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El-Mahallawy HA, Abdelfattah NE, Wassef MA, Abdel-Hamid RM. Alarming Increase of Azole-Resistant Candida Causing Blood Stream Infections in Oncology Patients in Egypt. Curr Microbiol 2023; 80:362. [PMID: 37796322 PMCID: PMC10556164 DOI: 10.1007/s00284-023-03468-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Accepted: 09/01/2023] [Indexed: 10/06/2023]
Abstract
Candidemia is a life-threatening invasive fungal infection in immunocompromised patients. The widespread use of azoles and the shift toward non-albicans Candida (NAC) species remarkably increase azole resistance in developing countries. We aimed to study candidemia trends and associated risk factors in oncology patients since they vary geographically, and rapid and appropriate treatment improves outcomes. Vitek 2 was used to identify the Candida species, and the E-test determined their susceptibility to azoles. Candida was the cause of 3.1% (n = 53/1701) of bloodstream infections (BSIs) during a 1-year study. Candida tropicalis was the most predominant species among the 30 candidemia episodes studied (36.7%), followed by C. albicans (33.3%). However, C. krusei, C. guilliermondii, C. pelliculosa, C. parapsilosis, C. famata, and C. inconspicua accounted for 30.0% of the isolates. An increased risk of NAC BSI was significantly associated with chemotherapy and leucopenia (P = 0.036 and 0.016, respectively). However, the multivariable analysis revealed that leucopenia was the only independent risk factor (P = 0.048). Fluconazole and voriconazole resistance were 58.3% and 16.7%, with NAC species showing higher resistance rates than C. albicans. Both fluconazole and voriconazole minimum inhibitory concentration (MIC) median values were higher in NAC than in C. albicans, but only voriconazole was significantly higher (0.220 versus 0.048 μg/ml, P = 0.047). In conclusion, the increased prevalence of NAC BSIs and incredibly high fluconazole resistance rates in cancer patients emphasize the necessity of antifungal stewardship to preserve voriconazole effectiveness, continued surveillance of candidemia, and future studies into azole resistance molecular mechanisms.
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Affiliation(s)
- Hadir A. El-Mahallawy
- Clinical Pathology Department, National Cancer Institute, Cairo University, Cairo, Egypt
| | - Nesma E. Abdelfattah
- Clinical Pathology Department, National Cancer Institute, Cairo University, Cairo, Egypt
| | - Mona A. Wassef
- Clinical & Chemical Pathology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Rasha M. Abdel-Hamid
- Clinical Pathology Department, National Cancer Institute, Cairo University, Cairo, Egypt
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Papadimitriou-Olivgeris M, Spiliopoulou A, Fligou F, Tsiata E, Kolonitsiou F, Nikolopoulou A, Papamichail C, Spiliopoulou I, Marangos M, Christofidou M. Risk factors for isolation of fluconazole and echinocandin non-susceptible Candida species in critically ill patients. J Med Microbiol 2021; 70. [PMID: 34431765 DOI: 10.1099/jmm.0.001401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Introduction. Resistance rates to azoles and echinocandins of Candida spp. increased over the last decade.Hypothesis/Gap Statement. Widespread use of antifungals could lead to development and dissemination of resistant Candida spp.Aim. To identify risk factors for isolation of Candida spp. non-susceptible to either fluconazole or echinocandins.Methodology. All patients hospitalized in the Intensive Care Unit (ICU) of the University General Hospital of Patras, Greece with Candida spp. isolated from clinical specimens during a ten-year period (2010-19) were included. Candida isolates were identified using Vitek-2 YST card. Consumption of antifungals was calculated.Results. During the study period, 253 isolates were included. C. non-albicans predominated (64.4 %) with C. parapsilosis being the most commonly isolated (42.3 %) followed by C. glabrata (nomenclatural change to Nakaseomyces glabrataa; 8.7 %) and C. tropicalis (11.9 %). Among all isolates, 45.8 and 28.5 % were non-susceptible and resistant to fluconazole, respectively. Concerning echinocandins, 8.7 % of isolates were non-susceptible to at least one echinocandin (anidulafungin or micafungin) and 3.1 % resistant. Multivariate analysis revealed that hospitalization during 2015-19, as compared to 2010-14, isolate being non-albicans or non-susceptible to at least one echinocandin was associated with isolation of fluconazole non-susceptible isolate. Administration of echinocandin, isolate being C. glabrata or C. tropicalis, or Candida spp. non-susceptible to fluconazole were independently associated with isolation of Candida spp. non-susceptible to at least one echinocandin. Fluconazole's administration decreased during the study period, whereas liposomal-amphotericin B's and echinoncandins' administration remained stable.Conclusion. Fluconazole's non-susceptibility increased during the study period, despite the decrease of its administration. Although echinocandins' administration remained stable, non-susceptibility among Candida spp. increased.
