Broad susceptibility of
Candida auris
strains to 8-hydroxyquinolines and mechanisms of resistance
Authors: Lohse Matthew B. , Laurie Matthew T. , Levan Sophia , Ziv Naomi , Ennis Craig L. , Nobile Clarissa J. , DeRisi Joseph , Johnson Alexander D. 
Published: July 2023

The fungal pathogen
Candida auris
represents a severe threat to hospitalized patients. Its resistance to multiple classes of antifungal drugs and ability to spread and resist decontamination in healthcare settings make it especially dangerous. We screened 1,990 clinically approved and late-stage investigational compounds for the potential to be repurposed as antifungal drugs targeting
C. auris
and narrowed our focus to five Food and Drug Administration (FDA)-approved compounds with inhibitory concentrations under 10 µM for
C. auris
and significantly lower toxicity to three human cell lines. These compounds, some of which had been previously identified in independent screens, include three dihalogenated 8-hydroxyquinolines: broxyquinoline, chloroxine, and clioquinol. A subsequent structure-activity study of 32 quinoline derivatives found that 8-hydroxyquinolines, especially those dihalogenated at the C5 and C7 positions, were the most effective inhibitors of
C. auris
. To pursue these compounds further, we exposed
C. auris
to clioquinol in an extended experimental evolution study and found that
C. auris
developed only twofold to fivefold resistance to the compound. DNA sequencing of resistant strains and subsequent verification by directed mutation in naive strains revealed that resistance was due to mutations in the transcriptional regulator
CAP1
(causing upregulation of the drug transporter
MDR1
) and in the drug transporter
CDR1
. These mutations had only modest effects on resistance to traditional antifungal agents, and the
CDR1
mutation rendered
C. auris
more susceptible to posaconazole. This observation raises the possibility that a combination treatment involving an 8-hydroxyquinoline and posaconazole might prevent
C. auris
from developing resistance to this established antifungal agent.

IMPORTANCE

The rapidly emerging fungal pathogen
Candida auris
represents a growing threat to hospitalized patients, in part due to frequent resistance to multiple classes of antifungal drugs. We identify a class of compounds, the dihalogenated 8-hydroxyquinolines, with broad fungistatic ability against a diverse collection of 13 strains of
C. auris
. Although this compound has been identified in previous screens, we extended the analysis by showing that
C. auris
developed only modest twofold to fivefold increases in resistance to this class of compounds despite long-term exposure; a noticeable difference from the 30- to 500-fold increases in resistance reported for similar studies with commonly used antifungal drugs. We also identify the mutations underlying the resistance. These results suggest that the dihalogenated 8-hydroxyquinolines are working inside the fungal cell and should be developed further to combat
C. auris
and other fungal pathogens. Lohse and colleagues characterize a class of compounds that inhibit the fungal pathogen
C. auris
. Unlike many other antifungal drugs,
C. auris
does not readily develop resistance to this class of compounds.