Biochemical Pharmacology xxx (2016) xxx–xxx

Contents lists available at ScienceDirect

Biochemical Pharmacology
journal homepage: www.elsevier.com/locate/biochempharm

Review

Antifungals
Sonia Campoy, José L. Adrio ⇑
Neol Biosolutions, S.A., c/Avicena, 4, Parque Tecnológico de la Salud, 18016 Granada, Spain

a r t i c l e i n f o a b s t r a c t

Article history: The need for new antifungal agents is undeniable. Current therapeutic choices for the treatment of
Received 25 September 2016 invasive fungal infections are limited to three classes of drugs. Most used antifungal agents are not com-
Accepted 18 November 2016 pletely effective due to the development of resistance, host toxicity and undesirable side effects that limit
Available online xxxx
their use in medical practice. Invasive fungal infections have significantly increased over the last decades
and the mortality rates remain unacceptably high. More threatening, new resistance patterns have been
Keywords: observed including simultaneous resistance to different antifungal classes.
Antifungals
In the last years, deeper insights into the molecular mechanisms for fungal resistance and virulence
Mycosis
Fungal resistance
have yielded some new potential targets for antifungal therapeutics. Chemical genomics-based screen-
Candida ings, high throughput screenings of natural products and repurposing of approved drugs are some of
Aspergillus the approaches being followed for the discovery of new antifungal molecules. However, despite the
Azole emerging need for effective antifungal agents, the current pipeline contains only a few promising
Polyenes molecules, with novel modes of action, in early clinical development stages.
Echinocandins ! 2016 Elsevier Inc. All rights reserved.
Pyrimidine analogs
Aspergillosis
Candidiasis

Contents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
2. Classification of antifungal agents. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
2.1. Inhibitors of ergosterol biosynthesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
2.1.1. Azoles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
2.1.2. Allylamines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
2.1.3. Morpholines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
2.2. Fungal membrane disruptors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
2.3. Fungal cell wall synthesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
2.3.1. Inhibitors b-glucan synthesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
2.3.2. Chitin synthesis inhibitors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
2.4. Sphingolipids biosynthesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
2.5. Nucleic acid synthesis inhibitors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
2.6. Protein biosynthesis inhibitors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
2.7. Microtubules biosynthesis inhibitors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
3. Strategies to develop new antifungal compounds . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
4. Mechanisms of antifungal resistance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
5. Antifungal pipeline. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
6. Conclusions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00

⇑ Corresponding author.
E-mail address: jladrio@neolbio.com (J.L. Adrio).

http://dx.doi.org/10.1016/j.bcp.2016.11.019
0006-2952/! 2016 Elsevier Inc. All rights reserved.

Please cite this article in press as: S. Campoy, J.L. Adrio, Antifungals, Biochem. Pharmacol. (2016), http://dx.doi.org/10.1016/j.bcp.2016.11.019
2 S. Campoy, J.L. Adrio / Biochemical Pharmacology xxx (2016) xxx–xxx
1. Introduction
Invasive fungal infections represent a continuous and serious
threat to human health and they are associated with at least 1.5
million deaths worldwide each year [1,2]. Estimates in the litera-
ture support a 30–40% mortality for invasive candidiasis, 20–30%
for disseminated cryptococcosis and a similar percentage for inva-
sive aspergillosis [3,4]. Such infections are very common in
immunocompromised patients as a result of aggressive therapies
(e.g. anticancer chemotherapy, long-term corticosteroids treat-
ment, or organ transplant) and immunosuppressive infections such
as HIV/AIDS. About 90% of these deaths are caused by species
belonging to genera of fungi Candida, Aspergillus, Cryptococcus,
Pneumocystis, Mucor and Rhizopus [5]. However, new and emerging
fungal pathogen species belonging to Zygomycetes, Fusarium or Sce-
dosporium have becoming increasingly important as etiological
agents of invasive mycoses [6].
Fungi also produced superficial infections (involving the skin
and mucosal surfaces) which have greater incidence than the inva-
sive infections diminishing the quality of life of affected individu-
als. Superficial mycoses are caused by Malasseria globose and M.
furfur. Cutaneous and subcutaneous mycoses that affect kera-
tinized structures are caused by dermatophyte genera like Tri-
chophyton, Epidermophyton and Microsporum [7]. Mucosal
infections are mostly caused by opportunistic yeasts being those
belonging to the Candida genus the most frequent by far.
In comparison with the development of new antibacterial
drugs, antifungal drug development is more challenging because
fungi are eukaryotes and many potential targets for therapy are
also found in humans with substantial host toxicity risk [8,9].
Currently, four classes of antifungal agents (azoles, echinocan-
dins, polyenes and pyrimidine analogs) are used orally, topically
Fig. 1. Antifungal agents targets.
Please cite this article in press as: S. Campoy, J.L. Adrio, Antifungals, Biochem. Pharmacol. (2016), http://dx.doi.org/10.1016/j.bcp.2016.11.019
or intravenously for the treatment of fungal infections [6,9]. A fifth
class, allylamines, is also existing although compounds of this class
are used only for treating superficial dermathophytic infections.
However, these antifungals have various drawbacks in terms of
toxicity, spectrum of activity, safety and pharmacokinetic proper-
ties [1,10]. The emergence of strains resistant to the current anti-
fungal agents has led great efforts to develop new drugs with
different mechanisms of action that target the biosynthesis of fun-
gal proteins, lipids and cell wall [10].
2. Classification of antifungal agents
Based on their targets for antifungal therapy (Fig. 1) antifungal
agents can be classified in the following groups:
2.1. Inhibitors of ergosterol biosynthesis
Ergosterol is the major component of the fungal cell membrane
and contributes to a variety of cellular functions such as fluidity
and integrity of the membrane and the proper function of
membrane-bound enzymes.
2.1.1. Azoles
Azoles are by far the most common antifungal drugs in clinical
use. They are highly used in the treatment and the prevention of
mycoses due to their broad spectrum activity. Azoles inhibit the
cytochrome P450-dependent enzyme 14a-lanosterol demethylase
(CYP51) encoded by the ERG11 gene that converts lanosterol to
ergosterol (Fig. 1) in the cell membrane inhibiting fungal growth
and replication [11–13]. This enzyme contains an iron protopor-
phyrin unit at its active site. Azoles bind to the iron of the
 S. Campoy, J.L. Adrio / Biochemical Pharmacology xxx (2016) xxx–xxx 3

