{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,3,26]],"date-time":"2026-03-26T05:46:44Z","timestamp":1774504004216,"version":"3.50.1"},"reference-count":45,"publisher":"Public Library of Science (PLoS)","issue":"12","license":[{"start":{"date-parts":[[2024,12,2]],"date-time":"2024-12-02T00:00:00Z","timestamp":1733097600000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["www.plosone.org"],"crossmark-restriction":false},"short-container-title":["PLoS ONE"],"abstract":"<jats:p><jats:italic>Aspergillus fumigatus<\/jats:italic> is a widely distributed pathogen responsible for severe infections, particularly in immunocompromised individuals. Triazoles are the primary treatments options for <jats:italic>Aspergillus<\/jats:italic> infections; however, the emergence of acquired resistance to this antifungal class is becoming a growing concern. In this study, we investigated the potential of the antiviral drug, lopinavir (LPV) to restore the susceptibility of <jats:italic>A<\/jats:italic>. <jats:italic>fumigatus<\/jats:italic> strains to a set of azoles, while also reducing the required azole dosage for treatment of susceptible isolates. The combination of LPV with either itraconazole (ITC) or posaconazole (POS) demonstrated potent synergistic interactions against 16 out of 23 (~70%) and 21 out of 23 (~91%) <jats:italic>A<\/jats:italic>. <jats:italic>fumigatus<\/jats:italic> isolates, respectively. Moreover, the combination showed synergistic activity against other clinically important <jats:italic>Aspergillus<\/jats:italic> species, including <jats:italic>A<\/jats:italic>. <jats:italic>niger<\/jats:italic>, <jats:italic>A<\/jats:italic>. <jats:italic>flavus<\/jats:italic>, and <jats:italic>A<\/jats:italic>. <jats:italic>brasiliensis<\/jats:italic>. The fractional inhibitory concentration index (FICI) for the combinations ranged from 0.18 to 0.313 for ITC and 0.091 to 0.313 for POS, indicating strong synergistic effects. Further investigation revealed that efflux pump inhibition contributed to the synergy observed between azole and LPV. Morphological examination of the fungal cells subjected to this combinational therapy at sub-inhibitory doses showed the presence of carbohydrate granules\/patches. The identification of LPV as a promising adjunct therapy holds promise for addressing the emerging challenge of azole resistance in <jats:italic>Aspergillus<\/jats:italic> species and improving treatment outcomes for patients.<\/jats:p>","DOI":"10.1371\/journal.pone.0314474","type":"journal-article","created":{"date-parts":[[2024,12,2]],"date-time":"2024-12-02T18:29:43Z","timestamp":1733164183000},"page":"e0314474","update-policy":"https:\/\/doi.org\/10.1371\/journal.pone.corrections_policy","source":"Crossref","is-referenced-by-count":3,"title":["Synergistic potential of lopinavir and azole combinational therapy against clinically important Aspergillus species"],"prefix":"10.1371","volume":"19","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-5885-2906","authenticated-orcid":true,"given":"Nicolas","family":"Burns","sequence":"first","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Ehab A.","family":"Salama","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Mohamed N.","family":"Seleem","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"340","published-online":{"date-parts":[[2024,12,2]]},"reference":[{"issue":"1","key":"pone.0314474.ref001","doi-asserted-by":"crossref","first-page":"45","DOI":"10.1183\/13993003.00583-2015","article-title":"Chronic pulmonary aspergillosis: rationale and clinical guidelines for diagnosis and management","volume":"47","author":"DW Denning","year":"2016","journal-title":"Eur Respir J"},{"key":"pone.0314474.ref002","doi-asserted-by":"crossref","first-page":"7","DOI":"10.1186\/s13054-014-0722-7","article-title":"Epidemiology of invasive aspergillosis in critically ill patients: clinical presentation, underlying conditions, and outcomes.","volume":"19","author":"FS Taccone","year":"2015","journal-title":"Crit Care."