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Lin SY, Huang HY, Chang LL, Wang YL, Chen TC, Chang K, Tu HP, Lu PL. The impact of the fluconazole trailing effect on the persistence of Candida albicans bloodstream infection when treated with fluconazole. Clin Microbiol Infect 2024; 30:945-950. [PMID: 38527614 DOI: 10.1016/j.cmi.2024.03.023] [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] [Received: 08/25/2023] [Revised: 03/10/2024] [Accepted: 03/19/2024] [Indexed: 03/27/2024]
Abstract
OBJECTIVES The trailing effect of Candida species is a phenomenon characterized by reduced but persistent growth at antifungal concentrations above the MIC. We assessed the impact of trailing growth on the persistence of Candida albicans candidemia in patients receiving fluconazole (FLC) therapy. METHODS We retrospectively investigated candidemia isolates at three hospitals in southern Taiwan between 2013 and 2020. Patients treated with FLC for FLC-susceptible C. albicans candidemia were enrolled. The degree of trailing was determined as the average growth above the MIC divided by the measured growth at the lowest drug concentration using the EUCAST method and classified into four categories: residual (0.1-5%), slight (6-10%), moderate (11-15%), and heavy trailers (>15%). RESULTS Among isolates from 190 patients, the proportions of heavy trailers at 24 hours, 48 hours, and 72 hours were 63.7% (121/190), 63.2% (120/190), and 74.7% (142/190), respectively. Persistent candidemia was observed in 17 (8.9 %) patients. The proportion of persistent C. albicans candidemia in heavy trailing isolates at 48 hours was higher than in isolates without heavy trailing (13.3% [16/120] vs. 1.4% [1/70], p = 0.007). A multivariate analysis showed that immunosuppression (OR = 7.92; 95% CI: 2.38-26.39, p = 0.001), hospitalization days after the index date of C. albicans identification (OR = 1.03; 95% CI: 1.01-1.05, p = 0.011), and heavy trailing isolates at 48 hours (OR = 10.04; 95% CI: 1.27-79.88, p = 0.029) were independent factors for persistent candidemia. DISCUSSION The current study revealed that heavy trailing in C. albicans isolates is associated with persistent candidemia in patients receiving FLC treatment.
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Affiliation(s)
- Shang-Yi Lin
- Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan; Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan; Department of Laboratory Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Ho-Yin Huang
- Department of Pharmacy, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Lin-Li Chang
- Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan; Department of Microbiology and Immunology, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan; Department of Medical Research, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Ya-Ling Wang
- Department of Pharmacy, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Tun-Chieh Chen
- Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Ko Chang
- Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan; Department of Internal Medicine, Kaohsiung Municipal Siaogang Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Hung-Pin Tu
- Department of Public Health and Environmental Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Po-Liang Lu
- Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan; Center for Liquid Biopsy and Cohort Research, Kaohsiung Medical University, Kaohsiung, Taiwan; School of Post-Baccalaureate Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.
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Chan KS, Tan LYC, Balasubramaniam S, Shelat VG. Should Empiric Anti-Fungals Be Administered Routinely for All Patients with Perforated Peptic Ulcers? A Critical Review of the Existing Literature. Pathogens 2024; 13:547. [PMID: 39057774 PMCID: PMC11279535 DOI: 10.3390/pathogens13070547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2024] [Revised: 06/20/2024] [Accepted: 06/26/2024] [Indexed: 07/27/2024] Open
Abstract
A perforated peptic ulcer (PPU) is a surgical emergency with a high mortality rate. PPUs cause secondary peritonitis due to bacterial and fungal peritoneal contamination. Surgery is the main treatment modality and patient's comorbidites impacts perioperative morbidity and surgical outcomes. Even after surgery, resuscitation efforts should continue. While empiric antibiotics are recommended, the role of empiric anti-fungal treatment is unclear due to a lack of scientific evidence. This literature review demonstrated a paucity of studies evaluating the role of empiric anti-fungals in PPUs, and with conflicting results. Studies were heterogeneous in terms of patient demographics and underlying surgical pathology (PPUs vs. any gastrointestinal perforation), type of anti-fungal agent, timing of administration and duration of use. Other considerations include the need to differentiate between fungal colonization vs. invasive fungal infection. Despite positive fungal isolates from fluid culture, it is important for clinical judgement to identify the right group of patients for anti-fungal administration. Biochemistry investigations including new fungal biomarkers may help to guide management. Multidisciplinary discussions may help in decision making for this conundrum. Moving forward, further research may be conducted to select the right group of patients who may benefit from empiric anti-fungal use.
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Affiliation(s)
- Kai Siang Chan
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore 308232, Singapore; (L.Y.C.T.); (V.G.S.)
- Department of General Surgery, Tan Tock Seng Hospital, Singapore 308433, Singapore;
| | - Lee Yee Calista Tan
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore 308232, Singapore; (L.Y.C.T.); (V.G.S.)
| | | | - Vishal G. Shelat
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore 308232, Singapore; (L.Y.C.T.); (V.G.S.)
- Department of General Surgery, Tan Tock Seng Hospital, Singapore 308433, Singapore;
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore
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Keighley C, Kim HY, Kidd S, Chen SCA, Alastruey A, Dao A, Bongomin F, Chiller T, Wahyuningsih R, Forastiero A, Al-Nuseirat A, Beyer P, Gigante V, Beardsley J, Sati H, Morrissey CO, Alffenaar JW. Candida tropicalis-A systematic review to inform the World Health Organization of a fungal priority pathogens list. Med Mycol 2024; 62:myae040. [PMID: 38935905 PMCID: PMC11210624 DOI: 10.1093/mmy/myae040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Revised: 01/14/2024] [Accepted: 04/29/2024] [Indexed: 06/29/2024] Open
Abstract
In response to the growing global burden of fungal infections with uncertain impact, the World Health Organization (WHO) established an Expert Group to identify priority fungal pathogens and establish the WHO Fungal Priority Pathogens List for future research. This systematic review aimed to evaluate the features and global impact of invasive candidiasis caused by Candida tropicalis. PubMed and Web of Science were searched for studies reporting on criteria of mortality, morbidity (defined as hospitalization and disability), drug resistance, preventability, yearly incidence, diagnostics, treatability, and distribution/emergence from 2011 to 2021. Thirty studies, encompassing 436 patients from 25 countries were included in the analysis. All-cause mortality due to invasive C. tropicalis infections was 55%-60%. Resistance rates to fluconazole, itraconazole, voriconazole and posaconazole up to 40%-80% were observed but C. tropicalis isolates showed low resistance rates to the echinocandins (0%-1%), amphotericin B (0%), and flucytosine (0%-4%). Leukaemia (odds ratio (OR) = 4.77) and chronic lung disease (OR = 2.62) were identified as risk factors for invasive infections. Incidence rates highlight the geographic variability and provide valuable context for understanding the global burden of C. tropicalis infections. C. tropicalis candidiasis is associated with high mortality rates and high rates of resistance to triazoles. To address this emerging threat, concerted efforts are needed to develop novel antifungal agents and therapeutic approaches tailored to C. tropicalis infections. Global surveillance studies could better inform the annual incidence rates, distribution and trends and allow informed evaluation of the global impact of C. tropicalis infections.
