Stimulation of superoxide production increases fungicidal action of miconazole against Candida albicans biofilms

Abstract

We performed a whole-transcriptome analysis of miconazole-treated Candida albicans biofilms, using RNA-sequencing. Our aim was to identify molecular pathways employed by biofilm cells of this pathogen to resist action of the commonly used antifungal miconazole. As expected, genes involved in sterol biosynthesis and genes encoding drug efflux pumps were highly induced in biofilm cells upon miconazole treatment. Other processes were affected as well, including the electron transport chain (ETC), of which eight components were transcriptionally downregulated. Within a diverse set of 17 inhibitors/inducers of the transcriptionally affected pathways, the ETC inhibitors acted most synergistically with miconazole against C. albicans biofilm cells. Synergy was not observed for planktonically growing C. albicans cultures or when biofilms were treated in oxygen-deprived conditions, pointing to a biofilm-specific oxygen-dependent tolerance mechanism. In line, a correlation between miconazole's fungicidal action against C. albicans biofilm cells and the levels of superoxide radicals was observed, and confirmed both genetically and pharmacologically using a triple superoxide dismutase mutant and a superoxide dismutase inhibitor N-N'-diethyldithiocarbamate, respectively. Consequently, ETC inhibitors that result in mitochondrial dysfunction and affect production of reactive oxygen species can increase miconazole's fungicidal activity against C. albicans biofilm cells.

Stimulation of superoxide production increases fungicidal action of miconazole against Candida albicans

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Kaat De Cremer,, Katrijn De Brucker, Ines Staes, Annelies Peeters, FreijaVan den Driessche, Tom Coenye, Bruno P. A. Cammue, & KarinThevissen

We performed a whole-transcriptome analysis of miconazole-treated Candida albicans pathogen to resist action of the commonly used antifungal miconazole. As expected, genes involved chain (ETC), of which eight components were transcriptionally downregulated. Within a diverse most synergistically with miconazole against C. albicans for planktonically growing C. albicans between miconazoles fungicidal action against C. albicans dismutase mutant and a superoxide dismutase inhibitor N-N-diethyldithiocarbamate, respectively.

oxygen species can increase miconazoles fungicidal activity against C. albicans

Candida albicans, the major fungal pathogen of humans, has the capacity to form biolms on biotic surfaces throughout the human gastro-intestinal tract and genital area. While this fungus can cause life-threatening invasive infections in immunocompromised patients, many more individuals are confronted with supercial mucosal infections. Though the latter type of infection is oen rather harmless and easy to treat, the incidence of recurrent oral and vulvovaginal candidiasis is signicant. About 70% of all premenopausal woman develop vulvovaginal candidiasis at some point in their lives1 and repeated attacks aect at least 75 million women annually2. Currently the preferred treatment of such infections remains a topical azole treatment3.

Azoles, including imidazoles (e.g. miconazole) and triazoles (e.g. uconazole), interfere with the biosynthesis of ergosterol by inhibiting the enzyme lanosterol 14-alpha-demethylase. Since ergosterol is a major constituent of the fungal membrane, its depletion results in growth inhibition4. This inhibitory eect is augmented by the accumulation of toxic ergosterol precursors5. Some azoles such as miconazole, induce accumulation of reactive oxygen species (ROS) in planktonic and biolm fungal cells612. In contrast to other azole-type antifungals, a fungicidal eect of ROS-inducing miconazole against biolms of several C. albicans strains was reported when used in high (millimolar) concentrations10,11, but the causal relationship between induction of ROS and fungicidal activity remains under debate13,14. Interestingly, targeting C. albicans oxidative defence system to sustain high ROS levels reportedly enhances the fungicidal activity of ROS-inducing antifungals6,11,13,15,16.

Given the high tolerance of C. albicans biolm cells to miconazole14, we aimed at obtaining more insight in the molecular pathways that are employed by the biolm cells to resist miconazole treatment. Compounds known to aect these particular processes and pathways might result in an increased and potentially fungicidal action

Belgium. Laboratory of and requests for materials should be addressed to B.P.A.C. (email: [email protected])

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Figure 1. Number of signicant (overlapping) dierentially expressed genes 4h and 24h aer miconazole treatment. Using EdgeR, a negative binomial distribution of the count reads was the basis to select dierentially expressed genes between miconazole treated and untreated samples at both time points, with a limited false discovery rate (FDR adjusted p-value <0.01).

(at lower concentrations) of miconazole against C. albicans biolm cells, which is highly desirable in the context of developing novel biolm eradication strategies.

Gene expression proling of drug-treated cell populations is a useful strategy to obtain new insights in the drugs mode of action, as well as in tolerance mechanisms against the drug1719. To our knowledge, there are currently no transcriptome datasets available of miconazole-treated C. albicans biolm nor planktonically grown cells. However, a single report documents the transcriptional response of C. albicans biolm cells against another azole, namely uconazole20. In the latter study, the transcriptome changes in biolm cells were studied aer 30120min of uconazole exposure. However, using this setup, the authors found only 5 dierentially expressed genes.

In the present study, a whole-genome transcriptional analysis of miconazole-treated C. albicans biolm cells was performed at 4h and 24h post miconazole treatment. By targeting particular miconazole-aected pathways identied via this transcriptomic approach we successfully identied compounds that increase the sensitivity of the C. albicans biolm cells to miconazole. However, this potentiating eect was not observed in planktonic C. albicans cultures. Interestingly, the increased killing by synergistic combinations of miconazole and such specic inhibitors correlated with an increased production of superoxide radicals in the biolm cells under aerobiosis. In line, the observed synergy between miconazole and the inhibitors under aerobic conditions was no longer apparent when biolms were treated in anaerobic conditions, pointing to biolm-specic miconazole tolerance pathways aimed at reducing superoxide production in the presence of oxygen. The latter was conrmed genetically using a triple superoxide dismutase mutant and pharmacologically using a superoxide dismutase inhibitor N-N-diethyldithiocarbamate.