},{"key":"pone.0314474.ref003","doi-asserted-by":"crossref","first-page":"141","DOI":"10.1016\/j.simyco.2014.07.004","article-title":"Phylogeny, identification and nomenclature of the genus Aspergillus.","volume":"78","author":"RA Samson","year":"2014","journal-title":"Stud Mycol."},{"issue":"Supplement_2","key":"pone.0314474.ref004","doi-asserted-by":"crossref","first-page":"S104","DOI":"10.1093\/mmy\/myy070","article-title":"Cpanet. Chronic pulmonary aspergillosis update: A year in review","volume":"57","author":"A Barac","year":"2019","journal-title":"Med Mycol"},{"issue":"23","key":"pone.0314474.ref005","doi-asserted-by":"crossref","first-page":"2547","DOI":"10.1001\/jama.2016.16477","article-title":"Prevalence of Immunosuppression Among US Adults, 2013","volume":"316","author":"R Harpaz","year":"2016","journal-title":"JAMA"},{"key":"pone.0314474.ref006","unstructured":"How Common Is Aspergilosis?: CDC; 2022 [cited 2022 9\/11\/2022]. CDC Statistic for Fugnal Diseases. Available from: https:\/\/www.cdc.gov\/fungal\/diseases\/aspergillosis\/statistics.html."},{"issue":"3","key":"pone.0314474.ref007","article-title":"Treatment of Aspergillosis.","volume":"4","author":"JD Jenks","year":"2018","journal-title":"J Fungi (Basel)."},{"issue":"9","key":"pone.0314474.ref008","doi-asserted-by":"crossref","first-page":"1463","DOI":"10.1093\/cid\/ciy859","article-title":"Voriconazole Resistance and Mortality in Invasive Aspergillosis: A Multicenter Retrospective Cohort Study","volume":"68","author":"PP Lestrade","year":"2019","journal-title":"Clin Infect Dis"},{"issue":"8","key":"pone.0314474.ref009","doi-asserted-by":"crossref","first-page":"4569","DOI":"10.1128\/AAC.00233-15","article-title":"Nationwide Surveillance of Azole Resistance in Aspergillus Diseases","volume":"59","author":"E Vermeulen","year":"2015","journal-title":"Antimicrob Agents Chemother"},{"issue":"6","key":"pone.0314474.ref010","doi-asserted-by":"crossref","first-page":"493","DOI":"10.1097\/QCO.0000000000000005","article-title":"Azole resistance in Aspergillus fumigatus: a growing public health concern.","volume":"26","author":"E Vermeulen","year":"2013","journal-title":"Curr Opin Infect Dis"},{"issue":"1709","key":"pone.0314474.ref011","article-title":"Clinical implications of globally emerging azole resistance in Aspergillus fumigatus","volume":"371","author":"JF Meis","year":"2016","journal-title":"Philos Trans R Soc Lond B Biol Sci"},{"issue":"12","key":"pone.0314474.ref012","doi-asserted-by":"crossref","first-page":"4934","DOI":"10.1111\/1462-2920.15274","article-title":"Mechanisms of triazole resistance in Aspergillus fumigatus","volume":"22","author":"AV Nywening","year":"2020","journal-title":"Environ Microbiol"},{"issue":"12","key":"pone.0314474.ref013","doi-asserted-by":"crossref","first-page":"1619","DOI":"10.1128\/EC.00171-13","article-title":"Contributions of Aspergillus fumigatus ATP-binding cassette transporter proteins to drug resistance and virulence","volume":"12","author":"S Paul","year":"2013","journal-title":"Eukaryot Cell"},{"issue":"6","key":"pone.0314474.ref014","doi-asserted-by":"crossref","first-page":"e1000486","DOI":"10.1371\/journal.ppat.1000486","article-title":"Efflux in fungi: la piece de resistance.","volume":"5","author":"JJ Coleman","year":"2009","journal-title":"PLoS Pathog."},{"issue":"7","key":"pone.0314474.ref015","doi-asserted-by":"crossref","first-page":"1486","DOI":"10.1093\/jac\/dkt075","article-title":"The cdr1B efflux transporter is associated with non-cyp51a-mediated itraconazole resistance in Aspergillus fumigatus","volume":"68","author":"MG Fraczek","year":"2013","journal-title":"J Antimicrob Chemother"},{"issue":"4","key":"pone.0314474.ref016","doi-asserted-by":"crossref","first-page":"835","DOI":"10.1093\/jac\/dky517","article-title":"Emerging threat of triazole-resistant Aspergillus fumigatus","volume":"74","author":"JM Rybak","year":"2019","journal-title":"J Antimicrob Chemother"},{"key":"pone.0314474.ref017","unstructured":"2019 AR Threats Report: CDC; 2019 [cited 2022 6\/17]. Available from: https:\/\/www.cdc.gov\/drugresistance\/biggest-threats.html#:~:text=CDC\u2019s%20Watch%20List&text=Aspergillus%20is%20a%20fungus%20that,treat%20fungal%20diseases%20in%20crops."