Repurposing the quinoline antibiotic nitroxoline to treat infections caused by the brain-eating amoebaBalamuthia mandrillaris

Abstract

Balamuthia mandrillaris is a pathogenic free-living amoeba that causes a rare but almost always fatal infection of the central nervous system called granulomatous amoebic encephalitis (GAE). Two distinct forms of B. mandrillaris -a proliferative trophozoite form and a non-proliferative cyst form, which is highly resistant to harsh physical and chemical conditions -have been isolated from environmental samples worldwide and are both observed in infected tissue. Patients suffering from GAE are typically treated with aggressive and prolonged multi-drug regimens often including the antimicrobial agents miltefosine and pentamidine isethionate. However, survival rates remain low and studies evaluating the susceptibility of B. mandrillaris to these compounds and other potential therapeutics are limited. To address the need for more effective treatments, we screened 2,177 clinically-approved compounds for in vitro activity against B. mandrillaris. The quinoline antibiotic nitroxoline, which has safely been used in humans to treat urinary tract infections, was identified as a lead compound. We show that nitroxoline inhibits both trophozoites and cysts at low micromolar concentrations, which are within a physiologically relevant range. We compare the in vitro efficacy of nitroxoline to drugs currently used in the standard of care for GAE and find that nitroxoline is the most potent and selective inhibitor of B. mandrillaris tested. Furthermore, we demonstrate that nitroxoline prevents B. mandrillaris-mediated destruction of host cells in cultured fibroblast and primary brain explant models also at physiologically relevant concentrations. Together, our findings indicate that nitroxoline is a promising candidate for repurposing as a novel treatment of B. mandrillaris infections. Laurie and White et al., Inhibition of Balamuthia mandrillaris by nitroxoline 3 Importance Balamuthia mandrillaris is responsible for hundreds of reported cases of amoebic encephalitis, the majority of which have been fatal. Despite being an exceptionally deadly pathogen, B. mandrillaris is understudied, leaving many open questions regarding epidemiology, diagnosis, and treatment. Due to the lack of effective drugs to fight B. mandrillaris infections, mortality rates remain high even for patients receiving intensive care. This study addresses the need for new anti-amoebic drugs using a high-throughput screening approach to identify novel B. mandrillaris inhibitors. The most promising candidate identified was the quinoline antibiotic nitroxoline, which has a long history of safe use in humans.We show that nitroxoline kills B. mandrillaris at physiologically relevant concentrations and exhibits greater potency and selectivity than drugs commonly used in the current standard of care. The findings we present demonstrate the potential of nitroxoline to be an important new tool in the treatment of life threatening B. mandrillaris infections.

Distribution and Current State of Molecular Genetic Characterization in Pathogenic Free-Living Amoebae

“…B. mandrillaris has been isolated from environmental samples (water, soil, and dust) and cases of infections in humans and animals. Interestingly, although it is distributed among all continents, it is more common in the southern United States and South America (especially Peru) [ 118 ]. Cope et al [ 119 ] discussed the epidemiology issue in the United States and the clinical characteristics of BAE from 1974–2016 and hypothesized that the hot and dry weather of the southwest side of the country would be the type of environment in which B. mandrillaris thrives.…”

Distribution and Current State of Molecular Genetic Characterization in Pathogenic Free-Living Amoebae

“…mandrillaris has been isolated from environmental samples (water, soil, and dust) and cases of infections in humans and animals. Interestingly, although it is distributed among all continents, it is more common in the southern United States and South America (especially Peru) [115]. Cope et al [116] discussed the epidemiology issue in the United States and the clinical characteristics of BAE from 1974-2016 and hypothesized that the hot and dry weather of the southwest side of the country would be the type of environment in which B. mandrillaris thrives.…”

Uncovering nitroxoline activity spectrum, mode of action and resistance across Gram-negative bacteria

“…1a) and FDA-approved antibiotic, used for more than 50 years as treatment and prophylaxis of acute and recurrent UTIs in several European and Asian countries [2][3][4] . Because of its excellent safety profile 3,[5][6][7] and activity against different organisms, nitroxoline has been recently proposed to be repurposed as antituberculosis 8 , antifungal 9,10 , antiviral 11,12 , antiparasitic 13 and anticancer [14][15][16][17] agent. Nitroxoline has been shown to exert bacteriostatic activity against a broad range of Gramnegative and Gram-positive species 18,19 .…”