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Affiliation(s)
- Caitlin Keighley
- Sydney Infectious Diseases Institute, The University of Sydney, Sydney, NSW, Australia
- Centre for Infectious Diseases and Microbiology Laboratory Services, Institute of Clinical Pathology and Medical Research, NSW Health Pathology, Westmead Hospital, Westmead, NSW, Australia
- Southern IML Pathology, 3 Bridge St, Coniston, NSW, Australia
| | - Hannah Yejin Kim
- Sydney Infectious Diseases Institute, The University of Sydney, Sydney, NSW, Australia
- Faculty of Medicine and Health, School of Pharmacy, The University of Sydney, Sydney, NSW, Australia
- Westmead Hospital, Westmead, NSW, Australia
| | - Sarah Kidd
- National Mycology Reference Centre, Microbiology & Infectious Diseases, SA Pathology, Adelaide, SA, Australia
- School of Biological Sciences, University of Adelaide, Adelaide, SA, Australia
| | - Sharon C-A Chen
- Sydney Infectious Diseases Institute, The University of Sydney, Sydney, NSW, Australia
- Centre for Infectious Diseases and Microbiology Laboratory Services, Institute of Clinical Pathology and Medical Research, NSW Health Pathology, Westmead Hospital, Westmead, NSW, Australia
| | - Ana Alastruey
- Mycology Reference Laboratory, National Centre for Microbiology, Instituto de Salud Carlos III, Majadahonda, Madrid, Spain
| | - Aiken Dao
- Sydney Infectious Diseases Institute, The University of Sydney, Sydney, NSW, Australia
- Westmead Hospital, Westmead, NSW, Australia
| | - Felix Bongomin
- Department of Medical Microbiology & Immunology, Faculty of Medicine, Gulu University, Gulu, Uganda
| | - Tom Chiller
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, GE, USA
| | - Retno Wahyuningsih
- Department of Parasitology, Faculty of Medicine, Universitas Kristen Indonesia, Jakarta, Indonesia
| | - Agustina Forastiero
- Servicio de Micologia, Laboratorio de Microbiologia, Hospital Britanico, Buenos Aires, Argentina
| | - Adi Al-Nuseirat
- World Health Organization Regional Office for the Eastern Mediterranean, Cairo 11371, Egypt
| | - Peter Beyer
- AMR Division, World Health Organization, Geneva
| | | | - Justin Beardsley
- Sydney Infectious Diseases Institute, The University of Sydney, Sydney, NSW, Australia
- Westmead Hospital, Westmead, NSW, Australia
| | - Hatim Sati
- AMR Division, World Health Organization, Geneva
| | - C Orla Morrissey
- The Alfred Hospital, Department of Infectious Diseases, Melbourne, Victoria, Australia
- Monash University, Department of Infectious Diseases, Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Melbourne, Victoria, Australia
| | - Jan-Willem Alffenaar
- Sydney Infectious Diseases Institute, The University of Sydney, Sydney, NSW, Australia
- Faculty of Medicine and Health, School of Pharmacy, The University of Sydney, Sydney, NSW, Australia
- Westmead Hospital, Westmead, NSW, Australia
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Baba H, Kanamori H, Nakayama A, Sato T, Katsumi M, Chida T, Ikeda S, Seki R, Arai T, Kamei K, Tokuda K. A cluster of Candida parapsilosis displaying fluconazole-trailing in a neonatal intensive care unit successfully contained by multiple infection-control interventions. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2024; 4:e86. [PMID: 38774118 PMCID: PMC11106732 DOI: 10.1017/ash.2024.77] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/03/2024] [Revised: 04/10/2024] [Accepted: 04/14/2024] [Indexed: 05/24/2024]
Abstract
Objective This study aimed to investigate and contain a cluster of invasive candidiasis cases caused by fluconazole-resistant Candida parapsilosis (FRC) in a neonatal intensive care unit. Methods Active surveillance was initiated. Direct observations of hand-hygiene compliance (HHC) among staff were conducted before and after the implementation of hand-hygiene (HH) education. Thirty-five environmental cultures were obtained. Phylogenetic analysis of FRC was performed using Fourier-transform infrared spectroscopy and microsatellite genotyping. Results A total of 14 patients (mean birth weight = 860 g, gestational age = 25 weeks) infected with FRC were identified using the fully automated analyzer, including 5 with clinical infection (three with catheter-related bloodstream infection, one with cutaneous infection, and one with fatal peritonitis) and 9 with colonization. The HHC rate in nurses before performing a sterile or aseptic procedure significantly improved after the HH education (P < .05). Sinks near the patients were contaminated with FRC. All FRC strains were confirmed to be susceptible to fluconazole using the CLSI method, and the microdilution procedure indicated a trailing effect. Phylogenetic analysis showed that all the fluconazole-trailing isolates from patients were clustered together and had the same genotype. Sinks were successfully decontaminated using accelerated hydrogen peroxide and drainage pipes were replaced. Ultraviolet-C decontamination was applied in the milk preparation room. No new cases were detected after the education and disinfection interventions. Conclusions Sinks are an important reservoir of C. parapsilosis. Active surveillance, environmental hygiene, and constant staff education on maintaining a high level of HHC are necessary to limit the spread of C. parapsilosis.
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Affiliation(s)
- Hiroaki Baba
- Department of Infectious Diseases, Internal Medicine, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
- Division of Infection Control, Tohoku University Hospital, Sendai, Miyagi, Japan
| | - Hajime Kanamori
- Department of Infectious Diseases, Internal Medicine, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
- Division of Infection Control, Tohoku University Hospital, Sendai, Miyagi, Japan
| | - Asami Nakayama
- Department of Laboratory Medicine, Tohoku University Hospital, Sendai, Miyagi, Japan
| | - Takami Sato
- Department of Laboratory Medicine, Tohoku University Hospital, Sendai, Miyagi, Japan
| | - Makoto Katsumi
- Department of Laboratory Medicine, Tohoku University Hospital, Sendai, Miyagi, Japan
| | - Takae Chida
- Division of Infection Control, Tohoku University Hospital, Sendai, Miyagi, Japan
| | - Shinobu Ikeda
- Division of Infection Control, Tohoku University Hospital, Sendai, Miyagi, Japan
| | - Rio Seki
- Medical Mycology Research Center, Chiba University, Chiba, Japan
| | - Teppei Arai
- Medical Mycology Research Center, Chiba University, Chiba, Japan
| | - Katsuhiko Kamei
- Medical Mycology Research Center, Chiba University, Chiba, Japan
| | - Koichi Tokuda
- Department of Infectious Diseases, Internal Medicine, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
- Division of Infection Control, Tohoku University Hospital, Sendai, Miyagi, Japan
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Feng Y, Lu H, Whiteway M, Jiang Y. Understanding fluconazole tolerance in Candida albicans: implications for effective treatment of candidiasis and combating invasive fungal infections. J Glob Antimicrob Resist 2023; 35:314-321. [PMID: 37918789 DOI: 10.1016/j.jgar.2023.10.019] [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] [Received: 05/04/2023] [Revised: 10/07/2023] [Accepted: 10/22/2023] [Indexed: 11/04/2023] Open
Abstract
OBJECTIVES Fluconazole (FLC) tolerant phenotypes in Candida species contribute to persistent candidemia and the emergence of FLC resistance. Therefore, making FLC fungicidal and eliminating FLC tolerance are important for treating invasive fungal diseases (IFDs) caused by Candida species. However, the mechanisms of FLC tolerance in Candida species remain to be fully explored. METHODS This review discusses the high incidence of FLC tolerance in Candida species and the importance of successfully clearing FLC tolerance in treating candidiasis. We further define and characterize FLC tolerance in C. albicans. RESULTS This review identifies global factors affecting FLC tolerance and suggest that FLC tolerance is a strategy of C. albicans response to FLC damage whose mechanism differs from FLC resistance. CONCLUSIONS This review highlights the significance of the cell membrane and cell wall integrity in FLC tolerance, guiding approaches to combat IFDs caused by Candida species..
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Affiliation(s)
- Yanru Feng
- Department of Pharmacy, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Hui Lu
- Department of Pharmacy, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, China
| | | | - Yuanying Jiang
- Department of Pharmacy, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, China.
