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Reinforcing the Immunocompromised Host Defense Against Fungi: Progress Beyond the Current State of the Art

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Reinforcing the Immunocompromised Host Defense Against Fungi: Progress Beyond the Current State of the Art Journal of Fungi Review Reinforcing the Immunocompromised Host Defense against Fungi: Progress beyond the Current State of the Art Georgios Karavalakis 1, Evangelia Yannaki 1,2 and Anastasia Papadopoulou 1,* 1 Hematology Department-Hematopoietic Cell Transplantation Unit, Gene and Cell Therapy Center, “George Papanikolaou” Hospital, 57010 Thessaloniki, Greece; [email protected] (G.K.); [email protected] (E.Y.) 2 Department of Medicine, University of Washington, Seattle, WA 98195, USA * Correspondence: [email protected]; Tel.: +30-2313-307-693; Fax: +30-2313-307-521 Abstract: Despite the availability of a variety of antifungal drugs, opportunistic fungal infections still remain life-threatening for immunocompromised patients, such as those undergoing allogeneic hematopoietic cell transplantation or solid organ transplantation. Suboptimal efficacy, toxicity, development of resistant variants and recurrent episodes are limitations associated with current antifungal drug therapy. Adjunctive immunotherapies reinforcing the host defense against fungi and aiding in clearance of opportunistic pathogens are continuously gaining ground in this battle. Here, we review alternative approaches for the management of fungal infections going beyond the state of the art and placing an emphasis on fungus-specific T cell immunotherapy. Harnessing the power of T cells in the form of adoptive immunotherapy represents the strenuous protagonist of the current immunotherapeutic approaches towards combating invasive fungal infections. The progress that has been made over the last years in this field and remaining challenges as well, will be discussed. Citation: Karavalakis, G.; Yannaki, E.; Papadopoulou, A. Reinforcing the Keywords: fungal infections; fungus-specific T cells; T cell immunotherapy Immunocompromised Host Defense against Fungi: Progress beyond the Current State of the Art. J. Fungi 2021, 7, 451. https://doi.org/10.3390/ 1. Introduction jof7060451 Fungal infections, either superficial or invasive, may affect both the immunocom- petent and immunocompromised individuals. For vulnerable patients with underlying Academic Editor: Joseph M. Bliss disease, invasive fungal infections (IFIs) represent a major cause of morbidity and mor- tality worldwide, resulting in nearly 1.5 to 2 million deaths per year [1,2]. Neutropenia, Received: 5 May 2021 allogeneic hematopoietic cell transplantation (allo-HCT), solid organ transplantation (SOT), Accepted: 2 June 2021 acquired or inherited immunodeficiencies and prolonged corticosteroid administration are Published: 6 June 2021 the major predisposing factors for IFI [3], most frequently caused by Candida, Aspergillus, or Cryptococcus genera [4]. Despite the recent significant advances in antifungal pharmacother- Publisher’s Note: MDPI stays neutral apy, mortality rates associated with IFIs remain high, especially in immunocompromised with regard to jurisdictional claims in published maps and institutional affil- patients, mainly due to delayed recognition and diagnosis of infection. Importantly, spe- iations. cific restrictions apply to antifungal drugs, associated with bioavailability to target tissues, toxicity, treatment failure, route of administration, activity spectrum, drug interactions and the most alarming, drug resistance [2]. Therefore, the development of effective and mini- mally toxic, alternative antifungal therapies overcoming the well-recognized limitations of conventional drug treatment, is a major unmet need. Copyright: © 2021 by the authors. In this review, we discuss therapeutic approaches beyond what is currently thought Licensee MDPI, Basel, Switzerland. as the gold standard for the management of fungal infections (Figure1), focusing on the This article is an open access article progress and challenges of T cell immunotherapy against invasive fungal diseases. distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/). J. Fungi 2021, 7, 451. https://doi.org/10.3390/jof7060451 https://www.mdpi.com/journal/jof J. Fungi 2021, 7, x FOR PEER REVIEW 2 of 23 J. Fungi 2021, 7, 451 2 of 23 FigureFigure 1. Standard 1. Standard and andalternative alternative therap therapeuticeutic approaches approaches for for the managementmanagement of of invasive invasive fungal fungal infections. infections. 