Fluvastatin potentiates the activity of caspofungin against Aspergillus fumigatus in vitro

Statins (anticholesterol drugs) inhibit HMG-CoA reductase, which is a key rate-limiting enzyme in the synthesis of sterols in fungi. We therefore investigated the in vitro inhibitory activity of various statins against Aspergillus fumigatus alone and in combination with antifungal drugs. Fresh conidial suspensions from 10 clinical isolates of A. fumigatus were obtained. The MIC and minimum fungicidal concentration (MFC) were determined by the Clinical and Laboratory Standards Institute M-38A protocol and the fungicidal activity by time–kill study. Fluvastatin (FST) showed good activity (MIC, 2 mg/L; MFC, 4 mg/L) against A. fumigatus; other statins had no activity (MIC ≥256 mg/L). FST enhanced the activity of caspofungin (CFG) against A. fumigatus; subinhibitory concentrations of FST in combination with CFG showed >99.9% killing of A. fumigatus conidia, whereas either drug alone showed poor activity at subinhibitory concentrations. FST potentiated the antifungal activity of CFG but displayed no specific interaction with voriconazole or amphotericin B.     

Influence of human sera on the in vitro activity of the echinocandin caspofungin (MK-0991) against Aspergillus fumigatus

There have been several reports that the activity of echinocandin antifungal agents is not affected or decreased in the presence of human sera. It is known that these drugs are bound >80% in animal and human sera. The activity of the echinocandin caspofungin (MK-0991), a 1,3-beta-D-glucan synthase inhibitor, against Aspergillus fumigatus with and without human sera was studied. Conidia of A. fumigatus in microtest plate wells formed germlings after overnight culture in RPMI 1640. Caspofungin was then added with or without serum, and the germlings were incubated at 37 degrees C for 24 h. Human serum (5%) in RPMI 1640 alone did not significantly inhibit the growth of A. fumigatus in vitro. Caspofungin in RPMI 1640 exhibited dose-dependent inhibition, with concentrations of 0.1 and 0.05 microg/ml inhibiting 24.9% +/- 10.4% and 11.7% +/- 3.6%, respectively (n = 10; P < 0.01). The addition of 5% human serum to caspofungin at 0.1 or 0.05 microg/ml increased the inhibition to 78.6% +/- 5.8% or 58.3% +/- 19.2%, respectively (n = 10; P < 0.01 versus controls and versus the drug without serum). Lower concentrations of serum also potentiated drug activity. The effect of human sera was further seen when using caspofungin that had lost activity (e.g., by storage) against A. fumigatus at 0.1 microg/ml. Inactive caspofungin alone demonstrated no significant inhibition of hyphal growth, whereas the addition of 5% human serum to the inactive drug showed 83% +/- 16.5% inhibition (n = 5; P < 0. 01). The restoration of activity of caspofungin was seen at concentrations as low as 0.05% human serum. In contrast to prior reports, this study suggests that human serum acts synergistically with caspofungin to enhance its inhibitory activity in vitro against A. fumigatus.     

The antifungal echinocandin caspofungin acetate kills growing cells of Aspergillus fumigatus in vitro

Caspofungin acetate is an antifungal antibiotic that inhibits synthesis of 1,3-beta-D-glucan, an essential component of the fungal cell wall. While caspofungin causes cell death in yeasts and dimorphic fungi such as Candida albicans, its effect on Aspergillus fumigatus is less well understood. We used the fluorescent dyes 5,(6)-carboxyfluorescein diacetate (CFDA) and bis-(1,3-dibutylbarbituric acid) trimethine oxonol (DiBAC), which stain live and dead cells, respectively, to further characterize the antifungal activity of caspofungin. For comparison, compounds whose mode of action was either fungistatic (fluconazole, itraconazole) or fungicidal (amphotericin B) were also evaluated. A correlation between caspofungin-induced loss of viability, decreased CFDA staining, and increased DiBAC staining was established first with C. albicans. For A. fumigatus, caspofungin caused similar dye-staining changes, which were quantified by fluorimetric analysis of stained hyphae grown in a medium that promoted dispersed growth. The minimum concentration of caspofungin required to produce these changes also decreased the level of growth-dependent reduction of the indicator dye Alamar Blue. We observed a differential effect of caspofungin as a function of cell position: 88% of apical cells and 61% of subapical branching cells failed to stain with the viable dye CFDA, but only 24% of subapical cells were unstained. Complementary results were seen with germlings from DiBAC-stained, caspofungin-treated cultures. Extended incubation of A. fumigatus with a single dose of caspofungin affected the same proportion of apical and subapical branching cells for up to 72 h. The dye-staining patterns illustrate that the cells at the active centers for new cell wall synthesis within A. fumigatus hyphae are killed when they are exposed to caspofungin.     

