Fluphenazine antagonizes with fluconazole but synergizes with amphotericin B in the treatment of candidiasis

  • Yangyu Lu
  • Zhiyan Zhou
  • Longyi Mo
  • Qiang Guo
  • Xian Peng
  • Tao Hu
  • Xuedong Zhou
  • Biao RenEmail author
  • Xin XuEmail author
Applied microbial and cell physiology


Candida albicans causes a high mortality rate in immunocompromised individuals, but the increased drug resistance challenges the current antifungal therapeutics. Fluphenazine (FPZ), a commonly used antipsychotic medication, can induce the expression of drug efflux pumps in C. albicans and, thus, may interfere with the therapeutic efficacy of antifungals, such as fluconazole (FLC) and amphotericin B (AmB). Here, we investigated the combined effects of FLC/FPZ and AmB/FPZ against C. albicans in vitro and in a systemic candidiasis mouse model. The antifungal activity of FLC was significantly reduced when supplemented with FPZ. The inhibitory effects of FLC on the expression of the Candida virulence-related genes ALS3 and HWP1 were antagonized by FPZ. However, FPZ enhanced the susceptibility of C. albicans to AmB and further downregulated the expression of ALS3 and HWP1 in a synergistic manner with AmB. FPZ also enhanced the gene expression of ERG11, a key gene of the ergosterol biosynthesis pathway that has been associated with the activities of both FLC and AmB. In our mammalian infection model, mice treated with FLC/FPZ showed notably poor living status and increased fungal burden in their kidneys and brains compared with those treated with FLC alone. Conversely, the combined application of AmB/FPZ significantly improved the survival rate, attenuated the weight loss and reduced the organ fungal burdens of the infected mice. These data suggest that FPZ antagonized the therapeutic efficacy of FLC but enhanced the antifungal activity of AmB in the treatment of candidiasis.


Drug interactions Ergosterol Antipsychotics Virulence factor Systemic candidiasis 


Funding information

This work was supported by the National Natural Science Foundation of China (NSFC, 81870778, 81771099, 81600858, 81500842) and research grants from the Department of Science and Technology of Sichuan Province (2018SZ0121, 2016JY0006).

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical statement

All animal protocols in this study were conducted in strict accordance with the guidelines of Ethics Committee of West China Hospital of Stomatology, Sichuan University, and the ethics approval was obtained from this institution (license number WCHSIRB-D-2017-134). All efforts were made to minimize suffering and ensure the highest ethical and humane standards.

Supplementary material

253_2019_9960_MOESM1_ESM.pdf (744 kb)
ESM 1 (PDF 744 kb)


