WO2018191692A1

WO2018191692A1 - Methods for treating fungal infections

Info

Publication number: WO2018191692A1
Application number: PCT/US2018/027614
Authority: WO
Inventors: Kenneth BARTIZAL; Paul Daruwala; Voon ONG
Original assignee: Cidara Therapeutics, Inc.
Priority date: 2017-04-14
Filing date: 2018-04-13
Publication date: 2018-10-18
Also published as: WO2018191692A8

Abstract

The invention relates to methods of treating vulvovaginal candidiasis in a subject by subcutaneously administering to the subject CD1 01 in salt or neutral form. In some embodiments, CD101 in salt or neutral form is administered in combination with at least one antifungal agent.

Description

METHODS FOR TREATING FUNGAL INFECTIONS

BACKGROUND

Vulvovaginal candidiasis is a common mucosal yeast infection of the vagina. Most vulvovaginal candidiasis cases (>85%) are caused by Candida albicans, whereas Candida glabrata is the second most common species. Between 5% and 20% of women suffer from recurrent vulvovaginal candidiasis with long-term discomfort. Prolonged treatment with oral fluconazole (6 months) is often used for recurrent infection . However, relapse is common.

Echinocandins are members of a leading class of antifungal agents for the treatment of fungal infections. These compounds target the cell wall by preventing the production of β-1 ,3-glucan through inhibition of the catalytic subunit of 1 ,3-p-D-glucan synthase enzyme complex. The three echinocandins approved by the U.S. Food and Drug Administration (FDA) for the treatment of invasive fungal infections (caspofungin, anidulafungin, and micafungin) are available only in intravenous formulation. The limitations on the route and frequency of delivery preclude the utilization these echinocandins for, e.g. , treatment of vulvovaginal candidiasis. There is a need in the art for improved methods of treatment for vulvovaginal candidiasis.

SUMMARY

The invention relates to methods of treating vulvovaginal candidiasis in a subject (e.g. , a human) by administering (e.g. , subcutaneously administering) to the subject a salt of CD1 01 , or a neutral form thereof. A salt of CD1 01 , or a neutral form thereof, displays long-acting pharmacokinetics with a long half-life, slow clearance, and strong activities against Candida spp. (e.g. , Candida albicans). The stability of CD1 01 in salt or neutral form especially enables non-intravenous formulations of CD1 01 , e.g., subcutaneous formulations.

In a first aspect, the invention features a method of treating vulvovaginal candidiasis in a subject.

The method includes subcutaneously administering to the subject doses of about 25 mg to about 600 mg (e.g. , about 25 mg to about 550 mg, about 25 mg to about 500 mg, about 25 mg to about 450 mg, about 25 mg to about 400 mg, about 25 mg to about 350 mg, about 25 mg to about 300 mg, about 25 mg to about 250 mg, about 25 mg to about 200 mg, about 25 mg to about 1 90 mg, about 25 mg to about 1 80 mg, about 25 mg to about 1 70 mg, about 25 mg to about 1 60 mg, about 25 mg to about 1 50 mg, about 25 mg to about 140 mg, about 25 mg to about 1 30 mg, about 25 mg to about 120 mg, about 25 mg to about 1 1 0 mg, about 25 mg to about 1 00 mg, about 25 mg to about 90 mg, about 25 mg to about 80 mg, about 25 mg to about 70 mg, about 25 mg to about 60 mg, about 25 mg to about 50 mg, about 25 mg to about 40 mg, about 25 mg to about 30 mg, about 50 mg to about 600 mg, about 1 00 mg to about 600 mg, about 1 50 mg to about 600 mg, about 200 mg to about 600 mg, about 250 mg to about 600 mg, about 300 mg to about 600 mg, about 350 mg to about 600 mg, about 400 mg to about 600 mg, about 450 mg to about 600 mg, about 500 mg to about 600 mg, about 550 mg to about 600 mg, about 50 mg to about 550 mg, about 1 00 mg to about 500 mg, about 1 50 mg to about 450 mg, about 200 mg to about 400 mg, about 250 mg to about 350 mg, about 250 mg to about 300 mg, or about 300 mg to about 350 mg ; about 25, 50, 75, 1 00, 125, 1 50, 1 75, 200, 225, 250, 275, 300, 325, 350, 375, 400, 425, 450, 475, 500, 525, 550, 575, or 600 mg) of CD1 01 ,

in salt or neutral form, wherein the CD101 in salt or neutral form is administered in one or more doses (e.g., 1 to 24, 1 to 20, 1 to 16, 1 to 12, 1 to 8, 1 to 4, 2 to 24, 2 to 20, 2 to 1 6, 2 to 12, 2 to 8, 2 to 4, 4 to 24, 4 to 20, 4 to 16, 4 to 12, 4 to 8, 6 to 24, 6 to 20, 6 to 16, 6 to 12, 6 to 8, 8 to 24, 8 to 20, 8 to 16, 8 to 12, 10 to 24, 10 to 20, 1 0 to 16, 10 to 12, 12 to 24, 12 to 20, or 12 to 16 doses; 1 , 2, 3, 4, 5, 6, 7, 8, 9, 10, 1 1 , 12, 13, 14, 1 5, 16, 1 7, 18, 19, 20, 21 , 22, 23, or 24 doses) to the subject and wherein no more than one dose is administered per week.

In some embodiments of the methods described herein, a single dose of CD101 in salt or neutral form is administered to the subject for the duration of the treatment.

In some embodiments, one dose of CD101 in salt or neutral form is administered once every 4 weeks over a period of 4 to 12 weeks (e.g., 4, 8, or 12 weeks). In some embodiments, one dose of CD101 in salt or neutral form is administered once every 3 weeks over a period of 3 to 12 weeks (e.g., 3, 6, 9, or 12 weeks). In some embodiments, one dose of CD101 in salt or neutral form is administered once every 2 weeks over a period of 2 to 12 weeks (e.g., 2, 4, 6, 8, 10, or 12 weeks). In some embodiments, one dose of CD101 in salt or neutral form is administered once a week over a period of 1 to 12 weeks (e.g., 1 , 2, 3, 4, 5, 6, 7, 8, 9, 10, 1 1 , or 12 weeks).

In some embodiments of the methods described herein, one or more doses of CD101 in salt or neutral form is administered over a period of 12 to 24 weeks. In some embodiments, one dose of CD101 in salt or neutral form is administered once every 4 weeks over a period of 12 to 24 weeks (e.g., 12, 16, 20, or 24 weeks). In some embodiments, one dose of CD101 in salt or neutral form is administered once every 3 weeks over a period of 12 to 24 weeks (e.g., 12, 15, 18, 21 , or 24 weeks). In some

embodiments, one dose of CD101 in salt or neutral form is administered once every 2 weeks over a period of 12 to 24 weeks (e.g., 12, 14, 1 6, 18, 20, 22, or 24 weeks). In some embodiments, one dose of CD101 in salt or neutral form is administered once a week over a period of 12 to 24 weeks (e.g., 12, 13, 14, 15, 1 6, 17, 1 8, 19, 20, 21 , 22, 23, or 24 weeks).

In some embodiments of the methods described herein, 1 to 3 doses (e.g., 1 , 2, or 3 doses) of CD101 in salt or neutral form is administered over a period of 3 weeks. In some embodiments, 2 to 6 doses (e.g., 2, 3, 4, 5, or 6 doses) of CD101 in salt or neutral form is administered over a period of 6 weeks. In some embodiments, 3 to 9 doses (e.g., 3, 4, 5, 6, 7, 8, or 9 doses) of CD101 in salt or neutral form is administered over a period of 9 weeks. In some embodiments, 4 to 12 doses (e.g., 4, 5, 6, 7, 8, 9, 10, 1 1 , or 12 doses) of CD101 in salt or neutral form is administered over a period of 12 weeks. In some embodiments of the methods described herein, one or more doses of CD101 in salt or neutral form is administered to the subject for at least 1 month (e.g., at least 2 months, at least 3 months, at least 4 months, at least 5 months, or at least 6 months). In some embodiments of the methods described herein, one or more doses of CD101 in salt or neutral form is administered to the subject for at least 1 year (e.g., at least 1 .5 years, at least 2 years, at least 3 years, at least 4 years, or at least 5 years). In some embodiments of the methods described herein, one or more doses of CD101 in salt or neutral form is administered to the subject for the subject's lifetime. In some embodiments of the methods described herein, one or more doses of CD101 in salt or neutral form is administered to the subject for at least six months to the subject's lifetime.

In some embodiments of the methods described herein, the subject is administered one dose of

CD101 in salt or neutral form every 1 to 12 weeks (e.g., every 1 to 1 1 weeks, every 1 to 10 weeks, every 1 to 9 weeks, every 1 to 8 weeks, every 1 to 7 weeks, every 1 to 6 weeks, every 1 to 5 weeks, every 1 to 4 weeks, every 1 to 3 weeks, or every 1 to 2 weeks; weekly, every 2 weeks, every 3 weeks, every 4 weeks, every 5 weeks, every 6 weeks, every 7 weeks, every 8 weeks, every 9 weeks, every 1 0 weeks, every 1 1 weeks, or every 12 weeks).

In some embodiments, the subject is administered one dose of CD101 in salt or neutral form once a week. In some embodiments, the subject is administered one dose of CD101 in salt or neutral form once every 2 weeks. In some embodiments, the subject is administered one dose of CD101 in salt or neutral form once every 4 weeks. In some embodiments, the subject is administered one dose of CD101 in salt or neutral form once every 6 weeks. In some embodiments, the subject is administered one dose of CD101 in salt or neutral form once every 8 weeks. In some embodiments, the subject is administered one dose of CD101 in salt or neutral form once every 1 0 weeks. In some embodiments, the subject is administered one dose of CD1 01 in salt or neutral form once every 12 weeks.

