Send Orders for Reprints to reprints@benthamscience.

ae
42 Infectious Disorders – Drug Targets, 2015, 15, 42-52

Candidiasis: A Fungal Infection- Current Challenges and Progress in

Prevention and Treatment

Umme Hani*, Hosakote G. Shivakumar, Rudra Vaghela, Riyaz Ali M. Osmani and Atul Shrivastava

Department of Pharmaceutics, JSS College of Pharmacy, JSS University, Sri Shivarathreeshwara

Nagar, Mysore-570 015, Karnataka, India

Abstract: Despite therapeutic advances candidiasis remains a common fungal infection most fre-
quently caused by C. albicans and may occur as vulvovaginal candidiasis or thrush, a mucocutaneous
candidiasis. Candidiasis frequently occurs in newborns, in immune-deficient people like AIDS pa-
tients, and in people being treated with broad spectrum antibiotics. It is mainly due to C. albicans
while other species such as C. tropicalis, C. glabrata, C. parapsilosis and C. krusei are increasingly
isolated. OTC antifungal dosage forms such as creams and gels can be used for effective treatment of
local candidiasis. Whereas, for preventing spread of the disease to deeper vital organs, candidiasis
antifungal chemotherapy is preferred. Use of probiotics and development of novel vaccines is an advanced approach for
the prevention of candidiasis. Present review summarizes the diagnosis, current status and challenges in the treatment and
prevention of candidiasis with prime focus on host defense against candidiasis, advancements in diagnosis, probiotics role
and recent progress in the development of vaccines against candidiasis.
Keywords: Antifungal agents, C. albicans, candidiasis, host defense, probiotics, vaccine.

1. INTRODUCTION different morphologies such as yeast, hyphae and pseudohy-

The eukaryotic organism fungi have a distinct nucleus
with the DNA (genetic material) and enclosed by a nuclear
membrane. The cell wall of true fungi is composed of chitin
as shown in (Fig. 1) [1]. Candida, yeast like fungus, is a
common organism present in the reproductive and gastroin-
testinal mucosa and can be isolated from the oral cavity and
hence upto 80% of the healthy population is found to be
prone to the most common fungal infections such as candidi-
asis. Candida species produce infections that range from
non-life threatening mucocutaneous illnesses to invasive
conditions which may involve severe infection to destruction
of vital organs [2, 3].
Historically, botanist Christine Marie Berkhout was the
first to describe about the genus Candida and species C. al-
bicans, which has evolved over the years. Mycotorula and
Torulopsis are obsolete expressions for the genus Candida.
Previously, these species had been referred to as Monilia
albicans and Oidium albicans. Out of the possible 150 dif-
ferent species of the genus Candida, few have been known
to cause human infections; with C. albicans being the most
pathogenic amongst all. Few other species found to be
pathogenic to humans includes C. krusei, C. glabrata, C.
tropicalis, C. parapsilosis, C. lusitaniae, C. dubliniensis, C.
kefyr, C. guilliermondii and C. stellatoidea [4].
C. albicans is a dimorphic fungus primarily existing and
the propagating through its phenotype blastophore also called
as blastoconidia. C. albicans has ability to transforms into
*Address correspondence to this author at the Department of Pharmaceutics,
JSS College of Pharmacy, JSS University, Sri Shivarathreeshwara Nagar,
Mysore-570 015, Karnataka, India; Tel: 919738746926;
Fax: 918212548394; E-mail: ummehaniahmed@gmail.com
phae upon perception of environmental signals which have
importance in virulence [5, 6]. Elongated, ellipsoidal cells
that are attached to one another are referred to as psuedohy-
phae, while cells that are considered to be true hyphae are
characterized by a cylindrical cellular morphology and are
separated by perpendicular septal walls [7].
Candidiasis or thrush is a fungal infection (presence of
parasitic infection in or on any part of body i.e., mycosis)
caused by any of the species from the genera Candida,
amongst which C. albicans is the most common causative
species. The infection is technically referred to as candidosis,
moniliasis as well as oidiomycosis and also commonly called
as yeast infection. These infections are broad spectrum, rang-
ing from superficially oral thrush and vaginitis to deep cited
systemic, which are mostly life threatening. Systemic infec-
tions are commonly referred to as candidemia and are one of
the prominent co-infections in immuno-compromised pa-
tients such as those suffering from cancer, HIV etc. as well
as patients in non-trauma emergency surgery, with extensive
use of powerful antibiotics and immune-suppressive thera-
pies during organ transplant or anti-leukemia therapies [8, 9-
12]. Depending on the area infected, signs and symptoms of
candidiasis vary, which are briefly depicted in (Fig. 2). A
number of antifungal drugs are found to be efficient and are
available for the treatment of candidiasis. Amphotericin B
has served as a standard treatment for five decades but its
usage is often limited due to toxic effects, fluconazole is as
effective as amphotericin B with superior safety but certain
non-albicans candida species are less susceptible to flucona-
zole. New agents from echinocandins class, such as caspo-
fungin, target the fungal cell wall and retain the activity
against isolates with resistance to azoles or polyenes [13].