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Alabi PE, Gautier C, Murphy TP, Gu X, Lepas M, Aimanianda V, Sello JK, Ene IV. Small molecules restore azole activity against drug-tolerant and drug-resistant Candida isolates. mBio 2023; 14:e0047923. [PMID: 37326546 PMCID: PMC10470600 DOI: 10.1128/mbio.00479-23] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Accepted: 04/13/2023] [Indexed: 06/17/2023] Open
Abstract
Each year, fungi cause more than 1.5 billion infections worldwide and have a devastating impact on human health, particularly in immunocompromised individuals or patients in intensive care units. The limited antifungal arsenal and emerging multidrug-resistant species necessitate the development of new therapies. One strategy for combating drug-resistant pathogens is the administration of molecules that restore fungal susceptibility to approved drugs. Accordingly, we carried out a screen to identify small molecules that could restore the susceptibility of pathogenic Candida species to azole antifungals. This screening effort led to the discovery of novel 1,4-benzodiazepines that restore fluconazole susceptibility in resistant isolates of Candida albicans, as evidenced by 100-1,000-fold potentiation of fluconazole activity. This potentiation effect was also observed in azole-tolerant strains of C. albicans and in other pathogenic Candida species. The 1,4-benzodiazepines selectively potentiated different azoles, but not other approved antifungals. A remarkable feature of the potentiation was that the combination of the compounds with fluconazole was fungicidal, whereas fluconazole alone is fungistatic. Interestingly, the potentiators were not toxic to C. albicans in the absence of fluconazole, but inhibited virulence-associated filamentation of the fungus. We found that the combination of the potentiators and fluconazole significantly enhanced host survival in a Galleria mellonella model of systemic fungal infection. Taken together, these observations validate a strategy wherein small molecules can restore the activity of highly used anti-infectives that have lost potency. IMPORTANCE In the last decade, we have been witnessing a higher incidence of fungal infections, due to an expansion of the fungal species capable of causing disease (e.g., Candida auris), as well as increased antifungal drug resistance. Among human fungal pathogens, Candida species are a leading cause of invasive infections and are associated with high mortality rates. Infections by these pathogens are commonly treated with azole antifungals, yet the expansion of drug-resistant isolates has reduced their clinical utility. In this work, we describe the discovery and characterization of small molecules that potentiate fluconazole and restore the susceptibility of azole-resistant and azole-tolerant Candida isolates. Interestingly, the potentiating 1,4-benzodiazepines were not toxic to fungal cells but inhibited their virulence-associated filamentous growth. Furthermore, combinations of the potentiators and fluconazole decreased fungal burdens and enhanced host survival in a Galleria mellonella model of systemic fungal infections. Accordingly, we propose the use of novel antifungal potentiators as a powerful strategy for addressing the growing resistance of fungi to clinically approved drugs.
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Affiliation(s)
- Philip E. Alabi
- Department of Chemistry, Brown University, Providence, Rhode Island, USA
- Department of Pharmaceutical Chemistry, University of California San Francisco, San Francisco, California, USA
| | - Cécile Gautier
- Institut Pasteur, Université Paris Cité, Fungal Heterogeneity Group, Paris, France
| | - Thomas P. Murphy
- Department of Molecular Microbiology and Immunology, Brown University, Providence, Rhode Island, USA
| | - Xilin Gu
- Department of Chemistry, Brown University, Providence, Rhode Island, USA
- Department of Pharmaceutical Chemistry, University of California San Francisco, San Francisco, California, USA
| | - Mathieu Lepas
- Institut Pasteur, Université Paris Cité, CNRS UMR2000, Molecular Mycology Unit, Paris, France
| | - Vishukumar Aimanianda
- Institut Pasteur, Université Paris Cité, CNRS UMR2000, Molecular Mycology Unit, Paris, France
| | - Jason K. Sello
- Department of Chemistry, Brown University, Providence, Rhode Island, USA
- Department of Pharmaceutical Chemistry, University of California San Francisco, San Francisco, California, USA
| | - Iuliana V. Ene
- Institut Pasteur, Université Paris Cité, Fungal Heterogeneity Group, Paris, France
- Department of Molecular Microbiology and Immunology, Brown University, Providence, Rhode Island, USA
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Druseikis M, Mottola A, Berman J. The Metabolism of Susceptibility: Clearing the FoG Between Tolerance and Resistance in Candida albicans. CURRENT CLINICAL MICROBIOLOGY REPORTS 2023; 10:36-46. [DOI: 10.1007/s40588-023-00189-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/30/2023]
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Oliveira NK, Bhattacharya S, Gambhir R, Joshi M, Fries BC. Novel ABC Transporter Associated with Fluconazole Resistance in Aging of Cryptococcus neoformans. J Fungi (Basel) 2022; 8:677. [PMID: 35887434 PMCID: PMC9320417 DOI: 10.3390/jof8070677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 06/24/2022] [Accepted: 06/26/2022] [Indexed: 11/27/2022] Open
Abstract
Cryptococcus neoformans causes meningoencephalitis in immunocompromised individuals, which is treated with fluconazole (FLC) monotherapy when resources are limited. This can lead to azole resistance, which can be mediated by overexpression of ABC transporters, a class of efflux pumps. ABC pump-mediated efflux of FLC is also augmented in 10-generation old C. neoformans cells. Here, we describe a new ABC transporter Afr3 (CNAG_06909), which is overexpressed in C. neoformans cells of advanced generational age that accumulate during chronic infection. The Δafr3 mutant strain showed higher FLC susceptibility by FLC E-Test strip testing and also by a killing test that measured survival after 3 h FLC exposure. Furthermore, Δafr3 cells exhibited lower Rhodamine 6G efflux compared to the H99 wild-type cells. Afr3 was expressed in the Saccharomyces cerevisiae ADΔ strain, which lacks several drug transporters, thus reducing background transport. The ADΔ + Afr3 strain demonstrated a higher efflux with both Rhodamine 6G and Nile red, and a higher FLC resistance. Afr3-GFP localized in the plasma membrane of the ADΔ + Afr3 strain, further highlighting its importance as an efflux pump. Characterization of the Δafr3 mutant revealed unattenuated growth but a prolongation (29%) of the replicative life span. In addition, Δafr3 exhibited decreased resistance to macrophage killing and attenuated virulence in the Galleria mellonella infection model. In summary, our data indicate that a novel ABC pump Afr3, which is upregulated in C. neoformans cells of advanced age, may contribute to their enhanced FLC tolerance, by promoting drug efflux. Lastly, its role in macrophage resistance may also contribute to the selection of older C. neoformans cells during chronic infection.
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Affiliation(s)
- Natalia Kronbauer Oliveira
- Department of Microbiology and Immunology, Renaissance School of Medicine, Stony Brook University, Stony Brook, NY 11794, USA;
| | - Somanon Bhattacharya
- Division of Infectious Diseases, Department of Medicine, Stony Brook University, Stony Brook, NY 11794, USA;
| | - Rina Gambhir
- Department of Medicine, Stony Brook University, Stony Brook, NY 11794, USA; (R.G.); (M.J.)
| | - Manav Joshi
- Department of Medicine, Stony Brook University, Stony Brook, NY 11794, USA; (R.G.); (M.J.)
| | - Bettina C. Fries
- Department of Microbiology and Immunology, Renaissance School of Medicine, Stony Brook University, Stony Brook, NY 11794, USA;
- Division of Infectious Diseases, Department of Medicine, Stony Brook University, Stony Brook, NY 11794, USA;
- Veterans Administration Medical Center, Northport, NY 11768, USA
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Ksiezopolska E, Schikora-Tamarit MÀ, Beyer R, Nunez-Rodriguez JC, Schüller C, Gabaldón T. Narrow mutational signatures drive acquisition of multidrug resistance in the fungal pathogen Candida glabrata. Curr Biol 2021; 31:5314-5326.e10. [PMID: 34699784 PMCID: PMC8660101 DOI: 10.1016/j.cub.2021.09.084] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 07/20/2021] [Accepted: 09/29/2021] [Indexed: 01/25/2023]
Abstract
Fungal infections are a growing medical concern, in part due to increased resistance to one or multiple antifungal drugs. However, the evolutionary processes underpinning the acquisition of antifungal drug resistance are poorly understood. Here, we used experimental microevolution to study the adaptation of the yeast pathogen Candida glabrata to fluconazole and anidulafungin, two widely used antifungal drugs with different modes of action. Our results show widespread ability of rapid adaptation to one or both drugs. Resistance, including multidrug resistance, is often acquired at moderate fitness costs and mediated by mutations in a limited set of genes that are recurrently and specifically mutated in strains adapted to each of the drugs. Importantly, we uncover a dual role of ERG3 mutations in resistance to anidulafungin and cross-resistance to fluconazole in a subset of anidulafungin-adapted strains. Our results shed light on the mutational paths leading to resistance and cross-resistance to antifungal drugs.