Results

Transcriptional analysis of miconazole-treated C. albicans In order to nd pathways and processes involved in generating tolerance of C. albicans biolm cells against miconazole, we performed a genome-wide transcriptome analysis of C. albicans SC5314 biolms treated with miconazole. First, twenty-four hour old C. albicans biolms were treated for an additional 24 h with a concentration series of miconazole to determine the minimal concentration needed to reduce the metabolic activity to 50% (i.e. the minimal biolm eradicating concentration or BEC50 = 75 M measured with the metabolic activity dye Cell-Titre Blue (CTB); data not shown). Next, 24h old C. albicans biolms treated for 4h and 24h with 75M miconazole or mock-treatment (0.5% DMSO) were collected from three independent experiments and RNA was isolated. RNA-sequencing (RNA-seq) generated an average of 8,325,004 reads per sample of which on average 6,459,852 aligned uniquely with annotated coding sequences of the C. albicans SC5314 genome (Supplementary Table S1). Using EdgeR, we compared the gene expression level of each gene in the miconazole-treated samples with control samples for both time points, identifying a total of 323 and 828 dierentially expressed (DE) genes at 4h and 24h aer miconazole treatment, respectively (Supplementary Data S1). The number of overlapping up- and down-regulated genes is summarized in Fig.1.

To examine the transcriptional response of C. albicans biolms upon miconazole treatment, we rst looked into the top-induced and repressed genes (colour-indicated in Supplementary Data S1), aer which we performed gene ontology (GO) analysis of the whole dataset.

Among the top-50 induced genes, expected miconazole-tolerance targets were found at both time points. More specically, many ergosterol biosynthesis genes (ERG6, ERG251, ERG3 and ERG2 at both time points), genes encoding drug efflux pumps (CDR2 and orf19.4531 at both time points and MDR1 only at 24 h post treatment) and a superoxide dismutase which protects against oxidative stress (SOD5 only at 24 h post treatment) were highly induced by miconazole. These data corroborate with previous studies demonstrating a role for these genes in azole resistance, also in C. albicans biolms11,2124. Interestingly, genes coding for degradative enzymes such as secreted aspartic-type proteinases (SAP3, SAP4 and SAP6 at both time points) and lipases (LIP5 at both time points and LIP8 only at 24h aer treatment) were also highly induced. Induction of expression of SAP genes

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(SAP2 and SAP9) was observed previously in C. albicans aer treatment with uconazole and this was conrmed at protein level, also for miconazole25. Interestingly, the expression of multiple SAP and LIP genes is upregulated in untreated C. albicans biolms compared to a planktonic culture as well26. However, no evidence for a role of the Saps or lipases in the tolerance mechanisms against azoles or in their mode of action currently exists. Potentially, this induction is only relevant in vivo to invade surrounding tissue and escape the drug treatment. Also the expression of many genes encoding cell wall proteins (PGA31, PGA37, orf19.675, PGA23 and SIM1 at both time points, RHD3 and SCW11 only at 4 h post treatment and PGA22 only at 24 h post treatment) and of a putative nicotinic acid transporter (TNA1 at both time points) was highly induced, while these genes have not been linked to miconazoles mode of action or tolerance pathways in biolm cells. The biolm transcriptional response to miconazole treatment suggested a broad disturbance of energy metabolism, illustrated by the high induction of genes encoding the key glyoxylate enzyme isocitrate lyase (ICL at both time points) and several fermentation enzymes ADH3 (only at 4 h post treatment) and ADH4 and ADH5 (only at 24 h post treatment). Fermentation was recently reported to be specically induced during C. albicans biolm formation compared to stationary phase planktonic cells, possibly because of the hypoxic environment within C. albicans biolms27,28, which might be stimulated when treated with ROS-inducing compounds such as miconazole. Moreover, multiple amino acid metabolism genes (LEU1 and MET3 at both time points, GDH3 only at 4 h post treatment and CAR2 only at 24 h post treatment) were highly induced. In addition, a gene encoding a putative secreted acid sphingomyelin phosphodiesterase (orf19.4707, induced at both time points), IPT1 (induced at 4 h post treatment only), which catalyses the synthesis of the most abundant sphingolipid mannose-(inositol-P)2-ceramide and LCB4 (induced at 24h post treatment only), encoding a sphingosine kinase, were induced (Supplementary Data S1). Interestingly, both C. albicans and Saccharomyces cerevisiae mutants aected in sphingolipid biosynthesis, including ipt1 and lcb4, portray altered miconazole-susceptibility, conrming a possible role for these sphingolipids in miconazoles mode of action29,30.

Whereas a large overlap was observed between the top genes induced at 4 h and 24 h after miconazole treatment, we found more differences between both time points when comparing the top-repressed genes (Supplementary Data S1). The most notable down-regulated genes were those involved in arginine biosynthesis (CPA1, CPA2, ARG1, ARG3, ARG4 and ARG8 and to lesser extent also ARG11 and ARG5,6) which was only observed at 24h post miconazole treatment. Also two putative gamma-aminobutyric acid transaminase encoding genes (UGA1 and UGA11) are only repressed at 24 h post miconazole treatment. For both processes, no obvious link with miconazole actions has been described. At 4h post miconazole treatment, the repression of genes involved in iron homeostasis (FRE7 and FRE30) was evident, and this downregulation was still ongoing at 24h post treatment (although at lower reduction levels). Interestingly, the catalase-encoding gene CAT1, conferring resistance to oxidative stress, was also repressed at both time points (most pronounced at 4h post treatment), which is in line with our previous hypothesis linking the miconazole-induced ROS production to miconazoles direct inhibition of ROS-degrading enzymes such as catalase7. Other top-repressed genes, which are signicantly dierentially expressed at both time points, include ARO10 (aromatic decarboxylase), FDH1 (formate dehydrogenase), GLT1 (a putative glutamate synthase), MSH6 (potentially involved in mismatch repair via interacting selectively and non-covalently with double-stranded DNA containing a single base insertion or deletion), NGT1 (N-acetylglucosamine-specic transporter) and the transcriptional regulator of cell cycle gene expression, NRM1 (Supplementary Data S1).

Gene ontology analysis. In parallel to a gene-specic expression analysis of the top-induced and -repressed genes, we also focused on the entire gene expression prole by performing a gene ontology (GO) enrichment analysis. This enables us to identify groups of dierentially expressed genes representing dierent biological processes, molecular functions or cellular components (Supplementary Data S2). In Fig.2 we depicted the most unique GO categories overrepresented in the corresponding gene lists.

At 4h post miconazole treatment, genes coding for sterol biosynthesis and related GO categories were significantly overrepresented among the induced genes, as well as those coding for ion transport and genes encoding proteins located in the extracellular region, cell surface and plasma membrane (Fig.2 and Supplementary Data S2). Gene groups signicantly over-represented in the down-regulated gene lists at 4 h post miconazole treatment included those correlated with calcium:proton antiporter activity, single base insertion or deletion binding and cellular bud (Fig.2 and Supplementary Data S2).