2212-3989/15 $58.00+.00 © 2015 Bentham Science Publishers

Candidiasis: A Fungal Infection- Current Challenges and Progress
Fig. (1). Schematic diagram of C. albicans cell wall.
Fig. (2). Signs and symptoms of candidiasis.
Apart from the conventional antifungal therapy use of probi-
otics and development of new efficient vaccines is an ad-
vanced approach in the direction of prevention and treatment
of candidiasis. Till date a number of protective and highly
immunogenic vaccine formulations have been developed
against candidiasis and relative further research is still going
on. Present review summarizes the diagnosis, current status
and challenges in the treatment and prevention of candidiasis
with prime focus on host defense against candidiasis, probi-
otics role and recent progress in the development of vaccines
against candidiasis.
2. DIAGNOSIS
Diagnosis is very crucial not only for confirmation of
infection but for species identification and to initiate antifun-
Infectious Disorders – Drug Targets, 2015, Vol. 15, No. 1 43
gal treatment as well. When compared to mucocutaneous
candidiasis, diagnosis of disseminated candidiasis is difficult
due to non-specific clinical presentation. For effective thera-
peutic outcome, accurate identification of Candida species is
very essential. Conventional methods for the diagnosis of
candidiasis are less sensitive and time consuming, hence,
immunodiagnostic and molecular techniques can be recom-
mended for early and specific diagnosis. Sachin et al. have
discussed in detail the laboratory approach for the diagnosis
of candidiasis [14], some of the methods are listed below:
2.1. Direct Examination
Direct microscopic examination is a cost effective, rapid
method for the diagnosis of candidiasis. It involves scraping
or swabbing of the affected area followed by placing the
swab on the microscopic slide. Further, 10% potassium hy-
44 Infectious Disorders – Drug Targets, 2015, Vol. 15, No. 1
droxide (KOH) solution is added in order to dissolve the skin
cells without affecting the integrity of the Candida cells.
This allows complete visualization of pseudohyphae as well
as the budding yeasts cells, which corresponds to various
Candida species.
In case of disseminated candidiasis, direct demonstration
of elements of fungi is done by wet and fixed mounts. Addi-
tion of calcofluor white allows rapid recognition of fungal
components by binding to chitin and cellulose in fungal cell
wall and on excitation by long wave ultraviolet rays, it fluo-
resces. Histological specimens are stained with periodic
acid-schiff or Gomori S methenamine silver stains [14].
2.2. Culture Method
Candida species readily grows on Sabouraud dextrose
agar media, the most commonly used media for the isolation
of Candida species, which permits the growth of Candida
and suppresses the growth of some bacteria because of low
pH. This method includes rubbing of the sterile swab onto
the infected area followed by streaking it on a Sabouraud
dextrose agar medium and incubating at 37°C for a couple of
days in order to allow the development of colonies. On the
basis of colony characterization, microscopic morphology,
physiological or biochemical characteristics, speciation of
Candida is done [10, 11].
A range of differential media available for Candida spe-
ciation includes Pagano-Levin agar, Nickerson s medium
[15], phosphomolybdate agar and chromogenic medium
[16]. Chromogenic media (Candida ID, CHROM agar, Can-
diselect 4 and Candida media) are also implied for speedy
identification of Candida [17]. Chromogenic substrates pre-
sent in these media react with yeast cells by enzymes se-
creted to give particular colony characteristic and pigmenta-
tions which are species specific and thus allow easy specia-
tion [18].
2.3. Diagnosis of Invasive Candidiasis (IC)
Diagnosis of invasive candidiasis can be carried against
recombinant fructose bisphosphate aldolase and C. albicans
enolase using antibodies as evaluated by Li et al. It was
found that it could be a powerful tool for diagnosing IC,
when they are used in combination [12].
2.4. Culture
Recent developments in blood culturing techniques have
improved the sensitivity as well as reduced the time required
to obtain a positive blood culture. The developments include
centrifugation tubes as well as automated monitoring of
blood-cultured bottles. Specific detergents are being used in
order to release the trapped fungi within the host phagocytic
cells thereby enhancing the yield of Candida spp. by lysis
centrifugation system [12]. The lytic mixture is responsible
for the disruption as well as inactivation of host cells and
some of the antimicrobial agents, which possess a threat to
the viability of the fungi.
2.5. (1→3)-β-D-Glucan Detection Method
The cell walls of Candida species contain (1→3)-β-D-
glucan (BDG) as a structural component. As this polysaccha-
Hani et al.
ride is not found in bacteria, viruses, or mammals, its pres-
ence in the circulation of patients has been used as an indica-
tor of invasive disease. An assay to detect BDG has been
developed, which utilizes the activation of a clotting path-
way found in amoebocyte lysates of the Japanese horseshoe
crab, Tachypleus tridentalis [19].
2.6. Serological Methods
The serological methods commonly used include agar gel
diffusion (AGD), counter immunoelectrophoresis (CEP),
whole cell agglutination (AGGL), latex agglutination (LAT),
indirect fluorescent antibody, and complement fixation. Of
these, the AGGL test, AGD test and CEP test are the most
frequently employed [20, 21]. One of the most common se-
rological tests for systemic candidiasis is AGGL test devel-
oped by Hasenclever and Mitchell [22]. This test detects
antibody specific primarily to the mannan component of the
Candida cell wall [23].
As very low numbers of yeasts are observed using direct
microscopic examination in peritoneal candidiasis, Corrales
et al. explored clinical utility and potential of molecular
methods and serum (1-3)-β-d-glucan (BDG) estimation as
novel tools in its diagnosis. They have compared perform-
ance of a polymerase chain reaction (PCR) with that of
automated culture method using peritoneal fluids from peri-
tonitis patients for Candida spp. detection. The PCR assay
and the culture method reflected good agreement with prom-
ising sensitivities as 93.5% and 74.19% respectively. It has
been found that serum BDG levels were high in peritoneal
fluids of patients with Candida spp. than those without the
yeast [24].
In another approach, Levesque et al. demonstrated the
importance of BDG as a biomarker in the diagnosis of inva-
sive candidiasis particularly after liver transplantation, which
asserts high morbidity and mortality around the globe [25].
Considering the steady increase of invasive Candida in-
fection incidences in intensive care requiring patients and
difficulties associated with their diagnosis, Kautzky et al.
have proposed clinical scoring systems (like four risk factor-
based Candida score and/or Candida colonization index) to
be extremely valuable tools in the diagnosis and selection of
higher risk patients for immediate systemic antifungal ther-
apy. They reported that both the Candida colonization index
and Candida score were incredibly practical tools; with cut-
off standards ≥ 0.5 and ≥ 2.5 respectively [26].
Apart from the conventional diagnostic methods, Ardiz-
zoni et al. have developed a ten protein array based immuno-
assay for assessing antibody (IgG) responses towards recog-
nized immunogenic proteins of C. albicans with a trial in
invasive candidiasis patients. Results of their studies sug-
gested probable implication of microarray immunoassay
along with conventional diagnostics, for a rapid and sensitive
detection of invasive candidiasis patients [27].
3. HOST DEFENSE AGAINST CANDIDA ALBICANS
A postulated pathway of response to infections caused by
C. albicans is sketched in (Fig. 3). Upon interaction of C.
albicans with epithelial cells, it triggers the release of cyto-
kines and chemokines, which in turn causes activation of
Candidiasis: A Fungal Infection- Current Challenges and Progress
Fig. (3). Schematic illustration of known and postulated pathways of response towards infection with C. albicans.
inflammatory as well as immune cells such as phagocytes,
antigen presenting cells (APCs) and T-cells. Fungus cells are
engulfed and killed by phagocytic cells by respiratory burst
as well as cytokine release.
Patients suffering from chronic mucocutaneous candidia-
sis express defective genes in type-I interferon pathway. This
pathway plays a significant role in anti-Candida host defense
in humans as it is a signature of Candida-induced inflamma-
tion. Pattern-recognition receptors such as Toll-like receptors
and C-type lectin receptors facilitate the recognition of C.
albicans. These recognition receptors interact with the cell
wall components of C. albicans, which are primarily ex-
pressed by Antigen Presenting Cells (APCs) [13].
Gauglitz et al. earlier discussed the various pattern-
recognition receptors that facilitate the recognition of the
special structures of C. albicans, responsible for activation of
intracellular signal, which ultimately leads to efficient host
defense [14]. Macrophage migration towards C. albicans is
dependent upon the glycosylation status of fungal cell wall
rather than cell viability or morphogenic switching from
yeast to hyphal forms. For determination of engulfment of C.
albicans by macrophages, spatial orientation of the hypha
and its attachment to macrophage are the important parame-
ters that are taken into consideration. Host defence against
Candida was improved using a rational novel therapeutic
approach of adjuvant immunotherapy [28, 29]. A study was
carried out on patients suffering from rare immune-
deficiencies such as dectin-1 deficiency, CARD9 deficiency,
chronic mucocutaneous candidiasis, hyper-IgE or Job's syn-
drome and chronic granulomatous disease; the results ex-
plained the role of dectin-1 and its signaling pathway, which
involves interleukins 17 and 22, defensins and phagocytic
cells for defense against Candida [6]. The susceptibility to
recurrent Candida infections can be a monogenetic Men-
Infectious Disorders – Drug Targets, 2015, Vol. 15, No. 1 45
delian trait. The sensing of Candida cell wall components
and the consecutive intracellular signaling in myeloid cells
via CARD9, and also the role of Th17 cells and their cytoki-
nes take the center stage in the human host defense against
Candida [30].
Neutrophils (PMNs) are responsible for the playing an
important role host defense against acute invasive and dis-
seminated candidiasis. Tumor necrosis factor-alpha (TNF-α),
interleukin-6 (IL-6) and granulocyte colony stimulating fac-
tor (G-CSF) are involved in staffing of the PMNs at the site
of invasive infection. Combination therapy with recombinant
G-CSF and fluconazole exhibits additive effect on fungal
reduction in the organs. In case of sub-acute or chronic dis-
seminated Candida infection, recombinant G-CSF was found
to be less effective; which indicates that neutrophil staffing
and activation play a crucial role in acute as well as life
threatening candidiasis. For invasive Candida infection,
other host defense mechanisms control the outcome [31].
4. TREATMENT OF CANDIDIASIS
Treatments for candidiasis for managing Candida infec-
tions are usually based upon the anatomic location of the
infection, immune status of the patient, risk factors for pa-
tients with infection, species responsible and lastly, upon the
susceptibility of the Candida species towards the anti-fungal
drug. Classification of antifungal agents used for the treat-
ment of candidiasis is given below:
4.1. Classification
4.1.1. Systemic Antifungal Agents
A. Polyenes: Amphotericin B.
B. Pyrimidine analogue: Flucytosine.
46 Infectious Disorders – Drug Targets, 2015, Vol. 15, No. 1 Hani et al.