The interaction of human monocytes, monocyte-derived macrophages, and polymorphonuclear neutrophils with caspofungin (MK-0991), an echinocandin, for antifungal activity against Aspergillus fumigatus

The collaboration between human effector cells and caspofungin (MK-0991), a 1,3-beta-D glucan synthase inhibitor, was studied for antifungal activity against Aspergillus fumigatus. Caspofungin was co-cultured for 24h with either human monocytes (Monos), monocyte-derived macrophages (MDM), or polymorphonuclear neutrophils (PMN) against germlings of A. fumigatus and antifungal activity assessed using the XTT metabolic assay. Caspofungin at 0.1 micorg/ml and 0.05 microg/ml or Monos alone against germlings caused significant inhibition. Microscopically this was correlated with less growth and stunted malformed hyphae. The addition of caspofungin at 0.1 microg/ml and 0.05 microg/ml to the monocyte cultures increased antifungal activity. The inhibition of the combination was significantly greater than drug alone (P <.01) and Monos alone (P <.01). MDM against Aspergillus germlings inhibited hyphal growth. The combination of caspofungin at 0.1 microg/ml and 0.05 microg/ml to the macrophage cultures increased antifungal activity. The growth inhibition by the combination was significantly greater than drug alone (P <.01) and MDM alone (P <.01). There was no significant interference with or enhancement of PMNs and caspofungin. These data support the activity of caspofungin against A. fumigatus in vitro, and indicates a cooperative activity with human effector cells. This suggests caspofungin in vivo would have increased efficacy as it combines with host defenses against A. fumigatus.     

Profiling the Aspergillus fumigatus proteome in response to caspofungin

The proteomic response of Aspergillus fumigatus to caspofungin was evaluated by gel-free isobaric tagging for relative and absolute quantitation (iTRAQ) as a means to determine potential biomarkers of drug action. A cell fractionation approach yielding 4 subcellular compartment fractions was used to enhance the resolution of proteins for proteomic analysis. Using iTRAQ, a total of 471 unique proteins were identified in soluble and cell wall/plasma membrane fractions at 24 and 48 h of growth in rich media in a wild-type drug-susceptible strain. A total of 122 proteins showed at least a 2-fold change in relative abundance following exposure to caspofungin (CSF) at just below the minimum effective concentration (0.12 μg/ml). The largest changes were seen in the mitochondrial hypoxia response domain protein (AFUA_1G12250), the level of which decreased >16-fold in the secreted fraction, and ChiA1, the level of which decreased 12.1-fold in the cell wall/plasma membrane fraction. The level of the major allergen and cytotoxin AspF1 was also shown to decrease by 12.1-fold upon the addition of drug. A subsequent iTRAQ analysis of an echinocandin-resistant strain (fks1-S678P) was used to validate proteins specific to drug action. A total of 103 proteins in the 2 fractions tested by iTRAQ were differentially expressed in the wild-type susceptible strain but not significantly changed in the resistant strain. Of these potential biomarkers, 11 had levels that changed at least 12-fold. Microarray analysis of the susceptible strain was performed to evaluate the correlation between proteomics and genomics, with a total of 117 genes found to be changing at least 2-fold. Of these, a total of 22 proteins with significant changes identified by iTRAQ also showed significant gene expression level changes by microarray. Overall, these data have the potential to identify biomarkers that assess the relative efficacy of echinocandin drug therapy.     

Combined activity in vitro of caspofungin, amphotericin B, and azole agents against itraconazole-resistant clinical isolates of Aspergillus fumigatus

Interactions in vitro between amphotericin B, itraconazole, voriconazole, and caspofungin against itraconazole-resistant Aspergillus fumigatus clinical strains were determined. Differential results were obtained depending on the criteria (MIC or minimal effective concentration) used. Caspofungin and voriconazole exhibited the most potent interactions, with synergy against at least 50% of isolates, and the average fractional concentration index was 0.38. Antagonism was not found for any combination.     

