Antifungal Drugs

1. Polyene Antifungals
Dr J Haylor, Department of Medicine, UCLan UM2010 2023

Fungal infections can be topical in the skin, such as ringworm or athletes foot, influence mucous membranes such as thrush or be a systemic infection inducing meningitis. Systemic fungal infections are said to be opportunistic and
develop when the immune system is comprised by disease or drug therapy. Systemic fungal infections tend to occur in patients who are seriously ill. Although the human immune system is normally very efficient at keeping fungal
infections under control, serious systemic infections can occur in immunocompromised patients caused either by disease such as AIDS or by medicines including either cancer chemotherapy or the immunosuppressive agents used
for the treatment of autoimmune disease or to suppress the rejection of organ transplants.
 The fungal
cell wall

The cell membrane and cell wall of fungi have important structural differences either animal cells or bacteria. Firstly the sterol present in the fungal cell membrane is ergosterol rather than the cholesterol found in mammalian cells.
An important element of the selectivity of antifungal drugs is therefore to target ergosterol and its synthesis without affecting the host cells. Secondly, notice that the general structure of the outer layer of the cell wall is very
different from that of bacteria. There are no peptidoglycan or lipopolysaccharide layers instead there are sugar protein residues linked to chitin, a fibrous polysaccharide polymer. The consequence of this wall structure is that cell
wall antibiotics do not affect fungi and antifungal drugs do not kill bacteria, with the possible exception perhaps of metronidazole. The cell membrane is the site of action for the major antifungal drug groups with the polyenes
effecting ergosterol, the azole group and terbinafine affecting ergosterol synthesis while the echinocandins inhibit a cell membrane enzyme to affect the polysaccharide layer of the cell wall.
 The first antifungal drugs
1954 – Nystatin (Streptomyces noursei)
first antifungal antibiotic - wide range activity skin, mouth, vagina.
Negligible oral absorption

1956 – Amphotericin (Streptomyces nodosus)

systemic fungal infections were normally fatal
first systemic antifungal agent – IV infusion
nicknamed amphoterrible due to adverse effect profile including nephrotoxicity.
liposomal injections have reduced side effect, but expensive.

1958 – Griseofulvin (Penicillium griseofluvin)

first orally administered antifungal drug – originally isolated 1939 but inactive against bacteria
largely replaced by newer synthetic azole drugs
The first antifungal drugs were introduced in the 1950’s, derived from soil bacteria and moulds. Technically the first antifungal agent isolated was griseofulvin in 1939 but since at the time the discovery programs were looking for
antibacterial rather than antifungal agents, it was discarded. Nystatin was the first antifungal agent, introduced in 1954, for infections of the skin and mucous membranes. Amphotericin was the second, introduced in 1956, but
was the first antifungal to be used for systemic infections which at the time were frequently fatal. Amphotericin however has a high degree of organ toxicity particularly in the kidney and was often nicknamed amphoterrible. More
recently the use of liposome injection formulations have markedly improved the adverse effect profile of amphotericin. Griseofulvin the third agent, was the first orally active antifungal although its use today has been largely
replaced by the azole compounds such as fluconazole. Both nystatin and amphotericin have important uses today but for drugs which work in a similar way, their uses are very different indeed.
 Antifungal Agents : Timeline

Terbinafine
Griseofluvin
Nystatin

The timeline for drug development shows the introduction of amphotericin to be followed some 15 years later by flucytosine in the early 1970’s, agents which work very well together. The azole derivatives were intoruced in the
1980’s with ketoconazole and in the 1990’s with fluconazole. Major adverse effects of amphotericin were reduced in the mid 1990’s, not by alternative drugs but by new amphotericin formulations. An entirely new drug group
the echinocandins was introduced in 2000 with caspofungin. Newer azole derivatives have a broader range of antifungal activity than fluconazole.
 Amphotericin E
E E = ergosterol
E
fungal cell
E
K+, Na+ Cl-
E
E
amphotericin E

Mechanism
IV infusion daily binds to ergosterol forming a cation pore for K+ efflux
Therapeutic use
Systemic fungal infections including cryptococcal meningitis (crosses B/B barrier)
Adverse effects
Acute - Fever/shaking chills due to pro-inflammatory cytokines (Bake and Shake)
Chronic - Organ failure especially kidney
distal tubular damage/acute renal failure - low blood magnesium, potassium, calcium