C. Triazoles: Fluconazole, Itraconazole, Voriconazole,
Ravuconazole, Posaconazole, Ketoconazle.
D. Echinocandins: Caspofungin, Anidulafungin, Mica-
fungin.
4.1.2. Topical Antifungal Agents
A. Topical azoles: Terconazole, Butaconazole, Micona-
zole, Clotrimazole, Tioconazole, Sulconazole, Oxicona-
zole and Econazole.
B. Topical allylammines: Terbinafine and Naftifine.
One of the selection criteria for anti-fungal agents is
Candida species susceptibility. Table 1 depicts in vitro sus-
ceptibility of Candida isolates from blood cultures to most
often used anti-fungal agents based on resistance testing by
CLSI-M27-A3 method [32].
Commercially available antifungal dosage forms for cur-
ing varied types of candidiasis are listed out in Table 2.
4.2. Mechanism of Action of Antifungal Agents
General mechanism of action for anti-fungal drugs in-
cludes:
a) Cell wall formation inhibition.
b) Disruption of cell membrane.
c) Cell division inhibition.
Inhibition of fungal cell biosynthesis has not been suc-
cessful and effective. Attempts have been made to interfere
with fungal cell wall synthesis, using some of the chemical
agents, which have demonstrated excellent anti-fungal activ-
ity in vitro. However, failure to develop these agents to use-
ful drugs has verified to be a difficult task and hence ulti-
mately development of new agents to target β-glucan synthe-
sis has been focused. Echinocandins are the recent class of
antifungal agents that act by inhibiting β-(1-3)D-glucan at
the fungal cell wall level, resulting in complete disruption of
the cell wall and consequently cell death. (Fig. 4) depicts
mechanisms of action of some most popular antifungal
drugs.
Anti-fungal agents disrupt the fungal cell wall by target-
ing the ergosterol component via binding with sterols, for-
mation of pores in the membrane, creating a transmembrane
ion channel and causing the membrane to become leaky,
which results in loss of intracellular K+ ions (polyene anti-
fungals) or by directly inhibiting ergosterol biosynthesis.
Enzyme CYP P450 α- demethylase in the fungi is responsi-
ble for conversion of lanosterol to ergosterol. The basic ni-
trogen of azole ring involves the formation of a bond with
the heme iron of the fungal P450; thereby preventing sub-
strate and oxygen binding. C-14 α-demethylase inhibition
consequently accumulates sterols comprising of C14 methyl
group, leading to changes in permeability and malfunction-
ing of membrane embedded proteins. These azoles have
minimum affinity towards mammalian P450’s. The overall
effect is fungistatic, which at higher concentrations may be
fungicidal.
Few anti-fungal agents act by targeting the microtubule;
which affects the formation of mitotic spindle, or by inhibi-
tion of DNA transcription ultimately affecting cell division
[20]. For example flucocystine converts to 5-fluorouracil,
which is an antimetabolite responsible for inhibition of
thymidylate synthetase and DNA synthesis.
The treatment recommendations for mucocutaneous can-
didiasis by Infectious Diseases Society of America (IDSA)
are summarized in Table 3 [33].
5. RECENT ADVANCES IN PROBIOTICS FOR PRE-
VENTION AND TREATMENT OF CANDIDIASIS
Lilley and Stillwell, 1965, were the first ones to describe
about substances secreted by one microorganism, which in
turn is responsible for stimulating the growth of another.
Fuller (1989) redefined probiotics as ‘a live microbial feed
supplement, which beneficially affects the host animal by
improving its intestinal microbial balance’ [34]. Probiotics
are defined as living microorganisms, which when adminis-
tered in adequate amounts, provide beneficial effects to the
host [35]. Probiotics are emerging as a new approach to
counteract vaginal candidiasis. They lower intravaginal pH
thereby forming a barrier against different types of yeasts
[21]. Probiotics inherit property of inhibiting pathogen

Table 1. In-vitro susceptibility of diverse Candida species.

Candida species AMB 5-FC FCZ ITZ VCZ PCZ AFG CFG MFG

Candida albicans S S S S S S S S S

Candida glabrata S S I-R S-I-R S-I-R S-I-R S S S

Candida tropicalis S S S-I S S S S S S

Candida parapsilosis S S S S S S I I I

Candida krusei S R R I-R S-I-R S-I-R S S S

Candida guilliermondii S S S S S S R R R

Candida lusitaniae S-I-R S S S S S S S S

Where, AMB: Amphotericin-B formulations; 5-FC: flucytosine; FCZ: fluconazole; ITZ: itraconazole; VCZ: voriconazole; PCZ: posaconazole; AFG: anidulafungin; CFG: caspo-
fungin; MFG: micafungin; S: susceptible; I: intermediate; R: resistant.
Candidiasis: A Fungal Infection- Current Challenges and Progress Infectious Disorders – Drug Targets, 2015, Vol. 15, No. 1 47

Table 2. Commercially available antifungal dosage forms for candidiasis.