  1. Almeida RS, Brunke S, Albrecht A, Thewes S, Laue M, Edwards JE, Filler SG, Hube B (2008) The hyphal-associated adhesin and invasin Als3 of Candida albicans mediates iron acquisition from host ferritin. PLoS Pathog 4(11):e1000217CrossRefGoogle Scholar
  2. Anderson JB (2005) Evolution of antifungal-drug resistance: mechanisms and pathogen fitness. Nat Rev Microbiol 3(7):547–556CrossRefGoogle Scholar
  3. Anderson TM, Clay MC, Cioffi AG, Diaz KA, Hisao GS, Tuttle MD, Nieuwkoop AJ, Comellas G, Maryum N, Wang S, Uno BE, Wildeman EL, Gonen T, Rienstra CM, Burke MD (2014) Amphotericin forms an extramembranous and fungicidal sterol sponge. Nat Chem Biol 10(5):400–406Google Scholar
  4. Bates DW, Su L, Yu DT, Chertow GM, Seger DL, Gomes DR, Dasbach EJ, Platt R (2001) Mortality and costs of acute renal failure associated with amphotericin B therapy. Clin Infect Dis 32(5):686–693CrossRefGoogle Scholar
  5. Brezis M, Rosen S, Silva P, Spokes K, Epstein FH (1984) Polyene toxicity in renal medulla: injury mediated by transport activity. Science 224(4644):66–68CrossRefGoogle Scholar
  6. Brown GD, Denning DW, Gow NA, Levitz SM, Netea MG, White TC (2012) Hidden killers: human fungal infections. Sci Transl Med 4(165):165rv13Google Scholar
  7. Carlisle PL, Banerjee M, Lazzell A, Monteagudo C, López-Ribot JL, Kadosh D (2009) Expression levels of a filament-specific transcriptional regulator are sufficient to determine Candida albicans morphology and virulence. Proc Natl Acad Sci U S A 106(2):599–604Google Scholar
  8. Castro-Nallar E, Bendall ML, Pérez-Losada M, Sabuncyan S, Severance EG, Dickerson FB, Schroeder JR, Yolken RH, Crandall KA (2015) Composition, taxonomy and functional diversity of the oropharynx microbiome in individuals with schizophrenia and controls. PeerJ 3:e1140Google Scholar
  9. Chan KY, Zhao FF, Meng S, Demaio AR, Reed C, Theodoratou E, Campbell H, Wang W, Rudan I (2015) Urbanization and the prevalence of schizophrenia in China between 1990 and 2010. World Psychiatry 14(2):251–252CrossRefGoogle Scholar
  10. Cheng G, Wozniak K, Wallig MA, Fidel PL Jr, Trupin SR, Hoyer LL (2005) Comparison between Candida albicans agglutinin-like sequence gene expression patterns in human clinical specimens and models of vaginal candidiasis. Infect Immun 73(3):1656–1663CrossRefGoogle Scholar
  11. Costa-de-Oliveira S, Miranda IM, Silva-Dias A, Silva AP, Rodrigues AG, Pina-Vaz C (2015) Ibuprofen potentiates the in vivo antifungal activity of fluconazole against Candida albicans murine infection. Antimicrob Agents Chemother 59(7):4289–4292CrossRefGoogle Scholar
  12. Cui J, Ren B, Tong Y, Dai H, Zhang L (2015) Synergistic combinations of antifungals and anti-virulence agents to fight against Candida albicans. Virulence 6(4):362–371CrossRefGoogle Scholar
  13. Delattin N, De Brucker K, Vandamme K, Meert E, Marchand A, Chaltin P, Cammue BP, Thevissen K (2014) Repurposing as a means to increase the activity of amphotericin B and caspofungin against Candida albicans biofilms. J Antimicrob Chemother 69(4):1035–1044CrossRefGoogle Scholar
  14. Flowers SA, Colón B, Whaley SG, Schuler MA, Rogers PD (2015) Contribution of clinically derived mutations in ERG11 to azole resistance in Candida albicans. Antimicrob Agents Chemother 59(1):450–460Google Scholar
  15. Global Burden of Disease Study 2013 Collaborators (2015) Global, regional, and national incidence, prevalence, and years lived with disability for 301 acute and chronic diseases and injuries in 188 countries, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet 386(9995):743–800CrossRefGoogle Scholar
