K., Singhi, S., Gupta, S., Hurst, S. F., Padhye, A. A. (2005) Brain abscess due to Aspergillus nidulans. J. Mycol. Med. 16, 100–104.
Padhye A. A. , 'Brain abscess due to Aspergillus nidulans ' (2005 ) 16 J. Mycol. Med. : 100 -104 .
Cohen, R. A., Fisher, M. (1989) Amantadine treatment of fatigue associated with multiple sclerosis. Arch. Neurol. 46, 676–680.
Fisher M. , 'Amantadine treatment of fatigue associated with multiple sclerosis ' (1989 ) 46 Arch. Neurol. : 676 -680 .
Crosby, N., Deane, K. H., Clarke, C. E. (2003) Amantadine in Parkinson’s disease. Cochrane Database Syst. Rev. 1, CD003468.
Clarke C. E. , 'Amantadine in Parkinson’s disease ' (2003 ) 1 Cochrane Database Syst. Rev. : CD003468 -.
Dannaoui, E., Persat, F., Monier, M. F., Borel, E., Piens, M. A., Picot, S. (1999) In-vitro susceptibility of Aspergillus spp. isolates to amphotericin B and itraconazole. J. Antimicrob. Chemother. 44, 553–555.
Picot S. , 'In-vitro susceptibility of Aspergillus spp. isolates to amphotericin B and itraconazole ' (1999 ) 44 J. Antimicrob. Chemother. : 553 -555 .
Dannaoui, E., Meletiadis, J., Mouton, J. W., Meis, J. F., Verweij, P. E., Eurofung Network (2003) In vitro susceptibilities of zygomycetes to conventional and new antifungals. J. Antimicrob. Chemother. 51, 45–52.
Verweij P. E. , 'In vitro susceptibilities of zygomycetes to conventional and new antifungals ' (2003 ) 51 J. Antimicrob. Chemother. : 45 -52 .
Deyde, V. M., Xu, X., Bright, R. A., Shaw, M., Smith, C. B., Zhang, Y., Shu, Y., Gubareva, L. V., Cox, N. J., Klimov, A. I. (2007) Surveillance of resistance to adamantanes among influenza A(H3N2) and A(H1N1) viruses isolated worldwide. J. Infect. Dis. 196, 249–257.
Klimov A. I. , 'Surveillance of resistance to adamantanes among influenza A(H3N2) and A(H1N1) viruses isolated worldwide ' (2007 ) 196 J. Infect. Dis. : 249 -257 .
Dotis, J., Roilides, E. (2007) Immunopathogenesis of central nervous system fungal infections. Neurol. India 55, 216–220.
Roilides E. , 'Immunopathogenesis of central nervous system fungal infections ' (2007 ) 55 Neurol. India : 216 -220 .
Eliopoulos, G. M., Moellering, R. C. (1996) Antimicrobial combinations. In: Lorian, V. (ed.) Antibiotics in Laboratory Medicine, 4th edn. Williams and Wilkins, Baltimore MD, USA, pp. 330–396.
Moellering R. C. , '', in Antibiotics in Laboratory Medicine, 4th edn , (1996 ) -.
Eltoukhy, N. S., Crank, C. W. (2010) Antifungal distribution into cerebrospinal fluid, vitreous humor, bone, and other difficult sites. Curr. Fungal. Infect. Rep. 4, 111–119.
Crank C. W. , 'Antifungal distribution into cerebrospinal fluid, vitreous humor, bone, and other difficult sites ' (2010 ) 4 Curr. Fungal. Infect. Rep. : 111 -119 .
Gallagher, C. G., Ashley, E. S. D., Drew, R. H., Perfect, J. R. (2003) Antifungal pharmacotherapy for invasive mould infections. Expert Opin. Pharm. 4, 147–164.
Perfect J. R. , 'Antifungal pharmacotherapy for invasive mould infections ' (2003 ) 4 Expert Opin. Pharm. : 147 -164 .