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Affiliation(s)
- Ewa Ksiezopolska
- Barcelona Supercomputing Centre (BSC-CNS), Life Sciences Department, Jordi Girona 29, 08034 Barcelona, Spain; Institute for Research in Biomedicine (IRB Barcelona), Mechanisms of Disease Program, The Barcelona Institute of Science and Technology, Baldiri Reixac 10, 08028 Barcelona, Spain
| | - Miquel Àngel Schikora-Tamarit
- Barcelona Supercomputing Centre (BSC-CNS), Life Sciences Department, Jordi Girona 29, 08034 Barcelona, Spain; Institute for Research in Biomedicine (IRB Barcelona), Mechanisms of Disease Program, The Barcelona Institute of Science and Technology, Baldiri Reixac 10, 08028 Barcelona, Spain
| | - Reinhard Beyer
- Institute of Microbial Genetics and Core Facility Bioactive Substances: Screening and Analysis, University of Natural Resources and Life Sciences, Vienna (BOKU), Konrad Lorenz Strasse 24, 3430 Tulln an der Donau, Austria
| | - Juan Carlos Nunez-Rodriguez
- Barcelona Supercomputing Centre (BSC-CNS), Life Sciences Department, Jordi Girona 29, 08034 Barcelona, Spain; Institute for Research in Biomedicine (IRB Barcelona), Mechanisms of Disease Program, The Barcelona Institute of Science and Technology, Baldiri Reixac 10, 08028 Barcelona, Spain
| | - Christoph Schüller
- Institute of Microbial Genetics and Core Facility Bioactive Substances: Screening and Analysis, University of Natural Resources and Life Sciences, Vienna (BOKU), Konrad Lorenz Strasse 24, 3430 Tulln an der Donau, Austria
| | - Toni Gabaldón
- Barcelona Supercomputing Centre (BSC-CNS), Life Sciences Department, Jordi Girona 29, 08034 Barcelona, Spain; Institute for Research in Biomedicine (IRB Barcelona), Mechanisms of Disease Program, The Barcelona Institute of Science and Technology, Baldiri Reixac 10, 08028 Barcelona, Spain; Catalan Institution for Research and Advanced Studies (ICREA), Passeig Lluis Companys 23, 08010 Barcelona, Spain.
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Mechanisms of Azole Resistance and Trailing in Candida tropicalis Bloodstream Isolates. J Fungi (Basel) 2021; 7:jof7080612. [PMID: 34436151 PMCID: PMC8396981 DOI: 10.3390/jof7080612] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Revised: 07/25/2021] [Accepted: 07/26/2021] [Indexed: 12/13/2022] Open
Abstract
Objectives: Azole-resistant Candida tropicalis has emerged in Asia in the context of its trailing nature, defined by residual growth above minimum inhibitory concentrations (MICs). However, limited investigations in C. tropicalis have focused on the difference of genotypes and molecular mechanisms between these two traits. Methods: Sixty-four non-duplicated C. tropicalis bloodstream isolates collected in 2017 were evaluated for azole MICs by the EUCAST E.def 7.3.1 method, diploid sequence type (DST) by multilocus sequencing typing, and sequences and expression levels of genes encoding ERG11, its transcription factor, UPC2, and efflux pumps (CDR1, CDR2 and MDR1). Results: Isavuconazole showed the highest in vitro activity and trailing against C. tropicalis, followed by voriconazole and fluconazole (geometric mean [GM] MIC, 0.008, 0.090, 1.163 mg/L, respectively; trailing GM, 27.4%, 20.8% and 19.5%, respectively; both overall p < 0.001). Fourteen (21.9%) isolates were non-WT to fluconazole/voriconazole, 12 of which were non-WT to isavuconazole and clustered in clonal complex (CC) 3. Twenty-five (39.1%) isolates were high trailing WT, including all CC2 isolates (44.0%) (containing DST140 and DST98). All azole non-WT isolates carried the ERG11 mutations A395T/W and/or C461T/Y, and most carried the UPC2 mutation T503C/Y. These mutations were not identified in low and high trailing WT isolates. Azole non-WT and high trailing WT isolates exhibited the highest expression levels of ERG11 and MDR1, 3.91- and 2.30-fold, respectively (both overall p < 0.01). Conclusions: Azole resistance and trailing are phenotypically and genotypically different in C. tropicalis. Interference with azole binding and MDR1 up-regulation confer azole resistance and trailing, respectively.
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Levinson T, Dahan A, Novikov A, Paran Y, Berman J, Ben-Ami R. Impact of tolerance to fluconazole on treatment response in Candida albicans bloodstream infection. Mycoses 2020; 64:78-85. [PMID: 33000505 DOI: 10.1111/myc.13191] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 09/04/2020] [Indexed: 01/05/2023]
Abstract
BACKGROUND Treatment of Candida albicans bloodstream infection with fluconazole is associated with significant mortality despite in vitro susceptibility to the drug. OBJECTIVES We sought to determine whether tolerance to fluconazole is predictive of treatment failure. METHODS We reviewed patients with monomicrobial C albicans bloodstream infection who received primary monotherapy with fluconazole. Tolerance to fluconazole, defined as the fraction of growth above the MIC, was quantified using the disc diffusion assay and digital image analyses. Survival analyses were performed with host and treatment factors as predictive variables. RESULTS Among 44 patients included in the study, all-cause mortality was 29.5% at 30 days and 43.1% at 12 weeks. Forty-one isolates (93%) were susceptible to fluconazole (MIC50, 0.5 mg/L). Fluconazole tolerance was strongly associated with death for patients treated with fluconazole within 24 h of candidemia onset (33.3% vs 0%; p = .007), but not among patients whose treatment was started later. MIC did not correlate with survival, regardless of treatment delay. A Cox regression model including time to treatment, tolerance to fluconazole, fluconazole exposure and Pitt bacteraemia score provided good prediction of treatment outcome (area under the receiver-operator curve, 0.82). CONCLUSIONS In patients with C albicans bloodstream infection, tolerance testing was predictive of fluconazole efficacy if the drug was started early. Further study is required to validate the utility of this metric to guide treatment choices.