At 24h post miconazole treatment, sterol biosynthesis and related GO categories were again among the most pronounced induced GO categories. The GO category other small molecule biosynthetic processes was also signicantly induced and the concomitant induction of the organo-nitrogen compound metabolic process suggests these small molecules are mainly related to metabolism of amino acids, although pyridoxine biosynthesis genes were also represented in this category (PDX3, SNO1 and RKI1). Additionally, one-carbon metabolic process (mainly genes involved in tetrahydrofolate interconversion) was signicantly induced at 24h post miconazole treatment. Regarding cellular components, many genes encoding for proteins located on the cell surface and plasma membrane were induced. Gene groups signicantly over-represented in the down-regulated gene lists at 24 h post miconazole treatment included the glutamine family amino acid biosynthetic process (linked to synthesis of glutamate, glutamine, arginine and proline of which mainly arginine biosynthetic genes were down-regulated at 24h post miconazole treatment), oxidation-reduction process and cellular respiration (including eight components of the respiratory electron transport chain (ETC), namely COX6, COX9, CYT1, RIP1, QCR2, QCR7, QCR9 and orf19.913.2). Also the GO categories related to molecular function and cellular component illustrate the repression of the ETC (Fig.2 and Supplementary Data S2). Finally, the GO analysis revealed down-regulation of genes encoding multiple mitochondrial ribosomal constituents (MRP17, MRP20, MRPS9, MRPL10, MPRL36, MRPL37, orf19.4751, orf19.1662, orf19.3348, orf19.3022, orf19.585, orf19.2639, orf19.688:

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Figure 2. Distribution of major signicantly overrepresented GO categories within the signicantly up- or down-regulated gene lists at 4h and 24h post miconazole treatment, respectively. The percentages represent the relative amount of dierentially expressed genes annotated to the respective GO category within the list of selected dierentially expressed genes. Note that the sum of all represented GO categories in each pie chart is not equal to 100% since some genes belong to multiple GO categories and many of the dierentially expressed genes are unannotated or annotated to GO categories that were not signicantly overrepresented. Signicant overrepresented GO categories were determined using the GO Term Finder at the Candida Genome Database (CGD) website (FDR adjusted p-value<0.05).

orf19.549 and orf19.6136). This repression could additionally lead to reduced respiration (including reduced ETC activity), the core function of proteins synthesized by mitochondrial ribosomes.

The apparent transcriptional downregulation of components of the ETC by miconazole in C. albicans biolm cells hinted us to compare the current RNA-seq dataset (24h post miconazole treatment) with a transcriptome study of C. albicans cells growing in hypoxic conditions31. Forty-two out of 245 hypoxia-induced genes (17%) were also induced in miconazole-treated C. albicans biolms. Among these genes were the transcriptional regulator UPC2, many ergosterol biosynthesis genes (ERG1, ERG3, ERG5, ERG11 and ERG251), the alcohol dehydrogenase encoding gene ADH5 and the transcriptional regulator gene RAS2. On the other hand, 22 out of 164 hypoxia-repressed genes (13%) were also signicantly down-regulated in miconazole-treated C. albicans biolms. Many of the common down-regulated genes were involved in oxidative respiration (TYE7, QCR2, CYT1, QCR7, RIP1, orf19.4016, NDH51), arginine bio-synthesis (CPA1, CPA2, ARG11 and ARG5,6) and Fe homeostasis (FRE7, FTR2 and orf19.7077). Interestingly, the similarity between the hypoxic condition and azole treatment was previously described for planktonic C. albicans cultures upon ketoconazole addition (which is also an imidazole, like miconazole)31.

Validation of the RNA-seq data was performed for both time points by qRT-PCR on a selection of 16 genes representing dierent biological processes that were transcriptionally aected, as described above (Supplementary Fig. S1). The resulting logFC values obtained by qRT-PCR were completely in line with the normalized logFC values from the RNA-seq data calculated with EdgeR (Pearson correlation coefficient= 0.97), thereby conrming the observed gene expression patterns in the RNA-seq data as basis for subsequent analysis (Supplementary Fig. S1).

Processes and pathways aected by miconazole in C. albicans biolms, as determined by the transcriptome analysis, can lead to the identication of compounds that aect the sensitivity to miconazole. Inhibitors or inducers of such pathways may act synergistically or antagonistically in combination with miconazole against C. albicans biolms, depending on the involvement of the pathway in miconazoles mode of action or biolm tolerance against this compound. To this end, 17 known inhibitors and inducers of miconazole-aected pathways or compounds that complement the repression of a certain pathway were selected. Their potential synergistic or antagonistic activity with miconazole against 24h old C. albicans biolms was assessed via checkerboard analysis and calculation of the fractional inhibitory concentration index (FICI) based on metabolic activity determination using CTB. Table1 categorizes their action as synergistic or indierent in combination with miconazole against C. albicans biolms. Because of the large amount of identied dierentially expressed genes and pathways, we were unable to tackle all of them by an appropriate inhibitor or inducer. Consequently, we focused on well-known and easily available compounds (Table1).

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Process or protein

Sterol biosynthetic process Induced Simvastatin 1.4mM S Secreted aspartic-type proteinases Induced Saquinavir mesylate >500M I Lipases Induced Orlistat >1mM I Glyoxylate cycle Induced Itaconate >2mM I ETC Repressed Antimycin A 570M S

CCCP 73M S Sodium azide 8.6mM S Sphingolipid biosynthesis Induced Myriocin >100M I Alcohol dehydrogenase Induced Disulram >500M I Branched-chain amino acid

(including leucine) biosynthesis Induced Chlorosulfuron >1 mM I Fe-S bonds (as in Leu1 and

many mitochondrial respiratory

enzymes)

Five inhibitors resulting in synergistic activity with miconazole (simvastatin, pyrithione zinc, antimycin A, CCCP and sodium azide) were selected for further analysis. A more detailed representation of the remaining metabolic activity in C. albicans biolms aer checkerboard analysis of the combined treatment of these inhibitors with miconazole is shown in Fig.3. All ve selected inhibitors were able to reduce the minimum miconazole concentration necessary to result in 50% residual metabolic activity of biolm cells (BEC50) at least 4.4-fold (Table2). The most pronounced synergistic eect with miconazole was obtained with antimycin A (FICI= 0.10). Applied at a concentration of 3.125M, antimycin A was able to reduce the BEC50 of miconazole almost 11-fold (Table2). Note that control curves of miconazole (Fig.3) and corresponding BEC50 values (Table2) may vary among the dierent experiments. Therefore, FICI calculations for the ve selected inhibitors were based on BEC50 values as determined within the experiments involving the compound that is being analysed.

