Nosocomial fungal infections: epidemiology, diagnosis, and treatment

Functional specialization and differential regulation of short-chain carboxylic acid transporters in the pathogen Candida albicans

The major fungal pathogen Candida albicans has the metabolic flexibility to assimilate a wide range of nutrients in its human host. Previous studies have suggested that C. albicans can encounter glucose-poor microenvironments during infection and that the ability to use alternative non-fermentable carbon sources contributes to its virulence. JEN1 encodes a monocarboxylate transporter in C. albicans and we show that its paralogue, JEN2, encodes a novel dicarboxylate plasma membrane transporter, subjected to glucose repression. A strain deleted in both genes lost the ability to transport lactic, malic and succinic acids by a mediated mechanism and it displayed a growth defect on these substrates. Although no significant morphogenetic or virulence defects were found in the double mutant strain, both JEN1 and JEN2 were strongly induced during infection. Jen1-GFP (green fluorescent protein) and Jen2-GFP were upregulated following the phagocytosis of C. albicans cells by neutrophils and macrophages, displaying similar behaviour to an Icl1-GFP fusion. In the murine model of systemic candidiasis approximately 20-25% of C. albicans cells infecting the kidney expressed Jen1-GFP and Jen2-GFP. Our data suggest that Jen1 and Jen2 are expressed in glucose-poor niches within the host, and that these short-chain carboxylic acid transporters may be important in the early stages of infection.

Zygomycosis: conventional laboratory diagnosis

A definitive diagnosis of zygomycosis caused by Mucorales can be made by histopathological examination with or without isolation of the fungus from the same site. Histopathological examination of the tissues affected typically shows characteristic broad, hyaline, ribbon-like, irregular fungal hyphae with wide-angle branching, accompanied by tissue necrosis and angioinvasion of the fungi. Tissue invasion by the fungal hyphae as seen by microscopy is essential to establish the diagnosis. Fungal elements can be stained with Gomori methenamine-silver, periodic acid-Schiff or Calcoflour white stain. All Mucorales grow rapidly on most fungal media such as Sabouraud dextrose agar incubated at 25-30 degrees C. Mucorales from a sterile site or repeated positive cultures of the fungi from a non-sterile site are considered significant in a high-risk patient with predisposing factors for acquisition of zygomycosis. Positive cultures from non-sterile specimens should be interpreted with caution and will require correlation between the finding and the clinical situation.

The yeast Candida albicans evades human complement attack by secretion of aspartic proteases

Candida albicans, which represents one of the most important human pathogenic yeasts, is directly attacked by the host innate immune system upon infection. However this pathogen has developed multiple strategies to escape host immune defense. Here, we show that C. albicans secreted proteases interfere and inactivate host innate immune effector components, such as complement proteins. Secreted aspartic proteases (Saps) in the culture supernatant of C. albicans cells and also recombinant Sap1, Sap2 and Sap3 degrade host complement components C3b, C4b and C5 and also inhibit terminal complement complex (TCC) formation. This proteolytic activity is specific to the three recombinant and wild type Sap proteins. The triple knock out C. albicans strain Delta sap1-3 and also the non-pathogenic yeast S. cerevisiae lack such degrading activities. The complement inhibitory role of Sap1, Sap2 and Sap3 was confirmed in hemolysis assays with rabbit erythrocytes and normal human plasma. Secretion of complement degrading proteases provides a highly efficient complement defense response of this human pathogenic yeast that acts after the immediate acquisition of host complement regulators to the cell surface.

Variation in susceptibility of bloodstream isolates of Candida glabrata to fluconazole according to patient age and geographic location in the United States in 2001 to 2007

We examined the susceptibilities to fluconazole of 642 bloodstream infection (BSI) isolates of Candida glabrata and grouped the isolates by patient age and geographic location within the United States. Susceptibility of C. glabrata to fluconazole was lowest in the northeast region (46%) and was highest in the west (76%). The frequencies of isolation and of fluconazole resistance among C. glabrata BSI isolates were higher in the present study (years 2001 to 2007) than in a previous study conducted from 1992 to 2001. Whereas the frequency of C. glabrata increased with patient age, the rate of fluconazole resistance declined. The oldest age group (> or = 80 years) had the highest proportion of BSI isolates that were C. glabrata (32%) and the lowest rate of fluconazole resistance (5%).