Garcia-Effron, G., Gomez-Lopez, A., Mellado, E., Monzon, A., Rodriguez-Tudela, J. L., Cuenca-Estrella, M. (2004) In vitro activity of terbinafine against medically important non-dermatophyte species of filamentous fungi. J. Antimicrob. Chemother. 53, 1086–1089.
Cuenca-Estrella M. , 'In vitro activity of terbinafine against medically important non-dermatophyte species of filamentous fungi ' (2004 ) 53 J. Antimicrob. Chemother : 1086 -1089 .
Gómez-López, A., Cuenca-Estrella, M., Mellado, E., Rodríguez-Tudela, J. L. (2003) In vitro evaluation of combination of terbinafine with itraconazole or amphotericin B against Zygomycota. Diagn. Microbiol. Infect. Dis. 45, 199–202.
Rodríguez-Tudela J. L. , 'In vitro evaluation of combination of terbinafine with itraconazole or amphotericin B against Zygomycota ' (2003 ) 45 Diagn. Microbiol. Infect. Dis. : 199 -202 .
Groll, A. H., Giri, N., Petraitis, V., Petraitiene, R., Candelario, M., Bacher, J. S., Piscitelli, S. C., Walsh, T. J. (2000) Comparative efficacy and distribution of lipid formulations of amphotericin B in experimental Candida albicans infection of the central nervous system. J. Infect. Dis. 182, 274–282.
Walsh T. J. , 'Comparative efficacy and distribution of lipid formulations of amphotericin B in experimental Candida albicans infection of the central nervous system ' (2000 ) 182 J. Infect. Dis. : 274 -282 .
Hosseini-Yeganeh, M., McLachlan, A. J. (2001) Tissue distribution of terbinafine in rats. J. Pharm. Sci. 90, 1817–1828.
McLachlan A. J. , 'Tissue distribution of terbinafine in rats ' (2001 ) 90 J. Pharm. Sci. : 1817 -1828 .
Hosseini-Yeganeh, M., McLachlan, A. J. (2002) Physiologically based pharmacokinetic model for terbinafine in rats and humans. Antimicrob. Agents. Chemother. 46, 2219–2228.
McLachlan A. J. , 'Physiologically based pharmacokinetic model for terbinafine in rats and humans ' (2002 ) 46 Antimicrob. Agents. Chemother. : 2219 -2228 .
Imbert, F., Jardin, M., Fernandez, C., Gantier, J. C., Dromer, F., Baron, G., Mentre, F., Van Beijsterveldt, L., Singlas, E., Gimenez, F. (2003) Effect of efflux inhibition on brain uptake of itraconazole in mice infected with Cryptococcus neoformans. Drug Metab. Dispos. 31, 319–325.
Gimenez F. , 'Effect of efflux inhibition on brain uptake of itraconazole in mice infected with Cryptococcus neoformans ' (2003 ) 31 Drug Metab. Dispos. : 319 -325 .
Karaarslan, A., Arikan, S., Ozcan, M., Ozcan, K. M. (2004) In vitro activity of terbinafine and itraconazole against Aspergillus species isolated from otomycosis. Mycoses. 47, 284–287.
Ozcan K. M. , 'In vitro activity of terbinafine and itraconazole against Aspergillus species isolated from otomycosis ' (2004 ) 47 Mycoses. : 284 -287 .
Kontoyiannis, D. P., Lewis, R. E., May, G. S., Osherov, N., Rinaldi, M. G. (2002) Aspergillus nidulans is frequently resistant to amphotericin B. Mycoses. 45, 406–407.
Rinaldi M. G. , 'Aspergillus nidulans is frequently resistant to amphotericin B ' (2002 ) 45 Mycoses. : 406 -407 .