porphyrin and cause the blockade of the fungal ergosterol biosyn-
thesis pathway resulting in the accumulation of 14-methylated
sterols [14]. The exact conformation of the active site differs
between fungal species and among the many mammalian P450
mono-oxygenases [15]. The nature of the interaction between each
azole molecule and each kind of P450 determines their antifungal
characteristics and side effects.
The azoles are cyclic organic molecules that can be classified
into two groups: imidazoles and triazoles. Imidazoles (clotrima-
zole, miconazole and ketoconazole) (Fig. 2 1–3) were the first
developed azoles [16,17]. However, because of their high toxicity,
severe side effects and numerous interactions with other drugs,
they were replaced by the triazoles. The first generation triazoles
(Itraconazole and Fluconazole) exhibit a broader antifungal activity
spectrum as compared to the imidazoles and have significant
improved safety profiles. Fluconazole (Fig. 2 4) is active against
Candida species, Cryptococcus neoformans, Histoplasma, Blastomyces
and Coccidioides species, but lacks activity against molds [18,19].
Itraconazole (Fig. 2 5) shows a broader spectrum of activity being
active against yeasts and Aspergillus species [5,20]. However, both
have certain clinical limitations as they are ineffective against
some emerging pathogens as Scedosporium, Fusarium and Muco-
rales [6,7]. Increase in azole resistance is mainly due to its fungi-
static nature instead of fungicidal [16].
To solve these problems, a second generation of triazoles was
developed. Voriconazole (Fig. 2 6) and Posaconazole (Fig. 2 7) were
approved by the US Food and Drug Administration (FDA) in 2002
and 2006, respectively [21–24]. They are considered fungicidal
[25] and have a broad spectrum of activity including Fusarium, Sce-
dosporium, Zygomycetes and Cryptococcus neoformans. Voriconazole
became the first-line antifungal drug for the treatment of invasive
aspergillosis due to A. fumigatus since its activity is superior to
many other antifungals for this infection [1]. Posaconazole is the
azole with the broadest activity and was approved by FDA for pro-
phylaxis against invasive Aspergillus and Candida infections.
Efinaconazole (Fig. 2 8) is a topical antifungal solution active
against dermatophytes and nondermatophytes, effective in treat-
ment of onychomycosis, as well as Candida spp. It was approved
by FDA in 2014 for the treatment of fungal nail infections [25].
Isavuconazole is the most recently approved triazole in the US
and the EU for the oral and intravenous treatment of invasive
aspergillosis and mucormycosis [25]. It has some advantages com-
pared with other approved azoles as it has expanded activity that
includes Zygomycetes such as Rhizopus, Mucor and Cunninghamella
species. Additionally, its intravenous preparation lacks cyclodex-
trin that is associated with nephrotoxicity in patients.
2.1.2. Allylamines
These synthetic fungicidal agents block ergosterol biosynthesis
as they are reversible, non-competitive inhibitors of squalene
epoxidase (ERG1). This enzyme catalyzes the conversion of squa-
lene into 2,3-squalene epoxide. The inhibition of this enzymatic
activity leads to squalene accumulation (Fig. 1) [5,20] that may
increase permeability leading to disruption of cellular organiza-
tion. Important members of this group include terbinafine and naf-
tifine [26]. Terbinafine (Fig. 2 9) was isolated from cultures of
Streptomyces sp. KH-F12. It is active against Aspergillus, Fusarium
and other filamentous fungi [12,20]. It is widely use for the treat-
ment of nail infections. Naftifine (Fig. 2 10) is active against Tri-
chophyton, Epidermophyton and Microsporum. Fungistatic activity
against Candida species [27,28].
2.1.3. Morpholines
The amorolfine (Fig. 2 11) is a synthetic water soluble morpho-
line derivative that inhibits two enzymes involved in ergosterol
biosynthesis, D7–D8 isomerase (ERG2) and the D14-reductase

Fig. 2. Antifungal agents structure. 1 Clotrimazole, 2 Miconazole, 3 Ketoconazole, 4 Fluconazole, 5 Itraconazole, 6 Voriconazole, 7 Posaconazole, 8 Efinaconazole, 9
Terbinafine, 10 Naftifine, 11 Amorolfine, 12 Nystatin, 13 Natamycin, 14 Amphotericin B, 15 Echinocandins, 16 Nikkomycin, 17 Polyoxins, 18 Aureobasidin A 19 Flucytosine, 20
Tavaborole, 21 Cispentacin, 22 Icofungipen, 23 Sordarins, 24 Griseofulvin.