},{"key":"pone.0314474.ref018","doi-asserted-by":"crossref","first-page":"106906","DOI":"10.1016\/j.ijantimicag.2023.106906","article-title":"Lopinavir and ritonavir act synergistically with azoles against Candida auris in vitro and in a mouse model of disseminated candidiasis.","author":"EA Salama","year":"2023","journal-title":"Int J Antimicrob Agents."},{"issue":"5","key":"pone.0314474.ref019","doi-asserted-by":"crossref","first-page":"e0163122","DOI":"10.1128\/aac.01631-22","article-title":"Atazanavir Resensitizes Candida auris to Azoles","volume":"67","author":"Y Elgammal","year":"2023","journal-title":"Antimicrob Agents Chemother"},{"issue":"1","key":"pone.0314474.ref020","doi-asserted-by":"crossref","DOI":"10.1128\/AAC.00684-20","article-title":"Potent Synergistic Interactions between Lopinavir and Azole Antifungal Drugs against Emerging Multidrug-Resistant Candida auris","volume":"65","author":"HE Eldesouky","year":"2020","journal-title":"Antimicrob Agents Chemother"},{"issue":"10","key":"pone.0314474.ref021","doi-asserted-by":"crossref","first-page":"6179","DOI":"10.1128\/AAC.03046-15","article-title":"The Synergistic Effect of Azoles and Fluoxetine against Resistant Candida albicans Strains Is Attributed to Attenuating Fungal Virulence","volume":"60","author":"W Gu","year":"2016","journal-title":"Antimicrob Agents Chemother"},{"issue":"8","key":"pone.0314474.ref022","doi-asserted-by":"crossref","first-page":"1672","DOI":"10.1093\/jac\/dkq209","article-title":"Protease inhibitors atazanavir, lopinavir and ritonavir are potent blockers, but poor substrates, of ABC transporters in a broad panel of ABC transporter-overexpressing cell lines","volume":"65","author":"WF Bierman","year":"2010","journal-title":"J Antimicrob Chemother"},{"key":"pone.0314474.ref023","unstructured":"Institute CaLS. Reference Method for Borth Dilution Antifungal Susceptiblity Testing of Filamentous Fungi. M38: CLSI; 2017."},{"issue":"3","key":"pone.0314474.ref024","article-title":"Itraconazole, Voriconazole, and Posaconazole CLSI MIC Distributions for Wild-Type and Azole-Resistant Aspergillus fumigatus Isolates.","volume":"4","author":"JB Buil","year":"2018","journal-title":"J Fungi (Basel)."},{"issue":"10","key":"pone.0314474.ref025","doi-asserted-by":"crossref","first-page":"5243","DOI":"10.1128\/JCM.43.10.5243-5246.2005","article-title":"Quality control and reference guidelines for CLSI broth microdilution susceptibility method (M 38-A document) for amphotericin B, itraconazole, posaconazole, and voriconazole.","volume":"43","author":"A Espinel-Ingroff","year":"2005","journal-title":"J Clin Microbiol"},{"issue":"1","key":"pone.0314474.ref026","doi-asserted-by":"crossref","first-page":"3098","DOI":"10.1038\/s41467-018-05497-7","article-title":"Azole-induced cell wall carbohydrate patches kill Aspergillus fumigatus","volume":"9","author":"B Geissel","year":"2018","journal-title":"Nat Commun"},{"key":"pone.0314474.ref027","unstructured":"Organization WH. WHO fungal priority pathogens list to guide research, development and public health action. WHO, 2022 25 October 2022. Report No."},{"issue":"4","key":"pone.0314474.ref028","doi-asserted-by":"crossref","first-page":"e0145821","DOI":"10.1128\/mBio.01458-21","article-title":"Screening of Chemical Libraries for New Antifungal Drugs against Aspergillus fumigatus Reveals Sphingolipids Are Involved in the Mechanism of Action of Miltefosine.","volume":"12","author":"TF Dos Reis","year":"2021","journal-title":"mBio."},{"issue":"3","key":"pone.0314474.ref029","doi-asserted-by":"crossref","first-page":"232","DOI":"10.1111\/myc.13203","article-title":"Alternative treatment of fungal infections: Synergy with non-antifungal agents.","volume":"64","author":"L Rossato","year":"2021","journal-title":"Mycoses."