Of importance, one should carefully evaluate the data that measures biolm metabolic activity (such as the CTB metabolic activity dye used in this study) in the presence of inhibitors of the ETC. Treatment of biolms with ETC inhibitors will result in reduction of signal in such assays and control treatments should always be taken into account (miconazole+ ETC inhibitor versus ETC inhibitor alone) as done in our FICI calculation. Moreover, we also investigated whether the ve selected inhibitors are eective in increasing the fungicidal activity of miconazole against C. albicans biolm cells by counting colony forming units (cfu) (Fig.4). The applied inhibitor concentrations were selected to have no signicant antibiolm activity on their own, based on the checkerboard analysis (Fig.3).

Untreated biolms contained almost 104 cfus/biolm and the miconazole-only treatment (125 M) did not signicantly aect this number (<0.5 log units). Signicant reductions in cfus compared to the control treatment (no miconazole and no additional inhibitor) could only be observed for the combined action of 125M miconazole with 500M simvastatin (97%), 25M antimycin A (99%), 15.6M CCCP (87%) or 1.25mM sodium azide (95%). The largest potentiating eect was observed for antimycin A, which was able to increase the miconazole fungicidal capacity by 26-fold (corresponding with a reduction of almost 2 log units compared to no treatment). The combination of 125M miconazole and 20M pyrithione zinc did not result in additional reduction of cfus in comparison with single miconazole treatment (Fig.4). Hence, only the synergistic activity of miconazole and simvastatin or ETC inhibitors on the metabolic activity of C. albicans biolm cells translate to induced killing of these cells.

To investigate whether the synergistic activity of the ve selected inhibitors with miconazole is biolm-specic, we also assessed the activity of the above-described synergistic combinations in checkerboard assays on planktonically growing C. albicans cultures (Supplementary Fig. S2). While no additional activity of miconazole in combination with four of the inhibitors (simvastatin, pyrithione zinc, antimycin A and sodium azide) in these

Eect in miconazole

RNAseq data Compound BEC50

Inhibitors

Activity in combination

with miconazolea

S

Tetrahydrofolate interconversion Induced Trimethoprim >500M I

Inducers

Nicotinic acid transporter Induced Nicotinic acid >1mM I Arginine biosynthesis Repressed Arginine >10mM I Leucine biosynthesis Induced Leucine >2mM I Citric acid cycle Repressed Sodium dichloroacetate >1mM I N-acetylglucosamine transporter Repressed N-acetyl-D-glucosamine >1mM I

Table 1. Selection of inhibitors and inducers of the miconazole-aected pathways and combinatory action with miconazole against C. albicans biolms determined by FICI calculation. aS=Synergy (FICI<0.5), I=Indierence (0.5<FICI<4), FICI=[CA/BEC50A]+[CB/BEC50B], in which BEC50A and BEC50B arethe BEC50values (biolm eradication concentration resulting in 50% remaining biolm metabolic activity)of compound A and B alone, while CA and CB are the concentrations of the drugs A and B at iso-eective combinations, respectively. Note that CB values were derived from the whole dose-response curves, whereas CA values represent the actual concentration of compound A in the checkerboard experiments.

Induced

275M

Pyrithione zinc

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Figure 3. Metabolic activity of C. albicans biolms treated with a combination of miconazole and simvastatin, pyrithione zinc, CCCP, antimycin A and sodium azide. The control curve of miconazole alone is represented by diamonds, whereas combinations of miconazole with decreasing concentrations of other compound are indicated by circles, squares, triangles and reverted triangles. Data are mean SEM of ve(n= 5) biologically independent experiments (each consisting of three repeats), determined with the metabolic activity dye CTB.

planktonic conditions could be observed, an antagonistic eect of the ETC inhibitor CCCP on miconazoles action could be seen, as conrmed by FICI calculation (FICI= 6.63 for 12.5M CCCP), which is in contrast with the eect on C. albicans biolms. Indeed, 12.5M CCCP was able to increase the MIC50 (i.e. the minimal inhibitory concentration reducing planktonic cell growth with 50%) of miconazole by nearly 6-fold (Supplementary Fig. S2). It appears that the selected inhibitors act synergistically with miconazole against biolm-specic tolerance mechanisms.

Boosting up miconazoles ROS production in C. albicans results in increased fungicidal activity. The fungicidal activity of antifungal compounds has oen been associated with the production of ROS14. Therefore, we assessed whether the observed synergistic eect between miconazole and the ve selected inhibitors led to increased production of superoxide radicals, using dihydroethidium staining. As the conversion of this dye depends on the number of live cells in the biolm, results were normalized to the number of cfu/biolm (Fig.5).

Treatment of C. albicans biolms with miconazole (125 M) resulted on average in a 3-fold increase of the basal superoxide accumulation of untreated biolm cells (Fig.5). Interestingly, our data show that all combinations with fungicidal capacity against C. albicans biolms (miconazole in combination with simvastatin or ETC inhibitors) cause additional superoxide production compared to treatment with the single compounds. The highest superoxide induction was observed for miconazole in combination with 25M antimycin A (28-fold increase compared to treatment with miconazole alone) (Fig.5), which corresponds with the largest reduction in cfus caused by miconazole in combination with this compound (Fig.4). On the other hand, combined addition of pyrithione zinc (20 M) and miconazole does not induce an increase in superoxide levels in the C. albicans biolms compared to miconazole treatment alone (Fig.5), which again is consistent with the lack of eective fungicidal capacity of this combination (Fig.4). Using the above data, we nd a tight correlation between the fold reduction in cfu versus the fold increase in superoxide levels for biolms treated with miconazole only or a combination treatment, which is conrmed by the Pearson correlation coefficient (0.95; p value = 0.0144; Supplementary Fig. S4).

To validate these ndings further, we assessed the antibiolm capacity of miconazole, antimycin A and the combination of both compounds in anaerobic conditions. Note that biolms were grown in standard aerobic conditions for these tests as done for all previous experiments and that only the treatment was performed in absence of oxygen. In these conditions, oxygen cannot serve as electron acceptor for the ETC and no mitochondrial ROS are produced. Therefore, we hypothesized that addition of antimycin A has no further eect on miconazole activity. Indeed, no signicant combinatory fungicidal eect of antimycin A and miconazole, compared to miconazole treatment alone, is present in anaerobic conditions (Supplementary Fig. S3). Surprisingly, the eect of miconazole alone was more pronounced in anaerobic conditions (signicant reduction in cfus of 0.8 log unit) compared to aerobic treatment. This observation was conrmed by metabolic staining of C. albicans biolms treated with a concentration series of miconazole in both aerobic and anaerobic conditions (Supplementary Fig. S3).