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4 S. Campoy, J.L. Adrio / Biochemical Pharmacology xxx (2016) xxx–xxx
(ERG24) (Fig. 1). Amorolfine is used in the topical treatment of nail
infections [29] and it has both fungistatic and fungicidal activity
in vitro.
2.2. Fungal membrane disruptors
Polyenes are macrocyclic organic molecules known as macro-
lides. Most of them consist of a 20–40 carbon macrolactone ring
conjugated with a d-mycosimine group [30]. Due to their amphi-
philic structure, these molecules bind to the lipid bilayer and form
a complex with the ergosterol producing pores. Pore formation
promotes disruption of the cell membrane, the leakage of the cyto-
plasmic contents and oxidative damage result in fungal cell death
[31–33]. Recently, it has been reported that polyenes (ampho-
tericin B) bind ergosterol and form an extramembranous fungicidal
sterol sponge destabilizing membrane function [34]. Polyenes
were the first antifungal drugs for clinical use. They are fungicidal
and have the broadest spectrum of activity compared to any other
antifungal molecules. Nystatin, natamycin and amphotericin B are
the only three polyenes in clinical use [35–37]. They are natural
products and were isolated from the cultivation broths of Strepto-
myces noursei, S. natalensis and S. nodosum, respectively.
Nystatin (Fig. 2 12) and natamycin (Fig. 2 13) are active against
Cryptococcus, Candida, Aspergillus and Fusarium. Nystatin is used for
the treatment of cutaneous, vaginal and esophageal candidiasis,
and natamycin can be used for the treatment of fungal keratosis
or corneal infections [38]. Amphotericin B (Fig. 2 14) is active
against most yeasts and filamentous fungi. It is recommended for
the treatment of infections caused by Candida, Aspergillus, Fusar-
ium, Mucor, Scedosporium and Cryptococcus among others [39,40].
Polyenes have a lower but non-negligible affinity for choles-
terol. This slight affinity for cholesterol explains the high toxicity
associated with these antifungals and is responsible for numerous
side effects [41]. Nystatin and natamycin are only used as topical
agents due to their low absorption in the gut and their high toxic-
ity. Amphotericin B is the most used polyene for the treatment of
systemic infections. Due to its hydrophobicity and poor absorption
through the gastrointestinal tract, it is administered intravenously
which causes adverse effects in kidneys and liver [42].
In recent years, the main efforts have been focused on finding
new molecules that minimize the toxicity of these three com-
pounds [43]. New semi-synthetic polyenes have been developed
showing improved water-solubility, lower hemotoxicity than
amphotericin B, superior selectivity toward ergosterol-containing
vesicles, and higher activity against both Saccharomyces cerevisiae
and amphotericin B-resistant Candida albicans strains [44,45]. Over
the last decade, the lipid formulations of amphotericin B have
allowed this polyene to be more effective in reducing host toxicity.
Formulations include encapsulation in liposomes or in ribbon-like
and disc-like lipid complexes [46,47]. Other formulations are under
investigation, including amphotericin B-cochleate preparations
[48] and arabinogalactan complexes [49].
2.3. Fungal cell wall synthesis
2.3.1. Inhibitors b-glucan synthesis
Glucans are polysaccharides that consist of D-glucose mono-
mers attached to each other by b-(1,3) or b-(1,6)-glucan linkages
[50]. b-(1,3)-D-Glucan constitutes more than 50% of the cell wall
and is the main structural polysaccharide to which other cell wall
components (chitins and glycoproteins) are attached.
Currently, the only available antifungal drugs targeting cell wall
are three echinocandins (caspofungin, micafungin and anidula-
fungin) [51,52]. Echinocandins are the newest antifungal agents
although they were approved for clinical use by FDA and EMA
(European Medicines Agency) more than a decade ago [7]. They
Please cite this article in press as: S. Campoy, J.L. Adrio, Antifungals, Biochem. Pharmacol. (2016), http://dx.doi.org/10.1016/j.bcp.2016.11.019
act as noncompetitive inhibitors of b-(1,3)-D-glucan synthase
enzyme complex, specifically targeting the FsK1 subunit which
leads to disruption of the structure of growing cell walls, resulting
in osmotic instability and fungal cells death (Fig. 1). Echinocandins
are semisynthetic lipopeptides derived from fungal natural prod-
ucts. Caspofungin is derived from pneumocandin B produced by
Glarea lozoyensis, micafungin is a semisynthetic product of
echinocandin B produced by Aspergillus nidulans var. echinulatus,
and anidulafungin is produced by chemical modification of a fer-
mentation product of Coleophoma empetri [53,54]. The basic struc-
ture of echinocandins consists in a cyclic hexapeptide with
different side chains at position R5 (Fig. 2 15) which are responsi-
ble for their antifungal activity [55,56]. At such position, caspo-
fungin has a fatty acid, micafungin has a complex aromatic
substituent and anidulafungin has an alkoxytriphenyl group.
These drugs are poorly absorbed in the gastrointestinal tract
because of their high molecular weights. Echinocandins show very
good safety profiles and their toxicity is very low due to their
unique target, that is absent in mammalian cells and interactions
with other drugs are minimal [22]. However, they have a short
half-life so they must be administered once-daily intravenously
limiting their use to the hospital [57].
Caspofungin, micafungin and anidulafungin have fungicidal
activity both in vitro and in vivo against many strains of Candida
and fungistatic activity against Aspergillus spp. Micafungin and
anidulafungin were licensed for the treatment of invasive candidi-
asis and esophageal candidiasis; caspofungin was also approved
for invasive aspergillosis [19,58–60].
Efforts to obtain new echinocandins are relevant since these
compounds show broad-spectrum antifungal activity and a possi-
ble use in combination with azoles or amphotericin B could
enhance their action against fungal pathogens without causing
the development of resistant strains [57].
2.3.2. Chitin synthesis inhibitors
Chitin is a minor component of the cell wall (3%) which consists
of a linear homopolymer of b-(1,4)-linked N-acetylglucosamine
covalently linked to b-(1,3)-D-glucan [50,59,61]. The synthesis of
chitin is mediated by several enzymes named chitin synthases.
Chitin provides structural integrity and when its synthesis is dis-
rupted, the cell wall becomes osmotically unstable. Because chitin
is absent in human cells, it is considered an excellent target for
antifungal agents. There most widely studied chitin synthase inhi-
bitors are Nikkomycins and Polyoxins. Nikkomycin (Fig. 2 16) is
active against highly chitinous dimorphic fungal pathogens and it
is not active against neither Candida albicans nor C. tropicalis [59].
Polyoxins (Fig. 2 17) is active against phytopathogenic fungi [50].
These are naturally occurring peptidyl nucleoside antifungals that
bind to the catalytic site acting as competitive analogs of UDP-N-
acetylglucosamine [6]. However, their current clinical use is com-
promised due to their hydrolytic liability and low in vivo activity.
Polyoxins are no longer in development since 2012 whereas Nikko-
mycin Z is being tested in clinical trials [9] (Table 1).
2.4. Sphingolipids biosynthesis
Sphingolipids are abundant components of membranes in
eukaryotic cells and, besides playing a variety of roles in fungal
cells, some of them play an important role in fungal pathogenesis
[62]. Recently, some studies have demonstrated that acting on
enzymes involved in sphingolipid biosynthesis could attenuate
the virulence of fungal pathogens.
Aureobasidin A (Fig. 2 18) is a cyclic depsipeptide isolated from
Aureobasidium pullulans [63], active against Saccharomyces cere-
visiae, Schizosaccharomyces pombe, C. albicans, C. glabrata, A. nidu-
lans, A. niger and C. neoformans, and less effective against A.
 S. Campoy, J.L. Adrio / Biochemical Pharmacology xxx (2016) xxx–xxx 5