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Affiliation(s)
- Tal Levinson
- Infectious Diseases Unit, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Alon Dahan
- The George S. Wise Faculty of Life Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Anna Novikov
- Infectious Diseases Unit, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Yael Paran
- Infectious Diseases Unit, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Judith Berman
- The George S. Wise Faculty of Life Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Ronen Ben-Ami
- Infectious Diseases Unit, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Arastehfar A, Hilmioğlu-Polat S, Daneshnia F, Hafez A, Salehi M, Polat F, Yaşar M, Arslan N, Hoşbul T, Ünal N, Metin DY, Gürcan Ş, Birinci A, Koç AN, Pan W, Ilkit M, Perlin DS, Lass-Flörl C. Recent Increase in the Prevalence of Fluconazole-Non-susceptible Candida tropicalis Blood Isolates in Turkey: Clinical Implication of Azole-Non-susceptible and Fluconazole Tolerant Phenotypes and Genotyping. Front Microbiol 2020; 11:587278. [PMID: 33123116 PMCID: PMC7573116 DOI: 10.3389/fmicb.2020.587278] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Accepted: 09/07/2020] [Indexed: 12/18/2022] Open
Abstract
Candida tropicalis is the fourth leading cause of candidemia in Turkey. Although C. tropicalis isolates from 1997 to 2017 were characterized as fully susceptible to antifungals, the increasing global prevalence of azole-non-susceptible (ANS) C. tropicalis and the association between high fluconazole tolerance (HFT) and fluconazole therapeutic failure (FTF) prompted us to re-evaluate azole susceptibility of C. tropicalis in Turkey. In this study, 161 C. tropicalis blood isolates from seven clinical centers were identified by ITS rDNA sequencing, genotyped by multilocus microsatellite typing, and tested for susceptibility to five azoles, two echinocandins, and amphotericin B (AMB); antifungal resistance mechanisms were assessed by sequencing of ERG11 and FKS1 genes. The results indicated that C. tropicalis isolates, which belonged to 125 genotypes grouped into 11 clusters, were fully susceptible to echinocandins and AMB; however, 18.6% of them had the ANS phenotype but only two carried the ANS-conferring mutation (Y132F). HFT was recorded in 52 isolates, 10 of which were also ANS. Large proportions of patients infected with ANS and HFT isolates (89 and 40.7%, respectively) showed FTF. Patients infected with azole-susceptible or ANS isolates did not differ in mortality, which, however, was significantly lower for those infected with HFT isolates (P = 0.007). There were significant differences in mortality (P = 0.02), ANS (P = 0.012), and HFT (P = 0.007) among genotype clusters. The alarming increase in the prevalence of C. tropicalis blood isolates with ANS and HFT in Turkey and the notable FTF rate should be a matter of public health concern.
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Affiliation(s)
- Amir Arastehfar
- Center for Discovery and Innovation, Hackensack Meridian Health, Nutley, NJ, United States
| | | | | | | | - Mohammadreza Salehi
- Department of Infectious Diseases and Tropical Medicine, Faculty of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Furkan Polat
- Department of Microbiology, Faculty of Medicine, Ege University, Izmir, Turkey
| | - Melike Yaşar
- Department of Microbiology, Faculty of Medicine, Ege University, Izmir, Turkey
| | - Nazlı Arslan
- Department of Microbiology, Faculty of Medicine, Dokuz Eylul University, Izmir, Turkey
| | - Tuğrul Hoşbul
- Department of Microbiology, Gulhane Training and Research Hospital, University of Health Sciences, Ankara, Turkey
| | - Nevzat Ünal
- Division of Mycology, Faculty of Medicine, Çukurova University, Adana, Turkey.,Department of Microbiology, Adana City Hospital, University of Health Sciences, Adana, Turkey
| | - Dilek Yeşim Metin
- Department of Microbiology, Faculty of Medicine, Ege University, Izmir, Turkey
| | - Şaban Gürcan
- Department of Microbiology, Faculty of Medicine, Trakya University, Edirne, Turkey
| | - Asuman Birinci
- Department of Microbiology, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey
| | - Ayşe Nedret Koç
- Department of Microbiology, Faculty of Medicine, Erciyes University, Kayseri, Turkey
| | - Weihua Pan
- Shanghai Key Laboratory Molecular Medical Mycology, Shanghai, China
| | - Macit Ilkit
- Division of Mycology, Faculty of Medicine, Çukurova University, Adana, Turkey
| | - David S Perlin
- Center for Discovery and Innovation, Hackensack Meridian Health, Nutley, NJ, United States
| | - Cornelia Lass-Flörl
- Division of Hygiene and Medical Microbiology, Medical University of Innsbruck, Innsbruck, Austria
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13
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Chromatin Structure and Drug Resistance in Candida spp. J Fungi (Basel) 2020; 6:jof6030121. [PMID: 32751495 PMCID: PMC7559719 DOI: 10.3390/jof6030121] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 07/21/2020] [Accepted: 07/25/2020] [Indexed: 12/14/2022] Open
Abstract
Anti-microbial resistance (AMR) is currently one of the most serious threats to global human health and, appropriately, research to tackle AMR garnishes significant investment and extensive attention from the scientific community. However, most of this effort focuses on antibiotics, and research into anti-fungal resistance (AFR) is vastly under-represented in comparison. Given the growing number of vulnerable, immunocompromised individuals, as well as the positive impact global warming has on fungal growth, there is an immediate urgency to tackle fungal disease, and the disturbing rise in AFR. Chromatin structure and gene expression regulation play pivotal roles in the adaptation of fungal species to anti-fungal stress, suggesting a potential therapeutic avenue to tackle AFR. In this review we discuss both the genetic and epigenetic mechanisms by which chromatin structure can dictate AFR mechanisms and will present evidence of how pathogenic yeast, specifically from the Candida genus, modify chromatin structure to promote survival in the presence of anti-fungal drugs. We also discuss the mechanisms by which anti-chromatin therapy, specifically lysine deacetylase inhibitors, influence the acquisition and phenotypic expression of AFR in Candida spp. and their potential as effective adjuvants to mitigate against AFR.
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14
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Marcos-Zambrano LJ, Gómez A, Sánchez-Carrillo C, Bouza E, Muñoz P, Escribano P, Guinea J. Isavuconazole is highly active in vitro against Candida species isolates but shows trailing effect. Clin Microbiol Infect 2020; 26:1589-1592. [PMID: 32712246 DOI: 10.1016/j.cmi.2020.07.023] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Isavuconazole is a triazole previously shown to have potent in vitro activity against Aspergillus spp., Mucorales, and Candida spp. Unlike for other azoles, it is unclear if isavuconazole may induce a trailing effect. We studied isavuconazole MICs for a large collection of Candida isolates from blood samples and determined the extent of the trailing effect when using the EUCAST Edef 7.3.1 method. METHODS 761 molecularly identified Candida isolates from blood samples of 742 patients admitted to the hospital (January 2007 to September 2017) were evaluated and further tested for in vitro susceptibility to isavuconazole following the EUCAST E.Def 7.3.1 test method. RESULTS C. albicans showed the highest susceptibility, followed by C. parapsilosis and C. tropicalis (geometric mean MIC 0.003 vs 0.005/0.006, respectively; P < 0.001). In contrast, C. glabrata, and C. krusei had significantly higher MIC values (geometric mean MIC 0.094 vs 0.093, respectively). Isavuconazole MIC distributions were not truncated at the lowest concentration tested, except for C. albicans. Overall, the mean percentage of trailing was 12.9% but differences among species were observed: C. glabrata, C. albicans, and C. tropicalis exhibited higher trailing in comparison to C. parapsilosis and non-Candida yeasts (P < 0.001). The percentage of non-wild-type C. albicans (considering the heavy trailer isolates as wild-type), C. parapsilosis and C. glabrata isolates were 0.56% (2/355), 1.5% (3/200), and 4.65% (4/86), respectively. CONCLUSIONS Isavuconazole showed high in vitro activity against Candida spp., particularly against C. albicans. Trailing effect is commonly observed with isavuconazole, particularly with C. glabrata.