Kornhuber, J., Quack, G., Danysz, W., Jellinger, K., Danielczyk, W., Gsell, W., Riederer, P. (1995) Therapeutic brain concentration of the NMDA receptor antagonist amantadine. Neuropharmacology. 34, 713–721.
Riederer P. , 'Therapeutic brain concentration of the NMDA receptor antagonist amantadine ' (1995 ) 34 Neuropharmacology. : 713 -721 .
Kurita, M., Nishino, S., Ohtomo, K., Rai, M., Shirakawa, H., Mashiko, H., Niwa, S., Nakahata, N. (2007) Sodium valproate at therapeutic concentrations changes Ca2+ response accompanied with its weak inhibition of protein kinase C in human astrocytoma cells. Prog. Neuropsychopharmacol. Biol. Psychiatry 31, 600–604.
Nakahata N. , 'Sodium valproate at therapeutic concentrations changes Ca2+ response accompanied with its weak inhibition of protein kinase C in human astrocytoma cells ' (2007 ) 31 Prog. Neuropsychopharmacol. Biol. Psychiatry : 600 -604 .
Mahmood, I. (1997) Clinical pharmacokinetics and pharmacodynamics of selegiline. An update. Clin. Pharmacokinet. 33, 91–102.
Mahmood I. , 'Clinical pharmacokinetics and pharmacodynamics of selegiline. An update ' (1997 ) 33 Clin. Pharmacokinet. : 91 -102 .
Meletiadis, J., te Dorsthorst, D. T. A., Verweij, P. E. (2006) The concentration-dependent nature of in vitro amphotericin B-itraconazole interaction against Aspergillus fumigatus: isobolographic and response surface analysis of complex pharmacodynamic interactions. Int. J. Antimicrob. Agents. 28, 439–449.
Verweij P. E. , 'The concentration-dependent nature of in vitro amphotericin B-itraconazole interaction against Aspergillus fumigatus: isobolographic and response surface analysis of complex pharmacodynamic interactions ' (2006 ) 28 Int. J. Antimicrob. Agents. : 439 -449 .
Minassian, B., Huczko, E., Washo, T., Bonner, T., Fung-Tomc, J. (2003) In vitro activity of ravuconazole against Zygomycetes, Scedosporium and Fusarium isolates. Clin. Microbiol. Infect. 9, 1250–1252.
Fung-Tomc J. , 'In vitro activity of ravuconazole against Zygomycetes, Scedosporium and Fusarium isolates ' (2003 ) 9 Clin. Microbiol. Infect. : 1250 -1252 .
Misra, R., Malik, A., Singhal, S. (2011) Comparison of the activities of amphotericin B, itraconazole, and voriconazole against clinical and environmental isolates of Aspergillus species. Indian. J. Pathol. Microbiol. 54, 112–116.
Singhal S. , 'Comparison of the activities of amphotericin B, itraconazole, and voriconazole against clinical and environmental isolates of Aspergillus species ' (2011 ) 54 Indian. J. Pathol. Microbiol. : 112 -116 .
Moosa, M. Y., Alangaden, G. J., Manavathu, E., Chandrasekar, P. H. (2002) Resistance to amphotericin B does not emerge during treatment for invasive aspergillosis. J. Antimicrob. Chemother. 49, 209–213.
Chandrasekar P. H. , 'Resistance to amphotericin B does not emerge during treatment for invasive aspergillosis ' (2002 ) 49 J. Antimicrob. Chemother. : 209 -213 .
Moreno, A. B., del Pozo, A. M., Borja, M., San Segudo, B. (2003) Activity of the antifungal protein from Aspergillus giganteus against Botrytis cinerea. Phytopathology 93, 1344–1353.
San Segudo B. , 'Activity of the antifungal protein from Aspergillus giganteus against Botrytis cinerea ' (2003 ) 93 Phytopathology : 1344 -1353 .
Murthy, J. M. (2007) Fungal infections of the central nervous system: the clinical syndromes. Neurol. India 55, 221–225.
