It was found in our previous study that berberine (BBR) and fluconazole (FLC) used concomitantly exhibited a synergism against FLC-resistant Candida albicans in vitro. The aim of the present study was to clarify how BBR and FLC worked synergistically and the underlying mechanism. Antifungal time-kill curves indicated that the synergistic effect of the two drugs was BBR dose dependent rather than FLC dose dependent. In addition, we found that BBR accumulated in C. albicans cells, especially in the nucleus, and resulted in cell cycle arrest and significant change in the transcription of cell cycle-related genes. Besides BBR, other DNA intercalators, including methylene blue, sanguinarine, and acridine orange, were all found to synergize with FLC against FLC-resistant C. albicans. Detection of intracellular BBR accumulation by fluorescence measurement showed that FLC played a role in increasing intracellular BBR concentration, probably due to its effect in disrupting the fungal cell membrane. Similar to the case with FLC, other antifungal agents acting on the cell membrane were able to synergize with BBR. Interestingly, we found that the efflux of intracellular BBR was FLC independent but strongly glucose dependent and associated with the drug efflux pump Cdr2p. These results suggest that BBR plays a major antifungal role in the synergism of FLC and BBR, while FLC plays a role in increasing the intracellular BBR concentration.
Candida albicans, one of the most prevalent human fungal pathogens, causes superficial mycoses, invasive mucosal infections, and disseminated systemic disease (1-4). Although the need for effective antifungal therapy is increasing, the available antifungal agents are still limited. Fluconazole (FLC) is most widely used due to its high bioavailability and low toxicity (5, 6). However, with the increasing clinical use of FLC, drug-resistant isolates are emerging rapidly (7-11). The high mortality rate of invasive Candida infections and limited availability of highly effective antifungal agents make it necessary to develop new antifungal therapeutics.The combinations of antimicrobial agents against drug-resistant Candida have been studied (12-15). Members of our group have shown that concomitant use of berberine (BBR; an alkaloid with a long history of medicinal use in traditional Chinese medicine [16]) and FLC is highly efficacious in killing FLC-resistant C. albicans in vitro, and the fractional inhibitory concentration (FIC) index ranges from 0.017 to 0.127 (17, 18). Our comparative proteomic study and further investigations indicated that FLC and BBR treatment affected the expression of proteins functioning in energy metabolism, increased mitochondrial membrane potential, decreased intracellular ATP level, inhibited ATP-synthase activity, and increased generation of endogenous reactive oxygen species (ROS) in FLC-resistant C. albicans strains (19). Nevertheless, the mechanism for how the combination of BBR and FLC augments the efficacy of each agent alone remains unclear.In this study, we fo...