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Affiliation(s)
- Laura Judith Marcos-Zambrano
- Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Ana Gómez
- Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Carlos Sánchez-Carrillo
- Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain; CIBER Enfermedades Respiratorias-CIBERES (CD06/06/0058), Madrid, Spain
| | - Emilio Bouza
- Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain; Medicine Department, School of Medicine, Universidad Complutense de Madrid, Madrid, Spain; CIBER Enfermedades Respiratorias-CIBERES (CD06/06/0058), Madrid, Spain
| | - Patricia Muñoz
- Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain; Medicine Department, School of Medicine, Universidad Complutense de Madrid, Madrid, Spain; CIBER Enfermedades Respiratorias-CIBERES (CD06/06/0058), Madrid, Spain
| | - Pilar Escribano
- Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain; CIBER Enfermedades Respiratorias-CIBERES (CD06/06/0058), Madrid, Spain
| | - Jesús Guinea
- Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain; Medicine Department, School of Medicine, Universidad Complutense de Madrid, Madrid, Spain; CIBER Enfermedades Respiratorias-CIBERES (CD06/06/0058), Madrid, Spain.
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15
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Ayadi R, Sitterlé E, d’Enfert C, Dannaoui E, Bougnoux ME. Candida albicans and Candida dubliniensis Show Different Trailing Effect Patterns When Exposed to Echinocandins and Azoles. Front Microbiol 2020; 11:1286. [PMID: 32612593 PMCID: PMC7308431 DOI: 10.3389/fmicb.2020.01286] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 05/20/2020] [Indexed: 11/18/2022] Open
Abstract
When Candida albicans and Candida dubliniensis isolates were tested for susceptibility to fluconazole and echinocandins using either EUCAST or Etest methods, differential patterns of growth were observed, independently of the methods used. For C. albicans, a trailing phenomenon (incomplete growth inhibition at supra-MICs) was observed with fluconazole in 90% and 93.3% for EUCAST and Etest, respectively, but not with echinocandins (<7% for EUCAST and 0% for Etest). In contrast, for C. dubliniensis, a trailing phenomenon was very rarely observed with fluconazole (20% for EUCAST and 0% for Etest), while the opposite pattern was observed with echinocandins (>50% for EUCAST and >86% for Etest). This suggests that the pathways involved in the trailing effect might be different between these two related species. Furthermore, clinical microbiologists must be aware of these species-specific patterns for a reliable MIC determination.
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Affiliation(s)
- Rania Ayadi
- Unité de Parasitologie-Mycologie, Service de Microbiologie, Faculté de Médecine, APHP, Hôpital Européen Georges Pompidou, Université Paris-Descartes, Paris, France
| | - Emilie Sitterlé
- Unité de Parasitologie-Mycologie, Service de Microbiologie, Faculté de Médecine, APHP, Hôpital Necker Enfants-Malades, Université Paris-Descartes, Paris, France
- Unité Biologie et Pathogénicité Fongiques, Institut Pasteur, USC 2019 INRA, Paris, France
| | - Christophe d’Enfert
- Unité Biologie et Pathogénicité Fongiques, Institut Pasteur, USC 2019 INRA, Paris, France
| | - Eric Dannaoui
- Unité de Parasitologie-Mycologie, Service de Microbiologie, Faculté de Médecine, APHP, Hôpital Européen Georges Pompidou, Université Paris-Descartes, Paris, France
- Dynamyc Research Group, Paris Est Créteil University (UPEC, EnvA), Créteil, France
| | - Marie-Elisabeth Bougnoux
- Unité de Parasitologie-Mycologie, Service de Microbiologie, Faculté de Médecine, APHP, Hôpital Necker Enfants-Malades, Université Paris-Descartes, Paris, France
- Unité Biologie et Pathogénicité Fongiques, Institut Pasteur, USC 2019 INRA, Paris, France
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Abstract
Systemic fungal infections pose a serious clinical problem. Treatment options are limited, and antifungal drug resistance is increasing. In addition, a substantial proportion of patients do not respond to therapy despite being infected with fungi that are susceptible to the drug. The discordance between overall treatment outcome and low levels of clinical resistance may be attributable to antifungal drug tolerance. In this Review, we define and distinguish resistance and tolerance and discuss the current understanding of the molecular, genetic and physiological mechanisms that contribute to those phenomena. Distinguishing tolerance from resistance might provide important insights into the reasons for treatment failure in some settings.
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17
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Minimal Inhibitory Concentration (MIC)-Phenomena in Candida albicans and Their Impact on the Diagnosis of Antifungal Resistance. J Fungi (Basel) 2019; 5:jof5030083. [PMID: 31487830 PMCID: PMC6787722 DOI: 10.3390/jof5030083] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 08/30/2019] [Accepted: 09/02/2019] [Indexed: 02/07/2023] Open
Abstract
Antifungal susceptibility testing (AFST) of clinical isolates is a tool in routine diagnostics to facilitate decision making on optimal antifungal therapy. The minimal inhibitory concentration (MIC)-phenomena (trailing and paradoxical effects (PXE)) observed in AFST complicate the unambiguous and reproducible determination of MICs and the impact of these phenomena on in vivo outcome are not fully understood. We aimed to link the MIC-phenomena with in vivo treatment response using the alternative infection model Galleria mellonella. We found that Candida albicans strains exhibiting PXE for caspofungin (CAS) had variable treatment outcomes in the Galleria model. In contrast, C. albicans strains showing trailing for voriconazole failed to respond in vivo. Caspofungin- and voriconazole-susceptible C. albicans strains responded to the respective antifungal therapy in vivo. In conclusion, MIC data and subsequent susceptibility interpretation of strains exhibiting PXE and/or trailing should be carried out with caution, as both effects are linked to drug adaptation and treatment response is uncertain to predict.
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18
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Implications of the EUCAST Trailing Phenomenon in Candida tropicalis for the In Vivo Susceptibility in Invertebrate and Murine Models. Antimicrob Agents Chemother 2018; 62:AAC.01624-18. [PMID: 30224538 DOI: 10.1128/aac.01624-18] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Accepted: 09/05/2018] [Indexed: 12/31/2022] Open
Abstract
Candida tropicalis isolates often display reduced but persistent growth (trailing) over a broad fluconazole concentration range during EUCAST susceptibility testing. Whereas weak trailing (<25% of the positive growth control) is common and found not to impair fluconazole efficacy, we investigated if more pronounced trailing impacted treatment efficacy. Fluconazole efficacy against two weakly (≤25% growth), two moderately (26% to 50% growth), and one heavily (>70% growth) trailing resistant isolate and one resistant (100% growth) isolate were investigated in vitro and in vivo (in a Galleria mellonella survival model and two nonlethal murine models). CDR1 expression levels and ERG11 sequences were characterized. The survival in fluconazole-treated G. mellonella was inversely correlated with the degree of trailing (71% to 9% survival in treatment groups). In mice, resistant and heavily trailing isolates responded poorly to fluconazole treatment. CDR1 expression was significantly higher in trailing and resistant isolates than in wild-type isolates (1.4-fold to 10-fold higher). All isolates exhibited ERG11 wild-type alleles. Heavily trailing isolates were less responsive to fluconazole in all in vivo models, indicating an impact on fluconazole efficacy. CDR1 upregulation may have contributed to the observed differences. Moderately trailing isolates responded less well to fluconazole in larvae only. This confirms clinical data suggesting fluconazole is effective against infections with such isolates in less severely ill patients and supports the current 50% growth endpoint for susceptibility testing. However, it is still unclear if the gradual loss of efficacy observed for moderately trailing isolates in the larva model may be a reason for concern in selected vulnerable patient populations.