Influences of methodological variables on susceptibility testing of caspofungin against Candida species and Aspergillus fumigatus

The influences of test variables on the outcome of susceptibility testing with caspofungin were tested with isolates of Candida spp. and Aspergillus fumigatus. Among six growth conditions tested with a range of inoculum sizes, the highest control growth yields were obtained in Sabouraud broth for all fungi, followed by RPMI 1640 (pH 7) for Candida spp. and antibiotic medium 3 (AM3) for A. fumigatus. RPMI 1640 gave unacceptably low growth yields with A. fumigatus. The caspofungin MICs under these various conditions ranged over more than 4 twofold dilutions for 7 of 16 fungi tested when a 50% inhibition (50% inhibitory concentration [IC(50)]) endpoint was used and for 12 of 16 fungi tested when an 80% inhibition (IC(80)) endpoint was used. A multifactorial design to study the influences of six test variables on control growth and the MIC showed that, for 14 isolates of Candida spp., the glucose concentration and the medium composition were the most common factors significantly influencing both control growth yields and the MIC. For eight A. fumigatus isolates, incubation time (24 versus 48 h) and temperature (30 versus 35 degrees C) significantly affected control optical density (OD) values, while growth medium (AM3 versus Sabouraud broth) was the most common process variable affecting the MICs. Tests with AM3 from three suppliers showed significant variations in control OD values related to supplier, but IC(50)s fell within a 2- or 3-dilution range for 19 (86%) of the 22 isolates tested. We recommend that, at present, AM3 is superior to RPMI 1640 for testing of the susceptibilities of both yeasts and filamentous fungi to caspofungin and that a minimum incubation time of 48 h is necessary to test A. fumigatus adequately.     

Efficacy of caspofungin against Aspergillus terreus

We investigated the in vitro and in vivo activities of caspofungin against Aspergillus terreus. The drug increased survival and reduced tissue fungal burden in neutropenic mice. Therefore, our data support the role of caspofungin in treating systemic infections due to this emerging pathogen.     

Sequential exposure of Aspergillus fumigatus to itraconazole and caspofungin: evidence of enhanced in vitro activity

We investigated the in vitro activity of sequential itraconazole and caspofungin against 10 isolates of Aspergillus fumigatus. Previous exposure of A. fumigatus to itraconazole resulted in dose-dependent enhanced effects of caspofungin and vice versa. Our finding suggests a preferential role for azole-caspofungin sequential combinations and merits further in vivo investigation.     

Effects of antifungal agent combinations administered simultaneously and sequentially against Aspergillus fumigatus.

The in vitro effects of antifungal agent combinations administered simultaneously and sequentially against 15 strains of Aspergillus fumigatus were tested by the yeast-malt broth method. The synergistic effect of the combination of amphotericin B (AMPH) and miconazole was observed in nine strains (60%). However, the combinations of AMPH and fluconazole, AMPH and ketoconazole, and AMPH and itraconazole administered simultaneously showed antagonistic effects against three (20%), five (34%), and four (26%) strains, respectively. The effects of combinations of azole antifungal agents administered simultaneously were indifferent or antagonistic against A. fumigatus. In experiments measuring the effects of sequentially administered antifungal agents, however, pretreatment with AMPH and then azole antifungal agents exhibited better in vitro efficacy than that found in experiments measuring the effects of simultaneously administered AMPH and azole compounds.     

In vitro evaluation of double and triple combinations of antifungal drugs against Aspergillus fumigatus and Aspergillus terreus

Microdilution broth checkerboard techniques based on the National Committee for Clinical Laboratory Standards methodology were used to study double and triple antifungal combinations against clinical isolates of Aspergillus fumigatus and A. terreus. The influences of the end-point definition (partial or complete inhibition) and the mode of reading (visually or spectrophotometrically) were determined. Interactions between antifungal drugs were also evaluated by agar diffusion tests. Combinations of caspofungin with either amphotericin B or voriconazole were additive for all the isolates, and antagonism was not observed. The interaction between caspofungin and flucytosine was synergistic for 62% of the isolates. In contrast, the interaction between voriconazole and flucytosine was never synergistic and antagonism was noted for 93% of the isolates. The triple combination of caspofungin with flucytosine and amphotericin B was synergistic for all the isolates tested. The triple combination of caspofungin with flucytosine and voriconazole was also mostly synergistic; but complex interactions were obtained for some isolates, with synergy or antagonism depending on the concentrations of caspofungin and voriconazole. Analysis of the influence of the reading technique on the results showed that spectrophotometric reading was a good alternative to the recommended visual reading. The results of these in vitro tests suggest that the activity of flucytosine as part of a double combination with caspofungin and as part of a triple combination with caspofungin and amphotericin B against Aspergillus spp. warrants further investigations. Animal studies are needed to evaluate the in vivo efficacies of these combinations.     