Superoxide production is crucial for miconazoles fungicidal action against C. albicans bio- To conrm the link between superoxide induction and miconazoles fungicidal capacity we explored the role of superoxide dismutases (Sods), enzymes that rapidly convert toxic superoxide into molecular oxygen

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Concentration

compound (M)

Simvastatin

500 14 5.6 0.49 250 30 2.6 0.54 125 38 2.1 0.5762.5 44 1.8 0.60 0 78 1.0 NA Pyrithione zinc

20 20 4.2 0.31 10 19 4.4 0.26 5 24 3.5 0.302.5 52 1.6 0.63 0 84 1.0 NA Antimycin A

25 6.4 12.7 0.1212.5 7.5 10.8 0.116.25 9.9 8.2 0.133.125 7.4 10.9 0.10 0 81 1.0 NA CCCP62.5 7.7 13.6 0.9331.25 18 5.8 0.6015.625 27 3.9 0.477.8125 62 1.7 0.70 0 105 1.0 NA Sodium azide

5,000 8.8 6.8 0.73 2,500 16 3.8 0.56 1,250 22 2.7 0.51 625 25 2.4 0.49 0 64 1.0 NA

Table 2. Synergistic activity of simvastatin, pyrithione zinc, antimycin A, CCCP and sodium azide with miconazole against C. albicans biolms. The BEC50 values are the mean SEM of at least ve (n=5) independent biological replicates (each consisting of three repeats). FICI values indicating a synergistic interaction are printed in bold. aBEC50= Biolm eradication concentration resulting in 50% remaining biolm metabolic activity, calculated using nonlinear regression. The BEC50 value of simvastatin, pyrithione zinc, antimycin A, CCCP and sodium azide is 1.6mM, 275M, 570M, 73M and 8.6mM, respectively.

bFold change= fold increase of biolm activity of miconazole due to the combination, calculated as (BEC50 of miconazole alone)/(BEC50 of miconazole in combination). cFICI= Fractional inhibitory concentration index, NA=Not Applicable.

in healthy C. albicans cells32,33. Six dierent Sods are present in C. albicans among which four Cu,Zn-containing superoxide dismutases (Sod1, Sod4, Sod5, and Sod6)32 that can be inhibited using the Cu,Zn-Sod inhibitor N,N -diethyldithiocarbamate (DDC), which chelates copper34. Our transcriptomic data revealed increased expression of SOD5 and SOD6 (Supplementary Table S2) at 24h aer miconazole treatment, suggesting their involvement in protection against these oxygen radicals. Indeed, a triple mutant in which both genes (and SOD4) were deleted, was hypersusceptible to miconazole compared to the wild type strain (Fig.6a). Interestingly, no dierence was observed in miconazole susceptibility between planktonically growing wild type and sod4sod5sod6 C. albi-cans cells as evidenced by the respective MIC values (MIC50 = 0.1 M for both the triple sod mutant and wild type C. albicans; data not shown), conrming the biolm-specic action of miconazole-induced superoxide. Finally, addition of the Sod inhibitor DDC (thereby mimicking the protein prole of the triple sod mutant) lead to increased fungicidal activity of miconazole against C. albicans biolms, which correlated with the rise in super-oxide production (Fig.6b,c).

Discussion

Miconazole is one of the most commonly recommended and eective topical antifungal treatments of e.g. vulvovaginal candidiasis3. In 8090% of patients who complete the therapy, treatment with such azoles results in relief of symptoms and full elimination of fungal burden. Unfortunately, approximately 1020% of women will be victim of complicated vulvovaginal candidiasis, requiring special therapeutic needs3. Also oral thrush, manifested by C. albicans, is oen treated with miconazole, but recurrence is frequent, leading to consideration of

BEC50

miconazole (M)a

Fold

changeb FICIc

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Figure 4. Number of cfus per C. albicans biolm in the presence and absence of miconazole and/or (a) simvastatin, (b) pyrithione zinc, (c) antimycin A, (d) CCCP and (e) sodium azide. Black bars represent untreated biolms or biolms treated with 500M simvastatin, 20M pyrithione zinc, 25M antimycin A, 15.6M CCCP and 1,250M sodium azide alone while grey bars represent biolms additionally treated with 125M miconazole. Data presented are the mean and SEM of at least three (n 3) independent experiments (each consisting of three replicates), measured by cfu counting. Two-way ANOVA statistical analysis with Tukeys correction for multiple comparisons was performed to assign signicant dierences between treatments (*=p<0.05, **p<0.01, ***p<0.001, ****p<0.0001).

Figure 5. Accumulation of superoxide radicals in Candida albicans biolms in the presence and absenceof miconazole and/or (a) simvastatin, (b) pyrithione zinc, (c) antimycin A, (d) CCCP and sodium azide. Superoxide production is expressed as uorescence per 1000cfus assessed by cfu counting. Black bars represent untreated biolms or biolms treated with 500M simvastatin, 20M pyrithione zinc, 25M antimycin A, 15.6M CCCP and 1250M sodium azide only while grey bars represent biolms additionally treated with 125M miconazole. Data presented are the mean and SEM of at least three (n 3) independent experiments (each consisting of three replicates). Two-way ANOVA statistical analysis with Tukeys correction for multiple comparisons was performed to assign signicant dierences between all treatments (*p<0.05, **p<0.01).

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Figure 6. Involvement of superoxide dismutases in C. albicans biolm tolerance to miconazole. (a) Percentage remaining biolm cfus in wild type (CA-IF100) and triple sod mutant (sod4sod5sod6) aer treatment with 30M miconazole. A two-tailed paired Students t-test was performed to assign signicant dierences between the two strains (*p<0.05). (b) Number of cfus per C. albicans SC5314 biolm and (c)

concomitant accumulation of superoxide radicals in the presence and absence of miconazole and/or DDC. Black bars represent untreated biolms or biolms treated with 10mM DDC alone while grey bars represent biolms additionally treated with 125M miconazole. Data presented are the mean and SEM of four (n=4) independent experiments (each consisting of three replicates). Two-way ANOVA statistical analysis with Tukeys correction for multiple comparisons was performed to assign signicant dierences between treatments (****p<0.0001).

other treatments35. Most pathogenesis studies suggest recurrence to be linked to host immune defects, however, a role for biolm formation during both vaginal and oral C. albicans infections and the recurrence thereof is suggested36,37.