In some embodiments of this aspect of the invention, the subject has failed treatment with an azole compound (e.g., fluconazole, clotrimazole, miconazole, tioconazole, butoconazole, or terconazole) for vulvovaginal candidiasis. In some embodiments, the subject has failed treatment with fluconazole.

In another aspect, the invention features a method of preventing or reducing the likelihood of vulvovaginal candidiasis in a subject by subcutaneously administering to the subject CD101 in salt or neutral form.

In some embodiments of the methods described herein, the subject is immunocompromised. In some embodiments, the subject is diagnosed with a disease (e.g., acquired immunodeficiency syndrome or diabetes) that causes immunosuppression. In some embodiments, the subject is pregnant. In some embodiments, the subject is being administered or is about to be administered immunosuppresive drugs. In some embodiments, the subject is being administered estrogen.

In some embodiments of the methods described herein, the vulvovaginal candidiasis is caused by a fungus in the genus Candida (e.g., Candida albicans, C. glabrata, C. dubliniensis, C. krusei, C. parapsilosis, C. tropicalis, C. orthopsilosis, C. guilliermondii, C. rugosa, C. auris, or C. lusitaniae). In some embodiments of the methods described herein, the vulvovaginal candidiasis is caused by Candida albicans. In some embodiments, the vulvovaginal candidiasis is caused by Candida glabrata. In some embodiments of the methods described herein, the vulvovaginal candidiasis is uncomplicated vulvovaginal candidiasis. In some embodiments, the vulvovaginal candidiasis is complicated vulvovaginal candidiasis (e.g., recurrent vulvovaginal candidiasis).

In some embodiments of the methods described herein, the method further includes

administering to the subject at least one antifungal agent. In some embodiments, CD101 in salt or neutral form and the antifungal agent are administered substantially simultaneously. In some embodiments, CD101 in salt or neutral form and the antifungal agent are administered separately. In some

embodiments, CD101 in salt or neutral form is administered first, followed by administration of the antifungal agent. In some embodiments, the antifungal agent is administered first, followed by administration of CD101 in salt or neutral form. In some embodiments, CD101 in salt or neutral form and the antifungal agent are administered substantially simultaneously, followed by administration of CD101 in salt or neutral form or the antifungal agent alone. In some embodiments, CD101 in salt or neutral form or the antifungal agent is administered alone, followed by administering of CD101 in salt or neutral form and the antifungal agent substantially simultaneously.

In some embodiments of the methods described herein, the antifungal agent is an azole compound, an allylamine compound, an echinocandin compound, a polygene compound, flucytosine (Ancobon^®)), enfumafungin, or SCY-078. In some embodiments of the methods described herein, the antifungal agent is an azole compound (e.g., fluconazole, clotrimazole, miconazole, tioconazole, butoconazole, or terconazole). In some embodiment, the antifungal agent is fluconazole.

In some embodiments of the methods described herein, the subcutaneous administration of CD101 in salt or neutral form does not cause any negative injection site effects. In some embodiments, CD101 is administered as an aqueous pharmaceutical composition (e.g., an aqueous pharmaceutical composition having a pH of from 4 to 8). In some embodiments of the methods described herein, CD101 in salt form is CD101 acetate.

Definitions

As used herein, the term "CD101 " refers to the compound having the structure shown below. The term "CD101 in salt form" or "a salt of CD101 " refers to CD101 when its tertiary ammonium ion positive charge is balanced with a negative counterion (e.g., an acetate).

As used herein, the term "a neutral form" includes to zwitterionic forms of CD101 in which CD1 01 has no net positive or negative charge. The zwitterion is present in a higher proportion in basic medium (e.g., pH 9) relative to CD101 or a salt of CD101 . In some embodiments, the zwitterion may also be present in its salt form.

As used herein, the term "vulvovaginal candidiasis" refers to a fungal infection of the vulva and vagina caused by Candida spp. Candida albicans is the most common cause of vulvovaginal candidiasis. Symptoms of vulvovaginal candidiasis include, e.g., itching, soreness, and/or burning discomfort in the vagina and vulva, heavy white curd-like vaginal discharge, and bright red rash affecting inner and outer parts of the vulva. Over-the-counter drugs for vulvovaginal candidiasis include azole drugs in cream (e.g., clotrimazole), suppository (e.g., miconazole), and oral formulations (e.g., fluconazole).

As used herein, the term "antifungal agent" refers to an antifungal drug used to treat a fungal infection. Antifungal drugs include, but are not limited to, azole compounds, allylamine compounds, echinocandin compounds, polyene compounds, flucytosine (Ancobon^®)), enfumafungin, and SCY-078. In some embodiments of the methods described herein, the subject may be administered both CD1 01 in salt or neutral form and at least one antifungal agent for the duration of the treatment. An antifungal agent as defined herein does not include CD101 in salt or neutral form.

As used herein, to "prevent " or "reduce the likelihood" of vulvovaginal candidiasis refers to prophylactic treatment of a subject who is not yet ill, but who is susceptible to, or otherwise at risk of, developing vulvovaginal candidiasis.

As used herein, the term "negative injection site effect" refers to any adverse reactions the subject might experience at the site of the subcutaneous injection after a drug is administered. Negative injection site effects at the injection site may include, e.g., pain or tenderness at the injection site, itching, bruising, and/or swelling of the skin, and skin rash. Some negative injection site effects may be caused by an allergic reaction to the drug or other components in the pharmaceutical composition.

As used herein, the term "about" refers to a range of values that is ± 10% of specific value. For example, "about 150 mg" includes ± 1 0% of 150 mg, or from 135 mg to 165 mg. Such a range performs the desired function or achieves the desired result. For example, "about" may refer to an amount that is within less than 10% of, within less than 5% of, within less than 1 % of, within less than 0.1 % of, and within less than 0.01 % of the stated amount.

By "dose" is meant the amount of CD101 administered to the subject (e.g., a human). As used herein, the amount in each dose refers to the amount of CD101 (structure shown above) that does not include the negative counterion (e.g., an acetate) if CD101 is in its salt form. For example, a dose of about 25 mg to about 600 mg of CD101 in salt or neutral form refers to about 25 mg to about 600 mg of CD101 , not including the acetate ion if CD101 is in an acetate salt form.

All publications, patents, and patent applications are herein incorporated by reference in their entirety to the same extent as if each individual publication, patent or patent application was specifically and individually indicated to be incorporated by reference in its entirety.

DESCRIPTION OF THE DRAWINGS

FIG. 1 shows an outline of the study design for Example 1 .

FIG. 2A is a line graph showing the average group weight of rats with vulvovaginal candidiasis throughout the study. Arrows on x-axis indicate the estradiol treatment days. FIG. 2B is a line graph showing the average group weights of rat with vulvovaginal candidiasis throughout the study relative to weight on day of infection (Day 0). Arrows on x-axis indicate the estradiol treatment days.

FIG. 3 is a graph showing the pharmacokinetic profile of CD101 in a rat model of vulvovaginal candidiasis (VVC) following a 10 mg/kg intravenous and subcutaneous dose injection.

FIG. 4 is a scatterplot showing vaginal lavage burden Day +1 (24 h) post infection/prior to treatments following localized vaginal infection with C. albicans 529L.

FIG. 5 is a scatterplot showing vaginal lavage burden Day +2 (48 h) post infection.

FIG. 6 is a scatterplot showing vaginal lavage burden Day +3 (72 h) post infection.

FIG. 7 is a scatterplot showing vaginal lavage burden Day +5 (120 h) post infection.

FIG. 8 is a scatterplot showing vaginal lavage burden Day +7 (168 h) post infection.

FIG. 9 is a scatterplot showing vaginal lavage burden Day +9 (216 h) post infection.

FIG. 10A is a bar graph showing the mean daily vaginal lavage burden of the rats in each group over duration of the study following localized vaginal infection with C. albicans 529L and administration with vehicle, CD101 , or fluconazole (error bars are geometric standard deviation).

FIG. 10B is a scatterplot showing the daily vaginal lavage burden of each rat over duration of study following localized vaginal infection with C. albicans 529L and administration with vehicle, CD101 , or fluconazole.

FIG. 10C is a line graph showing the daily vaginal lavage burden of the rats in each group over duration of study following localized vaginal infection with C. albicans 529L and administration with vehicle, CD1 01 , or fluconazole (error bars are geometric standard deviation).

FIG. 1 1 A is a bar graph showing the geometric mean terminal vaginal tissue burden (vagina, uterus, and uterine horns) Day +9 (216 h) post infection (error bars are geometric standard deviation).

FIG. 1 1 B is a scatterplot showing terminal vaginal tissue burden (vagina, uterus, and uterine horns) Day +9 (216 h) post infection.

FIG. 12 is a graph showing kidney fungal burden in neutropenic mice prophylactically treated with a single subcutaneous administration of CD1 01 and infected with Candida albicans.

FIG. 13A is a graph showing percent survival over time in neutropenic mice prophylactically treated with CD101 and infected with Aspergillus fumigatus (see Example 1 ).

FIG. 13B is a graph showing the pharmacokinetic profile of CD101 in mice following a 10-mg/kg subcutaneous dose injection.

FIG. 13C is a graph showing a correlation between free drug plasma concentration at time of infection over MIC (0.03 μg/mL) with higher free drug plasma concentration generating greater CFU reduction.

FIG. 14 is a graph showing reductions in kidney colony forming units following CD101 subcutaneous administration.

FIG. 15 is a graph showing plasma levels of CD1 01 in two cynomolgus monkeys over 10 days after a single 30 mg/kg dose administered subcutaneously.