Table 1
Antifungal pipeline. Compounds in preclinical or clinical development. QIDP (Qualified Infectious Disease Product).

Mode of action Compound Indication Development References

Ergosterol biosynthesis VT1129 Cryptococcal meningitis Phase 1. Granted QIDP and Orphan www.viamet.com [132]
drug status (US)
VT1161 Onychomycosis, Recurrent vulvovaginal Phase 2b [131]
candidiasis
Isavuconazole Invasive molds disease Candidemia, Phase 3 [129]
invasive candidiasis Phase 3 www.astellas.us
b-Glucan synthesis SCY-078 Invasive candidiasis, vulvovaginal Phase 2. Granted QIDP designation [133]
candidiasis www.scynexis.com
ASP9726 Invasive pulmonary aspergillosis Preclinical [134]
[135]
Biafungin (CD101) Invasive candidiasis, recurrent Phase 2. Granted QIDP and Orphan www.cidara.com
vulvovaginal candidiasis. Drug status (US)
Chitin synthesis Nikkomycin Z Coccidioidomycosis Phase 1. Granted Orphan Drug status www.valleyfeversolutions.com
(US)
Mitocondrial function T-2307 Candidiasis, Cryptococcosis, Phase 1 [136]
aspergillosis www.toyama-chemical.co.jp
Pyrimidine F901318 Invasive aspergillosis Phase 1 [137]
biosynthesis www.f2g.com
GPI anchor APX001 Fusariosis, pulmonary aspergillosis Phase 1 www.amplyx.com
biosynthesis
Carbon metabolism AR-12 (OSU-03012) Cryptococcosis, C. albicans (biofilms). Preclinical. Granted Orphan Drug [139]
status (EU)
Unknown VL2397 Invasive aspergillosis Phase 1 [139]
www.vical.com

fumigatus [64]. Aureobasidin A inhibits the inositol phosphorylce-
ramide (IPC) synthase that transfers the phosphoinositol group
from phosphatidylinositol (PI) to the 1-hydroxy group of phytoce-
ramide to form IPC [64,65]. The reaction is a key step in fungal sph-
ingolipid biosynthesis which plays essential roles both as
structural cell membrane components and cell signaling. IPC syn-
thase is not present in mammalian cells, so IPC synthase inhibitors
could be good candidates to develop antifungal agents [62].
Recently, novel Aureobasidin A derivatives have been synthetized
by modifying and/or exchanging amino acids in its sequence pro-
ducing compounds with high activity against A. fumigatus [66].
2.5. Nucleic acid synthesis inhibitors
Flucytosine (5-FC; 5-fluorocytosine) is a fluorinated pyrimidine
analog with fungistatic activity that interferes with pyrimidine
metabolism, as well as RNA/DNA and protein synthesis [67]. It is
taken up by fungal cells via cytosine permease and converted by
cytosine deaminase to 5-fluorouracil (5-FU) which is transformed
by UMP pyrophosphorylase into 5-fluorouridine monophosphate
(5-FUMP), which is phosphorylated and incorporated into RNA,
instead of UTP, resulting in inhibition of protein synthesis. 5-FU
(Fig. 2 19) also undergoes conversion into 5-FdUMP (5-
fluorodeoxyuridine monophosphate), a potent inhibitor of
thymidylate synthase, that inhibits fungal DNA synthesis and
nuclear division [60,67,68]. This compound is selectively toxic to
fungi as there is little or no cytosine deaminase activity in mam-
malian cells [69].
5-FC is active in vitro as well as in vivo against some strains of
Candida and Cryptococcus. Most filamentous fungi lack thymidylate
synthase and hence useful spectrum of flucytosine is restricted to
pathogenic yeasts. Resistance is quite commonly seen so 5-FC usu-
ally is used as adjunctive rather than on primary therapy [70].
2.6. Protein biosynthesis inhibitors
fungal enzyme for protein synthesis. Tavaborole targets this
enzyme by binding to the editing site together with tRNA so this
cannot complete the amino acid transfer to the ribosome for
assembly and protein synthesis is effectively blocked [72]. Tav-
aborole has 1.000-fold higher affinity for the fungal synthetase
than for the human enzyme [71].
Other b-amino acids to target protein biosynthesis through
inhibition of isoleucyl tRNA synthetase are Cispentacin [73]
(Fig. 2 21) isolated from the culture broth of a Bacillus cereus strain
and its synthetic derivative Icofungipen (Fig. 2 22). Both showed
high antifungal activity against Candida albicans [74].
Sordarin was isolated from the fermentation broth of the asco-
mycete Sordaria araneosa in 1969 [75]. This compound blocks the
function of the fungal, but not human, translation elongation factor
2 (EF2). The in vitro potency and the spectrum of activity of all sor-
darin analogs depend on the functional group (R) located at the 30 -
position (Fig. 2 23) [76]. At least, 22 new strains producing a num-
ber of different sordarin analogs have been found [77]. Also new
semi-synthetic derivatives have been synthetized by replacing
the glycoside part with different moieties like alkanesulfonate,
alkylthio, morpholinyl ring, oxazepane ring or trisubstituted
tetrahydrofuran ring [78–80]. Its high specificity makes sordarin
very interesting for the development of new derivatives.
2.7. Microtubules biosynthesis inhibitors
Microtubules are polymers of a- and b-tubulin dimers that form
a highly organized cellular skeleton in all eukaryotic cells [81].
Antifungal agents like griseofulvin (Fig. 2 24) or vinblastine belong
this group. Griseofulvin is a natural product isolated from Penicil-
lium griseofulvin in 1939 and was the earliest inhibitory agent to
fungal species [82]. It is toxic to the liver and the spectrum of
action is restricted to the dermatophyte fungi (causing ringworm
and athlete’s foot) [83,84]. This compound binds to tubulin, inter-
fering with fungal microtubule assembly and inhibiting mitosis.