In this study, we analysed the transcriptome of C. albicans biolms treated with miconazole aiming at gaining further insight in miconazoles activity against biolm cells and in biolm tolerance mechanisms against this drug. Via RNA-seq, we identied a variety of dierentially expressed genes and pathways, some of which conrmed previously observed miconazole actions (e.g. induction of ERG genes and genes encoding drug efflux pumps)2124, while others are unreported.

Members of the ERG gene family code for ergosterol biosynthesis enzymes and their induction probably results in reduced efficacy of miconazole, which targets the lanosterol 14-alpha-demethylase encoded by ERG11. Induction of several ERG genes has been reported during biolm development38, but contradictory, it was also reported that biolm cells contain less ergosterol in their cell membranes compared to free-living cells, which possibly reduces the efficiency of azole antifungals aecting biosynthesis of this compound22. Genes encoding efflux pumps have also been reported to be upregulated during biolm formation and development, which might explain the early acquisition of drug resistance23. However, C. albicans mutant strains decient in efflux pumps were still uconazole-resistant during biolm growth, indicating that the presence of efflux pumps is not sufficient to account for the observed uconazole resistance in C. albicans biolms22,23. Interestingly, one study reports on a relationship between upregulation of the efflux pump gene MDR1, uconazole resistance and uncoupled oxidative phosphorylation in C. albicans39, while uconazole hypersusceptibility has also been observed in C. albi-cans mitochondrial ETC complex I mutants40. The latter was conrmed by the use of ETC inhibitors (including antimycin A), resulting in increased sensitivity to uconazole. The authors suggest that the hampered ATP production results in down-regulation of efflux genes and concomitant azole susceptibility40. The down-regulation of calcium:proton antiporter activity (represented by VCX1 and orf19.7670) is probably related to the role of the calcineurin pathway in resistance against azoles41, which is reported to inhibit Vcx1-dependent H+/Ca2+ exchange in S. cerevisiae42.

Many of the genes repressed at 24h aer miconazole treatment are involved in cellular respiration, which has not been previously observed in miconazole-treated C. albicans. It was previously reported that miconazole-induced ROS was dependent on a functional citric acid cycle and respiratory ETC in S. cerevisiae and increased respiration was conrmed in planktonically growing C. albicans when treated with miconazole12, which is in contrast to our data on miconazole-treated C. albicans biolms. According to the GO analysis, other important signicantly aected biological processes unrelated to known miconazole targets are those involving organo-nitrogen compound metabolism and one carbon metabolic processes (induced at 24 h aer treatment), single base insertion or deletion binding (repressed at 4h aer treatment) and arginine amino acid biosynthesis (repressed 24 h aer

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treatment). When grown under certain conditions (e.g. miconazole stress), normal nutrition might be impeded and therefore other carbon sources become essential for growth and metabolism of the fungus. These can include amino acids, fatty acids and carboxylic acids43. Together with the observed repression of the ETC, this metabolism shi explains for a large part the high amount of dierentially expressed genes and overlap with hypoxia-induced gene expression changes31.

We selected 17 inhibitors or inducers of interesting pathways based on the GO analysis and the top-aected genes and assessed whether these compounds acted synergistically or antagonistically in combination with miconazole against C. albicans biolms. The action of ve inhibitors (aecting three dierent targets) could be dened as synergistic (FICI< 0.5) in combination with miconazole against C. albicans biolms. The pathways or features aected by these inhibitors were ergosterol biosynthesis, Fe/S bonds and the ETC. The lack of combination eect with miconazole for several of the selected compounds was not totally unexpected. On one hand, it is possible that the identied pathway is not involved in miconazoles mode of action or biolm tolerance against the compound. On the other hand, the biolm structure might prevent the compound from reaching its target in the C. albicans cells.

The rst compound, the HMG-CoA reductase inhibitor simvastatin, is a cholesterol-lowering drug for which antifungal activity has been described previously44. Both statins and azoles target the ergosterol biosynthesis pathway in C. albicans. Statins act more upstream compared to azoles, potentially depleting the fungal cells from alternative sterols and sterol precursors that could be inserted in the fungal membrane upon azole treatment45.

Interestingly, synergy between simvastatin and azoles has been described for planktonically growing yeast cultures46 as is the case for other statin-azole combinations47. However, from our data a synergistic activity between miconazole and simvastatin was biolm-specic as this could not be conrmed in planktonic conditions. The potential of statins in systemic antifungal therapy is debated, due to the low concentrations that can be reached in blood. Moreover, the combination of statins with azole antifungals is questionable since azoles are potent inhibitors of CYP enzymes, leading to arrested metabolism of many statins in the liver44.

The second compound, pyrithione zinc, is used in the treatment of seborrheic dermatitis48. Transcriptome analysis of the eect of sub-lethal concentrations of pyrithione zinc on Saccharomyces cerevisiae identied the strong induction of genes related to iron transport, and many of the strongly downregulated genes are related to the biosynthesis of cytochrome (heme). More recently, it was reported that pyrithione zinc acts through an increase in cellular copper levels that leads to loss of activity of Fe/S cluster-containing proteins49. Such Fe/S clusters are present in many ETC proteins (repressed at 24 h aer miconazole treatment) and in 3-isopropylmalate dehydratase (encoded by LEU1, which is one of the top-induced genes at both 4 h and 24 h aer miconazole treatment). The observed synergistic eect between pyrithione zinc and miconazole (which was only eective in inhibition of metabolic activity, not in eectively killing the C. albicans biolms) could be the consequence of zinc pyrithiones action on these types of enzymes. Interestingly, several synergistic combinations of pyrithione zinc with azoles have been described and some of these are on the market for the treatment of fungal topical infections. For example, combinations between ketoconazole or climbazole and pyrithione zinc have proven eective to treat seborrheic dermatitis, a fungal skin infection condition50.

A similar mechanism might be the basis for the synergistic fungicidal eect of miconazole in combination with the last three compounds (antimycin A, CCCP and sodium azide), known inhibitors of the ETC. Antimycin A binds to the quinone reduction site of complex III, thereby inhibiting the oxidation of ubiquinol in the ETC51. The inhibition of this reaction disrupts the formation of the proton gradient across the inner membrane. Moreover, toxic ROS are formed52. Sodium azide blocks the mitochondrial respiratory chain at complex IV and this action reportedly decreases cellular superoxide levels53, although augmentation of ROS levels has been reported as well aer treatment of dierent cell types with inhibitors of complex IV54. In contrast, the protonophore CCCP does not act on one particular ETC complex, but it generally enables protons to cross lipid bilayers, thereby separating the ow of electrons and the pumping of H+ ions. The latter implies that the energy from electron transfer cannot be used for ATP synthesis55. Also for CCCP treatment both induction and reduction of ROS levels has been reported56,57.