Type of candidiasis Class Generic name Brand name Dosage form

Oral Azole antifungals Miconazole Oravig Buccal Tablets

®
Loramyc Buccal Tablets
®
Daktarin Oral gels

Clotrimazole Mycelex Troche Troches

Fluconazole Diflucan Oral suspension

Vaginal Azole antifungals Miconazole nitrate Gyne-Lotrimin Cream

Monistat Gynazole-1 Cream

Butaconazole Vaginal Cream Cream

Antican Tablet

Clotrimazole Cancap-VT Tablet

Candid tab Tablet

Canesten Tablet

Gynostatum Tablet

Surfaz-VT Tablet

Vagibact Cream

Skin Azole antifungals Miconazole Monistat-Derm Cream

Aloe Vesta Cream

Baza Antifungal Cream

Miranel AF Liquid

Mitrazol Powder

Zeasorb-AF Powder

Clotrimazole Canesten Cream

Mycelex Cream

Ketoconazole Nizoral A-D Shampoo

Xolegel Gel

Polyene Nystatin Mycostatin Topical Powder and cream

Nyamyc Powder

Gastrointestinal Candidia- Polyenes Nystatin Mycostatin Tablets

sis Medications
Nilstat Tablets, troches, oral suspension

Mycostatin Pastilles Pastilles, lozenges

Bio-Statin Powder

Esophageal Candidiasis Azole antifungals Fluconazole Diflucan Tablet

Ketoconazole Nizoral Tablet

Itraconazole Sporanox Capsule

Voriconazole Vfend Lyophilized powder for solution for IV

infusion, film-coated tablets for oral
administration and as a powder for oral
suspension
48 Infectious Disorders – Drug Targets, 2015, Vol. 15, No. 1 Hani et al.

(Table 2) Contd….

Type of candidiasis Class Generic name Brand name Dosage form

Echinocandins Micafungin Mycamine IV Injection

Anidulafungin Eraxis IV Injection

Caspofungin Cancidas IV Injection

Polyenes Amphotericin- B Amphocin IV Injection

Fungizone IV Injection

Nail Azole antifungals Itraconazole Onmel Tablet

Miconazole Miranel AF Liquid

Table 3. Treatment recommendations by IDSA for mucocutaneous Candida infections.

Disorder Drug Dosage

Oropharyngeal candidosis Amphotericin B (oral suspension/tablets) 0.5 (to 2.4) g/day