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19
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Isavuconazole is highly active in vitro against Candida species isolates but shows trailing effect. Clin Microbiol Infect 2018; 24:1343.e1-1343.e4. [PMID: 30025834 DOI: 10.1016/j.cmi.2018.07.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Revised: 06/28/2018] [Accepted: 07/05/2018] [Indexed: 11/20/2022]
Abstract
OBJECTIVES Isavuconazole is a triazole previously shown to have potent in vitro activity against Aspergillus spp., Mucorales and Candida spp. Unlike other azoles, it is unclear whether isavuconazole induces a trailing effect. We studied isavuconazole MICs for a large collection of Candida isolates from blood samples and determined the extent of the trailing effect when using the European Committee on Antimicrobial Susceptibility Testing (EUCAST) E.Def 7.3.1 method. METHODS A total of 762 molecularly identified Candida isolates from blood samples of 743 patients admitted to hospital (January 2007 to September 2017) were evaluated and further tested for in vitro susceptibility to isavuconazole following the EUCAST E.Def 7.3.1 test method. RESULTS C. albicans showed the highest susceptibility, followed by C. parapsilosis and C. tropicalis (geometric mean MIC 0.0029 vs. 0.0049/0.0052, respectively; p <0.001). In contrast, C. glabrata and C. krusei had significantly higher MIC values (geometric mean MIC 0.171 vs. 0.117, respectively). Isavuconazole MIC distributions were not truncated at the lowest concentration tested except for C. albicans. Overall, the mean percentage of trailing was 13.6%, but differences among species were observed: C. glabrata, C. albicans and C. tropicalis exhibited higher trailing compared to C. parapsilosis and non-Candida yeasts (p <0.001). The percentage of non-wild-type C. albicans (considering the heavy trailer isolates as wild type), C. parapsilosis and C. glabrata isolates were 1.1% (4/357), 1.5% (3/201) and 1.1% (1/86), respectively. CONCLUSIONS Isavuconazole showed high in vitro activity against Candida spp., particularly against C. albicans. A trailing effect is commonly observed with isavuconazole, particularly with C. glabrata.
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20
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Antifungal tolerance is a subpopulation effect distinct from resistance and is associated with persistent candidemia. Nat Commun 2018; 9:2470. [PMID: 29941885 PMCID: PMC6018213 DOI: 10.1038/s41467-018-04926-x] [Citation(s) in RCA: 139] [Impact Index Per Article: 23.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Accepted: 06/05/2018] [Indexed: 11/23/2022] Open
Abstract
Tolerance to antifungal drug concentrations above the minimal inhibitory concentration (MIC) is rarely quantified, and current clinical recommendations suggest it should be ignored. Here, we quantify antifungal tolerance in Candida albicans isolates as the fraction of growth above the MIC, and find that it is distinct from susceptibility/resistance. Instead, tolerance is due to the slow growth of subpopulations of cells that overcome drug stress more efficiently than the rest of the population, and correlates inversely with intracellular drug accumulation. Many adjuvant drugs used in combination with fluconazole, a widely used fungistatic drug, reduce tolerance without affecting resistance. Accordingly, in an invertebrate infection model, adjuvant combination therapy is more effective than fluconazole in treating infections with highly tolerant isolates and does not affect infections with low tolerance isolates. Furthermore, isolates recovered from immunocompetent patients with persistent candidemia display higher tolerance than isolates readily cleared by fluconazole. Thus, tolerance correlates with, and may help predict, patient responses to fluconazole therapy. The authors show that antifungal tolerance, defined as the fraction of growth of a fungal pathogen above the minimal inhibitory concentration, is due to the slow growth of subpopulations of cells that overcome drug stress, and that high tolerance is often associated with persistent infections.
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Van Dijck P, Sjollema J, Cammue BPA, Lagrou K, Berman J, d’Enfert C, Andes DR, Arendrup MC, Brakhage AA, Calderone R, Cantón E, Coenye T, Cos P, Cowen LE, Edgerton M, Espinel-Ingroff A, Filler SG, Ghannoum M, Gow NA, Haas H, Jabra-Rizk MA, Johnson EM, Lockhart SR, Lopez-Ribot JL, Maertens J, Munro CA, Nett JE, Nobile CJ, Pfaller MA, Ramage G, Sanglard D, Sanguinetti M, Spriet I, Verweij PE, Warris A, Wauters J, Yeaman MR, Zaat SA, Thevissen K. Methodologies for in vitro and in vivo evaluation of efficacy of antifungal and antibiofilm agents and surface coatings against fungal biofilms. MICROBIAL CELL (GRAZ, AUSTRIA) 2018; 5:300-326. [PMID: 29992128 PMCID: PMC6035839 DOI: 10.15698/mic2018.07.638] [Citation(s) in RCA: 66] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Accepted: 05/24/2018] [Indexed: 12/13/2022]
Abstract
Unlike superficial fungal infections of the skin and nails, which are the most common fungal diseases in humans, invasive fungal infections carry high morbidity and mortality, particularly those associated with biofilm formation on indwelling medical devices. Therapeutic management of these complex diseases is often complicated by the rise in resistance to the commonly used antifungal agents. Therefore, the availability of accurate susceptibility testing methods for determining antifungal resistance, as well as discovery of novel antifungal and antibiofilm agents, are key priorities in medical mycology research. To direct advancements in this field, here we present an overview of the methods currently available for determining (i) the susceptibility or resistance of fungal isolates or biofilms to antifungal or antibiofilm compounds and compound combinations; (ii) the in vivo efficacy of antifungal and antibiofilm compounds and compound combinations; and (iii) the in vitro and in vivo performance of anti-infective coatings and materials to prevent fungal biofilm-based infections.
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Affiliation(s)
- Patrick Van Dijck
- VIB-KU Leuven Center for Microbiology, Leuven, Belgium
- KU Leuven Laboratory of Molecular Cell Biology, Leuven, Belgium
| | - Jelmer Sjollema
- University of Groningen, University Medical Center Groningen, Department of BioMedical Engineering, Groningen, The Netherlands
| | - Bruno P. A. Cammue
- Centre for Microbial and Plant Genetics, KU Leuven, Leuven, Belgium
- Department of Plant Systems Biology, VIB, Ghent, Belgium
| | - Katrien Lagrou
- Department of Microbiology and Immunology, KU Leuven, Leuven, Belgium
- Clinical Department of Laboratory Medicine and National Reference Center for Mycosis, UZ Leuven, Belgium
| | - Judith Berman
- School of Molecular Cell Biology and Biotechnology, Faculty of Life Sciences, Tel Aviv University, Ramat Aviv, Israel
| | - Christophe d’Enfert
- Institut Pasteur, INRA, Unité Biologie et Pathogénicité Fongiques, Paris, France
| | - David R. Andes
- Department of Medical Microbiology and Immunology, University of Wisconsin-Madison, Madison, Wisconsin, USA
- Department of Medicine, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Maiken C. Arendrup
- Unit of Mycology, Statens Serum Institut, Copenhagen, Denmark
- Department of Clinical Microbiology, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Axel A. Brakhage
- Leibniz Institute for Natural Product Research and Infection Biology - Hans Knoell Institute (HKI), Dept. Microbiology and Molecular Biology, Friedrich Schiller University Jena, Institute of Microbiology, Jena, Germany
| | - Richard Calderone
- Department of Microbiology & Immunology, Georgetown University Medical Center, Washington DC, USA
| | - Emilia Cantón
- Severe Infection Research Group: Medical Research Institute La Fe (IISLaFe), Valencia, Spain
| | - Tom Coenye
- Laboratory of Pharmaceutical Microbiology, Ghent University, Ghent, Belgium
- ESCMID Study Group for Biofilms, Switzerland
| | - Paul Cos
- Laboratory for Microbiology, Parasitology and Hygiene (LMPH), University of Antwerp, Belgium
| | - Leah E. Cowen
- Department of Molecular Genetics, University of Toronto, Toronto, Ontario, Canada
| | - Mira Edgerton
