Comparison of visual and spectrophotometric methods of MIC endpoint determinations by using broth microdilution methods to test five antifungal agents, including the new triazole D0870

Tioconazole-Loaded Transethosomal Gel Using Box-Behnken Design for Topical Applications: In Vitro, In Vivo, and Molecular Docking Approaches

Tioconazole (TCZ) is a broad-spectrum fungicidal BCS class II drug with reported activity against Candida albicans, dermatophytes, and certain Staphylococci bacteria. We report the use of TCZ-loaded transethosomes (TEs) to overcome the skin's barrier function. TCZ-loaded TEs were fabricated by using a cold method with slight modification. Box-Behnken composite design was utilized to investigate the effect of independent variables. The fabricated TEs were assessed with various physicochemical characterizations. The optimized formulation of TCZ-loaded TEs was incorporated into gel and evaluated for pH, conductivity, drug content, spreadability, rheology, in vitro permeation, ex vivo permeation, and in vitro and in vivo antifungal activity. The fabricated TCZ-loaded TEs had a % EE of 60.56 to 86.13, with particle sizes ranging from 219.1 to 757.1 nm. The SEM images showed spherically shaped vesicles. The % drug permeation was between 77.01 and 92.03. The kinetic analysis of all release profiles followed Higuchi's diffusion model. The FTIR, DSC, and XRD analysis showed no significant chemical interactions between the drug and excipients. A significantly higher antifungal activity was observed for TCZ-loaded transethosomal gel in comparison to the control. The in vivo antifungal study on albino rats indicated that TCZ-loaded transethosomal gel showed a comparable therapeutic effect in comparison to the market brand Canesten®. Molecular docking demonstrated that the TCZ in the TE composition was surrounded by hydrophobic excipients with increased overall hydrophobicity and better permeation. Therefore, TCZ in the form of transethosomal gel can serve as an effective drug delivery system, having the ability to penetrate the skin and overcome the stratum corneum barrier with improved efficacy.

Bos taurus (A-2) urine assisted bioactive cobalt oxide anchored ZnO: a novel nanoscale approach

In this study, a novel synthetic method for cobalt oxide (Co3O4) nanoparticles using Bos taurus (A-2) urine as a reducing agent was developed. In addition to this ZnO nanorods were produced hydrothermally and a nanocomposite is formed through a solid-state reaction. The synthesized materials were characterized through modern characterization techniques such as XRD, FE-SEM with EDS, DLS, zeta potential, FT-IR, Raman spectroscopic analysis, and TGA with DSC. The free radical destructive activity was determined using two different methods viz. ABTS and DPPH. The potential for BSA denaturation in vitro, which is measured in comparison to heat-induced denaturation of egg albumin and results in anti-inflammatory effects of nanomaterial was studied. All synthesized nanomaterials have excellent antibacterial properties, particularly against Salmonella typhi and Staphylococcus aureus. The composite exhibits excellent antioxidant and anti-inflammatory activities in comparison to pure nanomaterials. This reveals that these nanomaterials are advantageous in medicine and drug administration.

Anethole rich Clausena heptaphylla (Roxb.) Wight & Arn., essential oil pharmacology and genotoxic efficiencies

Anethole, a widely used industrial flavoring agent is majorly sourced from anise and star anise. The present study is aimed to the in-depth pharmacological analysis i.e. anti-diabetic, skin whitening, neurodegenerative disorder inhibitory activities of anethole-rich Clausena heptaphylla leaf essential oil (ARCHEO) (88.59%) as revealed by the Gas Chromatography/Mass Spectrometry (GC/MS) analysis and further confirmed by proton nuclear magnetic resonance ¹H-NMR as well as to compare with standard compound anethole. ARCHEO (ABTS EC₅₀ 6.97 ± 0.004 µg/mL; Protease assay 4.51 ± 0.004 µg/mL) outperformed the standard compound anethole (ABTS EC₅₀ 9.48 ± 0.048 µg/mL; Protease assay EC₅₀ 22.64 ± 0.016 µg/mL) in antioxidant and anti-inflammatory experiments. ARCHEO was also shown to be more effective than the reference compound anethole in terms of anti-diabetic activity (EC₅₀ 22.35 ± 0.121 µg/mL), tyrosinase inhibitory activity (EC₅₀ 16.45 ± 0.012 µg/mL), and anti-cholinesterase activity (EC₅₀ 22.32 ± 0.016 µg/mL). However, ARCHEO exhibited lower antimicrobial activity towards all the tested microbes compared to standard compound anethole and as for the MIC, ARCHEO was effective only towards Salmonella typhimurium (60 µg/mL), Streptococcus mutans (20 µg/mL), and Aspergillus fumigatus (75 µg/mL). ARCHEO (11.11%) and anethole (12.33%) showed no genotoxic effect based on Allium cepa assay mitotic index value. Thus, ARCHEO could be a commercially viable and widely available cheaper source of anethole, which has buoyant demand in the field of food flavoring, fragrance, and pharmaceutical industries.