In vitro activity of caspofungin combined with sulfamethoxazole against clinical isolates of Aspergillus spp

Caspofungin (CAS) inhibits fungal cell wall synthesis. Sulfamethoxazole (SMX) inhibits folate biosynthesis and is active in vitro against Aspergillus spp. We studied the activities of the combination of CAS and SMX against 31 Aspergillus isolates and compared them with that of SMX combined with amphotericin B (AMB) or itraconazole (ITC). MICs and minimal effective concentrations (MECs) were determined by the NCCLS broth microdilution method. With MIC endpoints, the combination of SMX and CAS showed synergy or synergy to additivity against 29 of 31 isolates. With MEC endpoints, synergy to additivity was found against 12 of 31 isolates and indifference was displayed against the rest of them. SMX in combination with AMB or ITC was not truly synergistic, while synergy to additivity was found for SMX-AMB and SMX-ITC against 17 of 31 and 3 of 12 isolates, respectively. No antagonism was found with any of the drug combinations. Further analysis of the synergy of CAS and SMX was performed by detailed measurement of hyphal length by microscopy and time-dependent 2,3-bis(2-methoxy-4-nitro-5-[(sulfenylamino)carbonyl]-2H-tetrazolium hydroxide (XTT)-based hyphal damage experiments. With MEC endpoints, the combination of CAS and SMX was characterized by a greater than 50% decrease in hyphal length compared to the hyphal lengths achieved with double the concentration of each drug alone. The XTT-based hyphal damage studies showed a statistically significant (P < 0.05) reduction in viability with CAS and SMX in combination compared to the viabilities achieved with double the concentration of each drug alone. These findings support the synergy results found by using MIC endpoints and suggest that visual MEC measurements may not be sufficient to identify the synergistic interactions seen by more sensitive, quantitative methods. Animal models are required to validate the significance of the synergy of CAS and SMX against Aspergillus spp. observed in vitro.     

Efficacy of the echinocandin caspofungin against disseminated aspergillosis and candidiasis in cyclophosphamide-induced immunosuppressed mice

The in vivo efficacy of the echinocandin antifungal caspofungin acetate (caspofungin; MK-0991) was evaluated in models of disseminated aspergillosis and candidiasis in mice with cyclophosphamide (CY)-induced immunosuppression. Caspofungin is a 1, 3-beta-D-glucan synthesis inhibitor efficacious against a number of clinically relevant fungi including Aspergillus and Candida species. Models of CY-induced transient or chronic leukopenia were used with once daily administration of therapy initiated 24 h after microbial challenge. Caspofungin was effective in treating disseminated aspergillosis in mice that were transiently leukopenic (significant prolongation of survival at doses of > or =0.125 mg/kg of body weight and a 50% protective dose [PD(50)] of 0.245 mg/kg/day at 28 days after challenge) or chronically leukopenic (50 to 100% survival at doses of > or =0.5 mg/kg and PD(50)s ranging from 0.173 to 0.400 mg/kg/day). Caspofungin was effective in the treatment and sterilization of Candida infections in mice with transient leukopenia with a 99% effective dose based on reduction in log(10) CFU of Candida albicans/gram of kidneys of 0.119 mg/kg and 80 to 100% of the caspofungin-treated mice having sterile kidneys at caspofungin doses from 0.25 to 2.0 mg/kg. In Candida-infected mice with chronic leukopenia, caspofungin was effective at all dose levels tested (0.25 to 1.0 mg/kg), with the log(10) CFU of C. albicans/gram of kidneys of caspofungin-treated mice being significantly lower (>99% reduction) than that of sham-treated mice from day 4 to day 28 after challenge. Also, 70 to 100% of the caspofungin-treated, chronic leukopenic mice had sterile kidneys at caspofungin doses of 0.5 to 1.0 mg/kg from day 8 to 28 after challenge. Sterilization of Candida infections by caspofungin in the absence of host leukocytes provides compelling in vivo evidence for fungicidal activity against C. albicans. Further human clinical trials with caspofungin against serious fungal infections are in progress.     