  16. Hamill RJ (2013) Amphotericin B formulations: a comparative review of efficacy and toxicity. Drugs 73(9):919–934CrossRefGoogle Scholar
  17. Hof H (2008) Is there a serious risk of resistance development to azoles among fungi due to the widespread use and long-term application of azole antifungals in medicine? Drug Resist Updat 11(1–2):25–31CrossRefGoogle Scholar
  18. Hull CM, Bader O, Parker JE, Weig M, Gross U, Warrilow AG, Kelly DE, Kelly SL (2012) Two clinical isolates of Candida glabrata exhibiting reduced sensitivity to amphotericin B both harbor mutations in ERG2. Antimicrob Agents Chemother 56(12):6417–6421CrossRefGoogle Scholar
  19. Kadosh D, Najvar LK, Bocanegra R, Olivo M, Kirkpatrick WR, Wiederhold NP, Patterson TF (2016) Effect of antifungal treatment in a diet-based murine model of disseminated candidiasis acquired via the gastrointestinal tract. Antimicrob Agents Chemother 60(11):6703–6708CrossRefGoogle Scholar
  20. Kamiński DM (2014) Recent progress in the study of the interactions of amphotericin B with cholesterol and ergosterol in lipid environments. Eur Biophys J 43(10–11):453–467Google Scholar
  21. Karababa M, Coste AT, Bnd R, Bille J, Sanglard D (2004) Comparison of gene expression profiles of Candida albicans azole-resistant clinical isolates and laboratory strains exposed to drugs inducing multidrug transporters. Antimicrob Agents Chemother 48(8):3064–3079CrossRefGoogle Scholar
  22. Leucht S, Burkard T, Henderson J, Maj M, Sartorius N (2007) Physical illness and schizophrenia: a review of the literature. Acta Psychiatr Scand 116(5):317–333CrossRefGoogle Scholar
  23. Li DD, Zhao LX, Mylonakis E, Hu GH, Zou Y, Huang TK, Yan L, Wang Y, Jiang YY (2014) In vitro and in vivo activities of pterostilbene against Candida albicans biofilms. Antimicrob Agents Chemother 58(4):2344–2355CrossRefGoogle Scholar
  24. Lin J, Oh SH, Jones R, Garnett JA, Salgado PS, Rusnakova S, Matthews SJ, Hoyer LL, Cota E (2014) The peptide-binding cavity is essential for Als3-mediated adhesion of Candida albicans to human cells. J Biol Chem 289(26):18401–18412CrossRefGoogle Scholar
  25. Liu Y, Mittal R, Solis NV, Prasadarao NV, Filler SG (2011) Mechanisms of Candida albicans trafficking to the brain. PLoS Pathog 7(10):e1002305CrossRefGoogle Scholar
  26. Mayer FL, Wilson D, Hube B (2013) Candida albicans pathogenicity mechanisms. Virulence 4(2):119–128CrossRefGoogle Scholar
  27. de Micheli M, Bille J, Schueller C, Sanglard D (2002) A common drug-responsive element mediates the upregulation of the Candida albicans ABC transporters CDR1 and CDR2, two genes involved in antifungal drug resistance. Mol Microbiol 43(5):1197–1214Google Scholar
  28. Mukhopadhyay K, Prasad T, Saini P, Pucadyil TJ, Chattopadhyay A, Prasad R (2004) Membrane sphingolipid-ergosterol interactions are important determinants of multidrug resistance in Candida albicans. Antimicrob Agents Chemother 48(5):1778–1787CrossRefGoogle Scholar
  29. Odds FC (2003) Synergy, antagonism, and what the chequerboard puts between them. J Antimicrob Chemother 52(1):1–1CrossRefGoogle Scholar
  30. Odds FC, Brown AJP, Gow NAR (2003) Antifungal agents: mechanisms of action. Trends Microbiol 11(6):272–279CrossRefGoogle Scholar
  31. Pasrija R, Panwar SL, Prasad R (2008) Multidrug transporters CaCdr1p and CaMdr1p of Candida albicans display different lipid specificities: both ergosterol and sphingolipids are essential for targeting of CaCdr1p to membrane rafts. Antimicrob Agents Chemother 52(2):694–704CrossRefGoogle Scholar