Antimicrobial Hybrid Coatings Combining Enhanced Biocidal Activity under Visible-Light Irradiation with Stimuli-Renewable Properties

Hybrid, organic-inorganic, biocidal films exhibiting polishing properties were developed as effective long-lasting antimicrobial surface coatings. The films were prepared using cationically modified chitosan, synthesized by the reaction with 3-bromo-N,N,N-trimethylpropan-1-aminium bromide, to introduce permanent biocidal quaternary ammonium salt (QAS) groups along the polymer backbone and were cross-linked by a novel, pH-cleavable acetal cross-linker, which allowed polishing the hybrid coatings with the solution pH. TiO₂ nanoparticles, modified with reduced graphene oxide (rGO) sheets, to narrow their band gap energy value and shift their photocatalytic activity in the visible light regime, were introduced within the polymer film to enhance its antibacterial activity. The hybrid coatings exhibited an effective biocidal activity in the dark (∼2 Log and ∼3 Log reduction for Gram-negative and Gram-positive bacteria, respectively), when only the QAS sites interacted with the bacteria membrane, and an excellent biocidal action upon visible-light irradiation (∼5 Log and ∼6 Log reduction for Gram-negative and Gram-positive bacteria, respectively) due to the synergistic antimicrobial effect of the QAS moieties and the rGO-modified TiO₂ nanoparticles. The gradual decrease in the film thickness, upon immersion of the coatings in mildly basic (pH 8), neutral (pH 7), and acidic (pH 6) media, reaching 10, 20, and 70% reduction, respectively, after 60 days of immersion time, confirmed the polishing behavior of the films, whereas their effective antimicrobial action was retained. The biocompatibility of the hybrid films was verified in human cell culture studies. The proposed approach enables the facile development of highly functional coatings, combining biocompatibility and bactericidal action with a "kill and self-clean" mechanism that allows the regeneration of the outer surface of the coating leading to a strong and prolonged antimicrobial action.

Antifungal Susceptibility Testing: Current Approaches

Although not as ubiquitous as antibacterial susceptibility testing, antifungal susceptibility testing (AFST) is a tool of increasing importance in clinical microbiology laboratories. The goal of AFST is to reliably produce MIC values that may be used to guide patient therapy, inform epidemiological studies, and track rates of antifungal drug resistance. There are three methods that have been standardized by standards development organizations: broth dilution, disk diffusion, and azole agar screening for Aspergillus Other commonly used methods include gradient diffusion and the use of rapid automated instruments. Novel methodologies for susceptibility testing are in development. It is important for laboratories to consider not only the method of testing but also the interpretation (or lack thereof) of in vitro data.

Study of Anti-oxidant, Anti-inflammatory, Genotoxicity, and Antimicrobial Activities and Analysis of Different Constituents found in Rhizome Essential Oil of Curcuma caesia Roxb., Collected from North East India

BACKGROUND

This investigation was designed to evaluate the chemical composition, antioxidant, anti-inflammatory, genotoxicity, and antimicrobial activities of Curcuma caesia Roxb rhizome essential oil.

METHODS

Gas Chromatography/Mass Spectroscopy (GC/MS) analysis was performed to determine the chemical composition, standard antioxidative test DPPH assay, reducing power assay, in vitro antiinflammatory activity (egg albumin denaturation, protease inhibitory assay) by using standard methods. Similarly, antimicrobial activity was tested using the disc diffusion method, minimum inhibitory concentration ability (MIC); while to test genotoxicity, Allium cepa assay was used.