Nystatin (oral suspension) 6 × 100,000 units/day

Fluconazole 50-200 mg/day

Itraconazole (oral solution) 100-200 mg/day

Posaconazole 100 mg/day

Laryngitis As for oropharyngeal

Oesophagitis Fluconazole 200-400 mg/day

Itraconazole (oral solution) 2 × 200 mg/day

D-AMB (i.v.) 0.5-0.7 mg/kg/day

L-AMB (i.v.) 1-3 mg/kg/day

Anidulafungin 100 mg/day

Caspofungin 50 mg/day

Micafungin 150 mg/day

Voriconazole 400 mg/day

Vaginal candidosis Clotrimazole (suppository) -

Fluconazole 150 mg/day

Skin/nails infections Fluconazole 50-200 mg/day

Itraconazole 100-200 mg/day

Chronic mucocutaneous candidosis (CMC) Fluconazole 50-400 mg/day

Itraconazole 100-400 mg/day

Posaconazole 100-400 mg/day

growth as well as modulate human immune response thereby
making it a new possibility towards antifungal therapy. The
different strains of lactobacillus proved to be effective
against C. albicans are Lactobacillus reuteri, Bifidobacte-
rium animalis, Lactobacillus acidophilus, Lactobacillus ca-
sei GG, or Lactobacillus fermentum L23 and LF5, Lactoba-
cillus casei etc. [36]. The probiotic bacteria such as Lactoba-
cillus acidophilus, Lactobacillus reuteri, Lactobacillus casei
GG and Bifidobacterium animalis have shown prophylactic
action against mucosal and systemic candidiasis and through
immunologic and non-immunologic responses, they pro-
tected mice from candidiasis [37].
Candidiasis: A Fungal Infection- Current Challenges and Progress
Fig. (4). Mechanism of action of antifungal agents.
To study the prevalence of oral candidiasis, Hatakka et
al., using probiotics, carried out a randomized controlled
trial in the elderly. About 32% reduction was found in the
prevalence of oral Candida in the probiotic group, whereas it
increased in the control group (28%-34%). It was found that
probiotics intervention reduced the risk of high yeast counts
by 75% with a 56% decrease in hypo-salivation. Therefore,
it was concluded that probiotics could be effective towards
controlling oral Candida as well as hypo salivation [38]. A
randomized study to determine the effectiveness of orally
supplemented probiotics towards prevention of gastro-
intestinal Candida species colonization in preterm, very low
birth weight neonates in a neonatal ICU were evaluated.
From results it was a reported that there was significant re-
duction in the incidence and the intensity of enteric coloniza-
tion of Candida species [39]. Kumar et al., highlighted that
10-20% of bloodstream infections in pediatric ICU are due
to candidiasis and thus there is significant increase in mor-
bidity, mortality and duration of hospital stay. Candida spe-
cies enteric colonization still remains one of the most alarm-
ing risk factors for invasive candidiasis. Localized defensive
action is either diminished or altered; thereby facilitating
Candida overgrowth and leading to candidiasis. Systemic
anti-fungal agents are proven to be effective towards reduc-
tion in colonization as well as invasive fungal infections, but
with some associated major side effects. Hence, for rapid
restoration of the intestinal flora, probiotics provides the
necessary tools for Candida reduction. Though studies de-
picted significant effect of probiotics towards prevention and
colonization of Candida in neonates, their role in preventing
invasive infections is yet unclear [40].
A pilot study carried out by Vicariotto et al., in order to
determine the effectiveness of association of two probiotic
strains viz. Lactobacillus fermentum LF10 (DSM 19187) and
Lactobacillus acidophilus LA02 (DSM 21717). The strains
were formulated into slow release effervescent vaginal tablet
(ActiCand 30) and its effect on women suffering from vul-
vovaginal candidiasis was studied. Results indicated that
ActiCand 30 not only cures Candida infections at high per-
Infectious Disorders – Drug Targets, 2015, Vol. 15, No. 1 49
centage in women but also provides longer physiological
defense on the account of vaginal mucosal adhesion and
colonization. Further, it also mediates the two types of bar-
rier effects i.e. formation of an anaerobic environment by
release of CO2 and by colonization and adhesion to the vagi-
nal epithelium by the probiotics L. acidophilus LA02 and L.
fermentum LF10, respectively [21].
Kohler et al., investigated the potential of two probiotics
Lactobacillus rhamnosus GR-1 and Lactobacillus reuteri
RC-14 in controlling C. albicans infections. In vitro results
reflected that at lower pH, lactic acid plays a major role in
suppressing fungal growth. Post staining observations re-
vealed that C. albicans cells lost their metabolic activity and
were eventually killed. Increased expression of stress-related
genes and lower expression of genes involved in flucona-
zole’s resistance explains augmented eradication of Candida
which was confirmed by Transcriptome analysis [41].
Bohbot et al., have conducted an open randomized pilot
study on 20 childbearing age healthy women in order to as-
sess vaginal impact on oral administration of completely
freeze-dried Lactobacillus casei rhamnosus LCR 35 culture.
It was concluded from the study that at minimum dose of
2*108 CFU/day of LCR 35 brings the nugent score to nor-
mal in healthy childbearing age women. The preventive or
culture impact of the orally administered strain on various
vaginal disorders such as bacterial vaginosis or vulvovaginal
candidiasis can be specified by Phase-III clinical trials [42].
A practitioner survey of complementary and alternative
medicine (CAM) in recurrent vulvovaginal candidiasis
(RVVC) was conducted by Watson et al., which included
lactobacillus, oral and vaginal yoghurt, vinegar, garlic, Chi-
nese medicine and tea-tree oil. Amongst these, Lactobacillus
was found to be most commonly recommended. In other
non-pharmacological management tips, they recommended
dietary changes as well as use of cotton undergarments.
From the survey researchers concluded that CAM is popular
with patients and many clinicians actively recommend its use
in RVVC despite limited supporting evidence [43].
50 Infectious Disorders – Drug Targets, 2015, Vol. 15, No. 1
Ishijima et al., developed a non-pathogenic oral probiotic
microorganism (Streptococcus salivarius K12), an innova-
tive therapeutic option for candidiasis, and evaluated its abil-
ity to curb C. albicans growth in vitro. Its therapeutic activ-
ity was also assessed in-vivo on experimental model of oral
candidiasis. By inhibiting the process of invasion of C. albi-
cans into mucous surfaces S. salivarius K12 protected the
experimental animal from severe candidiasis and hence
proved it an effective probiotic [44]. In an approach, Matsu-
bara et al. evaluated oral colonization by C. albicans in ex-
perimental murine immunosuppressed DBA/2 and probiotic
bacteria (Lactobacillus acidophilus and Lactobacillus rham-
nosus) treated animal groups. They reported that in compari-
son with animal group (untreated), a significant reduction in
C. albicans colonization was observed on the oral mucosa of
animal group treated with probiotics. Moreover, L. rhamno-
sus treated animal group reflected significantly higher reduc-