Amphotericin is a ‘ polyene ‘ antifungal agent defined by its chemical structure which contains a polyene chain within a macrolide ring. Amphotericin binds to ergosterol, the sterol constituent of the fungal cell membrane.
Binding creates pores in the cell membrane allowing cations such as potassium to flow out of the cell, causing cell death. Amphotericin binds much less avidly to the major sterol of mammalian cell walls, cholesterol and not at all
to the cell wall of bacteria. Amphotericin is delivered by intravenous infusion daily. It can induce a ‘shake & bake’ syndrome of alternate fever and shaking chills after a few hours. Due to poor solubility it has been conventionally
combined with deoxycholate, a detergent. In this form IV amphotericin can induce multiple organ failure with the kidney being particularly sensitive. Renal toxicity was reduced in the 1990’s by using either lipid (Abeicet) or
liposome (AmBisome) formulations for IV administration. Amphotericin remains important in the first line treatment of cryptococcal meningitis, especially in combination with flucytosine.
 Fungal only
cytosine cytosine
permease
Flucytosine deaminase

5-fluorouracil

Fungal cell

5-fluorouracil inhibits fungal cell proliferation

5-flucytosine, is converted into 5-fluorouracil in fungi by cytosine deaminase, an enzyme is absent from mammalian cells

1. 5-fluorouracil is an antimetabolite - incorporated into RNA, reduces DNA synthesis by inhibiting thymidylate synthase
2. Synergistic effect with amphotericin which improves the penetration of 5-flucytosine into the fungal cell.
Adverse effect – bone marrow suppression

Flucytosine is a prodrug, which is converted by the enzyme cytosine deaminase in fungal cells to 5-fluorouracil. Its selectivity is based on its entry across the cell membrane by the transport enzyme cytosine permease and its
metabolism to 5-fluorouracil by cytosine deaminase which is only present in fungal cells. 5-fluorouracil is an anti-metabolite which either gets incorporated into RNA or inhibits thymidylate synthase and thereby DNA synthesis.
Flucytosine is used with amphotericin. with a synergistic effect since amphotericin increases the permeability of the fungal cell to flucytosine. As you might expect, the adverse effects of flucytosine may include bone marrow
suppression. In man, 5-fluorouracil itself is also used in cancer chemotherapy.
 Amphotericin : Lipid Formulations
Formulations - lipid (Abelcet) or liposome (AmBisome) delivery reduces renal toxicity

Ribbon-like particles Disk-like particles Unilaminar liposome

Amphotericin is insoluble in water. It was originally formulated as an injection by combination with a detergent, deoxycholate to produce a soluble IV infusion in use for over 30 years. However its use was limited by its toxicity
including acute kidney failure. By the 1990’s, advances in pharmaceutics allowed amphotericin to be re-formulated by combination with lipids or incorporated in liposomes. The least toxic of these formulations appears to be
ambisome in which the amphotericin is essentially bound to cholesterol inside a liposome. Amphotericin is selectively released onto ergosterol present in the fungal cell membrane. The liposome being of high MW has a prolonged
duration of action with a much reduced urinary concentration only being excreted as the free drug, markedly reducing its renal toxicity. The impetus for the development of new amphotericin formulations in the 1990’s was the
presence of the HIV/AIDS epidemic.
 Cryptococcal Meningitis
Symptoms Treatment
• Headache, nausea, vomiting lethargy, sensitivity
to light, mental changes
(confusion/hallucination), stiff neck/fever Cochrane recommends delaying antiretroviral
therapy in order to treat the fungal infection

IV amphotericin + flucytosine

• Switch to fluconazole treatment when spinal

fluid negative (400mg daily for 8 weeks)

• If left untreated - brain damage, coma, hearing

Fluconazole treatment (200mg daily) maybe
loss, hydrocephalus, fatal indefinite to prevent relapse especially in AIDS
patients
• Upto 30% HIV-related CM die from the illness.