FIG. 16 is a graph showing total CD1 01 exposure following intravenous and subcutaneous administration. DETAILED DESCRIPTION

Provided are methods of treating or preventing vulvovaginal candidiasis in a subject (e.g., a human) by administering (e.g., subcutaneously administering) to the subject a salt of CD101 , or a neutral form thereof. In some embodiments of the methods described herein, CD101 in salt or neutral form is administered in combination with at least one antifungal agent. The inventors have found that CD101 displays long-acting pharmacokinetics with a long half-life, slow clearance, and strong and fast-acting activities against Candida spp. (e.g., Candida albicans). The stability of CD101 in salt or neutral form especially enables non-intravenous formulations of CD101 , e.g., subcutaneous formulations. I. Vulvovaginal Candidiasis

Vulvovaginal candidiasis is a fungal infection of the vulva and vagina and is estimated to be the second most common cause of vaginitis after bacterial vaginosis. About three-quarters of women have at least one episode of vulvovaginal candidiasis in their lifetime and approximately half have two or more episodes. Most cases of vulvovaginal candidiasis are caused by Candida albicans, with a minority of cases caused by other Candida spp. (e.g., Candida glabrata). In some embodiments, Candida spp. can also colonize without causing any symptoms.

Vulvovaginal candidiasis is often classified as uncomplicated or complicated vulvovaginal candidiasis. Uncomplicated cases are sporadic episodes of mile infections mainly caused by Candida albicans. Complicated cases are cases of severe infection for a prolonged period, vulvovaginal candidiasis during pregnancy, or vulvovaginal candidiasis associated with other medical conditions, such as immunosuppression or diabetes. Some cases of complicated vulvovaginal candidiasis are caused by other species of Candida (e.g., Candida glabrata). One form of complicated vulvovaginal candidiasis is recurrent vulvovaginal candidiasis, which is defined as four or more episodes of vulvovaginal candidiasis per year. Approximately 5 to 8% of vulvovaginal candidiasis cases are recurrent, and C. glabrata and other non-C. albicans are isolated in about 10 to 20% of these cases.

The most common symptoms of vulvovaginal candidiasis are burning pain and pruritus of the vulva with discomfort that can lead to dysuria and dyspareunia in more severe cases. Other symptoms include, e.g., edema and erythema of the vulva and the vagina accompanied by vaginal discharge that may be watery or thick and curdy. Clinical diagnosis of vulvovaginal candidiasis can be made in several ways, such as microscopic examination of the discharge, fungal culture, and the whiff test, which includes adding to the vaginal dischargel 0% potassium hydroxide that is used to distinguish between vulvovaginal candidiasis and bacterial vaginosis, with bacterial vaginosis releasing an amine-like odor.

Treatment of vulvovaginal candidiasis depends on whether the patient has uncomplicated or complicated vulvovaginal candidiasis. For uncomplicated vulvovaginal candidiasis, short-term local therapies (e.g., topical or suppository) or single-dose oral treatments are available, e.g., azole drugs. Examples of some over-the-counter azole drugs include, e.g., fluconazole 150 mg single oral dose, clotrimazole 1 % or 2% cream, miconazole 2% or 4% cream, miconazole 100 mg, 200 mg, or 1200 mg vaginal suppository, tioconazole 6.5% ointment, butoconazole 2% cream, terconazole 0.4% or 0.8% cream, terconazole 80 mg vaginal suppository. For complicated vulvovaginal candidiasis (e.g., recurrent vulvovaginal candidiasis), prolonged treatment is often needed. For example, three doses of oral fluconazole 150 mg may be given three times with a gap of 72 hours in between adjacent doses. Local therapies (e.g., topical or suppository) with azole drugs may be applied daily for at least one week.

Methods described herein include methods of treating or preventing complicated or

uncomplicated vulvovaginal candidiasis by subcutaneously administering to a subject CD101 in salt or neutral form. CD101 displays long-acting pharmacokinetics with a long half-life, slow clearance, and strong and fast-acting activities against Candida (e.g., Candida albicans). The stability of CD101 in salt or neutral form especially enables subcutaneous formulations of CD101 .

II. Methods of Treatment

The invention provides methods of treating vulvovaginal candidiasis (e.g., vulvovaginal candidiasis caused by Candida albicans or Candida glabrata) in a subject by administering (e.g., subcutaneously administering) to the subject CD1 01 in salt or neutral form thereof. In some

embodiments of the methods described herein, the subject has failed treatment with an azole compound (e.g., fluconazole, clotrimazole, miconazole, tioconazole, butoconazole, or terconazole) for vulvovaginal candidiasis. In some embodiments, the subject has failed treatment with a fluconazole.

Furthermore, the invention also provides methods of preventing or reducing the likelihood of vulvovaginal candidiasis (e.g., vulvovaginal candidiasis caused by Candida albicans or Candida glabrata) in a subject by subcutaneously administering to the subject CD101 in salt or neutral form.

In some embodiments of the methods described herein, the subject is in a demographic with high prevalence of vulvovaginal candidiasis. For example, the subject is more likely to develop vulvovaginal candidiasis, or the vulvovaginal candidiasis may be more difficult to treat in a subject, if the subject is, e.g., immunocompromised, diagnosed with a disease that causes immunosuppression (e.g., acquired immunodeficiency syndrome or diabetes), or pregnant. In some embodiments, the subject is also more likely to develop vulvovaginal candidiasis, or the vulvovaginal candidiasis may be more difficult to treat in a subject, if the subject is being administered or is about to be administered immunosuppresive drugs, or if the subject is being administered estrogen.

In methods of treating or preventing vulvovaginal candidiasis in a subject, the vulvovaginal candidiasis is caused by a fungus in the genus Candida (Candida albicans, C. glabrata, C. dubliniensis, C. krusei, C. parapsilosis, C. tropicalis, C. orthopsilosis, C. guilliermondii, C. rugosa, C. auris, or C. lusitaniae). In some embodiments of the methods described herein, the vulvovaginal candidiasis is caused by Candida albicans. In some embodiments, the vulvovaginal candidiasis is caused by Candida glabrata. The invention provides methods of treating or preventing vulvovaginal candidiasis caused by Candida albicans in a subject by administering (e.g., subcutaneously administering) to the subject CD101 in salt or neutral form. In some embodiments of the methods described herein, the vulvovaginal candidiasis is uncomplicated vulvovaginal candidiasis. In some embodiments, the vulvovaginal candidiasis is complicated vulvovaginal candidiasis (e.g., recurrent vulvovaginal candidiasis).

In some embodiments of the methods described herein, the administering step includes administering (e.g., subcutaneously administering) doses of about 25 mg to about 600 mg of CD101 in salt or neutral form thereof, in which one or more doses are administered to the subject and no more than one dose is administered per week. III. Combination Therapy

In some embodiments, in addition to administering CD101 in salt or neutral form to treat or prevent a subject from vulvovaginal candidiasis (e.g., vulvovaginal candidiasis caused by Candida albicans or Candida glabrata), the subject may also be administered at least one antifungal agent. The methods described herein further include administering at least one antifungal agent (e.g., one, two, or three antifungal agents) in combination with CD101 in salt or neutral form. In some embodiments of the methods, CD101 in salt or neutral form and the antifungal agent are administered substantially simultaneously. In some embodiments, CD101 in salt or neutral form and the antifungal agent are administered separately. For example, CD1 01 in salt or neutral form may be administered first, followed by administration of the antifungal agent. In other embodiments, the antifungal agent is administered first, followed by administration of CD101 in salt or neutral form. In some embodiments, CD101 in salt or neutral form and the antifungal agent are administered substantially simultaneously, followed by administration of CD101 in salt or neutral form or the antifungal agent alone. In other embodiments, CD101 in salt or neutral form or the antifungal agent is administered alone, followed by administration of CD101 in salt or neutral form and the antifungal agent substantially simultaneously.

Depending on the administration methods, in some embodiments, CD101 in salt or neutral form may be formulated in a pharmaceutical composition alone. In some embodiments, CD101 in salt or neutral form may be formulated in combination with at least one antifungal agent in the same

pharmaceutical composition.

Antifungal agents that may be administered in combination with CD101 in methods described herein include, but are not limited to, azole compounds, allylamine compounds, echinocandin

compounds, polyene compounds, flucytosine (Ancobon^®)), enfumafungin, and SCY-078. Azole compounds include, but are not limited to, fluconazole, albaconazole, bifonazole, butoconazole, clotrimazole, econazole, efinaconazole, fenticonazole, isavuconazole, isoconazole, itraconazole, ketoconazole, Miconazole, miconazole, omoconazole, oxiconazole, posaconazole, pramiconazole, ravuconazole, sertaconazole, sulconazole, terconazole, tioconazole, voriconazole, VT-1 161 , and VT- 1598. Allylamine compounds include, but are not limited to, terbinafine, butenafine, naftifine, and amorolfine. Echinocandin compounds include, but are not limited to, micafungin, caspofungin, anidulafungin, cilofungin, echinocandin B, and pneumocandin (but not CD101 in salt or neutral form). Polyene compounds include, but are not limited to, amphotericin B, nystatin, natamycin, rimocidin, filipin, candicin, hamycin, perimycin, and dermostatin.

Furthermore, in some embodiments of the methods described herein, CD101 in salt or neutral form may be administered in combination with one or more of the following azole compounds: fluconazole 150 mg single oral dose, clotrimazole 1 % or 2% cream, miconazole 2% or 4% cream, miconazole 1 00 mg, 200 mg, or 1200 mg vaginal suppository, tioconazole 6.5% ointment, butoconazole 2% cream, terconazole 0.4% or 0.8% cream, or terconazole 80 mg vaginal suppository.