In vitro activity of three new triazoles and one echinocandin against Candida bloodstream isolates from cancer patients

The in vitro activities of voriconazole, posaconazole, ravuconazole and micafungin were compared with those of fluconazole, itraconazole, ketoconazole, flucytosine and amphotericin B against 164 candidaemia isolates recovered from cancer patients in two Canadian centres. The MIC(50) results for ravuconazole, voriconazole, posaconazole and micafungin were 0.01, 0.03, 0.12 and 0.25 mg/L, respectively. The new antifungal agents showed substantial activity against isolates demonstrating in vitro resistance to fluconazole and itraconazole. These results suggest that the newer antifungal agents possess promising activity against invasive Candida isolates, particularly against those with reduced susceptibility to fluconazole and itraconazole.     

Anidulafungin in Combination with Amphotericin B against Aspergillus fumigatus

We investigated the effects of anidulafungin alone and in combination with amphotericin B against Aspergillus fumigatus. Indifference was the only type of interaction observed in vitro. Anidulafungin at 1 and 5 mg/kg of body weight/day, amphotericin B at 1 mg/kg/day, and combination therapy prolonged the survival of mice with invasive aspergillosis. Anidulafungin at 5 mg/kg/day, alone and in combination with amphotericin B, reduced the kidney fungal burden. Overall, the combination was not superior to the most active single drug.The high mortality rate of invasive aspergillosis has driven recent efforts to determine the efficacy of combination therapy in the treatment and management of those infections (1, 6, 7, 16, 17, 19, 20, 23, 29). Therefore, in this study, the in vitro and in vivo efficacies of the new echinocandin anidulafungin (AFG), alone and in combination with amphotericin B (AMB), against Aspergillus fumigatus were analyzed.Three clinical strains (F2, F3, and F4) isolated from bronchoalveolar lavage specimens from patients with hematological diseases were identified to species level by conventional methods (24).AMB was used as a pure powder (Sigma) for in vitro studies and as a commercial preparation (Fungizone; Bristol-Myers Squibb) for in vivo studies. Pure powder of AFG (Pfizer) was dissolved in dimethyl sulfoxide and further diluted in the test medium or sterile saline solution for in vitro and in vivo studies, respectively.MICs and minimum effective concentrations (MECs; the lowest concentrations that led to the growth of small, rounded, compact hyphal forms compared to the hyphal growth seen in the growth control well) were determined in RPMI 1640 medium by the CLSI M38-A2 broth microdilution method (10, 12).For both susceptibility and checkerboard assays, the MICs and MECs were read visually at 24 and 48 h (10, 25). Drug interactions were classified as synergistic, indifferent, or antagonistic based on the fractional inhibitory concentration (FIC) index (16).Minimum fungicidal concentration (MFC) was considered the concentration of antifungal agents, alone or in combination, that yielded no growth (27).Metabolic activities of conidia and hyphae were assessed in RPMI 1640 medium with l-glutamine, without phenol red and NaHCO₃, by XTT [2,3-bis(2-methoxy-4-nitro-5-sulfophenyl)-2H-tetrazolium-5-carboxyanilide inner salt] assay (Tox-2; Sigma) (2, 3, 21).An experimental CD1 mouse (Charles River, Calco, Italy) model of invasive aspergillosis was used by following previously reported procedures (4). A total of three separate in vivo studies were performed by injection of the A. fumigatus F3 isolate. The drug treatments were started 2 h after the infection. AMB at 0.5 and 1 mg/kg of body weight/day, AFG at 1 and 5 mg/kg/day, and combination doses were administered intraperitoneally.In survival studies, the mice were treated daily from day 0 to day 4 and observed for 10 consecutive days.Brain and kidney fungal burdens were determined at day 4 postinfection by CFU count and quantitative PCR based on procedures described by Bowman et al. (5).Histopathology analysis was performed at day 4 postinfection (4). The number of fungal microabscesses was evaluated in 20 consecutive microscopic fields. Each section was classified based on the number of fungal microabscesses as follows: absence, <5, ≥5 to ≤20, and >20.The in vitro results were analyzed by either Mann-Whitney U test or Student''s t test, with a P value of <0.05 considered significant. Survival and tissue burden studies were analyzed by log rank and Mann-Whitney U tests, respectively. Due to multiple comparisons, a P value of <0.016 was considered significant.Our in vitro results are shown in Table ​Table1.1. Overall, AFG MECs were significantly lower than AMB MICs and indifference was the only type of interaction among the two drugs.