Tavaborole (Fig. 2 20) is an oxaborole antifungal approved by
the FDA in 2014 for the topical treatment of toenail onychomycosis
caused by Trichophyton rubrum and T. mentagrophytes. It shows
antifungal activities against yeast, molds and dermatophytes
[71]. Tavaborole inhibits the leucyl-tRNA synthetase, an essential
3. Strategies to develop new antifungal compounds
The number of antifungal agents is limited as compared to
antibacterial drugs. Fungi are eukaryotic organisms that parasitize
eukaryotic hosts and therefore the scarce physiologic differences

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6 S. Campoy, J.L. Adrio / Biochemical Pharmacology xxx (2016) xxx–xxx
between both make more difficult to develop safe and broad spec-
trum antifungal agents. A number of antifungal agents are avail-
able in the market but, excluding amphotericin B and a few more
compounds, almost all them are fungistatic [85].
At the present the efforts are focused on identifying new fungal-
specific targets that are critical for fungal growth and have mini-
mal similarity to targets among human proteins.
Trehalose production seems to be required for the virulence of
several fungal species. Deletion of TPS2 encoding trehalose-6-
phosphate phosphatase leads to accumulation of trehalose-6-
phosphate and cell death. Recently, the crystal structure of C. albi-
cans Tsp2 has been reported [86] allowing for the identification of
specific inhibitors for this potential target. The signaling molecules
Ras GTPases play major roles in fungal virulence as they are
required for growth at high temperatures. Therefore, several inhi-
bitors of Ras function, like farnesyltransferase inhibitors, have been
proposed for the specific design of antifungal agents [87]. Cal-
cium/calmodulin signaling is another important regulator of stress
responses in fungi, including resistance to antifungal treatment.
Some calcineurin inhibitors are known to have a potent antifungal
activity although some of them are being used as immunosuppres-
sant drugs (e.g. tacrolimus). Therefore, development of non-
immunosuppressive calcineurin inhibitors could be another way
to develop antifungal drugs. Another protein being explored as
antifungal drug target is the Hsp90 heat shock protein since in
fungi this protein is involved in azole- and echinocandins-
resistance. To date, combination of Hsp90 inhibitors, like gel-
danamycin, with echinocandins or fluconazole improved the fungi-
cidal effect [88].
Glycosylphosphatidylinositol (GPI) cell wall anchor synthesis
pathway is another promising antifungal target. Novel inhibitors
of Gwt1 and Mcd4, two enzymes in the GPI anchor pathway were
identified by the chemical-genomics-based screening platform
CaFT (Candida albicans fitness test) [89]. Screening was performed
against more than 1000 synthetic compounds known to inhibit C.
albicans growth but for which their drug target and mechanism
of action were unknown. Two compounds, G884 and G365 were
identified as Gwt1 inhibitors. Both showed activity against C. albi-
cans and only G365 displayed strong activity against A. fumigatus.
M743 was identified under screening of natural products extracts.
This compound and its semisynthetic derivative M720 are specific
inhibitors of Mcd4 and displayed a potent activity against many
Candida and Aspergillus species.
The use of CaFT and other genetic platforms, such as the S. cere-
visiae haploinsufficiency profiling (HOP) that offer specific assays
for all possible drug targets in yeast [8] will continue to be extre-
mely helpful in the discovery and mechanism of action of novel
antifungals.
Chemical genomics-based approaches have been used to iden-
tify FDA-approved compounds that potentiate the fluconazole
activity against several yeasts [90]. An antifungal combination
matrix was developed to analyze around 86,000 chemical interac-
tions between 3600 small molecules and 6 approved antifungal
drugs against four species of fungi [91]. A susceptibility test against
fluconazole-resistant isolate of C. albicans unveiled combinations
capable of potentiating fluconazole activity in this strain. These
authors also found that combinations of clofazimine, a compound
with unreported antifungal activity, with several antifungals
exhibited activity against several fungal pathogens. A large gene
deletion library in C. neoformans and a decision-guiding process
were used to identify and analyze gene-drug interactions that
could help to find drugs that act synergistically against C. neofor-
mans [92]. Gene drug interactions were identified for over 80% of
the 1500 gene deletion strains tested. Interestingly, data from C.
neoformans were compared with those obtained with S. cerevisiae,
results revealed very few conserved responses.
Please cite this article in press as: S. Campoy, J.L. Adrio, Antifungals, Biochem. Pharmacol. (2016), http://dx.doi.org/10.1016/j.bcp.2016.11.019
Kaltdorf et al. (2016) [93] using bioinformatics tools have iden-
tified 64 targets in Aspergillus fumigatus that will be evaluated for
antifungal development. These targets include metabolic enzymes
involved in vitamins, lipids or amino acids biosynthesis that do not
have close orthologs in humans. Other strategies that are being fol-
lowed to find new specific fungal targets are those based on tran-
scriptome studies in A. fumigatus focused on identify invasion-
related gene expression changes [94] and detailed analyses of
protein-protein interactions in fungal infections [95].
Historically, the most common approach for identifying anti-
fungal molecules has been screening large libraries of synthetic
small molecules or natural products [1,8,96]. Indeed, two approved
antifungal drug classes, the echinocandins and polyenes, were dis-
covered by screening of natural products. Very recently a couple of
examples related to this strategy have been reported. Psoriasin, a
small fungicidal protein active against various filamentous fungi
including Trichophyton rubrum and A. fumigatus, but not against
C. albicans was isolated from lesional psoriasis scale extracts [97].
Psoriasin works by chelating free intracellular zinc leading to fun-
gal apoptosis. Thus, selective fungal cell-penetrating zinc-chelators
could be a new approach to find new antifungal agents.