tion in yeast colonization with respect to that of group
treated with nystatin [45]. A prospective double blinded,
randomized controlled trial was conducted by Kumar et al.
to evaluate efficacy of probiotics in prevention of Candida
colonization in a paediatric intensive care unit of Indian hos-
pital and concluded that in critically ill children treated with
broad spectrum antibiotics (to reduce candiduria and gastro-
intestinal Candida colonization), probiotics supplementation
could be a potential beneficial strategy [46].
6. RECENT PROGRESS IN THE DEVELOPMENT OF
VACCINES AGAINST CANDIDIASIS
A number of protective and highly immunogenic vaccine
formulations have been developed against candidiasis in the
last decade [47]. Vaccine can be defined as a biological
preparation which improves immunity against a particular
disease. Vaccines comprise of an agent that resembles a dis-
ease causing microorganism, synthesized either using killed
or weakened form of the microbe or one of its surface pro-
tein or its toxins, which stimulates the immune system of the
body to recognize the agent as antigen and to destroy it [48].
Liu et al. have shown that heat-killed Saccharomyces (HKY)
is a protective vaccine against aspergillosis and coccidioi-
domycosis. To test the hypothesis that the efficacy of HKY-
induced protection may be due to the cross-reactive antigens
in the cell walls of the different fungi, they studied the effect
of HKY against systemic candidiasis. Male CD-1 mice were
given different regimens of HKY subcutaneously prior to
intravenous challenge with C. albicans. They found that
HKY protects mice from infection by C. albicans in a dose-
and regimen-dependent manner [49].
C. albicans mannan extracts encapsulated in liposomes
were used previously to stimulate mice to produce antibodies
protective against candidiasis. Subsequently, mannan-protein
conjugates without liposomes as vaccine candidates were
tested. Mannan extracts were coupled to bovine serum albu-
min where isolated conjugates consisted of carbohydrate and
protein in a ratio of 0.7-1. It has been reported that the con-
jugate vaccine can induce protective antibody responses
against experimental disseminated candidiasis and Candida
vaginal infection [50]. Lack of C5 is known to aggravate
candidal infection. Conjugated-mannan is 100% protective
in C5-deficient mice against disseminated candidiasis; thus
Hani et al.
conjugate vaccines seem to be promising in eradication of
diverse C. albicans infections [51].
An optimal inhibitor of two protective monoclonal anti-
bodies i.e. β-(1→2)-linked mannose trisaccharide epitope,
which is specific for phosphomannan of cell wall of C. albi-
cans was used to develop a synthetic conjugate vaccine by
Lipinski et al. They concluded that in combating against C.
albicans infections, antibody mediated immunity plays an
important role and hence suggested that synthetic conjugate
vaccine possibly has therapeutic potential [52].
A study on disseminated candidiasis pathogenesis ob-
served that antibodies specific for C. albicans cell surface β-
1, 2-mannotriose [β-(Man)(3)] protect mice. A self-
adjuvanting vaccine was obtained by adding tetanus toxoid
to glycopeptide conjugate which enhances robust antibody
responses without additional adjuvant against disseminated
candidiasis [53].
De Bernardis et al. designed and studied a novel vaccine
(PEV7), comprised of influenza virosomes in which a trun-
cated, recombinant aspartyl proteinase-2 of C. albicans was
incorporated. Following intramuscular immunization in
mouse and rat, the aforesaid vaccines generated a potent se-
rum antibody response. Following the intravaginal admini-
stration of PEV7 in rats, anti-Sap2 IgG and IgA were de-
tected in vaginal fluid and induced significant, safe and long
lasting protection against Candida vaginitis [54]. To develop
both active and passive immunization strategies against can-
didiasis recombinant N-terminus of Hyr1p (rHyr1p-N) is a
novel target as it was reported to have efficacy to reduce the
fungal burden of disseminated candidiasis in both immuno-
compromised and immuncompetant mice, using alum; an
FDA approved adjuvant [55]. Using an antigen bearing dual
delivery system i.e. fibrin cross- linked plasma beads and C.
albicans cytosolic proteins (Cp) as antigen, a prophylactic
vaccine was developed against systemic candidiasis. It has
been found that the preparation comprising of liposomized
Cp entrapped in plasma beads exhibited superior protection
in the immunized mice in comparison with other antigen
delivery systems [56].
In another approach, significant protection was achieved
in murine models against vaginal candidiasis and dissemi-
nated candidiasis by a vaccine conjugated with a protein
laminaran (algal glucan) linked to a carrier protein diphtheria
toxoid [57, 58]. Laminaran vaccine was found to be a prom-
ising candidate and effective against fungi, which contains
glucan in cell wall [59]. The candidal vaccine furthest along
the developmental pathway is based on the agglutinin-like
sequence (Als) family of proteins from C. albicans. Vaccina-
tion with the recombinant N-termini of the candidal surface
adhesins Als1p or Als3p (rAls1p-N or rAls3p-N) protected
mice from lethal disseminated candidiasis, and also reduced
fungal burden in a vaginitis model and a steroid-treated oro-
pharyngeal candidiasis model [60].
Shibasaki et al. developed an oral vaccine against can-
didiasis using yeast molecular display system. They have
generated surface Enolase 1 (Eno1p) antigen engineered
Saccharomyces cerevisiae cells for oral delivery, that had
shown extended survival rate in C. albicans challenged mice.
Furthermore, vaccine produced using this molecular display
Candidiasis: A Fungal Infection- Current Challenges and Progress
technology was found promising in the prevention of a range
of fungal infections and it also overcomes the protein purifi-
cation requirement [61].
In a study adjuvant consequences interceded by Physali-
salkekengi L. fruit polysaccharide in DNA vaccine (pD-
HSP90C) were assessed in mice. Results depicted that poly-
saccharide notably enhanced serum concentration of inter-
leukin-2, interleukin-4 and precise antibody titers in DNA
vaccine immunized mice. In addition, just few colony form-
ing units (CFU) were traced in the kidneys of polysaccha-
ride-DNA vaccine immunized mice group with significantly
higher survival rate post Candida albican challenging, as
compared to the only DNA vaccine immunized group. Thus,
researchers concluded the aforesaid polysaccharide as a
promising adjuvant in enhancing the efficacy of DNA vac-
cines [62].
Such studies continue to build upon the fundamental
knowledge of protective immunity against Candida, which
will ultimately lead to ease, advancement in developing
novel potential and clinically efficient vaccines against can-
didiasis.
7. CONCLUSION
Candidiasis can be treated based on the type of candidia-
sis and severity of infection. Understanding in depth the host
defense mechanism against Candida albicans will be helpful