Cryptococcal meningitis is a fatal condition in upto 30% of HIV patients with this infection. Symptoms range from headache, vomiting and confusion to hydrocephalus and coma. The danger of this type of infection is highlighted
from the Cochrane reviews which suggest antifungal treatment should be started before introducing retroviral therapy. Following IV amphotericin + flucytosine there is a switch to fluconazole for 2 months. In marked contrast to
antibiotic therapy, antifungal therapy maybe given life long to prevent relapse in AIDS patients.
 Nystatin : Oral Candidiasis in Hospital Patients

A sore mouth can reduce appetite and delay recovery in

elderly patients in hospital

• Treatment with antibiotics or inhaled corticosteroids

predispose to oral candidiasis
• Antimuscarinic drugs reduce saliva

Encourage mouth care, treat with nystatin when necessary

(give after food, hold in the mouth, remove dentures)

Nystatin has a therapeutic use in the treatment of fungal infections of mucous membranes including the mouth. This could be iatrogenic, induced by drugs such as steroids or antimuscarinic agents. For elderly patients in
hospital this is something to look out for as it can both reduce appetite and delay recovery. The nystatin tablet or lozenge should be held in the mouth after food.
 Antifungal Drugs
2. Ergosterol Synthesis inhibitors
and Echinocandins
Dr J Haylor, Department of Medicine, UCLan UM2010 2023

The second bitesize recording on antifungal drugs deals with inhibitors of ergosterol synthesis such as the synthetic azole derivatives and the echinocandins which inhibit the synthesis of glycans involved in the structure of the
fungal cell wall.
 squalene

squalene lanosterol
epoxide α- demethylase

lanosterol x ergosterol

(A) Imidazoles
Inhibitors of ergosterol clotrimazole (1969)

synthesis miconazole (1971)

ketoconazole (1976)

In the 1970’s, drugs containing the ‘azole’ nucleus were discovered to inhibit fungal cell proliferation, resulting in new classes of synthetic antifungal drugs. Unlike amphotericin, rather than binding to ergosterol, they inhibit
ergosterol synthesis thereby preventing its incorporation into the fungal cell membrane. Azoles are enzyme inhibitors of lanosterol-α-demethylase, the enzyme which converts lanosterol into ergosterol, the lanosterol then
accumulates in the fungal cell. Lanosterol is the precursor sterol from which all animal and fungal sterols are derived. The first group of azole drugs were called imidazoles and include clotrimazole, miconazole and ketoconazole.
 Imidazole antifungals : Topical use only
• Therapeutic Use – topical only
• Clotrimazole (Canestan) – most well known also
miconazole, econazole, fanticonazole, ketoconazole –
similar use
• Vulvovaginal candidiasis (thrush) - common during
pregnancy treat with pessaries and cream
• Dermatophyses (ringworm, athletes foot) – treat skin
infection for 2 weeks after infection disappears to
prevent relapse
• Nails – penetration into hyperkeratotic lesion is slow
treatment may take upto a year.
• Scalp infection may require systemic therapy ringworm

The therapeutic use of imidazole antifungals is confined to topical administration in the treatment of skin, nail and vaginal fungal infection. The two major areas include the treatment of candidiasis or thrush, a common event
during pregnancy which can be treated with pessaries and/or cream, and the treatment of dermatophyses which includes ringworm and athletes foot. The keratin present in nails and hair reduces the penetration of these agents,
consequently foot nail fungal infections may take up to a year to resolve.
 squalene
squalene lanosterol
epoxide α- demethylase
lanosterol
x ergosterol

(B) Triazoles
fluconazole (1988)
Triazole inhibitors of itraconazole
ergosterol synthesis voriconazole
posaconazole

By the 1990’s, a second group of azoles were introduced called ‘triazoles’ with a greater affinity for lanosterol-α-demethylase and a greater ability to cross the blood brain barrier. Probably fluconazole is the most well known but
the triazole group also includes itraconazole, voriconazole and posaconazole.
 Fluconazole
• Oral and IV formulations
• Designed by Pfizer to have no enantiomers
• Wide distribution - crosses BB barrier
• Oral treatment - candidiasis
(oropharyngeal/oesophageal)
• Second line treatment in cryptococcal meningitis.
• Fluconazole not effective against aspergillus
• Drug Interactions – important inhibition of
cytochrome drug metabolising enzymes