Zygomycosis in Italy: a survey of FIMUA-ECMM (Federazione Italiana di Micopatologia Umana ed Animale and European Confederation of Medical Mycology)

The aims of the study were to analyze the clinical and epidemiological characteristics and treatments for patients who developed zygomycosis enrolled in Italy during the European Confederation of Medical Mycology of medical mycology survey. This prospective multicenter study was performed between 2004 and 2007 at 49 italian Departments. 60 cases of zygomycosis were enrolled: the median age was 59.5 years (range 1-87), with a prevalence of males (70%). The majority of cases were immunocompromised patients (42 cases, 70%), mainly hematological malignancies (37). Among non-immunocompromised (18 cases, 30%), the main category was represented by patients with penetrating trauma (7/18, 39%). The most common sites of infection were sinus (35%) with/without CNS involvement, lung alone (25%), skin (20%), but in 11 cases (18%) dissemination was observed. According to EORTC criteria, the diagnosis of zygomycosis was proven in 46 patients (77%) and in most of them it was made in vivo (40/46 patients, 87%); in the remaining 14 cases (23%) the diagnosis was probable. 51 patients received antifungal therapy and in 30 of them surgical debridement was also performed. The most commonly used antifungal drug was liposomal amphotericin B (L-AmB), administered in 44 patients: 36 of these patients (82%) responded to therapy. Altogether an attributable mortality rate of 32% (19/60) was registered, which was reduced to 18% in patients treated with L-AmB (8/44). Zygomycosis is a rare and aggressive filamentous fungal infection, still associated with a high mortality rate. This study indicates an inversion of this trend, with a better prognosis and significantly lower mortality than that reported in the literature. It is possible that new extensive, aggressive diagnostic and therapeutic procedures, such as the use of L-AmB and surgery, have improved the prognosis of these patients.

Increasing incidence of zygomycosis (mucormycosis), France, 1997-2006

We analyzed hospital records to provide a population-based estimate of zygomycosis incidence and trends over a 10-year period at a national level in France. Data showed an increasing incidence from 0.7/million in 1997 to 1.2/million in 2006 (p<0.001). We compared our data with those from the French Mycosis Study Group, a recently established voluntary network of French mycologists coordinated by the National Reference Center for Mycoses and Antifungals. We documented that incidence of zygomycosis increased, particularly in patients with hematologic malignancies or bone marrow transplants. The role of previous exposure to antifungal drugs lacking activity against zygomycetes could explain this increase but does not appear exclusive. Incidence also increased in the population of patients with diabetes mellitus. We conclude that observed trends reflect a genuine increase of zygomycosis cases in at-risk populations.

Nurturing scientific mutualism: a report from the 'Young Microbiologists Mini-Symposium on microbe signalling, organisation and pathogenesis'

In April 2009, over one hundred microbiologists, primarily early career scientists, from 17 different countries met to discuss their work, under the broad heading of 'Microbe signalling, organization and pathogenesis'. The meeting took place at University College Cork, Ireland and was supported by the British Council, Society for General Microbiology, American Society for Microbiology, EMBO and others. The key and relatively unusual feature of this meeting was that it was specifically aimed to provide a platform for junior scientists to present their work to a broad audience. In this review, we have tried to summarize and highlight a number of particular areas covered during the meeting, including bacterial intracellular signalling and regulation; microbe-microbe communication; biogenesis; structure and transport of the bacterial cell envelope; and pathogenic versus probiotic microbe-host interactions. We draw attention to new findings, highlight unanswered questions and reveal the anticipated future directions of a variety of areas, as described in both oral and poster presentations. Overall, this meeting provided high-quality science, with many intriguing findings being eloquently reported, in a setting that fostered interactions between diverse young and talented microbiologists.