  32. Pfaller MA, Diekema DJ (2007) Epidemiology of invasive candidiasis: a persistent public health problem. Clin Microbiol Rev 20(1):133–163CrossRefGoogle Scholar
  33. Phan QT, Myers CL, Fu Y, Sheppard DC, Yeaman MR, Welch WH, Ibrahim AS, Edwards JE Jr, Filler SG (2007) Als3 is a Candida albicans invasin that binds to cadherins and induces endocytosis by host cells. PLoS Biol 5(3):e64CrossRefGoogle Scholar
  34. Ren B, Dai HQ, Pei G, Tong YJ, Zhuo Y, Yang N, Su MY, Huang P, Yang YZ, Zhang LX (2014) ABC transporters coupled with the elevated ergosterol contents contribute to the azole resistance and amphotericin B susceptibility. Appl Microbiol Biotechnol 98(6):2609–2616CrossRefGoogle Scholar
  35. Sanglard D, Ischer F, Parkinson T, Falconer D, Bille J (2003) Candida albicans mutations in the ergosterol biosynthetic pathway and resistance to several antifungal agents. Antimicrob Agents Chemother 47(8):2404–2412CrossRefGoogle Scholar
  36. Shekhar-Guturja T, Gunaherath GM, Wijeratne EM, Lambert JP, Averette AF, Lee SC, Kim T, Bahn YS, Tripodi F, Ammar R, Dohl K, Niewola-Staszkowska K, Schmitt L, Loewith RJ, Roth FP, Sanglard D, Andes D, Nislow C, Coccetti P, Gingras AC, Heitman J, Gunatilaka AA, Cowen LE (2016) Dual action antifungal small molecule modulates multidrug efflux and TOR signaling. Nat Chem Biol 12(10):867–875CrossRefGoogle Scholar
  37. Staab JF, Bradway SD, Fidel PL, Sundstrom P (1999) Adhesive and mammalian transglutaminase substrate properties of Candida albicans Hwp1. Science 283(5407):1535–1538CrossRefGoogle Scholar
  38. Steimbach LM, Tonin FS, Virtuoso S, Borba HH, Sanches AC, Wiens A, Fernandez-Llimos F, Pontarolo R (2017) Efficacy and safety of amphotericin B lipid-based formulations-a systematic review and meta-analysis. Mycoses 60(3):146–154CrossRefGoogle Scholar
  39. Sundstrom P (2002) Adhesion in Candida spp. Cell Microbiol 4(8):461–469CrossRefGoogle Scholar
  40. Sundstrom P, Balish E, Allen CM (2002) Essential role of the Candida albicans transglutaminase substrate, hyphal wall protein 1, in lethal oroesophageal candidiasis in immunodeficient mice. J Infect Dis 185(4):521–530CrossRefGoogle Scholar
  41. Tardy M, Huhn M, Engel RR, Leucht S (2014) Fluphenazine versus low-potency first-generation antipsychotic drugs for schizophrenia. Cochrane Database Syst Rev 3(8):CD009230Google Scholar
  42. Tsuchimori N, Sharkey LL, Fonzi WA, French SW, Edwards JE Jr, Filler SG (2000) Reduced virulence of HWP1-deficient mutants of Candida albicans and their interactions with host cells. Infect Immun 68(4):1997–2002CrossRefGoogle Scholar
  43. Vandeputte P, Tronchin G, Bergès T, Hennequin C, Chabasse D, Bouchara JP (2006) Reduced susceptibility to polyenes associated with a missense mutation in the ERG6 gene in a clinical isolate of Candida glabrata with pseudohyphal growth. Antimicrob Agents Chemother 51(3):982–990Google Scholar
  44. Vandeputte P, Tronchin G, Larcher G, Ernoult E, Bergès T, Chabasse D, Bouchara JP (2008) A nonsense mutation in the ERG6 gene leads to reduced susceptibility to polyenes in a clinical isolate of Candida glabrata. Antimicrob Agents Chemother 52(10):3701–3709Google Scholar
  45. Vincent BM, Lancaster AK, Scherz-Shouval R, Whitesell L, Lindquist S (2013) Fitness trade-offs restrict the evolution of resistance to amphotericin B. PLoS Biol 11(10):e1001692CrossRefGoogle Scholar