Murthy J. M. , 'Fungal infections of the central nervous system: the clinical syndromes ' (2007 ) 55 Neurol. India : 221 -225 .
Nadkarni, T., Goel, A. (2005) Aspergilloma of the brain: an overview. J. Postgrad. Med. 51Suppl. uppl. 1, S37–41.
Goel A. , 'Aspergilloma of the brain: an overview ' (2005 ) 51 J. Postgrad. Med. : S37 -41 .
National Committee for Clinical Laboratory Standards. Reference method for broth dilution antifungal susceptibility testing of filamentous fungi; approved standard (2002) NCCLS document M38-A. NCCLS, Wayne, Pennsylvania, USA.
'', in NCCLS document M38-A , (2002 ) -.
Nosanchuk, J. D. (2006) Current status and future of antifungal therapy for systemic mycoses. Recent Pat. Antiinfect. Drug Discov. 1, 75–84.
Nosanchuk J. D. , 'Current status and future of antifungal therapy for systemic mycoses ' (2006 ) 1 Recent Pat. Antiinfect. Drug Discov. : 75 -84 .
Odds, F. C. (2003) Synergy, antagonism, and what the chequerboard puts between them. J. Antimicrob. Chemother. 52, 1.
Odds F. C. , 'Synergy, antagonism, and what the chequerboard puts between them ' (2003 ) 52 J. Antimicrob. Chemother. : 1 -.
Rath, P. M. (1998) Susceptibility of Aspergillus strains from culture collections to amphotericin B and itraconazole. J. Antimicrob. Chemother. 41, 567–570.
Rath P. M. , 'Susceptibility of Aspergillus strains from culture collections to amphotericin B and itraconazole ' (1998 ) 41 J. Antimicrob. Chemother. : 567 -570 .
Ribes, J. A., Vanhover-Sams, C. L., Baker, D. J. (2000) Zygomycetes in human disease. Clin. Microbiol. Rev. 13, 236–301.
Baker D. J. , 'Zygomycetes in human disease ' (2000 ) 13 Clin. Microbiol. Rev. : 236 -301 .
Sabatelli, F., Patel, R., Mann, P. A., Mendrick, C. A., Norris, C. C., Hare, R., Loebenberg, D., Black, T. A., McNicholas, P. M. (2006) In vitro activities of posaconazole, fluconazole, itraconazole, voriconazole, and amphotericin B against a large collection of clinically important molds and yeasts. Antimicrob. Agents Chemother. 50, 2009–2015.
McNicholas P. M. , 'In vitro activities of posaconazole, fluconazole, itraconazole, voriconazole, and amphotericin B against a large collection of clinically important molds and yeasts ' (2006 ) 50 Antimicrob. Agents Chemother. : 2009 -2015 .
Schwartz, S., Ruhnke, M., Ribaud, P., Reed, E., Troke, P., Thiel, E. (2007) Poor efficacy of amphotericin B-based therapy in CNS aspergillosis. Mycoses. 50, 196–200.
Thiel E. , 'Poor efficacy of amphotericin B-based therapy in CNS aspergillosis ' (2007 ) 50 Mycoses. : 196 -200 .
Schwartz, S., Thiel, E. (2009) Cerebral aspergillosis: tissue penetration is the key. Med. Mycol. 47Suppl. uppl. 1, S387–393.
Thiel E. , 'Cerebral aspergillosis: tissue penetration is the key ' (2009 ) 47 Med. Mycol. : S387 -393 .
Scully, E. P., Baden, L. R., Katz, J. T. (2008) Fungal brain infections. Curr. Opin. Neurol. 21, 347–352.
Katz J. T. , 'Fungal brain infections ' (2008 ) 21 Curr. Opin. Neurol. : 347 -352 .
Sharma, R.R. (2010) Fungal infections of the nervous system: current perspective and controversies in management. Int. J. Surg. 8, 591–601.