RESULTS

GC/MS analysis revealed eucalyptol (28.55%), epicurzerenone (19.62%), and camphor (21.73%) as the major components of C. caesia rhizome essential oil. Potent antioxidant (IC50= 48.08±0.003 μg/mL), anti-inflammatory (IC50= 121.7±0.0013 μg/mL), and antimicrobial activities of the essential oil were recorded better than the standard drugs Fluconazole for fungus and Ciprofloxacin for bacteria. The essential oil also possessed a strong antibacterial effect against two tested bacterial strains B. subtilis and B. cereus with 7.5 μg/mL MIC value, while for fungal strains the essential oil was most effective against S. cereviaceae with an MIC value of 2.5 μg/mL. All the data were recorded in triplicates. Allium cepa assay revealed minor genotoxicity with mitotic index, MI= 27.70%; chromosome aberration, A= 1.1% of C. caesia rhizome essential oil.

CONCLUSION

C. caesia rhizome essential oil possesses potent antioxidant, anti-inflammatory, and antimicrobial properties with negligible genotoxicity. Hence, the present study is highly significant for the utilization of rhizome of C. caesia, a high-value ethnopharmacological plant for advanced R & D and commercial application.

SCY-078 Is Fungicidal against Candida Species in Time-Kill Studies

SCY-078 is an orally bioavailable ß-1,3-glucan synthesis inhibitor (GSI) and the first-in-class of structurally novel triterpene antifungals in clinical development for treating candidemia and invasive candidiasis. In vitro susceptibilities by broth microdilution, antifungal carryover, and time-kill dynamics were determined for three reference (ATCC) strains (Candida albicans 90028, Candida parapsilosis 90018, and Candida tropicalis 750), a quality-control (QC) strain (Candida krusei 6258), and four other strains (C. albicans MYA-2732, 64124, and 76485 and Candida glabrata 90030). Caspofungin (CASP), fluconazole (FLC), and voriconazole (VRC) were comparators. For time-kill experiments, SCY-078 and CASP were evaluated at 0.25, 1, 2, 4, 8, and 16 times the MIC₈₀, and FLU and VRC were evaluated at 4× MIC₈₀. The time to reach 50%, 90%, and 99.9% reduction in the number of CFUs from the starting inoculum was determined. Net change in the number of CFU per milliliter was used to determine 50% and 90% effective concentrations and maximum effect (EC₅₀, EC₉₀, and E_max, respectively). The SCY-078 MIC range was between 0.0625 and 1 μg/ml and generally similar to that of CASP. Antifungal carryover was not observed for SCY-078. SCY-078 was fungicidal against seven isolates at ≥4× MIC (kill of ≥3 log₁₀) and achieved a 1.7-log₁₀ reduction in CFU count/milliliter against C. albicans 90028. CASP behaved similarly against each isolate and achieved a 1.5-log₁₀ reduction in the number of CFU/milliliter against C. albicans 90028. Reductions of 50% in CFU count/milliliter were achieved rapidly (1 to 2.8 h); fungicidal endpoints were reached at 12.1 to 21.8 h at ≥4× MIC. EC₉₀ was reached at ∼5× MIC at each time point to 24 h. The EC₅₀ and EC₉₀ values were generally similar (8 to 24 h). Time-kill behavior of CASP was similar to that of SCY-078. FLC and VRC were fungistatic. Overall, SCY-078 has primarily fungicidal activity against Candida spp. and behaved comparably to CASP.

Cellulose Nanocrystal Membranes as Excipients for Drug Delivery Systems

In this work, cellulose nanocrystals (CNCs) were obtained from flax fibers by an acid hydrolysis assisted by sonochemistry in order to reduce reaction times. The cavitation inducted during hydrolysis resulted in CNC with uniform shapes, and thus further pretreatments into the cellulose are not required. The obtained CNC exhibited a homogeneous morphology and high crystallinity, as well as typical values for surface charge. Additionally, CNC membranes were developed from CNC solution to evaluation as a drug delivery system by the incorporation of a model drug. The drug delivery studies were carried out using chlorhexidine (CHX) as a drug and the antimicrobial efficiency of the CNC membrane loaded with CHX was examined against Gram-positive bacteria Staphylococcus aureus (S. Aureus). The release of CHX from the CNC membranes is determined by UV-Vis. The obtaining methodology of the membranes proved to be simple, and these early studies showed a potential use in antibiotic drug delivery systems due to the release kinetics and the satisfactory antimicrobial activity.