in the development of vaccines against candidiasis. Com-
monly used antifungal agents for oral and vaginal candidiasis
are nystatin, Amphotericin-B and azole derivatives. As pro-
biotic bacteria are capable of inhibiting the growth of patho-
gens and thereby modulating human immune response as
discussed in the article they necessitate research attention.
Further, they would offer innovative prospects in candidiasis
and antifungal therapy in the near future. Moreover, progress
in development of clinically useful vaccines is swiftly evolv-
ing day by day which may proffer an ideal remedy and para-
mount way out to invasive candidiasis and associated tribula-
tions.
CONFLICT OF INTEREST
The author(s) confirm that this article content has no con-
flict of interest.
ACKNOWLEDGEMENTS
Declared none.
REFERENCES
[1] Tortora, G.J.; Funke, B.R.; Case, C.L. Microbiology: An introduc-
tion, 10th ed.; The Benjamin/Cummings Publishing Co. Inc.: Red-
wood City, CA, 1995, 601-2 and 758-9.
[2] Walsh, T.J.; Dixon, D.M. In Baron's Medical Microbiology; Sam-
uel Baron, Ed.; Galveston (TX): University of Texas Medical
Branch at Galveston: Galveston, Texas, 1996.
[3] Eckert, L.O.; Lentz, G.M. In Comprehensive Gynecology; Lentz,
G.M.; Lobo, R.A.; Gershenson, D.M.; Katz, V.L., Ed.; 6th ed.;
Mosby Elsevier: Philadelphia, 2012.
[4] James, W.D.; Berger, T.G.; Elston, D.M.; Odom, R.B. Andrews'
Diseases of the Skin: clinical Dermatology, 10th ed.; Saunders El-
sevier: Philadelphia, 2006, 308-311.
[5] Kourkoumpetis, T.; Manolakaki, D.; Velmahos, G.; Chang, Y.;
Alam, H.B.; De Moya, M.M.; Sailhamer, E.A.; Mylonakis, E. Can-
Infectious Disorders – Drug Targets, 2015, Vol. 15, No. 1 51
dida infection and colonization among non-trauma emergency sur-
gery patients. Virulence, 2010, 1(5), 359-66.
[6] van der Meer, J.W.; van de Veerdonk, F.L.; Joosten, L.A.; Kull-
berg, B.J.; Netea, M.G. Severe Candida spp. infections: new in-
sights into natural immunity. Int. J. Antimicrob. Agents, 2010,
36(2), 58-62.
[7] Mohamed, S.P.; Muzzammil, S.; Pramod, K.T. Buccoadhesive
dosage form containing antifungal agent for treating oropharyngeal
candidiasis: A review. Current Drug Therapy, 2011, 6, 55-64.
[8] Antifungal chemotherapy in patients with acquired immuno defi-
ciency syndrome. British Society for Antimicrobial Chemotherapy
Working Party. Lancet, 1992, 340(8820), 648-51.
[9] Greenspan, D.; John, S.G. HIV-related oral disease. Lancet, 1996,
348, 729-734.
[10] Chakravarthi, S.; Haleagrahara N. A comprehensive review of the
occurrence and management of systemic candidiasis as an oppor-
tunistic infection. Microbiology J., 2011, 1(1), 1-7.
[11] Guzel, MAB. The epidemiology, pathogenesis, and diagnosis of
vulvovaginal candidosis: A mycological perspective. Critical Re-
views in Microbiology, 2011, 37(3), 250-61.
[12] Li, F.Q.; Ma, C.F.; Shi, L.N.; Lu, J.F.; Wang, Y.; Huang, M.;
Kong, Q.Q. Diagnostic value of immunoglobulin G antibodies
against Candida enolase and fructose-bisphosphate aldolase for
candidemia. BMC Infect. Dis., 2013, 13, 253.
[13] Smeekens, S.P.; Ng, A.; Kumar, V.; Johnson, M.D.; Plantinga,
T.S.; van Diemen, C.; Arts, P.; Verwiel, E.T.; Gresnigt, M.S.; Fran-
sen, K.; van Sommeren, S.; Oosting, M.; Cheng, S.C.; Joosten,
L.A.; Hoischen, A.; Kullberg, B.J.; Scott, W.K.; Perfect, J.R.; van
der Meer, J.W.; Wijmenga, C.; Netea, M.G.; Xavier, R.J. Func-
tional genomics identifies type-I interferon pathway as central for
host defense against C. albicans. Nat. Commun., 2013, 4, 1342.
[14] Gauglitz, G.G.; Callenberg, H.; Weindl, G.; Korting, H.C. Host
defense against C. albicans and the role of pattern-recognition re-
ceptors. Acta Derm. Venereol., 2012, 92(3), 291-8.
[15] Costa, S.; de Lourdes Branco, C. Evaluation of molybdenum cul-
ture medium as selective and differential for yeasts. J. Pathol. Bac-
teriol., 1964, 87, 428-431.
[16] Odds, F.; Bernaerts, R. CHROMagar Candida; a new differential
isolation medium for presumptive identification of clinically im-
portant Candida species. J. Clin. Microbiol., 1994, 32, 1923-1029.
[17] Ghelardi, E.; Pichierri, G.; Castagna, B.; Barnini, S.; Tavanti, A.;
Campa, M. Efficacy of chromogenic Candida agar for isolation and
presumptive identification of pathogenic yeast species. Eur. J. Clin.
Microbiol. Infect. Dis., 2008, 14, 141-147.
[18] Horvath, L.L; Hospenthal, D.R.; Murray, C.K.; Dooley, D.P. Direct
isolation of Candida spp. from blood cultures on chromogenic me-
dium CHROMagar Candida. J. Clin. Microbiol., 2003, 41, 2629-
2632.
[19] Ellepola, A.N.; Morrison, J.C. Laboratory diagnosis of invasive
candidiasis. The J. Microbiol., 2005, 43, 65-84.
[20] Myers, R.S. Immunizing and antimicrobial agents. MEDCH, 2006,
401, 2-3.
[21] Vicariotto, F.; Del Piano, M.; Mogna, L.; Mogna, G. Effectiveness
of the association of two probiotic strains formulated in a slow re-
lease vaginal product, in women affected by vulvovaginal candidi-
asis: A pilot study. J. Clin. Gastroenterol., 2012, 46, S73-80.
[22] Hasenclever, H.F.; Mitchell, W.O. Observation of two antigenic
groups in Candida albicans. J. Bacteriol., 1961, 82, 570-573.
[23] Merz, W.G.; Evans, G.L.; Shadomy, S.; Anderson, S.; Kaufman,
L.; Kozinn, P.J.; Mackenzie, D.W.; Protzman, W.P.; Remington,
J.S. Laboratory evaluation of serological tests for systemic candidi-
asis: A cooperative study. J. Clin. Microbiol., 1977, 5, 596-603.
[24] Corrales, I.; Gimenez, E.; Aguilar, G.; Delgado, C.; Puig, J.;
Izquierdo, A.; Belda, J.; Navarro, D. Detection of fungal DNA in
peritoneal fluids by a PCR DNA low-density microarray system
and quantitation of serum (1-3)-β-D-glucan in the diagnosis of peri-
toneal candidiasis. Med. Mycol., 2014, pii: myu075 (Epub ahead of
print).
[25] Levesque, E.; El Anbassi, S.; Sitterle, E.; Foulet, F.; Merle, J.C.;
Botterel, F. Contribution of (1,3)-beta-D-glucan (BG) to the diag-
nosis of invasive candidiasis after liver transplantation. J. Clin. Mi-
crobiol., 2014, pii: JCM.03018-14 (Epub ahead of print).
[26] Kautzky, S.; Staudinger, T.; Prester, E. Invasive Candida infections
in patients of a medical intensive care unit: Attempt of improving
diagnosis by quantifying the colonization. Wien KlinWochenschr.,
2014 (Epub ahead of print).
52 Infectious Disorders – Drug Targets, 2015, Vol. 15, No. 1
[27] Ardizzoni, A.; Posteraro, B.; Baschieri, M.C.; Bugli, F.; Saez-
Roson, A.; Manca, L.; Cacaci, M.; Paroni Sterbini, F.; De Waure,
C.; Sevilla, M.J.; Peppoloni, S.; Sanguinetti, M.; Moragues, M.D.;
Blasi, E. An antibody reactivity-based assay for diagnosis of inva-
sive candidiasis using protein array. Int. J. Immunopathol. Pharma-
col., 2014, 27(3), 403-12.
[28] Lewis, L.E.; Bain, J.M.; Lowes, C.; Gillespie, C.; Rudkin, F.M.;
Gow, N.A.; Erwig, L.P. Stage specific assessment of C. albicans
phagocytosis by macrophages identifies cell wall composition and
morphogenesis as key determinants. PLoS Pathog., 2012, 8(3),
e1002578.
[29] van de Veerdonk, F.L.; Kullberg, B.J.; Netea, M.G. Adjunctive im-
munotherapy with recombinant cytokines for the treatment of dis-
seminated candidiasis. Clin. Microbiol. Infect., 2012, 18(2), 112-9.