IV. Pharmaceutical Compositions and Preparations

CD101 may be prepared in a pharmaceutical composition. In some embodiments, the pharmaceutical composition includes a salt of CD101 , or a neutral form thereof, and pharmaceutically acceptable carriers and excipients. Depending on the mode of administration (e.g., subcutaneously, topically, orally, intravenously, intravaginally, intraorally, intramuscularly, intradermally, intraarterially, or by inhalation) and the dosage, CD101 used in the methods described herein may be formulated into suitable pharmaceutical compositions to permit facile delivery. In some embodiments, for subcutaneous administration of CD101 in salt or neutral form in methods described herein, CD101 may be formulated as an aqueous pharmaceutical composition, e.g., an aqueous pharmaceutical composition at a pH of from 4 to 8. In some embodiments, CD101 in salt form may be formulated in a pharmaceutical composition as CD101 acetate. A summary of such techniques is found in Remington: The Science and Practice of Pharmacy, 22^nd Edition, Lippincott Williams & Wilkins, (2012); and Encyclopedia of

Pharmaceutical Technology, eds. J. Swarbrick and J. C. Boylan, 2006, Marcel Dekker, New York, each of which is incorporated herein by reference.

In some embodiments of the methods described herein, when CD101 in salt or neutral form and at least one antifungal agent are used in combination (e.g., used in combination by administering substantially simultaneously or used in combination separately), CD101 and the antifungal agent(s) may be formulated in separate pharmaceutical compositions. In some embodiments, CD101 and the antifungal agent(s) may be formulated in the same pharmaceutical composition.

CD101 or pharmaceutical compositions containing CD101 may be administered in a manner compatible with the dosage formulation and in such amount as is therapeutically effective to result in an improvement or remediation of the symptoms. The pharmaceutical compositions are administered in a variety of dosage forms, e.g., subcutaneous dosage forms, topical dosage forms, intravenous dosage forms, and oral dosage forms (e.g., ingestible solutions, drug release capsules). CD101 or

pharmaceutical compositions may be in the form of, e.g., tablets, capsules, pills, powders, granulates, suspensions, emulsions, solutions, gels including hydrogels, pastes, ointments, creams, plasters, drenches, osmotic delivery devices, suppositories, enemyas, injectables, implants, sprays, preparations suitable for iontophoretic delivery, or aerosols. The compositions may be formulated according to conventional pharmaceutical practice.

Acceptable carriers and excipients in the pharmaceutical compositions are nontoxic to recipients at the dosages and concentrations employed. Acceptable carriers and excipients may include buffers such as phosphate, citrate, HEPES, and TAE, antioxidants such as ascorbic acid and methionine, preservatives such as hexamethonium chloride, octadecyldimethylbenzyl ammonium chloride, resorcinol, and benzalkonium chloride, proteins such as human serum albumin, gelatin, dextran, and

immunoglobulins, hydrophilic polymers such as polyvinylpyrrolidone, amino acids such as glycine, glutamine, histidine, and lysine, and carbohydrates such as glucose, mannose, sucrose, and sorbitol.

The pharmaceutical compositions can be administered parenterally in the form of an injectable formulation. Pharmaceutical compositions for injection can be formulated using a sterile solution or any pharmaceutically acceptable liquid as a vehicle. Pharmaceutically acceptable vehicles include, but are not limited to, sterile water, physiological saline, and cell culture media (e.g., Dulbecco's Modified Eagle Medium (DMEM), a-Modified Eagles Medium (a-MEM), F-12 medium). Formulation methods are known in the art, see e.g., Gibson (ed.) Pharmaceutical Preformulation and Formulation (2^nd ed.) Taylor & Francis Group, CRC Press (2009).

The pharmaceutical compositions can be prepared in the form of an oral formulation.

Formulations for oral use include tablets containing the active ingredient(s) in a mixture with non-toxic pharmaceutically acceptable excipients. These excipients may be, for example, inert diluents or fillers (e.g., sucrose, sorbitol, sugar, mannitol, microcrystalline cellulose, starches including potato starch, calcium carbonate, sodium chloride, lactose, calcium phosphate, calcium sulfate, or sodium phosphate); granulating and disintegrating agents (e.g., cellulose derivatives including microcrystalline cellulose, starches including potato starch, croscarmellose sodium, alginates, or alginic acid); binding agents (e.g., sucrose, glucose, sorbitol, acacia, alginic acid, sodium alginate, gelatin, starch, pregelatinized starch, microcrystalline cellulose, magnesium aluminum silicate, carboxymethylcellulose sodium,

methylcellulose, hydroxypropyl methylcellulose, ethylcellulose, polyvinylpyrrolidone, or polyethylene glycol); and lubricating agents, glidants, and antiadhesives (e.g., magnesium stearate, zinc stearate, stearic acid, silicas, hydrogenated vegetable oils, or talc). Other pharmaceutically acceptable excipients can be colorants, flavoring agents, plasticizers, humectants, buffering agents, and the like. Formulations for oral use may also be provided as chewable tablets, or as hard gelatin capsules wherein the active ingredient is mixed with an inert solid diluent (e.g., potato starch, lactose, microcrystalline cellulose, calcium carbonate, calcium phosphate or kaolin), or as soft gelatin capsules wherein the active ingredient is mixed with water or an oil medium, for example, peanut oil, liquid paraffin, or olive oil. Powders, granulates, and pellets may be prepared using the ingredients mentioned above under tablets and capsules in a conventional manner using, e.g., a mixer, a fluid bed apparatus or a spray drying equipment.

The pharmaceutical composition may be formed in a unit dose form as needed. The amount of active component, e.g., CD101 , included in the pharmaceutical compositions are such that a suitable dose within the designated range is provided (e.g., a dose within the range of 0.01 -100 mg/kg of body weight).

V. Routes, Dosage, and Administration

CD101 or pharmaceutical compositions including CD101 may be formulated for, e.g., subcutaneous administration, topical administration, oral administration, intravaginal administration, intravenous administration, intraoral administration, intramuscular administration, intradermal administration, intraarterial administration, by suppository, or by inhalation. In particular embodiments, CD101 or pharmaceutical compositions including CD101 may be formulated for subcutaneous administration. In particular embodiments, CD101 or pharmaceutical compositions including CD101 may be formulated for subcutaneous administration in the treatment or prevention of vulvovaginal candidiasis (e.g., vulvovaginal candidiasis caused by Candida albicans or Candida glabrata). CD101 , in salt or a neutral form, displays long-acting pharmacokinetics with a long half-life, slow clearance, and strong activities against Candida spp. (e.g., Candida albicans). The stability of CD101 in salt or neutral form especially enables non-intravenous formulations of CD101 , e.g., subcutaneous formulations. For injectable formulations, various effective pharmaceutical carriers are known in the art. See, e.g., Remington: The Science and Practice of Pharmacy, 22^nd ed., (2012) and ASHP Handbook on Injectable Drugs, 18^th ed., (2014).

The dosage of CD101 or the pharmaceutical composition depends on factors including the route of administration, the infection to be treated, and physical characteristics, e.g., age, weight, general health, of the subject (e.g., a human). The dosage may be adapted by the physician in accordance with conventional factors such as the extent of the disease and different parameters of the subject. In some embodiments, the amount of CD101 or the pharmaceutical composition contained within a single dose may be an amount that effectively treats the infection without inducing significant toxicity.

In some embodiments of the methods described herein, the administering step includes administering (e.g., subcutaneously administering) doses of about 25 mg to about 600 mg (e.g., about 25 mg to about 550 mg, about 25 mg to about 500 mg, about 25 mg to about 450 mg, about 25 mg to about 400 mg, about 25 mg to about 350 mg, about 25 mg to about 300 mg, about 25 mg to about 250 mg, about 25 mg to about 200 mg, about 25 mg to about 1 90 mg, about 25 mg to about 180 mg, about 25 mg to about 170 mg, about 25 mg to about 160 mg, about 25 mg to about 1 50 mg, about 25 mg to about 140 mg, about 25 mg to about 130 mg, about 25 mg to about 120 mg, about 25 mg to about 1 10 mg, about 25 mg to about 100 mg, about 25 mg to about 90 mg, about 25 mg to about 80 mg, about 25 mg to about 70 mg, about 25 mg to about 60 mg, about 25 mg to about 50 mg, about 25 mg to about 40 mg, about 25 mg to about 30 mg, about 50 mg to about 600 mg, about 100 mg to about 600 mg, about 1 50 mg to about 600 mg, about 200 mg to about 600 mg, about 250 mg to about 600 mg, about 300 mg to about 600 mg, about 350 mg to about 600 mg, about 400 mg to about 600 mg, about 450 mg to about 600 mg, about 500 mg to about 600 mg, about 550 mg to about 600 mg, about 50 mg to about 550 mg, about 100 mg to about 500 mg, about 150 mg to about 450 mg, about 200 mg to about 400 mg, about 250 mg to about 350 mg, about 250 mg to about 300 mg, or about 300 mg to about 350 mg; about 25, 50, 75, 100, 125, 150, 175, 200, 225, 250, 275, 300, 325, 350, 375, 400, 425, 450, 475, 500, 525, 550, 575, or 600 mg) of CD101 in salt or neutral form, in which one or more doses are administered to the subject and no more than one dose is administered per week.

In some embodiments, a single dose of CD101 in salt or neutral form is administered to the subject for the duration of the treatment.

In some embodiments of the methods described herein, the subject is administered one dose of CD101 in salt or neutral form every 1 to 12 weeks (e.g., every 1 to 1 1 weeks, every 1 to 10 weeks, every 1 to 9 weeks, every 1 to 8 weeks, every 1 to 7 weeks, every 1 to 6 weeks, every 1 to 5 weeks, every 1 to 4 weeks, every 1 to 3 weeks, or every 1 to 2 weeks; weekly, every 2 weeks, every 3 weeks, every 4 weeks, every 5 weeks, every 6 weeks, every 7 weeks, every 8 weeks, every 9 weeks, every 1 0 weeks, every 1 1 weeks, or every 12 weeks).