TABLE 1.

In vitro susceptibility tests of AFG and AMB, alone and in combination, against three clinical isolates of A. fumigatus^a

Efficacy of caspofungin against central nervous system Aspergillus fumigatus infection in mice determined by TaqMan PCR and CFU methods

We have reported previously that prolonged caspofungin (CAS) dosing enhances survival in a murine model of central nervous system aspergillosis. In this study we determined by quantitative PCR (qPCR) and CFU enumeration whether CAS could reduce fungal burdens, prior to the deaths of untreated animals, and also assessed progressive infection in untreated mice. Mice were infected intracranially and treated for 4 days with CAS (1, 5, or 10 mg/kg of body weight/day) or amphotericin B (AMB) (3 mg/kg/day) starting 1 day postinfection. Fungal burdens in brains and kidneys of untreated controls were determined on days 1, 3, and 5 to assess progressive infection; burdens in treated animals were determined on day 5. qPCR showed higher burdens than CFU enumeration in all comparisons. In untreated animals, qPCR showed transiently increased burdens in brains, while CFU enumeration showed a decrease. qPCR showed increased burdens in kidneys, but CFU enumeration did not. Neither method indicated drug efficacy in the brain. Both methods showed AMB efficacy in the kidneys, and qPCR demonstrated CAS efficacy at all doses. Spearman correlations of qPCR and CFU determination results showed a significant correlation for most untreated groups; results correlated well for kidneys (P < or = 0.03) but not for brains in treated mice. Regression analyses of qPCR and CFU groups indicated different slopes for progressive infection in untreated animals but the same slopes for CAS dose-response efficacy. qPCR appeared to better reflect the progression of untreated infection. The lack of demonstration of efficacy in the brain suggests that longer dosing is necessary to cause burden reduction. These results also suggest that, when there is drug efficacy in a therapeutic study, either method appears to be useful for determining Aspergillus fumigatus burdens.     

Collaboration of human phagocytes with LY 303366 for antifungal activity against Aspergillus fumigatus.

LY 303366, an inhibitor of 1, 3-beta-D-glucan synthase, was tested alone, or in co-culture with neutrophils or monocytes, for antifungal activity against Aspergillus fumigatus using the XTT metabolism assay. LY 303366 at 0.1 mg/L for 48 h significantly inhibited growth by conidia in a microtest plate XTT assay system. Inhibition was similar if the drug was removed after only 24 h. Microscopically this correlated with less growth and stunted malformed hyphae. LY 303366 (0.1 mg/L) also inhibited the further growth of germlings (43%) in a 24 h assay. Antifungal activity of neutrophils against 24 h control hyphal growth was limited at an effector: target ratio of 400:1. In co-cultures of neutrophils plus drug with hyphal growth from 24 h LY 303366 cultures the antifungal activity was additive. Neutrophils had a similar additive effect even if the drug were not present (i.e. when germinating conidia were pretreated with drug). Under conditions where monocytes did not have significant antifungal activity against hyphae, they collaborated with LY 303366 for significantly increased inhibition from 38% by LY 303366 alone to 67% by co-culture. Thus, LY 303366 has activity against germinating or germinated conidia of Aspergillus, human effector cells act co-operatively with LY 303366, and LY 303366 can sensitize germinating conidia for damage by host cells.     

Efficacy of caspofungin against Aspergillus flavus, Aspergillus terreus, and Aspergillus nidulans

The echinocandin caspofungin is a potent inhibitor of the activity of 1,3-beta-D-glucan synthase from Aspergillus flavus, Aspergillus terreus, and Aspergillus nidulans. In murine models of disseminated infection, caspofungin prolonged survival and reduced the kidney fungal burden. Caspofungin was at least as effective as amphotericin B against these filamentous fungi in vivo.