We further attempted to unravel the role for ROS in the fungicidal combinations of miconazole and ETC inhibitors antimycin A, CCCP and sodium azide, by measuring the amount of superoxide radicals present aer treatment. In addition, we included simvastatin and pyrithione zinc in this assay. Only the combinations that were able to eectively kill C. albicans biolms (miconazole in combination with simvastatin, antimycin A, CCCP or sodium azide, as validated by cfu counting) showed a signicant increase in superoxide production compared to single compound treatment. In contrast, the synergistic combinatory eect of pyrithione zinc with miconazole, which was only observed aer metabolic staining and not conrmed by cfu counting, was not associated with increased superoxide levels. Moreover, a signicant correlation was observed between the fold reduction in cfus versus fold increase in superoxide levels for C. albicans biolms treated with miconazole only or treated with miconazole and inhibitor.

It was previously described that miconazole induces an oxidative-damage pathway in planktonically growing C. albicans cultures leading to cell death as a result of the production of ROS via the citric acid cycle and respiratory chain12. Our data of miconazole-treated C. albicans biolms points to an opposite eect occurring in sessile structures. Miconazole treatment results in down-regulation of the citric acid cycle and the respiratory chain and it appears that miconazoles antibiolm eect is enhanced by perturbing the latter. Previous biolm transcriptomic and metabolomic proling studies have demonstrated that mitochondrial respiration is down-regulated in mature C. albicans biolms compared to planktonic growth28,58,59, suggesting this might be part of a protective mechanism for C. albicans biolms as we show for miconazole in this study. The observed down-regulation of cellular respiration in the miconazole-treated C. albicans biolms in this study suggests that these cells are attempting to halt toxic ROS production when treated with miconazole, a feature possibly unique to biolm cells (in contrast with planktonic cultures), making them more tolerant to miconazole action. A similar observation

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was previously made in tobramycin-treated biolms of the Gram-negative bacterium Burkholderia cenocepacia60.

Compounds that restore the ROS-inducing capacity of miconazole appear to act synergistically with miconazole against C. albicans biolms and reduce the living population within the biolm. The ETC inhibitors probably succeed in this action by causing an imbalance in electron transport resulting in increased ROS production (and therefore increased fungicidal activity) by miconazole. Additionally, also inhibition of sterol precursor biosyn-thesis (by simvastatin) in combination with miconazole appears to synergistically increase superoxide induction and fungicidal capacity. In line, when tested under anaerobic conditions, the combination of antimycin A and miconazole had no synergistic activity against C. albicans biolms. The crucial role of superoxide in the antibiolm activity of miconazole was illustrated by the increased miconazole-sensitivity of the sod4sod5sod6 mutant, which is hampered in detoxication of superoxide. Moreover, combination treatment of C. albicans biolms with miconazole and the Sod inhibitor DDC, conrmed the mutant phenotype. Note that DDC was previously reported to also reduce the levels of persister cells within miconazole-treated C. albicans biolms11.

In conclusion, our results show that the above described synergistic combinations (under aerobic conditions) between miconazole and simvastatin, pyrithione zinc or ETC inhibitors are biolm-specic and lead in case of simvastatin and ETC inhibitors to increased killing of C. albicans biolm cells. Hence, inhibition of biolm-specic miconazole-aected pathways seems a promising route for the rational design of fungicidal miconazole combinations against C. albicans biolms.

Materials and Methods

Strains and chemicals. C. albicans strains SC531461, the homozygous triple deletion mutant in SOD4, SOD5 and SOD6 (sod4sod5sod6 mutant) and the corresponding isogenic wild-type strain, CA-IF10033,

were grown routinely on YPD (1% yeast extract, 2% peptone (International Medical Products, Belgium) and 2% glucose (Sigma-Aldrich, USA)) agar plates at 30C. RPMI 1640 medium (pH 7.0) with L-glutamine and without sodium bicarbonate was purchased from Sigma-Aldrich and buered with MOPS (Sigma-Aldrich). Stock solutions of miconazole (Sigma-Aldrich) were prepared in DMSO (VWR International, Belgium). Other chemical compounds were purchased at Sigma-Aldrich (pyrithione zinc, antimycin A, CCCP, sodium azide, chlorosulfuron, myriocin, saquinvair mesylate, orlistat, itaconate, disulram, N-acetyl-D-glucosamine, sodium dichloroacetate and DDC) or TCI Europe (simvastatin and trimethoprim). Nicotinic acid, L-arginine and L-leucine were purchased at VWR International.

Transcriptomic experiment. An overnight culture of C. albicans, grown in YPD, was diluted to an optical density of 0.1 (approximately 106cells/mL) in RPMI 1640 medium and 500L thereof was added to the wells of a 12-well polystyrene microtiter plate (Greiner Bio-One). Aer 1h of adhesion at 37C, the medium was aspirated and biolms were washed with 500L phosphate buered saline (PBS) to remove non-adherent cells, followed by addition of 500 L RPMI 1640 medium. Biolms were allowed to grow for 24 h at 37 C. Miconazole (75 M in RPMI 1640 medium) was then delivered to the biolms (0.5% DMSO background). Biolm samples were collected at 4and 24h aer miconazole treatment for RNA isolation. Measurement of metabolic activity was performed on biolms grown in the same conditions aer washing wit PBS. To this end, 500L Cell-Titre Blue (CTB; Promega, USA)62 diluted 1/10 in PBS was added to each well. Aer 1 h of incubation in the dark at 37 C, uorescence was measured and percentage of metabolically active biolm cells was calculated as described before63.

RNA isolation. Before RNA isolation, biolm material was washed with ice cold PBS, scraped of the bottom of the plate and washed 3 times more with ice cold PBS. RNA was isolated using a hot-phenol protocol as described previously64, combined with mechanical disruption using acid-washed glass beads (Sigma-Aldrich) in the Precellys 24 (Bertin technologies; 2 45s with 15s break at 6,000rpm). Control of the quality and integrity of the RNA was done with the NanoDrop ND-1000 spectrophotometer (NanoDrop Technologies, USA) and the BioAnalyzer (Agilent, USA).