The rise of an opportunistic infection called "Invasive Zygomycosis"

Invasive zygomycosis is a devastating fungal infection seen mostly in immune-compromised patients. We present a case of a 48-year old diabetic man, with aplastic anemia, who developed severe pulmonary mucormycosis that led to his rapid demise despite early diagnosis and treatment with liposomal amphotericin B. We also conducted an extensive review of the pathogenesis of invasive zygomycosis, its history, predisposing factors, clinical aspects, diagnostic modalities, treatment options, morbidity and mortality.

Cross-kingdom interactions: Candida albicans and bacteria

Bacteria and fungi are found together in a myriad of environments and particularly in a biofilm, where adherent species interact through diverse signaling mechanisms. Yet, despite billions of years of coexistence, the area of research exploring fungal-bacterial interactions, particularly within the context of polymicrobial infections, is still in its infancy. However, reports describing a multitude of wide-ranging interactions between the fungal pathogen Candida albicans and various bacterial pathogens are on the rise. An example of a mutually beneficial interaction is coaggregation, a phenomenon that takes place in oral biofilms where the adhesion of C. albicans to oral bacteria is considered crucial for its colonization of the oral cavity. In contrast, the interaction between C. albicans and Pseudomonas aeruginosa is described as being competitive and antagonistic in nature. Another intriguing interaction is that occurring between Staphylococcus aureus and C. albicans, which although not yet fully characterized, appears to be initially synergistic. These complex interactions between such diverse and important pathogens would have significant clinical implications if they occurred in an immunocompromised host. Therefore, understanding the mechanisms of adhesion and signaling involved in fungal-bacterial interactions may lead to the development of novel therapeutic strategies for impeding microbial colonization and development of polymicrobial disease.

Increased number of glutamine repeats in the C-terminal of Candida albicans Rlm1p enhances the resistance to stress agents

The highly polymorphic microsatellite CAI described for Candida albicans genotyping was found to be located within the RLM1 gene which codes for a transcription factor from the MADS box family that, in Saccharomyces cerevisiae, is known to regulate the expression of genes involved in the cell wall integrity pathway. The aim of this work was to study CAI genetic variability in a wide group of C. albicans isolates and determine the response of genetic variants to cell wall damaging stress agents. One hundred twenty-three C. albicans isolates were genotyped with CAI microsatellite (CAA/G)(n), and 35 alleles were found with repeat units varying from 11 to 49. Alleles with less than 29 repetitions were the most frequent, while the longer ones were underrepresented and had a more complex internal structure. Combinations of RLM1 alleles generated 66 different genotypes. Significant differences (P < 0.05) in the susceptibility patterns to menadione, hydrogen peroxide, SDS, acetic acid, and CFW, stress agents affecting cell integrity, were found between strains harbouring alleles ranging from 17 to 28 repetitions and strains with longer alleles, suggesting that an increased number of repetitive units in the C. albicans RLM1 gene could be related to stress response.

Identifying infection-associated genes of Candida albicans in the postgenomic era

The human pathogenic yeast Candida albicans can cause an unusually broad range of infections reflecting a remarkable potential to adapt to various microniches within the human host. The exceptional adaptability of C. albicans is mediated by rapid alterations in gene expression in response to various environmental stimuli and this transcriptional flexibility can be monitored with tools such as microarrays. Using such technology it is possible to (1) capture a genome-wide portrait of the transcriptome that mirrors the environmental conditions, (2) identify known genes, signalling pathways and transcription factors involved in pathogenesis, (3) identify new patterns of gene expression and (4) identify previously uncharacterized genes that may be associated with infection. In this review, we describe the molecular dissection of three distinct stages of infections, covering both superficial and invasive disease, using in vitro, ex vivo and in vivo infection models and microarrays.