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Affiliation(s)
- Matthaios Papadimitriou-Olivgeris
- Division of Infectious Diseases, School of Medicine, University of Patras, Patras, Greece
- Present address: Infectious Diseases Service, Lausanne University Hospital, Lausanne, Switzerland
| | | | - Fotini Fligou
- Division of Anaesthesiology and Intensive Care Medicine, School of Medicine, University of Patras, Patras, Greece
| | - Ekaterini Tsiata
- Department of Pharmacy, University General Hospital of Patras, Patras, Greece
| | - Fevronia Kolonitsiou
- Department of Microbiology, School of Medicine, University of Patras, Patras, Greece
| | - Alexandra Nikolopoulou
- Division of Anaesthesiology and Intensive Care Medicine, School of Medicine, University of Patras, Patras, Greece
| | - Chrysavgi Papamichail
- Division of Anaesthesiology and Intensive Care Medicine, School of Medicine, University of Patras, Patras, Greece
| | - Iris Spiliopoulou
- Department of Microbiology, School of Medicine, University of Patras, Patras, Greece
| | - Markos Marangos
- Division of Infectious Diseases, School of Medicine, University of Patras, Patras, Greece
| | - Myrto Christofidou
- Department of Microbiology, School of Medicine, University of Patras, Patras, Greece
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Scorzoni L, Fuchs BB, Junqueira JC, Mylonakis E. Current and promising pharmacotherapeutic options for candidiasis. Expert Opin Pharmacother 2021; 22:867-887. [PMID: 33538201 DOI: 10.1080/14656566.2021.1873951] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Introduction: Candida spp. are commensal yeasts capable of causing infections such as superficial, oral, vaginal, or systemic infections. Despite medical advances, the antifungal pharmacopeia remains limited and the development of alternative strategies is needed.Areas covered: We discuss available treatments for Candida spp. infections, highlighting advantages and limitations related to pharmacokinetics, cytotoxicity, and antimicrobial resistance. Moreover, we present new perspectives to improve the activity of the available antifungals, discussing their immunomodulatory potential and advances on drug delivery carriers. New therapeutic approaches are presented including recent synthesized antifungal compounds (Enchochleated-Amphotericin B, tetrazoles, rezafungin, enfumafungin, manogepix and arylamidine); drug repurposing using a diversity of antibacterial, antiviral and non-antimicrobial drugs; combination therapies with different compounds or photodynamic therapy; and innovations based on nano-particulate delivery systems.Expert opinion: With the lack of novel drugs, the available assets must be leveraged to their best advantage through modifications that enhance delivery, efficacy, and solubility. However, these efforts are met with continuous challenges presented by microbes in their infinite plight to resist and survive therapeutic drugs. The pharmacotherapeutic options in development need to focus on new antimicrobial targets. The success of each antimicrobial agent brings strategic insights to the next phased approach in treatingCandida spp. infections.
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Affiliation(s)
- Liliana Scorzoni
- Department of Biosciences and Oral Diagnosis, Institute of Science and Technology, São Paulo State University/UNESP, SP Brazil
| | - Beth Burgwyn Fuchs
- Division of Infectious Diseases, Rhode Island Hospital, Alpert Medical School, Brown University, Providence, RI USA
| | - Juliana Campos Junqueira
- Department of Biosciences and Oral Diagnosis, Institute of Science and Technology, São Paulo State University/UNESP, SP Brazil
| | - Eleftherios Mylonakis
- Division of Infectious Diseases, Rhode Island Hospital, Alpert Medical School, Brown University, Providence, RI USA
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Dynamics of in vitro development of azole resistance in Candida tropicalis. J Glob Antimicrob Resist 2020; 22:553-561. [PMID: 32339847 DOI: 10.1016/j.jgar.2020.04.018] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Revised: 03/31/2020] [Accepted: 04/15/2020] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVES Increasing incidence of azole resistance in Candida tropicalis, especially to fluconazole, has been seen in Asian countries including India. Limited knowledge is available on the molecular mechanisms associated with the development of azole resistance in C. tropicalis. The present study examined the dynamics of in vitro azole resistance in C. tropicalis after prolonged treatment with fluconazole. METHODS Nine fluconazole-susceptible isolates of C. tropicalis were used in this study. Fluconazole resistance was induced experimentally in C. tropicalis isolates. The stability of induced resistance and cross-resistance to other azoles was examined. The molecular mechanisms of azole resistance were assessed by measuring the expression and mutation analysis of different genes. RESULTS Varying degrees of resistance [five with minimum inhibitory concentrations (MICs) ≤32 mg/L and four with MICs ≥128 mg/L] were noticed, and the resistance was developed in 3 months. Of the nine resistant isolates, four induced resistant isolates with MICs ≥128 mg/L presented temporal resistance stability up to 10 subcultures. These four isolates presented cross-resistance to other azoles and also an inducible overexpression of transporters (CDR1, CDR2, CDR3 and MDR1), ergosterol biosynthesis pathway genes (ERG1, ERG2, ERG3 and ERG11), transcription factors (TAC1 and UPC2) and stress-responsive genes (HSP90 and MKC1) was noticed. No mutations were seen in any of the four genes (ERG1, ERG3, ERG11 and UPC2) tested. CONCLUSIONS Candida tropicalis isolates adapt themselves in the presence of continuous drug exposure and switch back to being susceptible in the absence of the drug. The acquisition of resistance in C. tropicalis is mediated by the overexpression of different resistance-related genes without any molecular alterations.