  46. Vincent BM, Langlois JB, Srinivas R, Lancaster AK, Scherz-Shouval R, Whitesell L, Tidor B, Buchwald SL, Lindquist S (2016) A fungal-selective cytochrome bc1 inhibitor impairs virulence and prevents the evolution of drug resistance. Cell Chem Biol 23(8):978–991Google Scholar
  47. Wijemanne S, Wu LJ, Jankovic J (2014) Long-term efficacy and safety of fluphenazine in patients with Tourette syndrome. Mov Disord 29(1):126–130CrossRefGoogle Scholar
  48. Wu BY, Wu BJ, Lee SM, Sun HJ, Chang YT, Lin MW (2014) Prevalence and associated factors of comorbid skin diseases in patients with schizophrenia: a clinical survey and national health database study. Gen Hosp Psychiatry 36(4):415–421CrossRefGoogle Scholar
  49. Xiang MJ, Liu JY, Ni PH, Wang S, Shi C, Wei B, Ni YX, Ge HL (2013) Erg11 mutations associated with azole resistance in clinical isolates of Candida albicans. FEMS Yeast Res 13(4):386–393CrossRefGoogle Scholar
  50. Xiao Y, Tang J, Guo H, Zhao Y, Tang R, Ouyang S, Zeng Q, Rappleye CA, Rajaram MVS, Schlesinger LS, Tao L, Brown GD, Langdon WY, Li BT, Zhang J (2016) Targeting CBLB as a potential therapeutic approach for disseminated candidiasis. Nat Med 22(8):906–914CrossRefGoogle Scholar
  51. Zakikhany K, Naglik JR, Schmidt-Westhausen A, Holland G, Schaller M, Hube B (2007) In vivo transcript profiling of Candida albicans identifies a gene essential for interepithelial dissemination. Cell Microbiol 9(12):2938–2954CrossRefGoogle Scholar
  52. Zhang L, Yan K, Zhang Y, Huang R, Bian J, Zheng C, Sun H, Chen Z, Sun N, An R, Min F, Zhao W, Zhuo Y, You J, Song Y, Yu Z, Liu Z, Yang K, Gao H, Dai H, Zhang X, Wang J, Fu C, Pei G, Liu J, Zhang S, Goodfellow M, Jiang Y, Kuai J, Zhou G, Chen X (2007) High-throughput synergy screening identifies microbial metabolites as combination agents for the treatment of fungal infections. Proc Natl Acad Sci U S A 104(11):4606–4611CrossRefGoogle Scholar
  53. Zheng X, Cheng X, Wang L, Qiu W, Wang S, Zhou Y, Li M, Li Y, Cheng L, Li J, Zhou X, Xu X (2015) Combinatorial effects of arginine and fluoride on oral bacteria. J Dent Res 94(2):344–353CrossRefGoogle Scholar
  54. Zhou Y, Yang H, Zhou X, Luo H, Tang F, Yang J, Alterovitz G, Cheng L, Ren B (2018) Lovastatin synergizes with itraconazole against planktonic cells and biofilms of Candida albicans through the regulation on ergosterol biosynthesis pathway. Appl Microbiol Biotechnol 102(12):5255–5264CrossRefGoogle Scholar
  55. Zhu W, Phan QT, Boontheung P, Solis NV, Loo JA, Filler SG (2012) EGFR and HER2 receptor kinase signaling mediate epithelial cell invasion by Candida albicans during oropharyngeal infection. Proc Natl Acad Sci U S A 109(35):14194–14199CrossRefGoogle Scholar
  56. Zuluaga AF, Salazar BE, Rodriguez CA, Zapata AX, Agudelo M, Vesga O (2006) Neutropenia induced in outbred mice by a simplified low-dose cyclophosphamide regimen: characterization and applicability to diverse experimental models of infectious diseases. BMC Infect Dis 6:55CrossRefGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  1. 1.State Key Laboratory of Oral Diseases and National Clinical Research Center for Oral Diseases, West China Hospital of StomatologySichuan UniversityChengduChina
  2. 2.Department of Cariology and Endodontics, West China Hospital of StomatologySichuan UniversityChengduChina
  3. 3.Department of Preventive Dentistry, West China Hospital of StomatologySichuan UniversityChengduChina

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