Humidimycin, a ring peptide produced by Streptomyces humidus
that improves the antifungal activity of caspofungin by 10-fold was
identified from the screening of a collection of 20,000 microbial
extracts [98]. Humidimycin acts by inhibiting the fungal high
osmolarity glycerol (HOG) response pathway, reducing the protec-
tive stress response induced by caspofungin [98]. As the HOG path-
way is not present in human cells, humidimycin is not toxic,
resulting in a promising drug.
Growth-inhibition assays are the most commonly used to iden-
tify antifungal small molecules. However, they have several facts
that limit their use since many pathogenic fungi grow as filaments
making difficult a correlation between growth and OD (optical
density). They are not useful for identifying molecules active
against fungal biofilms and they cannot differentiate molecules
that inhibit growth and those that kill the microorganism [8].
Recently, to address such limitations, new high throughput screen-
ing assays have been developed. In many of them, the approach has
been to asses loss of cellular integrity using as markers of cell lysis
the cytoplasmic enzyme adenylate kinase [99], or dyes such as Ala-
marBlue", XTT and resazurine that are converted to fluorescent
molecules when they are metabolized by viable cells organisms
[100,101].
4. Mechanisms of antifungal resistance
Antifungal resistance is an evolutionary process based on natu-
ral selection of organisms that enhance their ability to survive and
grow in the presence of drug. The evolution of resistance against
antimicrobial agents is ubiquitous in nature and microbes evolve
various strategies to combat the action of drugs.
The mechanisms of antifungal resistance have been reported at
the molecular level for most antifungal agents and fungal patho-
gens [102–104]. To counteract the fungicidal or fungistatic effects
of all antifungal classes, microorganisms develop three major
mechanisms of resistance [7,104]. The first is based on decreasing
the effective drug concentration, the second is drug target alter-
ations and the third is due to modifications of metabolism to divert
the toxic effects exerted by some antifungal agents.
One mechanism to decrease the drug intracellular concentra-
tion is to increase drug efflux. Antifungal drug resistance is medi-
ated by the activity of transport systems like the pleiotropic drug
resistance (PDR) class of ATP-binding cassette (ABC) transporters,
and transporters of the major facilitator superfamily (MFS).
 S. Campoy, J.L. Adrio / Biochemical Pharmacology xxx (2016) xxx–xxx
CDR1 and CDR2 are the major transporters involved in azole
resistance in C. albicans. Upregulation enhances drug efflux and
reduces their accumulation in the cells [105,106]. Many others
ABC transporters involved in azole resistance have been described
in C. glabrata (CgCDR1, CgCDR2, CgSNQ2) and AFR1 in C. neofor-
mans. In A. fumigatus and A. nidulans ABC transporters have been
identified as a resistance mechanism to azole. MDR1 is the MFS
involved in the development of azole resistance in clinical isolates
form C. albicans and C. dubliniensis and its upregulation results in
increased azole efflux [107]. FLU1 from C. albicans is another MFS
involved in fluconazole resistance [108].
Upregulation of ABC and MFS transporters is mediated by speci-
fic regulations in resistant fungal pathogens. Point mutations
defined as gain-of-function mutations (GOF) in these regulators
confer an inherent high expression level of the transporters in
the drug-resistance strains [7]. GOF mutations in the transcription
factor Upc2p [109] caused increased fluconazole resistance in C.
albicans. In the same way, upregulation of Cyp51A in A. fumigatus
lead to azole resistance mediated by duplication of 34 and 42 bp
in the Cyp51A promoter [110].
Another way to decrease the effective drug concentration is
overexpression of the ERG11 (gene encoding 14-a sterol demethy-
lase) and/or other genes of sterol biosynthesis, such as ERG1, ERG3,
ERG7, ERG9 or ERG25 which encode enzymes downstream C14a-
demethylase such upregulation leads to azole resistance
[99,111,112,113].
Another mechanism to reduce the effective drug concentration
in some medically relevant fungi including Candida, Aspergillus,
Cryptococcus, Trichosporon, Coccidioides and Pneumocystis
[114,115] is the ability to form biofilms increasing their resistance
to several drugs including azoles, pyrimidine analogs and polyenes
[116]. Biofilms are multicellular structures in which cells form a
dense network that is covered by a matrix of polysaccharides, car-
bohydrates, proteins and signaling molecules that restricts the
penetration of drugs by formation of a diffusion barrier sequester-
ing the antifungal agents [117–120].
Only amphotericin B and the echinocandins (e.g. caspofungin
and micafungin) have demonstrated consistent in vitro activity
against C. albicans biofilms [121]. However, even with these two
agents, Candida biofilm-related infections are extremely difficult,
if not impossible, to eradicate [122].
Target drug alteration is another mechanism by which fungal
pathogens are able to develop resistance. This mechanism has been
reported for azoles and echinocandins. Mutations in ERG11 in C.
albicans decrease affinity for azoles leading to resistance. Many of
these point mutations decreased affinity to fluconazole and have
a moderate effect on posaconazole [123]. In A. fumigatus single
mutations in Cyp51A are the most frequent mechanism to confer
high level resistance to azoles in clinical isolates of this species
[124].
Echinocandin resistance is systematically associated with point
mutations in either FSK1 or FSK2 genes [7,104]. These mutations
are located in two different not spot regions of these genes named
HS1 and HS2. Hot spot mutations have been reported in C. albicans,
C. glabrata, C. tropicalis, C. krusei, Scedosporium apiospermum and A.
fumigatus [7,104]. Such mutations alter the kinetics of the glucan
synthase resulting in significantly higher inhibitory concentrations
and inhibition constant [125,126].
The most common mechanism of resistance to pyrimidine ana-
logs (5FC) is a point mutation in the FUR1 gene. This mutation leads
to complete resistance to 5FC and 5FU in fungi [7]. A second point