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Pogreba-Brown K, Austhof E, Ellingson K. Methodology minute: An overview of the case-case study design and its applications in infection prevention. Am J Infect Control 2020; 48:342-344. [PMID: 31606255 DOI: 10.1016/j.ajic.2018.11.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Revised: 11/08/2018] [Accepted: 11/09/2018] [Indexed: 10/25/2022]
Abstract
The case-case study design is a potentially useful tool for infection preventionists during outbreak or cluster investigations. This column clarifies terminology related to case-case, case-control, and case-case-control study designs. Examples of practical applications of the case-case study design include determining risk factors for health care-onset versus community-onset infections, or antibiotic-resistant versus antibiotic-susceptible infections.
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Gene Expression Analysis of Key Players Associated with Fluconazole Resistance in Candida albicans. Jundishapur J Microbiol 2019. [DOI: 10.5812/jjm.88521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Fan C, Tian Q, Huang G, Zhang L, Wu Q, Zhang K. Candida tropicalis burn wound sepsis: A series of histopathology-confirmed cases. Intensive Crit Care Nurs 2018; 46:6-9. [DOI: 10.1016/j.iccn.2018.01.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Revised: 01/10/2018] [Accepted: 01/12/2018] [Indexed: 12/26/2022]
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Jin L, Cao Z, Wang Q, Wang Y, Wang X, Chen H, Wang H. MDR1 overexpression combined with ERG11 mutations induce high-level fluconazole resistance in Candida tropicalis clinical isolates. BMC Infect Dis 2018; 18:162. [PMID: 29631565 PMCID: PMC5891969 DOI: 10.1186/s12879-018-3082-0] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Accepted: 04/03/2018] [Indexed: 12/02/2022] Open
Abstract
Background Marked increases in fluconazole resistance in Candida tropicalis have been recently reported. In this study, the molecular mechanisms behind fluconazole resistance were investigated. Methods Twenty-two C. tropicalis clinical isolates, including 12 fluconazole-resistant isolates and 10 fluconazole-susceptible isolates, were collected from a tertiary care teaching hospital in Beijing between 2013 and 2017. Antifungal susceptibility testing, multilocus sequence typing, ERG11 amplification and sequencing, quantitative real-time reverse transcription-polymerase chain reaction (ERG11, UPC2, MDR1, and CDR1), and clinical data collection were performed for all C. tropicalis isolates. Results Multilocus sequence typing revealed that the 10 fluconazole-susceptible isolates and 12 fluconazole-resistant isolates were divided into nine and seven diploid sequence types, respectively. Of the 12 patients with fluconazole-resistant isolates, six had been previously exposed to azole and four had a fatal outcome. Y132F and S154F amino acid substitutions in Erg11p were found in all fluconazole-resistant isolates except one. MDR1 gene overexpression was identified in fluconazole-resistant isolates. In particular, seven high-level fluconazole resistant isolates (minimum inhibitory concentration ≥ 128 mg/L) and three pan-azole resistant isolates were identified. CDR1, ERG11, and UPC2 gene expression levels in fluconazole-resistant isolates were not significantly different from the control isolates (P = 0.262, P = 0.598, P = 0.114, respectively). Conclusions This study provides evidence that the combination of MDR1 gene overexpression and ERG11 missense mutations is responsible for high-level fluconazole resistance and pan-azole resistance in C. tropicalis clinical isolates. To the best of our knowledge, this is the first study investigating the relationship between MDR1 gene overexpression and increased fluconazole resistance.
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Affiliation(s)
- Longyang Jin
- Department of Clinical Laboratory, Peking University People's Hospital, No. 11 Xizhimen South Street, Xicheng District, Beijing, 100044, People's Republic of China
| | - Zhuorui Cao
- International Curriculum Center, The High School Affiliated to the Renmin University of China, Beijing, 100080, China
| | - Qi Wang
- Department of Clinical Laboratory, Peking University People's Hospital, No. 11 Xizhimen South Street, Xicheng District, Beijing, 100044, People's Republic of China
| | - Yichen Wang
- International Curriculum Center, The High School Affiliated to the Renmin University of China, Beijing, 100080, China
| | - Xiaojuan Wang
- Department of Clinical Laboratory, Peking University People's Hospital, No. 11 Xizhimen South Street, Xicheng District, Beijing, 100044, People's Republic of China
| | - Hongbin Chen
- Department of Clinical Laboratory, Peking University People's Hospital, No. 11 Xizhimen South Street, Xicheng District, Beijing, 100044, People's Republic of China
| | - Hui Wang
- Department of Clinical Laboratory, Peking University People's Hospital, No. 11 Xizhimen South Street, Xicheng District, Beijing, 100044, People's Republic of China.
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