Requisite role for the dectin-1 beta-glucan receptor in pulmonary defense against Aspergillus fumigatus

Immune suppression increases the incidence of invasive fungal infections, particularly those caused by the opportunistic mold Aspergillus fumigatus. Previous investigations revealed that members of the TLR family are not absolutely required for host defense against A. fumigatus in nonimmunosuppressed hosts, suggesting that other pattern recognition receptors are involved. We show in this study that naive mice (i.e., not pharmacologically immunosuppressed) lacking the beta-glucan receptor Dectin-1 (Dectin-1(-/-)) are more sensitive to intratracheal challenge with A. fumigatus than control mice, exhibiting >80% mortality within 5 days, ultimately attributed to a compromise in respiratory mechanics. In response to A. fumigatus challenge, Dectin-1(-/-) mice demonstrated impaired IL-1alpha, IL-1beta, TNF-alpha, CCL3/MIP-1alpha, CCL4/MIP-1beta, and CXCL1/KC production, which resulted in insufficient lung neutrophil recruitment and uncontrolled A. fumigatus lung growth. Alveolar macrophages from Dectin-1(-/-) mice failed to produce proinflammatory mediators in response to A. fumigatus, whereas neutrophils from Dectin-1(-/-) mice had impaired reactive oxygen species production and impaired killing of A. fumigatus. We further show that IL-17 production in the lung after A. fumigatus challenge was Dectin-1 dependent, and that neutralization of IL-17 significantly impaired A. fumigatus clearance. Collectively, these results support a requisite role for Dectin-1 in in vivo defense against A. fumigatus.

Farnesol-induced apoptosis in Candida albicans

Farnesol, a precursor in the isoprenoid/sterol pathway, was recently identified as a quorum-sensing molecule produced by the fungal pathogen Candida albicans. Farnesol is involved in the inhibition of germination and biofilm formation by C. albicans and can be cytotoxic at certain concentrations. In addition, we have shown that farnesol can trigger apoptosis in mammalian cells via the classical apoptotic pathways. In order to elucidate the mechanism behind farnesol cytotoxicity in C. albicans, the response to farnesol was investigated, using proteomic analysis. Global protein expression profiles demonstrated significant changes in protein expression resulting from farnesol exposure. Among the downregulated proteins were those involved in metabolism, glycolysis, protein synthesis, and mitochondrial electron transport and the respiratory chain, whereas proteins involved in folding, protection against environmental and oxidative stress, actin cytoskeleton reorganization, and apoptosis were upregulated. Cellular changes that accompany apoptosis (regulated cell death) were further analyzed using fluorescent microscopy and gene expression analysis. The results indicated reactive oxygen species accumulation, mitochondrial degradation, and positive terminal deoxynucleotidyltransferase-mediated dUTP-biotin nick end labeling (TUNEL) in the farnesol-exposed cells concurrent with increased expression of antioxidant-encoding and drug response genes. More importantly, the results demonstrated farnesol-induced upregulation of the caspase gene MCA1 and the intracellular presence of activated caspases. In conclusion, this study demonstrated that farnesol promotes apoptosis in C. albicans through caspase activation, implying an important physiological role for farnesol in the fungal cell life cycle with important implications for adaptation and survival.

A novel immune evasion strategy of candida albicans: proteolytic cleavage of a salivary antimicrobial peptide

Oropharyngeal candidiasis is an opportunistic infection considered to be a harbinger of AIDS. The etiologic agent Candida albicans is a fungal species commonly colonizing human mucosal surfaces. However, under conditions of immune dysfunction, colonizing C. albicans can become an opportunistic pathogen causing superficial or even life-threatening infections. The reasons behind this transition, however, are not clear. In the oral cavity, salivary antimicrobial peptides are considered to be an important part of the host innate defense system in the prevention of microbial colonization. Histatin-5 specifically has exhibited potent activity against C. albicans. Our previous studies have shown histatin-5 levels to be significantly reduced in the saliva of HIV+ individuals, indicating an important role for histatin-5 in keeping C. albicans in its commensal stage. The versatility in the pathogenic potential of C. albicans is the result of its ability to adapt through the regulation of virulence determinants, most notably of which are proteolytic enzymes (Saps), involved in tissue degradation. In this study, we show that C. albicans cells efficiently and rapidly degrade histatin-5, resulting in loss of its anti-candidal potency. In addition, we demonstrate that this cellular activity is due to proteolysis by a member of the secreted aspartic proteases (Sap) family involved in C. albicans pathogenesis. Specifically, the proteolysis was attributed to Sap9, in turn identifying histatin-5 as the first host-specific substrate for that isoenzyme. These findings demonstrate for the first time the ability of a specific C. albicans enzyme to degrade and deactivate a host antimicrobial peptide involved in the protection of the oral mucosa against C. albicans, thereby providing new insights into the factors directing the transition of C. albicans from commensal to pathogen, with important clinical implications for alternative therapy. This report characterizes the first defined mechanism behind the enhanced susceptibility of HIV+ individuals to oral candidiasis since the emergence of HIV.