In some embodiments of the methods described herein, one or more doses of CD101 in salt or neutral form is administered to the subject for at least 1 month (e.g., at least 2 months, at least 3 months, at least 4 months, at least 5 months, or at least 6 months). In some embodiments of the methods described herein, one or more doses of CD101 in salt or neutral form is administered to the subject for at least 1 year (e.g., at least 1 .5 years, at least 2 years, at least 3 years, at least 4 years, or at least 5 years). In some embodiments of the methods described herein, one or more doses of CD101 in salt or neutral form is administered to the subject for the subject's lifetime. In some embodiments of the methods described herein, one or more doses of CD101 in salt or neutral form is administered to the subject for at least six months to the subject's lifetime.

In some embodiments of the methods described herein, one or more doses (e.g., 1 to 12, 1 to 10, 1 to 8, 1 to 6, 1 to 4, 1 to 2, 2 to 12, 2 to 10, 2 to 8, 2 to 6, 2 to 4, 4 to 12, 4 to 10, 4 to 8, 4 to 6, 6 to 12, 6 to 10, 6 to 8, 8 to 12, 8 to 1 0, or 1 0 to 12 doses; 1 , 2, 3, 4, 5, 6, 7, 8, 9, 10, 1 1 , or 12 doses) of CD101 is administered over a period of 1 to 12 weeks. In some embodiments, one dose of CD101 in salt or neutral form is administered (e.g., subcutaneously administered) once every 4 weeks for 4 to 12 weeks (e.g., 4 to 8 weeks; 4, 8, or 12 weeks). In some embodiments, one dose of CD101 in salt or neutral form is administered (e.g., subcutaneously administered) once every 3 weeks for 3 to 12 weeks (e.g., 3 to 9 or 3 to 6 weeks; 3, 6, 9, or 12 weeks). In some embodiments, one dose of CD101 in salt or neutral form is administered (e.g., subcutaneously administered) once every 2 weeks for 2 to 12 weeks (e.g., 2 to 10, 2 to 8, 2 to 6, or 2 to 4 weeks; 2, 4, 6, 8, 1 0, or 12 weeks). In some embodiments, one dose of CD101 in salt or neutral form is administered (e.g., subcutaneously administered) once a week for 1 to 12 weeks (e.g., 1 to 1 1 , 1 to 10, 1 to 9, 1 to 8, 1 to 7, 1 to 6, 1 to 5, 1 to 4, 1 to 3, or 1 to 2 weeks; 1 , 2, 3, 4, 5, 6, 7, 8, 9, 10, 1 1 , or 12 weeks).

In some embodiments of the methods described herein, one or more doses (e.g., 1 to 24, 1 to 20, 1 to 16, 1 to 12, 1 to 8, 1 to 4, 2 to 24, 2 to 20, 2 to 16, 2 to 12, 2 to 8, 2 to 4, 4 to 24, 4 to 20, 4 to 1 6, 4 to 12, 4 to 8, 6 to 24, 6 to 20, 6 to 16, 6 to 12, 6 to 8, 8 to 24, 8 to 20, 8 to 16, 8 to 12, 10 to 24, 10 to 20, 10 to 16, 10 to 12, 12 to 24, 12 to 20, or 12 to 16 doses; 1 , 2, 3, 4, 5, 6, 7, 8, 9, 10, 1 1 , or 12 doses) of CD101 is administered over a period of 12 to 24 weeks. In some embodiments, one dose of CD1 01 in salt or neutral form is administered once every 4 weeks over a period of 12 to 24 weeks (e.g., 12 to 20 or 12 to 16 weeks; 12, 1 6, 20, or 24 weeks). In some embodiments, one dose of CD101 in salt or neutral form is administered once every 3 weeks over a period of 12 to 24 weeks (e.g., 12 to 21 , 12 to 18, or 12 to 15 weeks; 12, 1 5, 18, 21 , or 24 weeks). In some embodiments, one dose of CD101 in salt or neutral form is administered once every 2 weeks over a period of 12 to 24 weeks (e.g., 12 to 22, 12 to 20, 12 to 18, 12 to 16, or 12 to 14, weeks; 12, 14, 16, 18, 20, 22, or 24 weeks). In some embodiments, one dose of CD101 in salt or neutral form is administered once a week over a period of 12 to 24 weeks (e.g., 12 to 23, 12 to 22, 12 to 21 , 12 to 20, 12 to 19, 12 to 18, 12 to 17, 12 to 16, 12 to 15, 12 to 14, or 12 to 13 weeks; 12, 13, 14, 15, 1 6, 17, 1 8, 19, 20, 21 , 22, 23, or 24 weeks).

In some embodiments, one dose of CD101 in salt or neutral form is administered over a period of 3 weeks. In some embodiments, two doses of CD101 in salt or neutral form is administered over a period of 3 weeks. In some embodiments, three doses of CD101 in salt or neutral form is administered over a period of 3 weeks (e.g., one dose every week).

In some embodiments, one dose of CD101 in salt or neutral form is administered over a period of 6 weeks. In some embodiments, two doses of CD101 in salt or neutral form is administered over a period of 6 weeks (e.g., one dose every three weeks). In some embodiments, three doses of CD101 in salt or neutral form is administered over a period of 6 weeks (e.g., one dose every two weeks). In some embodiments, six doses of CD101 in salt or neutral form is administered over a period of 6 weeks (e.g., one dose every week).

In some embodiments, one dose of CD101 in salt or neutral form is administered over a period of 9 weeks. In some embodiments, two doses of CD101 in salt or neutral form is administered over a period of 9 weeks. In some embodiments, three doses of CD101 in salt or neutral form is administered over a period of 9 weeks (e.g., one dose every three weeks). In some embodiments, nine doses of CD101 in salt or neutral form is administered over a period of 9 weeks (e.g., one dose every week).

In some embodiments, one dose of CD101 in salt or neutral form is administered over a period of 12 weeks. In some embodiments, two doses of CD101 in salt or neutral form is administered over a period of 12 weeks (e.g., one dose every six weeks). In some embodiments, three doses of CD101 in salt or neutral form is administered over a period of 12 weeks (e.g., one dose every four weeks). In some embodiments, six doses of CD101 in salt or neutral form is administered over a period of 12 weeks (e.g., one dose every two weeks). In some embodiments, 12 doses of CD1 01 in salt or neutral form is administered over a period of 12 weeks (e.g., one dose every week).

In some embodiments, one dose of CD101 in salt or neutral form is administered over a period of

15 weeks. In some embodiments, two doses of CD101 in salt or neutral form is administered over a period of 15 weeks. In some embodiments, three doses of CD101 in salt or neutral form is administered over a period of 15 weeks (e.g., one dose every five weeks). In some embodiments, five doses of CD101 in salt or neutral form is administered over a period of 15 weeks (e.g., one dose every three weeks). In some embodiments, 15 doses of CD101 in salt or neutral form is administered over a period of 15 weeks (e.g., one dose every week).

In some embodiments, one dose of CD101 in salt or neutral form is administered over a period of 18 weeks. In some embodiments, two doses of CD101 in salt or neutral form is administered over a period of 18 weeks (e.g., one dose every 9 weeks). In some embodiments, three doses of CD101 in salt or neutral form is administered over a period of 18 weeks (e.g., one dose every six weeks). In some embodiments, six doses of CD101 in salt or neutral form is administered over a period of 18 weeks (e.g., one dose every three weeks). In some embodiments, 9 doses of CD1 01 in salt or neutral form is administered over a period of 18 weeks (e.g., one dose every two weeks). In some embodiments, 18 doses of CD101 in salt or neutral form is administered over a period of 18 weeks (e.g., one dose every week).

In some embodiments, one dose of CD101 in salt or neutral form is administered over a period of 21 weeks. In some embodiments, three doses of CD101 in salt or neutral form is administered over a period of 21 weeks (e.g., one dose every 8 weeks). In some embodiments, four doses of CD101 in salt or neutral form is administered over a period of 21 weeks. In some embodiments, seven doses of CD101 in salt or neutral form is administered over a period of 21 weeks (e.g., one dose every three weeks). In some embodiments, 21 doses of CD101 in salt or neutral form is administered over a period of 21 weeks (e.g., one dose every week).

In some embodiments, one dose of CD101 in salt or neutral form is administered over a period of 24 weeks. In some embodiments, two doses of CD101 in salt or neutral form is administered over a period of 24 weeks (e.g., one dose every 12 weeks). In some embodiments, three doses of CD1 01 in salt or neutral form is administered over a period of 24 weeks (e.g., one dose every eight weeks). In some embodiments, six doses of CD101 in salt or neutral form is administered over a period of 24 weeks (e.g., one dose every four weeks). In some embodiments, 12 doses of CD1 01 in salt or neutral form is administered over a period of 24 weeks (e.g., one dose every two weeks). In some embodiments, 24 doses of CD101 in salt or neutral form is administered over a period of 24 weeks (e.g., one dose every week).

As used herein, the amount in each dose refers to the amount of CD101 that does not include the negative counterion (e.g., an acetate) if CD101 is in its salt form. For example, a dose of about 400 mg or 200 mg of CD101 in salt or neutral form refers to 400 mg or 200 mg of CD101 , not including the acetate ion if CD1 01 is in an acetate salt form.

The following Example is intended to further illustrate but not to limit the disclosure herein.

EXAMPLES

EXAMPLE 1. Efficacy of CD101 in the treatment of vulvovaginal candidiasis in a rat model

Methods and Experimental Design

Animal Strain. Wistar rats were supplied by Harlan Laboratories UK and were specific pathogen free. Rats weighed 80-100 g at the time of surgery. Ovariectomies were performed. Rats were allowed 4-7 days recovery before transportation to the facility where the experiment was to be performed.

Following arrival, rats were allowed at least 4 days acclimatization before start of the experiment. Rats weighed 100-120 g at the time of ovariectomy and were about 300g at start of the experiment.

Animal Housing. Rats were housed in sterilized individual ventilated cages that expose the animals at all times to HEPA filtered sterile air. Rats had free access to food and water (sterile) and had sterile aspen chip bedding (changed every 3-4 days). Additionally, during infection, rats had additional access to wet food if required to ensure they remained fully hydrated.