Library preparation, RNA-sequencing and data analysis. Library preparation for RNA sequencing was performed using the Illumina (USA) TruSeq kit and sequencing was performed in one lane of an Illumina HiSeq2000 sequencer using the HiSeq Reagent Kit (Illumina, USA) according to the manufacturers instructions. An average of 7,761,850 reads per sample (50 bp) was generated (Supplementary Table S1). Raw sequencing reads were deposited at the Sequence Read Archive of NCBI (accession number SRA306211). Low quality ends (Q < 20) were trimmed and adapters were trimmed at the end when there was at least a 10bp overlap and 90% match. Reads that were shorter than 35 bp aer trimming were removed. Poly-A reads (more than 90% of the bases equal A), ambiguous reads (containing N), low quality reads (more than 50% of the bases Q < 25) and artefact reads (all but 3 bases in the read equal one base type) were removed. Aer processing, 99.8% of the initial reads remained. Processed reads were mapped to the reference C. albicans genome SC5314_A21 with Tophat v2.0.8b65. We removed reads from the alignment that are non-primary mappings or have a mapping quality 20. An average of 93.8% of the processed reads were mapped to the reference genome. The number of mapped reads that overlap with gene features (using the C_albicansSC5314_version_A21_s02_m07_r10-features.g annotation le66) were determined with HTSeq 0.5.4p367. Genes for which all samples have less than 1 count per million reads (absent genes) were not considered for dierentially expressed gene analysis. For each of the 5,910 remaining genes, we performed dierential expression analysis for each time point (i.e. 4 h and 24 h aer miconazole treatment) with the EdgeR package of Bioconductor, by tting a negative binomial generalized linear model68.

The resulting p values were corrected for multiple testing with Benjamini-Hochberg to control the false discovery rate at 1%69. For identication of GO terms overrepresented in each of the dierentially expressed gene lists, enrichment analysis was conducted with the Candida Genome Database GO Term Finder Tool70.

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Quantitative reverse transcription PCR. Primers for reverse transcription were designed using Primer-BLAST (www.ncbi.nlm.nih.gov/tools/primer-blast) (Supplementary Table S2). DNase treatment, reverse transcription and qRT-PCR analysis were carried out as described previously71. Two normalization genes, ACT1 and EFB1, were used. Relative log2 induction ratios of treated samples compared with mock-treatment were calculated based on the Ct method72.

To determine the minimal concentration of the compound that results in 50% remaining biolm metabolic activity (BEC50) for the respective compounds, C. albicans SC5314 biolms were grown and treated in a round bottomed microplate as described before63. Measurement of metabolic activity was performed using the metabolic activity dye CTB63.

In order to determine possible synergistic interactions between compounds, checkerboard analysis and FICI calculations were performed as described before using the metabolic activity dye CTB63 and FICI (fractional inhibitory concentration index) was calculated as FICI = [CA/BEC50A] + [CB/

BEC50B], in which BEC50A and BEC50B are the BEC50 values of compound A and B alone, respectively, and CA and CB are the concentrations of the drugs A and B at iso-eective combinations, respectively73. Note that CB values were derived by linear regression from the whole dose-response curves, whereas CA values represent the actual concentration of compound A (i.e. simvastatin, pyrithione zinc, antimycin A, CCCP or sodium azide) in the checkerboard experiments, as indicated in Table2. The interaction was dened as synergistic for a value of FICI 0.5, indierent for 0.5<FICI< 4 and antagonistic for FICI4.074.

Planktonic assay. Synergistic action of compounds on planktonically growing C. albicans SC5314 cells was determined by FICI calculations as described above. MIC50 values (minimal concentration of the compound that causes a 50% reduction of planktonic cell growth), determined by OD measurement as described previously75

were used instead of BEC50 values. Sensitivity to miconazole (MIC50) was similarly assessed for planktonically growing sod4sod5sod6 mutant and the corresponding isogenic wild-type strain, CA-IF100.

Cfu determination and superoxide detection. Biolms were grown and treated as described above. Alternatively, biolms were grown as described above but the treatment was performed in anaerobic conditions by placing the biolm plates in a jar in the AnoxomatTM Mark II System (Advanced Instruments INC, Massachusetts, USA). Aer 24h of treatment at 37C, biolm cells were washed and dissolved in 100L PBS by vigorously pipetting. Of this cell suspension, 10 L was diluted and plated out on YPD agar plates to determine the number of fungal cfu aer 2days of incubation at 30C. To determine the amount of superoxide formed, the remaining 90 L was stained by adding 10 L of a 200 M dihydroethidium (Life Technologies Europe) stock solution. This suspension was transferred to black-walled microplates (Greiner) and incubated for 20 min at room temperature in the dark. Finally, uorescence was measured with a uorescence spectrometer (Synergy Mx multi-mode microplate reader, BioTek, USA) at ex 510 nm and eem 595 nm and values were corrected for uorescence measured in blank wells. Cfu determination was also performed for the sod4sod5sod6 mutant and the corresponding isogenic wild-type strain, CA-IF100, aer treatment with 30M miconazole. Calculation of the Pearson correlation coefficient and analysis of signicance was performed in GraphPad Prism 6.

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Acknowledgements

The authors thank Evelien Gerits and Els Meert for technical assistance and Kim Vriens for assistance regarding statistical analyses. This work was supported by Agentschap voor Innovatie door Wetenschap en Techniek (IWTVlaanderen, Belgium, grant number SBO 120005) and by Fonds voor Wetenschappelijk Onderzoek (FWOVlaanderen, Belgium grant number WO.026.11N). K.D.C. and K.T. acknowledge the receipt of a mandate from FWO-Vlaanderen (12F0516N) and the Industrial Research Fund (KU Leuven, Belgium, IOFm/05/022), respectively.

Author Contributions

Experiments were designed by K.D.C., K.D.B., T.C., B.P.A.C. and K.T. and performed by K.D.C., I.S., F.V.D.D. and A.P.; K.T. coordinated the study. The manuscript was written by K.D.C. and revised by K.D.B., B.P.A.C. and K.T. All authors reviewed the manuscript.

Additional Information

Supplementary information accompanies this paper at http://www.nature.com/srep

Competing nancial interests: The authors declare no competing nancial interests.

How to cite this article: De Cremer, K. et al. Stimulation of superoxide production increases fungicidal action of miconazole against Candida albicans biolms. Sci. Rep. 6, 27463; doi: 10.1038/srep27463 (2016).

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