Simple and highly discriminatory microsatellite-based multiplex PCR for Aspergillus fumigatus strain typing

The answers to important questions concerning Aspergillus fumigatus pathogenicity, transmissions routes and efficacy of treatments require highly discriminating and reproducible genotyping methods. The present study was aimed at improving microsatellite methodology for A. fumigatus typing by reducing the task of strain identification to a single multiplex reaction and by selecting highly accurate short tandem repeat polymorphisms. A set of eight primer pairs was used for the genotype determination of 116 clinical isolates of A. fumigatus obtained from three healthcare centres. A new, automated and highly discriminatory typing method is described for A. fumigatus strains. The optimized multiplex PCR was successfully performed with all tested clinical strains and showed a discriminatory power of 0.9997 among presumably unrelated isolates. The comparison of groups of strains from different health centres showed that 99.6% of the genotypic variation was present within groups. Strains with the same genotype were isolated from the same patient, sometimes recovered more than 1 year later. A few cases of patients at the same clinic unit carrying strains of identical genotype strongly suggested colonization by A. fumigatus during their hospitalization. Specific measures must therefore be taken in order to prevent and restrict such incidents.

A simple and reproducible 96-well plate-based method for the formation of fungal biofilms and its application to antifungal susceptibility testing

The incidence of fungal infections has increased significantly over the past decades. Very often these infections are associated with biofilm formation on implanted biomaterials and/or host surfaces. This has important clinical implications, as fungal biofilms display properties that are dramatically different from planktonic (free-living) populations, including increased resistance to antifungal agents. Here we describe a rapid and highly reproducible 96-well microtiter-based method for the formation of fungal biofilms, which is easily adaptable for antifungal susceptibility testing. This model is based on the ability of metabolically active sessile cells to reduce a tetrazolium salt (2,3-bis(2-methoxy-4-nitro-5-sulfo-phenyl)-2H-tetrazolium-5-carboxanilide) to water-soluble orange formazan compounds, the intensity of which can then be determined using a microtiter-plate reader. The entire procedure takes approximately 2 d to complete. This technique simplifies biofilm formation and quantification, making it more reliable and comparable among different laboratories, a necessary step toward the standardization of antifungal susceptibility testing of biofilms.

Host defense mechanisms in invasive candidiasis originating in the GI tract

Candida spp. rank among the leading causative agents of nosocomial infections. The increasing number of patients at risk of invasive candidiasis makes a rise in the incidence of this fungal infection expected. Disruption of GI tract integrity and ablation of immune cell populations, such as those resulting from cancer chemotherapy, are recognized as key factors leading to fungal dissemination. However, the individual role of these immune barriers in preventing Candida host colonization and invasion are yet to be fully understood. This article evaluates recently published results on a new murine model of systemic candidiasis originating in the GI tract that might prove a valuable setting for the accurate study of host immune mechanisms, fungal virulence factors and novel therapeutic approaches.

The study of fungi in drinking water

The occurrence of fungi in drinking water has received increased attention in the last decades, and fungi are now generally accepted as drinking water contaminants. The knowledge about the occurrence and diversity of fungi in water has increased considerably from a low knowledge base. However, the relevance of waterborne fungi for water quality and human health is poorly understood and still conflicting. Scientific reports on effective treatment against fungi in water are also few. This article presents a review of the literature on fungal water studies, including some general results, and considerations of significance, limits, contradictions, precautions, and practical consequences.