},{"issue":"2","key":"pone.0314474.ref030","doi-asserted-by":"crossref","first-page":"568","DOI":"10.1128\/AAC.48.2.568-574.2004","article-title":"Three-dimensional models of wild-type and mutated forms of cytochrome P450 14alpha-sterol demethylases from Aspergillus fumigatus and Candida albicans provide insights into posaconazole binding","volume":"48","author":"L Xiao","year":"2004","journal-title":"Antimicrob Agents Chemother"},{"key":"pone.0314474.ref031","doi-asserted-by":"crossref","first-page":"1024","DOI":"10.3389\/fmicb.2017.01024","article-title":"Azole Resistance in Aspergillus fumigatus: A Consequence of Antifungal Use in Agriculture?","volume":"8","author":"S Berger","year":"2017","journal-title":"Front Microbiol."},{"issue":"2","key":"pone.0314474.ref032","doi-asserted-by":"crossref","DOI":"10.1128\/mBio.00338-20","article-title":"Characterization of the Efflux Capability and Substrate Specificity of Aspergillus fumigatus PDR5-like ABC Transporters Expressed in Saccharomyces cerevisiae.","volume":"11","author":"BD Esquivel","year":"2020","journal-title":"mBio."},{"issue":"6","key":"pone.0314474.ref033","doi-asserted-by":"crossref","first-page":"616","DOI":"10.1093\/mmy\/myw005","article-title":"Identification of Aspergillus fumigatus multidrug transporter genes and their potential involvement in antifungal resistance","volume":"54","author":"I Meneau","year":"2016","journal-title":"Med Mycol"},{"key":"pone.0314474.ref034","first-page":"w14281","article-title":"Common invasive fungal diseases: an overview of invasive candidiasis, aspergillosis, cryptococcosis, and Pneumocystis pneumonia.","volume":"146","author":"Y Schmiedel","year":"2016","journal-title":"Swiss Med Wkly"},{"issue":"1","key":"pone.0314474.ref035","doi-asserted-by":"crossref","first-page":"91","DOI":"10.4314\/ahs.v20i1.14","article-title":"Atazanavir \/ ritonavir versus Lopinavir \/ ritonavir-based combined antiretroviral therapy (cART) for HIV-1 infection: a systematic review and meta-analysis.","volume":"20","author":"BM Tigabu","year":"2020","journal-title":"Afr Health Sci"},{"issue":"2","key":"pone.0314474.ref036","doi-asserted-by":"crossref","first-page":"359","DOI":"10.1007\/s11046-017-0208-7","article-title":"Comparison Between Etest and Broth Microdilution Methods for Testing Itraconazole-Resistant Aspergillus fumigatus Susceptibility to Antifungal Combinations","volume":"183","author":"LB Denardi","year":"2018","journal-title":"Mycopathologia"},{"key":"pone.0314474.ref037","doi-asserted-by":"crossref","first-page":"e0266623","DOI":"10.1128\/spectrum.02666-23","article-title":"In vivo efficacy of pitavastatin combined with itraconazole against Aspergillus fumigatus in silkworm models","author":"H Majima","year":"2023","journal-title":"Microbiol Spectr"},{"issue":"2","key":"pone.0314474.ref038","doi-asserted-by":"crossref","first-page":"602","DOI":"10.1128\/AAC.00999-09","article-title":"Defining fractional inhibitory concentration index cutoffs for additive interactions based on self-drug additive combinations, Monte Carlo simulation analysis, and in vitro-in vivo correlation data for antifungal drug combinations against Aspergillus fumigatus","volume":"54","author":"J Meletiadis","year":"2010","journal-title":"Antimicrob Agents Chemother"},{"key":"pone.0314474.ref039","volume-title":"Reference method for broth dilution antifungal susceptiblity testing of yeasts","year":"2017","edition":"4"},{"issue":"1","key":"pone.0314474.ref040","doi-asserted-by":"crossref","first-page":"1466","DOI":"10.1080\/21505594.2020.1838741","article-title":"Aprepitant, an antiemetic agent, interferes with metal ion homeostasis of Candida auris and displays potent synergistic interactions with azole drugs.","volume":"11","author":"HE Eldesouky","year":"2020","journal-title":"Virulence."},{"issue":"1","key":"pone.0314474.ref041","doi-asserted-by":"crossref","first-page":"6089","DOI":"10.1038\/s41598-020-62976-y","article-title":"Ospemifene displays broad-spectrum synergistic interactions with itraconazole through potent interference with fungal efflux activities.","volume":"10","author":"HE Eldesouky","year":"2020","journal-title":"Sci Rep."},{"key":"pone.0314474.ref042","first-page":"62","article-title":"Reversal of Azole Resistance 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