The room temperature was 22 °C +/- 1 °C, with a relative humidity of 60% and maximum background noise of 56 dB. Mice were exposed to 12 hour light/dark cycles.

Pre-conditioning. Female Wistar rats underwent ovariectomy at least 10 days prior to the study commencing. They were further pre-conditioned by treatment with 5 mg/kg 17-p-estradiol administered subcutaneously (SC) every other day on days -7, -5, -3 and -1 prior to infection with C. albicans strain 529. Estradiol treatment continued every other day throughout the study to 7 days post-infection.

Yeast Isolate. Candida albicans strain 529L was used in this chronic rat vaginal infection model. Infection. Yeast strains were inoculated aerobically onto Sabouraud dextrose agar media (SAB) containing 0.05 mg/mL chloramphenicol and incubated at 30 °C for 48-72 h. 18-24 h prior to infection, Yeast Peptone Dextrose (YPD) broths were inoculated with 2-3 isolated colonies from agar plates and incubated overnight (37 °C on an orbital shaker). Broths containing C. albicans strain 529L were washed 3 times with sterile phosphate buffered saline (PBS) before dilution to the correct inoculum for infection. Cell counts were determined using a haemocytometer and confirmed by quantitative culture on

Sabouraud dextrose agar.

Rats were infected with 0.1 mL by intravaginal administration under inhaled isoflurane anaesthesia using about 9.8x10⁵ CFU/mL (9.8x10⁴ CFU/Rat) C. albicans strain 529L

Preparation of ΊΊ-β-estradiol, CD 101, and Fluconazole

17-p-estradiol in 20% 2-hydroxypropyl-p-cyclodextrin (HPBCD). 90 mg of 17-p-estradiol (Sigma, UK) was weighed and added to 7.2 g HPBCD (Sigma, UK) and water for infection (WFI) added to obtain a final volume of 36 mL of suspension and used immediately to dose animals at 2.5 mg/mL.

Vehicle: 12.81 mg/mL Mannitol in WFI. 384.3 mg of mannitol was weighed and 30 mL of WFI was added. The mixture was briefly vortexed until completely solubilized and was filter sterilized using a 0.2 μιτι filter. This was stored at 2-8 °C until required and was warmed to room temperature before use.

CD101 . To 61 .3 mg of CD101 add 12.26 mL of vehicle and mixture briefly vortexed until completely solubilized. This was used neat at 2 mL/kg for the 10 mg/kg dose and was diluted in vehicle 1 :2 to prepare the 5 mg/kg dose. These were stored at 2-8 °C until required and were allowed to warm to room temperature before use. Animals were dosed at 2 mL/kg dosing volume by the SC route.

Fluconazole. Clinical oral suspension was used to prepare fluconazole as follows: 1 ) Oral suspension was prepared as per manufacturer instructions (10 mg/mL Fluconazole); and 2) The 10 mg/mL oral suspension was further diluted 1 :5 in WFI to give 2 mg/mL (20 mg/kg) dosing solution. This was maintained at room temperature until required and animals dosed at 10 mg/mL dosing volume orally (by the PO route).

Treatment. CD101 , fluconazole, and vehicle treatments started at 24 h post infection by the SC route following the dose volume and frequency shown in Table 1 . The fluconazole treatment also started at 24 h post infection but was administered by the PO route at the dose volume and frequency shown in Table 1 . The study design is further outlined in FIG. 1 . Table 1

Endpoints. The rats were monitored at a frequency appropriate for their clinical condition. Rat weights were recorded at least once daily to ensure animals remained within ethical limits.

Rats do not typically succumb to infection in this model but untreated rats may experience some weight loss, dehydration, and piloerection. Reduction in weight and general loss of condition due to estradiol treatment are also typical in this rat model. Colonization with C. albicans was determined by quantitative culture of daily vaginal lavage samples. Rats were euthanized 9 days post infection and C. albicans determined by quantitative culture of vaginal tissue (including uterine horns).

Lavage samples were obtained on days 1 (pre-treatment), 2, 3, 5, 7, and 9 days post infection by flushing rat vaginas 4 times with 0.1 mL pre-warmed sterile PBS. Following euthanasia, vaginal tissue including uterine horns was removed prior to weighing. Tissues were homogenized in 2 mL sterile PBS using a bead-beater. Vaginal wash and tissue homogenates were diluted appropriately then

quantitatively cultured on to Sabouraud dextrose agar containing 0.05 mg/mL chloramphenicol and incubated at 37 °C for up to 72 h before being counted.

Statistical analysis. Data were analysed using StatsDirect software (version 2.7.8) using the non- parametric Kruskal-Wallis test and if this was statistically significant all pairwise comparisons were analysed (Conover-lnman).

Results

In this study, the in vivo efficacy of CD101 dosed SC once at 5 and 1 0 mg/kg or dosed SC twice at 5 mg/kg was investigated in a rat model of vulvovaginal candidiasis caused by C. albicans strain 529L. CD101 and Fluconazole Tolerability and Clinical Condition. CD101 and fluconazole at all treatment dose and duration were well tolerated with no adverse events observed. Animal weights following localized vaginal infection with C. albicans and treatment with CD101 or fluconazole are shown in FIGS. 1 A and 1 B. Animal weights are shown as daily group average weights (FIG. 2A) and the weight relative to that measured on day of infection (day 0, FIG. 2B). As is typical of this model, ovariectomised rats slowly lost weight following multiple doses of 17-p-estradiol. Weight loss observed was typical of the model and did not seem to be exacerbated by CD101 treatment.

Pharmacokinetic Profile of CD101. The pharmacokinetic (PK) profile of CD101 in female rats (three per group) was characterized. Following subcutaneous (SC) administration, the time to Cmax (i.e. Tmax) was observed between 8 to 24 hours post-dose suggesting slow absorption/distribution from the site of administration (FIG. 3). The half-life, t¹/2, values were similar to those observed from intravenous (IV) dosing and shows a V/≥ of 48 hrs and SC bioavailability of 97%.

Efficacy Data. A robust model of localized C. albicans strain 529L vaginal infection was successfully established. The geometric mean burden of all infected rats was about 0.9 x10³ CFU/mL on Day 1 post infection in pre-treatment vaginal lavage samples (Table 2 and FIG. 4). This level of infection recovered from vehicle only lavage samples increased slightly (about 2.0 Log10 CFU/mL) over the duration of the study and was stable between day 5 to end of study. A high level (about 5.5 Log10 CFU/g) of C. albicans burden was also obtained from terminal vagina, uterus, and uterine horn tissue taken from vehicle control rats at the end of the study (see Table 8 and FIGS. 1 1 A and 1 1 B) as is typical of this model (the fungi are tightly adherent to the vaginal mucosa due to pseudo-hyphal invasion).

Table 2. Geometric mean burden on Day 1 post infection in pre-treatment vaginal lavage samples

The daily lavage data showed the following results:

Day 1 post treatment (Day 2 post infection, Table 3 and FIG. 5) - All doses of CD101 showed similar reduction in burden (about 1 .3 Log1 0 CFU/mL). Fluconazole showed slightly higher reduction (about 1 .6 Log1 0 CFU/mL). However, neither the CD101 nor fluconazole burden was statistically different from the vehicle burden.

Table 3. Geometric mean burden on Day 1 post treatment (Day 2 post infection)

Day 2 post treatment ( Day 3 post infection, Table 4 and FIG. 6) - CD1 01 dosed once at 10 mg/kg showed a higher reduction in burden compared to CD1 01 dosed once or twice at 5 mg/kg. The CD101 burden data was more variable compared to vehicle or fluconazole treated animals.

Fluconazole showed the greatest reduction in burden with 1 1 /12 rats having burden below the limit of detection. All CD1 01 and fluconazole treatments were statistically different from the vehicle treatments.

Table 4. Geometric mean burden on Day 2 post treatment (Day 3 post infection)

Standard Log Group Log reduction

Group Geometric

Treatment Deviation Geometric mean from vehicle mean (CFU/mL)

(CFU/mL) (CFU/mL) control (CFU/mL)

Fluconazole

20mg/kg PO - 1 .49 4.08 0.17 3.40

Dosed Twice

• Day 4 post treatment (Day 5 post infection, Table 5 and FIG. 7) - CD101 dosed at 5 mg/kg once or twice reduced the burden to about 1 Log10 CFU/m but this was not statistically different from the vehicle treatments. CD1 01 dosed once at 10 mg/kg was highly efficacious and reduced the burden to about 4 Log10 CFU/mL with 5/6 rats having burden below the limit of detection and almost similar to the fluconazole. All rats treated with the fluconazole once or twice had burdens that were below the limit of detection.

Table 5. Geometric mean burden on Day 4 post treatment (Day 5 post infection)

Day 6 post treatment (Day 7 post infection, Table 6 and FIG. 8) - CD101 dosed once at 5 mg/kg showed slight increase in fungal burden compared to day 5 post infection. CD101 dosed twice at 5 mg/kg reduced the burden more than day 5 post infection but was not statistically significant. CD101 dosed at 10 mg/kg was similar to day 5 post infection but the overall burden reduction was not as high as day 5. The single rat with detectable burden on day 5 had a slightly increased fungal burden. Table 6. Geometric mean burden on Day 6 post treatment (Day 7 post infection)

Day 8 post treatment (Day 9 post infection, Table 7 and FIG. 9) - Data were similar to day 6 post treatment.