mutation in the gene encoding for cytosine deaminase results in
5FC resistance in many Candida strains [127].
The third mechanism by which fungal pathogens can develop
resistance against antifungal agents is by modifying metabolic
pathways leading to loss or strong decrease of their specific func-
Please cite this article in press as: S. Campoy, J.L. Adrio, Antifungals, Biochem. Pharmacol. (2016), http://dx.doi.org/10.1016/j.bcp.2016.11.019
7
tion. Alteration of the last steps of the ergosterol biosynthesis
through inactivation of the ERG3 gene results in no production of
toxic methylated sterols that lead to cross resistance to all azole
drugs [104]. Furthermore, mutations in non-essential genes of this
pathway (ERG3, ERG6, ERG24 and ERG2) also lead to a decrease, or
even total absence, of ergosterol in plasma membrane [128]. As
reported above mutations in the FUR1 gene decrease the conver-
sion of 5FU into toxic metabolites able to enter the cytosine meta-
bolism and exert their toxic effect. Downregulation of FUR1 also
decreased 5FC susceptibility. A 4-fold lower expression of this gene
leads to total resistance to 5FC in C. glabrata species [7].
In the recent years reports on novel resistance profiles have
been reported and the most problematic is the development of
simultaneous resistance to at least two different classes of antifun-
gal agents (a condition known as multidrug resistance, MDR) [104].
Loss of function point mutations or simultaneous mutations in
ERG2, ERG3, ERG5 and ERG11 result in MDR to azoles and ampho-
tericin B in Candida species [104,128].
Resistance to echinocandins (e.g. caspofungin) and azoles has
also been reported. The resistance mechanisms seem to be due
to combinations of mutations in the FSK2 gene and ABC trans-
porters upregulation [104]. Although not very common, a few
cases of resistance for more than two drug classes have been
recently described in C. albicans and C. lusitaniae isolates [144].
The current trends show that the highest proportion of resistant
isolates is from C. glabrata [9] representing more than 10% of total
isolates in the European Union and more than 20% in the USA. Such
isolates show high resistance to azoles (fluconazole and voricona-
zole) as well as to echinocandins. New infections due to Fusarium
spp., Zygomycetes and azole- and echinocandins-resistant C. glab-
rata isolates are being more frequently observed.
5. Antifungal pipeline
Despite it is clear that there is an urgent need for new antifun-
gal agents [8–10,96,104] in their complex development as well as
the lack of investment are responsible for a limited drug develop-
ment pipeline. However, antifungal development has been recently
boosted by two Acts from the US Administration. The first is GAIN
(Generating Antibiotic Incentives Now) that provides a fast track
description and priority review by FDA to QIDP (Qualified Infec-
tions Disease Products) as well as a 5 year extension of market
exclusivity. The second is the Orphan Drug Act that encourages
the development of drugs for rare diseases, including several inva-
sive mycoses, and provides 7 year market exclusivity.
The new antifungal drugs should improve fungal disease mor-
tality, show better fungicidal activity, extend the spectrum of
activity against drug-resistant fungi and rare molds such as Sce-
dosporium spp., improve the pharmacokinetics and pharmacody-
namics, reduce/avoid host toxicity, cause few drug-drug
interactions, and act by new, selective and different mechanisms
of action. Indeed, no new classes of antifungals have been
approved since 2006 when the FDA and the EMA (European
Medicines Agency) authorized anidulafungin.
The current antifungal pipeline contains several categories of
compounds at different stages of development [1,9,10,96]. In
Table 1 we summarize the most promising antifungal molecules
that are in preclinical and in clinical development.
Several compounds in the pipeline are derivatives of the azoles,
echinocandins and polyenes and, therefore, they have the same
mechanism of action targeting ergosterol biosynthesis, membrane
disruption and cell wall synthesis (b-1,3-D-glucan synthesis),
respectively.
Isavuconazole, the most recently approved triazole, is being
evaluated in two different phase 3 trials. The results from the first
8 S. Campoy, J.L. Adrio / Biochemical Pharmacology xxx (2016) xxx–xxx
trial to assess the efficacy and safety of isavuconazole versus
voriconazole for the treatment of invasive molds diseases caused
by Aspergillus and other filamentous fungi (SECURE) have been
recently reported. Results showed that isavuconazole was not infe-
rior to voriconazole for the primary treatment of such disease and
it was well tolerated compared with voriconazole, with fewer
study drug-related adverse effects [129]. Isavuconazole is also cur-
rently in a second phase 3 clinical trial to evaluate its efficacy and
safety of intravenous and oral formulations for the treatment of
candidemia and invasive Candida infections (ACTIVE) [www.astel-
las.us].
VT1129 and VT1161 belong to a novel class of triazoles that
were identified as part of an effort trying to find molecules with
very low affinity to human CYP enzymes, including human
CYP51. In vitro, VT1161 is about 1000-fold more selective for Can-
dida CYP51 than for the human enzyme, while VT1129 is approxi-
mately 3000-fold more selective for the Cryptococcus isoforms over
human [130]. VT1129 inhibits the growth of Cryptococcus neofor-
mans and C. gattii, and in a mouse model of cryptococcal meningitis
performed better than fluconazole. This molecule has been granted
QIDP designation and orphan drug status by FDA and is in phase 1
clinical trials for the treatment of cryptococcal meningitis. VT1161
which is very effective against fluconazole-resistant Candida iso-
lates is in phase 2b trials for the treatment of onychomycosis and
recurrent vulvovaginal candidiasis [131].
SCY-078 is a novel b-1,3-glucan synthase inhibitor structurally
different than the current echinocandins. It is a derivative from
enfumafungin, a triterpene glycoside produced by fermentation
of a Hormonema sp. [140]. SCY-078 shows activity against
echinocandin-resistant isolates of Candida and Aspergillus [141],
against non-Aspergillus molds comparable to that of echinocandins