Sharma R.R. , 'Fungal infections of the nervous system: current perspective and controversies in management ' (2010 ) 8 Int. J. Surg. : 591 -601 .
Skiada, A., Vrana, L., Polychronopoulou, H., Prodromou, P., Chantzis, A., Tofas, P., Daikos, G. L. (2009) Disseminated zygomycosis with involvement of the central nervous system. Clin. Microbiol. Infect. 15Suppl. uppl. 5, 46–49.
Daikos G. L. , 'Disseminated zygomycosis with involvement of the central nervous system ' (2009 ) 15 Clin. Microbiol. Infect. : 46 -49 .
Smith, J., Andes, D. R. (2006) Pharmacokinetics of antifungals: Implications for drug selections. Infect. Med. 23, 328–333.
Andes D. R. , 'Pharmacokinetics of antifungals: Implications for drug selections ' (2006 ) 23 Infect. Med. : 328 -333 .
Sun, Q. N., Fothergill, A. W., McCarthy, D. I., Rinaldi, M. G., Graybill, J. R. (2002) In vitro activities of posaconazole, itraconazole, voriconazole, amphotericin B, and fluconazole against 37 clinical isolates of zygomycetes. Antimicrob. Agents. Chemother. 46, 1581–1582.
Graybill J. R. , 'In vitro activities of posaconazole, itraconazole, voriconazole, amphotericin B, and fluconazole against 37 clinical isolates of zygomycetes ' (2002 ) 46 Antimicrob. Agents. Chemother. : 1581 -1582 .
Sutton, D. A., Sanche, S. E., Revankar, S. G., Fothergill, A. W., Rinaldi, M. G. (1999) In vitro amphotericin B resistance in clinical isolates of Aspergillus terreus, with a head-to-head comparison to voriconazole. J. Clin. Microbiol. 37, 2343–2345.
Rinaldi M. G. , 'In vitro amphotericin B resistance in clinical isolates of Aspergillus terreus, with a head-to-head comparison to voriconazole ' (1999 ) 37 J. Clin. Microbiol. : 2343 -2345 .
van der Linden, J. W., Jansen, R. R., Bresters, D., Visser, C. E., Geerlings, S. E., Kuijper, E. J., Melchers, W. J., Verweij, P. E. (2009) Azole-resistant central nervous system aspergillosis. Clin. Infect. Dis. 48, 1111–1113.
Verweij P. E. , 'Azole-resistant central nervous system aspergillosis ' (2009 ) 48 Clin. Infect. Dis. : 1111 -1113 .
Vazquez, J. A. (2007) Combination antifungal therapy: the new frontier. Future Microbiol. 2, 115–139.
Vazquez J. A. , 'Combination antifungal therapy: the new frontier ' (2007 ) 2 Future Microbiol. : 115 -139 .
Vyzantiadis, T. A., Kioumi, A., Papadakis, E., Braimi, M., Dermitzakis, E., Tsitouridis, I., Antoniadis, A. (2002) Rhino-cerebral zygomycosis resistant to antimycotic treatment: a case report. Mycoses. 52, 87–90.
Antoniadis A. , 'Rhino-cerebral zygomycosis resistant to antimycotic treatment: a case report ' (2002 ) 52 Mycoses. : 87 -90 .
Yasar, S., Justinova, Z., Lee, S. H., Stefanski, R., Goldberg, S. R., Tanda, G. (2006) Metabolic transformation plays a primary role in the psychostimulant-like discriminative-stimulus effects of selegiline [(R)-(-)-deprenyl]. J. Pharmacol. Exp. Ther. 317, 387–394.
Tanda G. , 'Metabolic transformation plays a primary role in the psychostimulant-like discriminative-stimulus effects of selegiline [(R)-(-)-deprenyl] ' (2006 ) 317 J. Pharmacol. Exp. Ther. : 387 -394 .