Risk factors in a patient with fungemia caused by fluconazole-resistant Candida albicans

Blood stream infections due to Candida species are becoming increasingly important causes of morbidity and mortality in hospitalized patients. Risk factors that predispose patients to developing invasive Candida infections have been documented as, iatrogenic and/or nosocomial conditions and immunosuppression. In the present report, we want to emphasize the risk factors that predispose individuals to the development of candidemia, particularly those that are relevant to our patient. We describe a female patient with diabetes mellitus who had been receiving glucocorticoids for 20 years as replacement therapy for hypopituitarism resulting from hypophysis adenoma surgery. The patient received antibiotic therapy for recurrent wound infections and was hospitalized for a long time, including a period in the intensive care unit and instrumented. The patient eventually succumbed to fungemia caused by a fluconazole-resistant strain of C. albicans strain.

Proteome analysis for pathogenicity and new diagnostic markers for Aspergillus fumigatus

With the completion of the Aspergillus fumigatus genome it is now possible to study protein regulation on a global scale. One of the most suitable protein separation techniques is based on 2D-gel electrophoresis, which allows the separation of proteins based on their charge and size in a gel matrix. In addition, gel-free proteomics techniques based on liquid-chromatography coupled with mass spectrometry have gained importance. With the application of proteomic tools a comprehensive overview about the proteins of A. fumigatus present or induced during environmental changes and stress conditions can be obtained. For A. fumigatus, several proteomic studies have already been published including the response of the fungus to oxidative stress that induced the up-regulation of many proteins including catalases and thioredoxin peroxidase. Since many of the identified proteins/genes were apparently regulated by a putative Saccharomyces cerevisiae Yap1 homolog, the corresponding gene of A. fumigatus was identified, designated Afyap1 and further characterized. In addition, some of the gene products expressed under stress conditions are also known fungal antigens, such as the thioredoxin peroxidase AspF3. Thus, besides pathogenicity studies, proteomics also delivers the tools to screen for new antigens which could improve the diagnosis of diseases caused by A. fumigatus.

Evolving strategies in the management of aspergillosis

Aspergillus spp. remain the most common causes of invasive mould infections among patients with hematologic malignancies and recipients of solid-organ and hematopoietic stem-cell transplants. Despite advances in prevention and treatment, invasive aspergillosis continues to be a deadly disease. This paper reviews current approaches to treatment of aspergillosis in adults, including surgical and immune-based strategies, and developments in prophylaxis for aspergillosis in high-risk patient populations.

Management of oral infections in cancer patients

The myelosuppressive and mucosal-damaging consequences of cancer and cancer therapies place patients at high risk for developing infectious complications. Bacterial, fungal, and viral infections are all commonly encountered in the oral cavity, contributing to both morbidity and mortality in this patient population. Prevention, early and definitive diagnosis, and appropriate management are critical to ensure optimal treatment outcomes. With the majority of cancer patients treated as outpatients in the community setting, oral health care professionals play an important role in managing such infectious complications of cancer therapy.

Mechanism-of-action determination of GMP synthase inhibitors and target validation in Candida albicans and Aspergillus fumigatus

Mechanism-of-action (MOA) studies of bioactive compounds are fundamental to drug discovery. However, in vitro studies alone may not recapitulate a compound's MOA in whole cells. Here, we apply a chemogenomics approach in Candida albicans to evaluate compounds affecting purine metabolism. They include the IMP dehydrogenase inhibitors mycophenolic acid and mizoribine and the previously reported GMP synthase inhibitors acivicin and 6-diazo-5-oxo-L-norleucine (DON). We report important aspects of their whole-cell activity, including their primary target, off-target activity, and drug metabolism. Further, we describe ECC1385, an inhibitor of GMP synthase, and provide biochemical and genetic evidence supporting its MOA to be distinct from acivicin or DON. Importantly, GMP synthase activity is conditionally essential in C. albicans and Aspergillus fumigatus and is required for virulence of both pathogens, thus constituting an unexpected antifungal target.