and also against Scedosporium prolificans, a resistant mold for
which there are no good treatment options. It is also interesting
the good activity against Paecilomyces variotii, fungi associated
with disseminated infections (fungemia and peritonitis in patients
undergoing peritoneal dialysis) [133]. It has received QIDP desig-
nation and its oral formulation is currently in phase 2 clinical trials
for the treatment of invasive candidiasis, while its IV (intra-
venously) formulation is in phase 1. Novel semi-synthetic enfuma-
fungin derivatives are been studied to improve antifungal potency
and oral pharmacokinetic properties [142].
Biafungin (CD101) is a novel echinocandin that shows similar
activity to caspofungin and anidulafungin against Aspergillus and
Candida species, but its advantage lies in its pharmacokinetics. Its
half-time life is about 4-fold longer (81 h) than the half-time of
anidulafungin (24 h), the longest-acting echinocandin to date. Like
other echinocandins, it shows few drug interactions and excellent
safety profile. Biafungin has been granted QIDP designation and
orphan drug status and it is currently in phase 2 clinical trials for
the treatment of candidemia.
Nikkomycin Z is a competitive inhibitor of chitin synthesis. It
has been recently received Orphan Drug status and it is being
tested in phase 1 clinical trials for treatment for
coccidioidomycosis.
Very interestingly, there are some new candidates that show
either different modes of action from the currently marketed
drugs, or that even have not been identified yet. T-2307 is a novel
arylamidine that collapses fungal mitochondrial membrane com-
promising energy production for essential cellular processes
[136]. Interestingly, this activity is specific to fungi as it seems to
be due to the selective uptake of this drug by the high-affinity fun-
gal specific Agp2 spermine-spermidine transporter. T-2307 under-
went successful phase 1 trials for the treatment of candidiasis.
F901318 is an orotomide, a novel class of antifungals, which
inhibits pyridine biosynthesis by blocking dihydroorotate
dehydrogenase (URA1) activity [137]. Although this pathway is
Please cite this article in press as: S. Campoy, J.L. Adrio, Antifungals, Biochem. Pharmacol. (2016), http://dx.doi.org/10.1016/j.bcp.2016.11.019
conserved in humans, human URA1 is only 20% identical to its fun-
gal homolog and it is inhibited 2000-fold less effectively by this
drug. F901318 is highly active against azole and amphotericin B-
resistant Aspergillus strains but is inactive against the Mucorales
and Candida spp. F901318 is currently in phase 1 clinical trials
for invasive aspergillosis.
APX001A (previously named E1210) is an inhibitor of the fungal
Gwt1 protein that catalyzes an early step in the biosynthesis of the
glycosylphosphatidylinositol (GPI) anchor that is required for the
anchoring of mannosylated proteins of the fungal cell wall and cell
membrane. It has activity against Candida, Aspergillus, Fusarium and
Scedosporium in vitro. It also shows activity against azole and
echinocandin-resistant strains of Candida [143]. Very recently,
APX001 has been granted QIDP designation by FDA. This product
is currently in phase 1 clinical trials for the treatment of invasive
aspergillosis, invasive candidiasis, and coccidioidomycosis.
AR-12 (OSU-03012) was identified through a repurposing
screen of protein kinase inhibitors looking for antifungal agents.
It has been granted the European Orphan Drug status for the treat-
ment of cryptococcosis. AR-12 inhibits acetyl-CoA synthetase that
leads to defects in several cellular processes [138]. It is in preclin-
ical development for the treatment of cryptococcosis.
VL-2397 is a new class of antifungal that has received QIDP des-
ignation for development for treatment of aspergillosis. Its mecha-
nism of fungal cell inhibition is not known, although it seems that
the import of this drug into fungal cells requires the siderophore
transporter Sit1. As this transporter is absent in mammalian cells,
this mechanism of entry could be specific for fungal pathogens. VL-
2397 shows fungicidal activity against Aspergillus, but it has no
activity against Candida albicans or other Candida species. It is cur-
rently in phase 1 clinical trials for the treatment of invasive
aspergillosis.
6. Conclusions
Invasive fungal infections have remarkably increased in the last
few years and the number of patients at risk for these infections is
increasing as immunomodulatory therapies continue to expand.
Despite the numerous available antifungal drugs, they do not
meet the expectations for managing these fungal infections. Mor-
tality rates are still unacceptably high, increasing azole- and
echinocandin-resistant strains are being reported more frequently,
and acute and chronic side effects are often observed. Therefore, as
reported and agreed by many researchers there is an emerging
need to fill the pipeline with new antifungal drugs [8–10,96].
However, although antifungal development has been pushed
forward by FDA, through GAIN (QIDP designation) and Orphan
Drug Acts, the pipeline only shows a few compounds with novel
modes of action that are in preclinical development or in early clin-
ical trials. Therefore, it is quite hard to predict which (if any) of
these molecules will emerge as a new clinical antifungal. Due to
the challenges that the development of broad spectrum antifungals
take, the development of narrow-spectrum drugs could make the
early stages of drug development more straightforward. Recent
gene–drug interaction dataset analysis suggest that focusing on
antifungal development that is geared toward particular patho-
gens, may lead to more potent and effective therapies for invasive
fungal infections.
The identification of new therapeutic targets by use of genomic
techniques, and the expanding knowledge on the cellular processes
required for fungal survival and virulence will help to find and
develop compounds with novel mode of actions. The repurposing
of available drugs for their use as antifungal agents and new
derivatives from azoles, echinocandins and polyenes, as well as
 S. Campoy, J.L. Adrio / Biochemical Pharmacology xxx (2016) xxx–xxx 9

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