2. Treatment2. Treatment of of Invasive Invasive Fungal Fungal Infections:Infections: The The Unmet Unmet Clinical Clinical Need Need TheThe number number of of patients patients atat riskrisk for for invasive invasive fungal fungal infections infections is continuously is continuously increasing increas- ingas as a a result result of theof the emerging emerging medical medical innovations innovations and the useand of the immunomodulatory use of immunomodulatory agents. In contrast, the rate of development of new antifungal drugs is inversely correlated to agents. In contrast, the rate of development of new antifungal drugs is inversely correlated clinical demands; in fact, only one new class of antifungal drugs has been developed in the to clinicallast 30 years demands; (echinocandins). in fact, only A fundamental one new class challenge of antifungal in anti-fungal drugs drug has developmentbeen developed is in thethe last evolutionary 30 years (echinocandins). relationship with conservedA fundamental important challenge biochemical in anti-fungal and biological drug features, develop- mentbetween is the humansevolutionary and fungi relationship and because with of this,conserved toxicity againstimportant yeast biochemical will be also directedand biologi- cal tofeatures, humans. between Reasonably, humans the three and classesfungi and of antifungal because drugsof this, (azoles, toxicity echinocandins against yeast and will be alsopolyenes) directed target to humans. structures Reasonably, unique to fungi. the three classes of antifungal drugs (azoles, echi- nocandinsIn addition, and polyenes) antifungal target drug structures resistance unique is more andto fungi. more frequently now recognized andIn multi-drugaddition, antifungal resistant fungi, drug such resistance as Candida is more auris, and have more risen frequently spontaneously now over recognized the globe. Candida auris is a recently recognized yeast with high transmissibility, multi-drug and multi-drug resistant fungi, such as Candida auris, have risen spontaneously over the resistance and adverse outcomes, causing invasive infections and outbreaks in health care globe.facilities Candida and auris intensive is a carerecently units [recognized5]. yeast with high transmissibility, multi-drug resistanceGiven and the adverse above, theoutcomes, development causing of novel, invasive alternative infections antifungal and outbreaks approaches in that health will care facilitiesovercome and current intensive limitations care units and [5]. meet therapeutic needs, becomes imperative in patients withGiven compromised the above, immunity. the development of novel, alternative antifungal approaches that will overcome current limitations and meet therapeutic needs, becomes imperative in pa- 3. Strategies to Reinforce the Host Defense against Fungi tients with compromised immunity. Antifungal drugs often fail to eradicate the infection, mainly in immunocompromised 3. Strategiesindividuals. to Immunomodulators, Reinforce the Host including Defense cytokines, against monoclonalFungi antibodies and recently check-point inhibitors, enhance the impaired host defense and are used as an adjunctive immuneAntifungal therapy drugs for invasive often fail fungal to diseases.eradicate the infection, mainly in immunocompro- mised individuals. Immunomodulators, including cytokines, monoclonal antibodies and recently check-point inhibitors, enhance the impaired host defense and are used as an ad- junctive immune therapy for invasive fungal diseases. J. Fungi 2021, 7, 451 3 of 23 3.1. Recombinant Cytokines Cytokines are key players in controlling the homeostasis of the immune system and commercially available recombinant cytokines have exerted a potential adjunctive role to conventional antifungal therapy. 3.1.1. Colony-Stimulating Factors (CSFs) Neutrophil defects or chemotherapy-induced neutropenia are the main risk factors for the development of fungal infections. CSFs are a host-directed and non-specific therapy stimulating the production, maturation and activation of neutrophils, thus enhancing the host defense against a variety of pathogens. Three types of recombinant human CSFs are available: Granulocyte CSF (G-CSF), granulocyte macrophage CSF (GM-CSF), and macrophage CSF (M-CSF). Among CFCs, G-CSF is the most widely used and well-tolerated CFC, used adjunctly to restore neutrophil counts after myelosuppressive chemotherapy. G-CSF is a European Medicines Agency (EMA)- and United States Food and Drug Ad- ministration (FDA)-approved growth factor, stimulating the growth and differentiation of hematopoietic progenitor cells to neutrophils and enhancing phagocytosis and neu- trophils’ antifungal activity in vitro and in experimental mouse models [6–9]. In clinical settings, G-CSF when used alongside with antifungal agents as an adjunctive treatment, resulted in faster neutrophil recovery and decreased risk of fungal infections in neu- tropenic individuals following intensive chemotherapy or bone marrow transplantation for hematological malignancies [10,11]. In the setting of immunodeficiencies, G-CSF alone or in combination with antifungal
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