- Department of Oral Biology, School of Dental Medicine, University at Buffalo, Buffalo, NY USA
| | | | - Scott G. Filler
- Division of Infectious Diseases, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Mahmoud Ghannoum
- Center for Medical Mycology, Department of Dermatology, University Hospitals Cleveland Medical Center and Case Western Re-serve University, Cleveland, OH, USA
| | - Neil A.R. Gow
- MRC Centre for Medical Mycology, Institute of Medical Sciences, University of Aberdeen, Aberdeen, UK
| | - Hubertus Haas
- Biocenter - Division of Molecular Biology, Medical University Innsbruck, Innsbruck, Austria
| | - Mary Ann Jabra-Rizk
- Department of Oncology and Diagnostic Sciences, School of Dentistry; Department of Microbiology and Immunology, School of Medicine, University of Maryland, Baltimore, USA
| | - Elizabeth M. Johnson
- National Infection Service, Public Health England, Mycology Reference Laboratory, Bristol, UK
| | | | | | - Johan Maertens
- Department of Microbiology and Immunology, KU Leuven, Leuven, Belgium and Clinical Department of Haematology, UZ Leuven, Leuven, Belgium
| | - Carol A. Munro
- MRC Centre for Medical Mycology, Institute of Medical Sciences, University of Aberdeen, Aberdeen, UK
| | - Jeniel E. Nett
- University of Wisconsin-Madison, Departments of Medicine and Medical Microbiology & Immunology, Madison, WI, USA
| | - Clarissa J. Nobile
- Department of Molecular and Cell Biology, School of Natural Sciences, University of California, Merced, Merced, USA
| | - Michael A. Pfaller
- Departments of Pathology and Epidemiology, University of Iowa, Iowa, USA
- JMI Laboratories, North Liberty, Iowa, USA
| | - Gordon Ramage
- ESCMID Study Group for Biofilms, Switzerland
- College of Medical, Veterinary and Life Sciences, University of Glasgow, UK
| | - Dominique Sanglard
- Institute of Microbiology, University of Lausanne and University Hospital, CH-1011 Lausanne
| | - Maurizio Sanguinetti
- Institute of Microbiology, Università Cattolica del Sacro Cuore, IRCCS-Fondazione Policlinico "Agostino Gemelli", Rome, Italy
| | - Isabel Spriet
- Pharmacy Dpt, University Hospitals Leuven and Clinical Pharmacology and Pharmacotherapy, Dpt. of Pharmaceutical and Pharma-cological Sciences, KU Leuven, Belgium
| | - Paul E. Verweij
- Center of Expertise in Mycology Radboudumc/CWZ, Radboud University Medical Center, Nijmegen, the Netherlands (omit "Nijmegen" in Radboud University Medical Center)
| | - Adilia Warris
- MRC Centre for Medical Mycology, Aberdeen Fungal Group, University of Aberdeen, Foresterhill, Aberdeen, UK
| | - Joost Wauters
- KU Leuven-University of Leuven, University Hospitals Leuven, Department of General Internal Medicine, Herestraat 49, B-3000 Leuven, Belgium
| | - Michael R. Yeaman
- Geffen School of Medicine at the University of California, Los Angeles, Divisions of Molecular Medicine & Infectious Diseases, Har-bor-UCLA Medical Center, LABioMed at Harbor-UCLA Medical Center
| | - Sebastian A.J. Zaat
- Department of Medical Microbiology, Amsterdam Infection and Immunity Institute, Academic Medical Center, University of Am-sterdam, Netherlands
| | - Karin Thevissen
- Centre for Microbial and Plant Genetics, KU Leuven, Leuven, Belgium
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Update from a 12-Year Nationwide Fungemia Surveillance: Increasing Intrinsic and Acquired Resistance Causes Concern. J Clin Microbiol 2018; 56:JCM.01564-17. [PMID: 29212705 DOI: 10.1128/jcm.01564-17] [Citation(s) in RCA: 75] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Accepted: 11/30/2017] [Indexed: 12/18/2022] Open
Abstract
New data from the years 2012 to 2015 from the Danish National Fungemia Surveillance are reported, and epidemiological trends are investigated in a 12-year perspective (2004 to 2015). During 2012 to 2015, 1,900 of 1,939 (98%) fungal bloodstream isolates were included. The average incidence was 8.4/100,000 inhabitants, and this appears to represent a stabilizing trend after the increase to 10.1/100,000 in 2011. The incidence was higher in males than females (10.0 versus 6.8) and in patients above 50 years, and those changes were mainly driven by an increasing incidence among 80-to-89-year-old males (65.3/100,000 in 2014 to 2015). The proportion of Candida albicans isolates decreased from 2004 to 2015 (64.4% to 42.4%) in parallel with a doubling of the proportion of Candida glabrata isolates (16.5% to 34.6%, P < 0.0001). C. glabrata was more common among females (34.0% versus 30.4% in males). Following an increase in 2004 to 2011, the annual drug use stabilized during the last 2 to 3 years of that time period but remained higher than in other Nordic countries. This was particularly true for the fluconazole and itraconazole use in the primary health care sector, which exceeded the combined national levels of use of these compounds in each of the other Nordic countries. Fluconazole susceptibility decreased (68.5%, 65.2%, and 60.6% in 2004 to 2007, 2008 to 2011, and 2012 to 2015, respectively, P < 0.0001), and echinocandin resistance emerged in Candida (0%, 0.6%, and 1.7%, respectively, P < 0.001). Amphotericin B susceptibility remained high (98.7%). Among 16 (2.7%) echinocandin-resistant C. glabrata isolates (2012 to 2015), 13 harbored FKS mutations and 5 (31%) were multidrug resistant. The epidemiological changes and the increased incidence of intrinsic and acquired resistance emphasize the importance of continued surveillance and of strengthened focus on antifungal stewardship.
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The Etest Performed Directly on Blood Culture Bottles Is a Reliable Tool for Detection of Fluconazole-Resistant Candida albicans Isolates. Antimicrob Agents Chemother 2017; 61:AAC.00400-17. [PMID: 28483951 DOI: 10.1128/aac.00400-17] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Accepted: 04/28/2017] [Indexed: 11/20/2022] Open
Abstract
We assessed the ability of the Etest performed directly on positive blood cultures (ETDIR) to detect fluconazole susceptibility in 6 fluconazole-resistant and 12 fluconazole-susceptible Candida albicans isolates, according to CLSI M27-A3 and EUCAST EDef 7.2 procedures. Categorical agreement between ETDIR and broth microdilution was 100% when the trays were incubated at 25°C and trailing effect was ruled out. ETDIR is a reliable procedure when screening for the presence of fluconazole resistance in C. albicans.
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Evaluation of the possible influence of trailing and paradoxical effects on the clinical outcome of patients with candidemia. Clin Microbiol Infect 2016; 23:49.e1-49.e8. [PMID: 27677697 DOI: 10.1016/j.cmi.2016.09.016] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Revised: 08/05/2016] [Accepted: 09/20/2016] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Paradoxical growth (PG) and trailing effect (TE) are frequently observed during antifungal susceptibility testing (AFST). These two phenomena interfere with the determination of the minimal inhibitory concentration (MIC). The aim of this study was to assess the clinical impact of TE and PG. METHODS We analysed the frequency of TE and PG of 690 Candida isolates collected from a population-based study performed in Spain (CANDIPOP) and correlated the results with clinical outcome of the patients. RESULTS Around 70% (484/690) of the isolates exhibited TE to azoles. Candida tropicalis showed the highest presence of TE (39/53 isolates exhibited residual growth >25% of control). No TE was seen in most of the isolates from the psilosis complex. PG was mainly associated with echinocandins. In patients treated with fluconazole within the first 48 hours after blood sampling (n = 221), the presence of TE to azoles tended to be associated with lower 30-day mortality (odds ratio (OR) 0.55, 95% confidence interval (CI) 0.25-1.00) but not with clinical failure (OR 0.85, 95% CI 0.45-1.54). In the subgroup of 117 patients treated with echinocandins, the presence of PG was not associated with patient's response to antifungal treatment (OR for 30-day mortality 1.63, 95% CI 0.76-4.03; OR for clinical failure 1.17, 95% CI 0.53-2.70). CONCLUSIONS TE or PG are widely expressed among Candida spp., although they do not seem to influence clinical outcome.
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