[30] Glocker, E.; Grimbacher, B. Chronic mucocutaneous candidiasis
and congenital susceptibility to Candida. Curr. Opin. Allergy Clin.
Immunol., 2010, 10(6), 542-50.
[31] Kullberg, B.J.; Netea, M.G.; Vonk, A.G.; van der Meer, J.W.
Modulation of neutrophil function in host defense against dissemi-
nated C. albicans infection in mice. FEMS Immunol. Med. Micro-
biol., 1999, 26(3-4), 299-307.
[32] Ruhnke, M.; Rickerts, V.; Cornely, O.A.; Buchheidt, D.; Glockner,
A.; Heinz, W.; Hohl, R.; Horre, R.; Karthaus, M.; Kujath, P.; Will-
inger, B.; Presterl, E.; Rath, P.; Ritter, J.; Glasmacher, A.; Lass-
Florl, C.; Groll, A.H. Diagnosis and therapy of Candida infections:
Joint recommendations of the German Speaking Mycological Soci-
ety and the Paul-Ehrlich-Society for Chemotherapy. Mycoses,
2011, 54(4), 279-310.
[33] Pappas, P.G.; Kauffman, C.A.; Andes, D.; Benjamin, D.K.; Calan-
dra, T.F.; Edwards, J.E.; Filler, S.G.; Fisher, J.F.; Kullberg, B.J.;
Ostrosky-Zeichner, L.; Reboli, A.C.; Rex, J.H.; Walsh, T.J.; Sobel,
J.D. Clinical practice guidelines for the management of candidiasis:
2009 update by the Infectious Diseases Society of America. Clin.
Infect. Dis., 2009, 48(5), 503-35.
[34] Fuller, R. History and development of probiotics. Probiotics, 1992, 1-8.
[35] Ardatskaia, M.D.; Minushkin, O.N. Probiotics in the treatment of
functional intestinal diseases. Eksp. Klin. Gastroenterol., 2012, 3,
106-13.
[36] Mailander-Sanchez, D.; Wagener, J.; Schaller, M. Potential role of
probiotic bacteria in the treatment and prevention of localized can-
didosis. Mycoses, 2012, 55(1), 17-26.
[37] Wagner, R.D.; Pierson, C.; Warner, T.; Dohnalek, M.; Farmer, J.;
Roberts, L.; Hilty, M.; Balish, E. Biotherapeutic effects of probiotic
bacteria on candidiasis in immunodeficient mice. Infect. Immun.,
1997, 10, 4165-4173.
[38] Hatakka, K.; Ahola, A.J.; Yli-Knuuttila, H.; Richardson, M.;
Poussa, T.; Meurman, J.H.; Korpela, R. Probiotics reduce the
prevalence of oral Candida in the elderly-A randomized controlled
trial. JDR, 2007, 86(2), 125-130.
[39] Manzoni, P.; Mostert, M.; Leonessa, M.L.; Priolo, C.; Farina, D.;
Monetti, C.; Latino, M.A.; Gomirato, G. Oral supplementation with
Lactobacillus casei subspecies rhamnosus prevents enteric coloni-
zation by Candida species in preterm neonates: A randomized
study. Clin. Infect. Dis., 2006, 42(12), 1735-42.
[40] Kumar, S.; Singhi, S. Role of probiotics in prevention of Candida
infection in critically ill children. Mycoses, 2013, 56(3), 204-11.
[41] Kohler, G.A.; Assefa, S.; Reid, G. Probiotic interference of Lacto-
bacillus rhamnosus GR-1 and Lactobacillus reuteri RC-14 with the
opportunistic fungal pathogen C. albicans. Infect. Dis. Obstet. Gy-
necol., 2012, 2012, 636474.
[42] Bohbot, J.M.; Cardot, J.M. Vaginal impact of the oral administra-
tion of total freeze-dried culture of LCR 35 in healthy women. In-
fect. Dis. Obstet. Gynecol., 2012, 2012, 503648.
[43] Watson, C.J.; Pirotta, M.; Myers, S.P. Use of complementary and
alternative medicine in recurrent vulvovaginal candidiasis-results of a
practitioner survey. Complement Ther. Med., 2012, 20(4), 218-21.
Received: November 09, 2014 Revised: February 12, 2015 Accepted: February 16, 2015
Hani et al.
[44] Ishijima, S.A.; Hayama, K.; Burton, J.P.; Reid, G.; Okada, M.;
Matsushita, Y.; Abe, S. Effect of Streptococcus salivarius K12 on
the in vitro growth of C. albicans and its protective effect in an oral
candidiasis model. Appl. Environ. Microbiol., 2012, 78(7), 2190-9.
[45] Matsubara, V.H.; Silva, E.G.; Paula, C.R.; Ishikawa, K.H.; Naka-
mae, A.E. Treatment with probiotics in experimental oral coloniza-
tion by C. albicans in murine model (DBA/2). Oral Dis., 2012,
18(3), 260-4.
[46] Kumar, S.; Bansal, A.; Chakrabarti, A.; Singhi, S. Evaluation of
efficacy of probiotics in prevention of Candida colonization in a
PICU-a randomized controlled trial. Crit. Care Med., 2013, 41(2),
565-72.
[47] Cassone, A.; Casadevall, A. Recent progress in vaccines against
fungal diseases. Curr. Opin. Microbiol., 2012, 15(4), 427-33.
[48] http://en.wikipedia.org/wiki/Vaccine.
[49] Liu, M.; Clemons, K.V.; Johansen, M.E.; Martinez, M.; Chen, V.;
Stevens, D.A. Saccharomyces as a vaccine against systemic can-
didiasis. Immunol. Invest., 2012, 41(8), 847-55.
[50] Han, Y.; Ulrich, M.A.; Cutler, J.E. C. albicans mannan extract-
protein conjugates induce a protective immune response against
experimental candidiasis. J. Infect. Dis., 1999, 179(6), 1477-84.
[51] Han, Y.; Rhew, K.Y. Comparison of two Candida mannan vac-
cines: The role of complement in protection against disseminated
candidiasis. Arch Pharm. Res., 2012, 35(11), 2021-7.
[52] Lipinski, T.; Wu, X.; Sadowska, J.; Kreiter, E.; Yasui, Y.; Cheri-
aparambil, S.; Rennie, R.; Bundle, D.R. A β-mannan trisaccharide
conjugate vaccine aids clearance of C. albicans in immunocom-
promised rabbits. Vaccine, 2012, 30(44), 6263-9.
[53] Xin, H.; Cartmell, J.; Bailey, J.J.; Dziadek, S.; Bundle, D.R.; Cut-
ler, J.E. Self-adjuvanting glycopeptide conjugate vaccine against
disseminated candidiasis. PLoS One, 2012, 7(4), e35106.
[54] De Bernardis, F.; Amacker, M.; Arancia, S.; Sandini, S.; Gremion,
C.; Zurbriggen, R.; Moser, C.; Cassone, A. A virosomal vaccine
against candidal vaginitis: Immunogenicity, efficacy and safety
profile in animal models. Vaccine, 2012, 30(30), 4490-8.
[55] Luo, G.; Ibrahim, A.S.; French, S.W.; Edwards, J.E.; Fu, Y. Active
and passive immunization with rHyr1p-N protects mice against
hematogenously disseminated candidiasis. PLoS One, 2011, 6(10),
e25909.
[56] Ahmad, E.; Fatima, M.T.; Saleemuddin, M.; Owais, M. Plasma
beads loaded with C. albicans cytosolic proteins impart protection
against the fungal infection in BALB/c mice. Vaccine, 2012,
30(48), 6851-8.
[57] Pietrella, D.; Rachini, A.; Torosantucci, A.; Chiani, P.; Brown,
A.J.; Bistoni, F.; Costantino, P.; Mosci, P.; d'Enfert, C.; Rappuoli,
R.; Cassone, A.; Vecchiarelli, A. A beta-glucan-conjugate vaccine
and anti-betaglucan antibodies are effective against murine vaginal
candidiasis as assessed by a novel in- vivo imaging technique. Vac-
cine, 2010, 28, 1717-25.
[58] Torosantucci, A.; Bromuro, C.; Chiani, P.; De Bernardis, F.; Berti,
F.; Galli, C.; Norelli, F.; Bellucci, C.; Polonelli, L.; Costantino, P.;
Rappuoli, R.; Cassone, A. A novel glyco-conjugate vaccine against
fungal pathogens. J. Exp. Med., 2005, 202, 597-606.
[59] Bromuro, C.; Romano, M.; Chiani, P.; Berti, F.; Tontini, M.;
Proietti, D.; Mori, E.; Torosantucci, A.; Costantino, P.; Rappuoli,
R.; Cassone, A. Beta- glucan-CRM197 conjugates as candidate
antifungal vaccines. Vaccine, 2010, 28, 2615-23.
[60] [60]Spellberg, B. Vaccines for invasive fungal infections. F1000
Medicine Reports, 2011, 3, 1-8.
[61] Shibasaki, S.; Aoki, W.; Nomura, T.; Miyoshi, A.; Tafuku, S.;
Sewaki, T.; Ueda, M. An oral vaccine against candidiasis generated
by a yeast molecular display system. Pathog. Dis., 2013, 69(3),
262-268.
[62] Yang, H.; Han, S.; Zhao, D.; Wang, G. Adjuvant effect of polysac-
charide from fruits of Physalisalkekengi L. in DNA vaccine against
systemic candidiasis. Carbohydr. Polym., 2014, 109, 77-84.