Table 7. Geometric mean burden on Day 8 post treatment (Day 9 post infection)

The lavage burden data are summarized in FIGS. 10A-10C. A robust VVC model was established (FIG. 10C); vehicle-treated rats maintained a high fungal burden throughout the study, rising to 2x10⁴ CFU/mL by day 9 post infection. CD101 administered once at 10 mg/kg was the most effective dose and similar to fluconazole dosed at 20 mg/kg showing comparable CFU by day 5 post infection and thereafter the burden increased slightly. The increase was caused by a single rat that had a small fungal burden on day 5 but which increased on day 7 and 9 post infection. As expected, day 9 tissue CFU were higher than lavage CFU for all treatments, but the overall pattern was similar to lavage CFU. All but 1 rat treated with CD101 once at 10 mg/kg had undetectable CFU.

The terminal vaginal tissue burdens (vagina, uterus, and uterine horns) are shown in Table 8 and FIGS. 1 1 A and 1 1 B. The data is in line with that observed in the vaginal lavage washes. The data showed that CD101 dosed once at 5 mg/kg resulted in the smallest reduction in burden (about 0.4 Log10 CFU/g) followed by CD101 dosed twice at 5 mg/kg (about 0.9 Log10 CFU/g), neither were statistically lower than vehicle treatments. 5/6 rats treated with CD101 dosed once at 1 0 mg/kg had burdens below the levels of detection. A single rat had low level of burden. All rats treated with fluconazole once or twice had burdens below the limit of detection.

Table 8. Terminal vaginal tissue burden (vagina, uterus, and uterine horns) (Day +9 post infection)

Summary

A robust model of localized rat chronic model of vulvovaginal candidiasis following infection with C. albicans strain 529L was established. The infectious burden peaked to >4Log10 CFU/mL in lavage samples from the vehicle treatment group. A high level of C .albicans burden was also recovered from vagina, uterus, and uterine horn tissue taken from vehicle control rats.

Treatment with CD101 administered by the SC route showed the following in lavage wash burdens:

• A single dose of 5 mg/kg administered 24 h post infection reduced fungal burden with a peak effect at day 3 post infection (48 h post treatment) but which was not maintained to the end of the study. Burden reduction was statistically significant vs. vehicle controls only at day 3 post infection.

• A single dose of 5 mg/kg given twice; once at 24 h and another at 48 h post infection resulted in a superior burden reduction compared to the single dose which was maintained for the duration of the study. But like the single dose, statistical significance was only observed at day 3 post infection. • A single dose at 10 mg/kg (equivalent to 200 mg in human) given at 24 h post infection resulted in substantial reduction in fungal burden at 3 day post infection (48 h post treatment) with a peak effect at 5 day post infection. Thereafter burden appeared to increase again but this was due to a single rat that retained burden whereas all others had actually burdens below the level of detection. These results suggest excellent CD101 distribution/penetration into vaginal mucosa via a single SC dose.

Treatment with CD101 administered by the SC route showed the following vaginal tissue burden:

• A single dose at 5 mg/kg 24 h post infection resulted in a slight reduction in burden.

• A single dose at 5 mg/kg given twice; once at 24 h and another at 48 h post infection (total of 2

doses) resulted in a larger decrease in burden compared to the single dose.

• A single dose at 10 mg/kg (equivalent to 200 mg in human) given at 24 h post infection resulted in substantial reduction in burden with clearance in fungal burden to below the level of detection in 5 of the 6 rats. Similar to the lavage data, a single rat retained fungal burden. These results suggest excellent CD101 distribution/penetration into vaginal mucosa via a single SC dose.

All rats treated with fluconazole at 20 mg/kg PO dosed once at 24 h post infection or single dose twice (24 h and 48 h post infection) showed a faster reduction in burden from lavage washes compared to CD101 . At the end of the study, all rats had cleared the infection to below the level of detection in both the lavage wash and vaginal tissue.

Example 2. Prophylactic, single-dose, subcutaneous administ ation of CD101 shows robust efficacy in neutropenic mouse models of candidiasis and aspergillosis.

The potential for intermittent subcutaneous (SC) administration of CD1 01 may extend the utility of CD101 beyond that of other echinocandins, to include antifungal treatment and prophylaxis in the outpatient setting. Neutropenic mouse models of candidiasis and aspergillosis were used to evaluate the in vivo efficacy of single SC doses of CD101 as antifungal prophylaxis.

Method

Candidiasis model: ICR mice (5/group) were rendered neutropenic by cyclophosphamide on day- 4 (150 mg/kg) and day-1 (100 mg/kg), then challenged (day-0) with Candida albicans ATCC SC5314 via IV (100 μΙ_, 105 CFU/mouse). Prior to challenge, mice were given one SC dose (5, 10, or 20 mg/kg) of CD101 on day -5, day-3, or day-1 . At 24 hours post-challenge, kidneys were removed for CFU enumeration.

Aspergillosis model: ICR mice (6/group) were rendered neutropenic by cyclophosphamide on day-3 (6 mg/mouse), day+1 , and day+4 (2 mg/mouse). Challenge with Aspergillus fumigatus ATCC via IV (100 μΙ_, 104 CFU/mouse) occurred on day-0. Prior to challenge, mice were given one SC dose (5, 10 or 20 mg/kg) of CD101 on day-5, day-3, or day-1 . Survival was monitored for 14 days. Results

In the candidiasis model (FIG. 12), kidney CFU decreased with increasing doses of CD101 and prophylaxis occurring closer to challenge. Complete clearance was observed in all animals receiving 10 mg/kg at day-3 and day-1 and all but one animal receiving 20 mg/kg on day-3. At doses of 5 or 10 mg/kg, prophylaxis with CD101 demonstrated a significant decrease in CFU at day-3 and day-1 . At the highest dose of 20 mg/kg, CD101 reduced CFU burden regardless of prophylactic treatment day.

In the aspergillosis model (FIG. 13A), survival was monitored for 14 days after challenge.

Subcutaneous CD101 at 5, 10, and 20 mg/kg on day -5, day-3 or day-1 were associated with significant (>50%) increases in survival compared with vehicle. The 5 mg/kg group showed increased survival when prophylaxis was given closer to challenge. All animals in the 10 and 20 mg/kg groups survived regardless of prophylactic treatment day.

The pharmacokinetic profile of CD101 in mice following a 1 0-mg/kg subcutaneous dose shows a half-life of -25 hrs with an absolute bioavailability of -50% (FIG. 13B). The AUC from subcutaneous 1 0 mg/kg in mouse approximates an IV 200 mg dose in human. In general, a correlation was noted between free drug plasma concentration at time of infection over MIC (0.03 μg/mL) with higher free drug plasma concentration generating greater CFU reduction as shown in FIG. 13C for the candidiasis model.

Exceptions as indicated by (1 ) and (2) in FIG. 13C correspond to 10 and 20 mg/kg (Day -3 and -5 respectively) and indicate an apparent hysteresis where effective prophylaxis occurs despite low plasma concentration likely due to slower clearance from tissues.

Conclusion

CD101 , a novel echinocandin, administered in a single SC dose was found to be protective against fungal challenge. CD101 SC may provide a potential new agent and route of administration for intermittent outpatient echinocandin treatment and prophylaxis.

Example 3. Subcutaneous injection of CD101

Single dose subcutaneous (SC) administration may further extend the utility of CD101 beyond that of other echinocandins, to antifungal treatment and prophylaxis in the outpatient setting. Preclinical studies were conducted to evaluate the feasibility of using SC administration of CD101 for these purposes.

Methods

The efficacy of CD101 SC was studied in an immunocompetent DBA/2 mouse model of disseminated candidiasis. Mice (5/grp) were challenged with Candida albicans SC5314 (ATCC: MYA- 2876, fluconazole- sensitive human clinical isolate shown to be pathogenic in mice) via IV injection (100 μΙ_, 5.0 log CFU/mouse) and treated with CD1 01 SC (1 , 3 or 1 0 mg/kg). Micafungin via IP administration was tested as a positive control at the same 3 doses. At 24 hours following challenge, kidneys were harvested and processed for CFU enumeration. All comparisons were made between the treatment and time-matched vehicle groups. CD101 SC (5 mg/kg) was also tested in a similar disseminated candidiasis model using ICR mice rendered neutropenic by cyclophosphamide on day -4 (150 mg/kg) and day -1 (1 00 mg/kg) prior to infection by the same C. albicans SC5314 strain (IV injection, 1 00 μΙ_, 4.5 log CFU/mouse, See Example 1 ).

Previous toxicology studies by the IV route of administration conducted in cynomolgus monkeys have shown CD1 01 to be safe and well tolerated at up to at least 30 mg/kg, which generates very high systemic exposures upon initial infusion of CD1 01 into the bloodstream . Therefore, only local tolerability (and PK) of CD1 01 by SC administration required evaluation. For this purpose, male and female monkeys were observed for up to 1 0 days following a single 30 mg/kg SC dose. In the same study, to determine the pharmacokinetics of CD1 01 following SC administration, whole blood samples were collected and the plasma was harvested at approximately 0.25, 0.5, 1 , 2, 4, 8, 24, 36, and 48 hours, and 3, 4, 5, 7, and 1 0 days postdose. Plasma concentrations were then quantified by liquid chromatography with tandem mass spectrometric detection (LC-MS/MS). Bioavailability from SC dosing was calculated by comparing the calculated area under the concentration-time profile (AUC) from SC against the AUC from IV administration of the same dose. Results

In the DBA/2 mouse efficacy study (FIG. 14) , at 2 hr post infection, vehicle-treated mice demonstrated an average kidney CFU of 3.8 log CFU that increased to 6.1 log CFU at 24 hr. Groups treated with CD1 01 SC (1 , 3, and 1 0 mg/kg) showed significant reduction in kidney CFU when compared with the vehicle control. Animals receiving 3 or 1 0 mg/kg of CD1 01 SC showed complete CFU clearance, and 4 of 5 animals in the 1 mg/kg group were completely cleared of CFU burden by 24 hr. Micafungin also showed good dose response in CFU reduction with the same treatment doses but complete clearance was only observed with the 1 0 mg/kg dose suggesting that it was less efficacious than CD1 01 at comparable doses.