Geographic and temporal trends in isolation and antifungal susceptibility of Candida parapsilosis: a global assessment from the ARTEMIS DISK Antifungal Surveillance Program, 2001 to 2005

We examined data from the ARTEMIS DISK Antifungal Surveillance Program to describe geographic and temporal trends in the isolation of Candida parapsilosis from clinical specimens and the in vitro susceptibilities of 9,371 isolates to fluconazole and voriconazole. We also report the in vitro susceptibility of bloodstream infection (BSI) isolates of C. parapsilosis to the echinocandins, anidulafungin, caspofungin, and micafungin. C. parapsilosis represented 6.6% of the 141,383 isolates of Candida collected from 2001 to 2005 and was most common among isolates from North America (14.3%) and Latin America (9.9%). High levels of susceptibility to both fluconazole (90.8 to 95.8%) and voriconazole (95.3 to 98.1%) were observed in all geographic regions with the exception of the Africa and Middle East region (79.3 and 85.8% susceptible to fluconazole and voriconazole, respectively). C. parapsilosis was most often isolated from blood and skin and/or soft tissue specimens and from patients hospitalized in the medical, surgical, intensive care unit (ICU) and dermatology services. Notably, isolates from the surgical ICU were the least susceptible to fluconazole (86.3%). There was no evidence of increasing azole resistance over time among C. parapsilosis isolates tested from 2001 to 2005. Of BSI isolates tested against the three echinocandins, 92, 99, and 100% were inhibited by concentrations of < or = 2 microg/ml of anidulafungin (621 isolates tested), caspofungin (1,447 isolates tested), and micafungin (539 isolates tested), respectively. C. parapsilosis is a ubiquitous pathogen that remains susceptible to the azoles and echinocandins; however, both the frequency of isolation and the resistance of C. parapsilosis to fluconazole and voriconazole may vary by geographic region and clinical service.

Candida parapsilosis endocarditis: a comparative review of the literature

Fungal endocarditis (FE) is an uncommon disease, and while accounting for only 1.3-6% of all cases of infectious endocarditis, it carries a high mortality risk. Although Candida albicans represents the main etiology of FE, C. parapsilosis is the most common non-albicans species. We report the case of a 32-year-old man with a history of prior intravenous drug (IVD) use hospitalized with endocarditis due to C. parapsilosis and review all 71 additional cases documented in the literature. A retrospective analysis of the 72 C. parapsilosis cases compared to 52 recently reviewed cases of C. albicans endocarditis was conducted to identify organism-specific clinical peculiarities. The most common predisposing factor for C. parapsilosis endocarditis (41/72; 57.4%) involved prosthetic valves followed by IVD use (12/72; 20%). Peripheral embolic and/or hemorrhagic events occurred in 28/64 (43.8%) patients, mostly in cerebral and lower limb territories. Overall mortality was 41.7%. Combined surgical and clinical treatment was associated with a lower mortality. Few patients received the newer antifungal agents, and it would appear that more experience is required for their use in the treatment of C. parapsilosis endocarditis.

Dectin-1 Fc targeting of aspergillus fumigatus beta-glucans augments innate defense against invasive pulmonary aspergillosis

Invasive pulmonary aspergillosis (IPA) has significantly increased over the last decade. Here, a fusion protein consisting of the Dectin-1 extracellular domain linked to the Fc portion of murine immunoglobulin G1 augmented alveolar macrophage killing of Aspergillus fumigatus and shifted mortality associated with IPA via attenuation of A. fumigatus growth in the lung.

Prospects for and barriers to a fungal vaccine

Vaccination is a desirable strategy to prevent life-threatening fungal infections. Candidiasis is the most common invasive fungal infection, and promising vaccine targets are nearing clinical testing to prevent such infections. One barrier to developing antifungal vaccines is the perceived risk of blunted immune responses in at-risk patients. However, vaccines stimulate effective immune responses even in highly immunocompromised patients. The biggest barrier to development of fungal vaccines is the lack of available capital to translate discoveries made at the bench into biologics used at the bedside. Nevertheless, vaccines targeting invasive fungal infections are an extremely promising avenue of research and development. It is desirable that additional sources of capital be made available to academic scientists to facilitate development of such vaccines.