Repurposing approach identifies phenylpentanol derivatives as potent azole chemosensitizing agents effective against azole-resistant Candida species

Abstract

The limited number of systemic antifungals and the emergence of azole-resistant Candida species constitute a growing challenge to human medicine. Combinatorial drug therapy represents an appealing approach to enhance the activity of, or restore the susceptibility to current antifungals. Here, we evaluated the fluconazole chemosensitization activity of the Pharmakon 1600 drug library against azole-resistant Candida albicans. We identified 33 non-antifungal drugs that were able to restore susceptibility to fluconazole in an azole-resistant C. albicans. Structural investigation of identified hits revealed phenylpentanol scaffold as a valuable pharmacophore for re-sensitizing azole-resistant Candida species to the effect of current azole antifungal drugs. All phenylpentanol derivatives displayed potent fluconazole chemosensitizing activities ({Sigma}FICI 0.13-0.28) and were able to reduce fluconazoles MIC by 15-31 fold against the tested strain. Particularly pitavastatin displayed the most potent fluconazole chemosensitizing activity ({Sigma}FICI 0.06-0.50). The pitavastatin-fluconazole combination displayed a broad-spectrum synergistic relationship against 90% of the tested strains, including strains of C. albicans, C. glabrata, and C. auris. Moreover, pitavastatin restored the susceptibility of the multidrug-resistant C. auris to the antifungal activities of itraconazole and voriconazole. Additionally, the pitavastatin-fluconazole combination significantly reduced the biofilm-forming abilities of the tested Candida species and successfully reduced the fungal burdens in a Caenorhabditis elegans infection model. Both pitavastatin and the plain phenylpentanol scaffold were able to interfere significantly with Candidas efflux activities as demonstrated by Nile Red efflux assays and flow cytometry. This study presents phenylpentanol derivatives as potent azole chemosensitizers that warrant further investigation.