Early pharmacokinetic studies in rats and monkeys had indicated that CD1 01 subcutaneous administration was well-tolerated, although these initial studies were aimed at characterizing the pharmacokinetics at lower doses (< 5 mg/kg). Therefore, a separate study was designed to evaluate the tolerability of a SC dose of CD1 01 as a highly concentrated solution (1 00 mg/mL; 30 mg/kg) in two cynomolgus monkeys. FIG . 1 5 shows plasma levels of CD1 01 in two cynomolgus monkeys over 1 0 days after a single 30 mg/kg dose administered subcutaneously. The drug reaches a maximum concentration within a few hours then remains nearly constant over the course of 1 0 days. Table 9 further shows various pharmacokinetic characteristics of SC administered CD1 01 in the monkeys. Table 1 0 shows the SC formulation of CD1 01 used in the monkey study.

Table 9

Table 10

Component Function Concentration

CD101 acetate Active ingredient 100 mg/mL

Mannitol Tonicity 1 1 .4 mg/mL

HCI pH adjustment As needed to adjust to pH 5.6

NaOH pH adjustment As needed to adjust to pH 5.6

Water for injection medium q.s to 1 .0 mL

In the monkey SC tolerability/PK study, no sign of irritation or local (injection site) adverse toxicity was noted following a single high dose of 30 mg/kg CD101 . There was also no effect on bodyweight or food consumption upon further follow-up observations for 1 0 days after administration.

From the same monkey SC tolerability/PK study, the pharmacokinetic profile following SC administration of CD101 at 30 mg/kg showed that total exposure measured over a 10-day period was comparable (80% bioavailability) to that following IV administration at the same dose (FIG. 16), indicating high/equivalent bioavailability from SC administration. The maximum plasma

concentration from SC administration was reached after 24 hours and was sustained throughout the first week post-dose. Concentrations started to decrease one week after injection and the terminal half- life estimated was high at approximately 124 hours. Both routes show comparable elimination rates/slopes. Table 1 1 further shows various pharmacokinetic characteristics of subcutaneously and intravenously administered CD1 01 .

Table 11

Other Embodiments

All publications, patents, and patent applications mentioned in this specification are incorporated herein by reference to the same extent as if each independent publication or patent application was specifically and individually indicated to be incorporated by reference.

While the invention has been described in connection with specific embodiments thereof, it will be understood that it is capable of further modifications and this application is intended to cover any variations, uses, or adaptations of the invention following, in general, the principles of the invention and including such departures from the invention that come within known or customary practice within the art to which the invention pertains and may be applied to the essential features hereinbefore set forth, and follows in the scope of the claims.

Other embodiments are within the claims.

Claims

CLAIMS What is claimed is:

1 . A method of treating or reducing the likelihood of vulvovaginal candidiasis in a subject, the method comprising subcutaneously administering to the subject doses of about 25 mg to about 600 mg of CD101 ,

in salt or neutral form, wherein the CD101 in salt or neutral form is administered in one or more doses to the subject and wherein no more than one dose is administered per week.

2. The method of claim 1 , wherein a single dose of CD101 in salt or neutral form is administered to the subject for the duration of the treatment.

3. The method of claim 1 , wherein one dose of CD1 01 in salt or neutral form is administered once every 4 weeks over a period of 4 to 12 weeks.

4. The method of claim 1 , wherein one dose of CD1 01 in salt or neutral form is administered once every

3 weeks over a period of 3 to 12 weeks.

5. The method of claim 1 , wherein one dose of CD1 01 in salt or neutral form is administered once every 2 weeks over a period of 2 to 12 weeks.

6. The method of claim 1 , wherein one dose of CD1 01 in salt or neutral form is administered once a week over a period of 1 to 12 weeks.

7. The method of claim 1 , wherein one or more doses of CD101 in salt or neutral form is administered over a period of 12 to 24 weeks.

8. The method of claim 7, wherein one dose of CD1 01 in salt or neutral form is administered once every

4 weeks over a period of 12 to 24 weeks.

9. The method of claim 7, wherein one dose of CD1 01 in salt or neutral form is administered once every 3 weeks over a period of 12 to 24 weeks.

10. The method of claim 7, wherein one dose of CD101 in salt or neutral form is administered once every 2 weeks over a period of 12 to 24 weeks.

1 1 . The method of claim 7, wherein one dose of CD101 in salt or neutral form is administered once a week over a period of 12 to 24 weeks.

12. The method of claim 1 , wherein 1 to 3 doses of CD101 in salt or neutral form is administered over a period of 3 weeks.

13. The method of claim 1 , wherein 2 to 6 doses of CD101 in salt or neutral form is administered over a period of 6 weeks.

14. The method of claim 1 , wherein 3 to 9 doses of CD101 in salt or neutral form is administered over a period of 9 weeks.

15. The method of claim 1 , wherein 4 to 12 doses of CD101 in salt or neutral form is administered over a period of 12 weeks.

16. The method of claim 1 , wherein the subject is administered one dose of CD101 in salt or neutral form every 1 to 12 weeks.

17. The method of claim 16, wherein the subject is administered one dose of CD101 in salt or neutral form once a week.

18. The method of claim 16, wherein the subject is administered one dose of CD101 in salt or neutral form once every 2 weeks.

19. The method of claim 16, wherein the subject is administered one dose of CD101 in salt or neutral form once every 4 weeks.

20. The method of claim 16, wherein the subject is administered one dose of CD101 in salt or neutral form once every 6 weeks.

21 . The method of claim 16, wherein the subject is administered one dose of CD101 in salt or neutral form once every 8 weeks.

22. The method of claim 16, wherein the subject is administered one dose of CD101 in salt or neutral form once every 10 weeks.

23. The method of claim 16, wherein the subject is administered one dose of CD101 in salt or neutral form once every 12 weeks.

24. The method of claim 1 , wherein one or more doses of CD101 in salt or neutral form is administered to the subject for at least 1 month.

25. The method of claim 24, wherein one or more doses of CD101 in salt or neutral form is administered to the subject for at least 1 year.

26. The method of claim 25, wherein one or more doses of CD101 in salt or neutral form is administered to the subject for the subject's lifetime.

27. The method of any one of claims 1 -26, wherein the subject has failed treatment with an azole compound for vulvovaginal candidiasis.

28. The method of claim 27, wherein the azole compound is fluconazole, clotrimazole, miconazole, tioconazole, butoconazole, or terconazole.

29. The method of claim 28, wherein the azole compound is fluconazole.

30. The method of any one of claims 1 -29, wherein the subject is immunocompromised.

31 . The method of any one of claims 1 -30, wherein the subject is diagnosed with a disease that causes immunosuppression.

32. The method of claim 31 , wherein said disease is acquired immunodeficiency syndrome or diabetes.

33. The method of any one of claims 1 -32, wherein the subject is pregnant.

34. The method of any one of claims 1 -33, wherein the subject is being administered or is about to be administered immunosuppresive drugs.

35. The method of any one of claims 1 -34, wherein the subject is being administered estrogen.

36. The method of any one of claims 1 -35, wherein the vulvovaginal candidiasis is caused by a fungus in the genus Candida.

37. The method of any one of claims 1 -36, wherein the vulvovaginal candidiasis is caused by Candida albicans, C. glabrata, C. dubliniensis, C. krusei, C. parapsilosis, C. tropicalis, C. orthopsilosis, C.

guilliermondii, C. rugosa, C. auris, or C. lusitaniae.

38. The method of claim 37, wherein the vulvovaginal candidiasis is caused by Candida albicans.

39. The method of claim 37, wherein the vulvovaginal candidiasis is caused by Candida glabrata.

40. The methods of any one of claims 1 -39, wherein the vulvovaginal candidiasis is uncomplicated vulvovaginal candidiasis.

41 . The methods of any one of claims 1 -39, wherein the vulvovaginal candidiasis is complicated vulvovaginal candidiasis.

42. The method of claim 41 , wherein the complicated vulvovaginal candidiasis is recurrent vulvovaginal candidiasis.

43. The method of any one of claims 1 -42, further comprising administering to the subject at least one antifungal agent.

44. The method of claim 43, wherein CD1 01 in salt or neutral form and the antifungal agent are administered substantially simultaneously.

45. The method of claim 43, wherein CD1 01 in salt or neutral form and the antifungal agent are administered separately.

46. The method of claim 45, wherein CD1 01 in salt or neutral form is administered first, followed by administration of the antifungal agent.

47. The method of claim 45, wherein the antifungal agent is administered first, followed by administration of CD101 in salt or neutral form.

48. The method of claim 43, wherein CD1 01 in salt or neutral form and the antifungal agent are administered substantially simultaneously, followed by administration of CD101 in salt or neutral form or the antifungal agent alone.

49. The method of claim 43, wherein CD1 01 in salt or neutral form or the antifungal agent is administered alone, followed by administering of CD101 in salt or neutral form and the antifungal agent substantially simultaneously.

50. The method of any one of claims 43-49, wherein the antifungal agent is an azole compound, an allylamine compound, an echinocandin compound, a polygene compound, flucytosine (Ancobon^®)), enfumafungin, or SCY-078.

51 . The method of any one of claims 43-50, wherein the antifungal agent is an azole compound.

52. The method of claim 51 , wherein the azole compound is fluconazole, clotrimazole, miconazole, tioconazole, butoconazole, or terconazole.

53. The method of claim 52, wherein the azole compound is fluconazole.

54. The method of any one of claims 1 -53, wherein the subcutaneous administration of CD101 in salt or neutral form does not cause any negative injection site effects.

55. The method of any one of claims 1 -54, wherein CD101 is administered as an aqueous

pharmaceutical composition.

56. The method of claim 55, wherein the pharmaceutical composition has a pH of from 4 to 8.

57. The method of any one of claims 1 -56, wherein CD101 in salt form is CD101 acetate.