Fluconazole was a drug designed by Pfizer to have no isomers and therefore avoid some of complications of using racemic mixtures. Fluconazole is available in both oral and injectable formulations used to treat systemic fungal infections or when topical therapy is ineffective. However in
comparison to other triazole agents, fluconazole has a narrower antifungal spectrum and is ineffective against aspergillus. Fluconazole does however cross the blood brain barrier, and is important in providing maintenance antifungal therapy following the use of amphotericin/flucytosine
to treat cryptococcal meningitis. Triazole drugs may also inhibit many of the drug metabolising enzymes in the liver with the possibility of contributing to many pharmacokinetic drug interactions.
 Other Triazole Antifungal Drugs
Spectrum of activity - fluconazole < itraconazole < voriconazole = posoconazole

Itraconazole Voriconazole
• Oral/IV preparations • Drug of choice in aspergillosis
• Broader spectrum than fluconazole • Lung infection in patients with TB/COPD
• No penetration into CNS – although • If immune system suppressed -
can concentrate in meninges dissemination to heart/lungs.
• Effective against aspergillus • Adverse Effect – Heptotoxic, visual
especially in patients with TB/COPD disturbance (30% patients) - blurred
and normal immune systems vision, increased sensitivity to light.
• Aspergillosis – fungus ball in the Posaconazole
lungs which can disseminate to
• Invasive fungal infections in patients
multiple organ failure unresponsive/intolerant to
• Adverse Effect - Heart failure, amphotericin and fluconazole
hepatotoxic

The other antifungal drugs in the triazole group have two distinctive features which are different from fluconazole. Firstly they do not cross the BB barrier but secondly they have a broader
spectrum of activity being effective against aspergillus infections which can colonise healed lung scars or abscesses in patients with either TB or COPD or in those patients with a suppressed
immune system. Other triazoles include voriconazole and itraconazole both of which have a higher affinity for lanosterol-a-demethylase than fluconazole, with voriconazole being the drug
of choice to treat aspergillus infections. Important adverse effects for itraconazole include heart failure and for voriconazole include visual disturbances of blurred vision and increased
sensitivity to light. A fourth triazole, posaconazole is effective against multi-drug resistant fungi, including resistance to both amphotericin and fluconazole
 squalene lanosterol
squalene α- demethylase
epoxide

x lanosterol

ergosterol

Inhibitor of
terbinafine squalene epoxide

Terbinafine, like the azole drugs also reduces ergosterol synthesis. However, it inhibits a different enzyme, squalene epoxide which catalyses the cyclisation of squalene into lanosterol an earlier step in the synthesis of ergosterol
 Terbinafine
• Discovered in 1991
• Inhibits the enzyme squalene epoxide, preventing
the synthesis of lanosterol.
• Used for dermatophyte infections including
ringworm & nails. Effective for jock itch and
athletes foot.
• Highly hydrophobic accumulated in hair, skin, nails
& fat.
• Treatment of nail infection requires oral dosing
(topical treatment can’t penetrate to cuticle)
• Adverse effects on oral use include hepatotoxicity

Terbinafine is highly hydrophobic and accumulates in hair, skin, nails and fat. It major use is in the treatment of dermatophyte infections including athletes foot, ringworm and jock itch.
Although terbinafine accumulates in nails and hair, topical administration cannot easily reach the nail cuticle so oral administration may be required. Adverse effects following oral
administration include hepatotoxicity.
 Echinocandins
Fungal fermentation products - lipopeptides with a
hexapeptide nucleus
Inhibits 1,3 glycan synthase, reducing cell wall integrity

Caspofungin
• IV infusion
• Aspergillus, candida
• Disseminated candidiasis but not effective in CNS
• Aspergillosis – patients refractory/intolerant to
amphotericin & voriconazole
• Empirical treatment of serious fungal infection in
immunocompromised patients

The final group of antifungal drugs, the echinocandins, are lipopeptides derived from fungal fermentation. Echinocandins have a novel mechanism of action, inhibiting glucan synthase, an enzyme complex present in the fungal
plasma membrane responsible for the synthesis of glucan sugars, important components of the fungal cell wall, reducing cell wall integrity. Caspofungin is given by IV infusion for systemic candida infection and is also effective
against aspergillus where it is reserved for patients refractory or intolerant to amphotericin or voriconazole. Unlike fluconazole however, the echinocandins do not cross the blood brain barrier.
 Summary : Antifungal Drug Mechanisms

This is the summary diagram for antifungal drug mechanisms which can be found in Medical Pharmacology at a Glance.
Important Antifungal Drugs

• Amphotericin
• Flucytosine
• Nystatin
• Clotrimazole
• Fluconazole
• Voriconazole
• Caspofungin