Progressive development in experimental models of transungual drug delivery of anti-fungal agents

Pre-clinical development comprises of different procedures that relate drug discovery in the laboratory for commencement of human clinical trials. Pre-clinical studies can be designed to recognize a lead candidate from a list to develop the procedure for scale-up, to choose the unsurpassed formulation, to determine the frequency, and duration of exposure; and eventually make the foundation of the anticipated clinical trial design. The foremost aim in the pharmaceutical research and industry is the claim of drug product quality throughout a drug's life cycle. The particulars of the pre-clinical development process for different candidates may vary; however, all have some common features. Typically in vitro, in vivo or ex vivo studies are elements of pre-clinical studies. Human pharmacokinetic in vivo studies are often supposed to serve as the 'gold standard' to assess product performance. On the other hand, when this general assumption is revisited, it appears that in vitro studies are occasionally better than in vivo studies in assessing dosage forms. The present review is compendious of different such models or approaches that can be used for designing and evaluation of formulations for nail delivery with special reference to anti-fungal agents.

Rational design and synthesis of covalent organic polymers with hollow structure and excellent antibacterial efficacy

A covalent organic polymer with hollow structure (COP-H) has been synthesizedviaSonogashira coupling from the precursors containing positive charge.

Terpenoids of plant origin inhibit morphogenesis, adhesion, and biofilm formation by Candida albicans

Biofilm-related infections caused by Candida albicans and associated drug resistant micro-organisms are serious problems for immunocompromised populations. Molecules which can prevent or remove biofilms are needed. Twenty-eight terpenoids of plant origin were analysed for their activity against growth, virulence attributes, and biofilms of C. albicans. Eighteen molecules exhibited minimum inhibitory concentrations of <2 mg ml(-1) for planktonic growth. Selected molecules inhibited yeast to hyphal dimorphism at low concentrations (0.031-0.5 mg ml(-1)), while adhesion to a solid surface was prevented at 0.5-2 mg ml(-1). Treatment with 14 terpenoids resulted in significant (p < 0.05) inhibition of biofilm formation, and of these, linalool, nerol, isopulegol, menthol, carvone, α-thujone, and farnesol exhibited biofilm-specific activity. Eight terpenoids were identified as inhibitors of mature biofilms. This study demonstrated the antibiofilm potential of terpenoids, which need to be further explored as therapeutic strategy against biofilm associated infections of C. albicans.

In vitro synergistic interactions of the effects of various statins and azoles against some clinically important fungi

The treatment of opportunistic fungal infections is often difficult as the number of available antifungal agents is limited. Nowadays, there is increasing interest in the investigation of the antifungal activity of nonantifungal drugs, and in the development of efficient antifungal combination therapy. In this study, the in vitro interactions of the effects of various statins (lovastatin, simvastatin, fluvastatin, atorvastatin (ATO), rosuvastatin (ROS) and pravastatin) and various azole antifungals [miconazole, ketoconazole, itraconazole and fluconazole (FLU)] against different opportunistic pathogenic fungi were investigated using a standard chequerboard broth microdilution method. When the investigated strains were sensitive to both compounds of the combination, additive interactions were frequently noticed. Synergistic interactions were observed in many cases when a strain was sensitive only to the azole compound (as in certain combinations with ATO or ROS) or the statin compound (as in certain combinations with FLU). In many combinations with an additive effect, the concentrations of drugs needed for total growth inhibition could be decreased by several dilution steps. Similar interactions were observed when the variability of the within-species sensitivities to some selected drug combinations was investigated.

Susceptibility testing of Cryptococcus diffluens against amphotericin B, flucytosine, fluconazole, itraconazole, voriconazole and posaconazole

Cryptococcus diffluens is a recently re-established species that shares several phenotypic features with Cryptococcus neoformans. We evaluated the application of the Clinical Laboratory Standards Institute (CLSI, formerly NCCLS) macro- and microbroth dilution methods and the E-test agar diffusion method to determine the in vitro susceptibilities of known strains of C. diffluens against amphotericin B (AMB), flucytosine (5-FC), fluconazole (FLC), itraconazole (ITC) and the novel triazoles, voriconazole (VRC) and posaconazole (PSC). Seven strains were found to be resistant in vitro to AMB (MICs >/=2 microg/ml), five were resistant to 5-FC (MICs of >/=32 microg/ml), four were resistant to FLC (MICs of FLC >/=32 microg/ml) and nine were resistant to ITC (MICs of ITC >1 microg/ml). In contrast, VRC and PSC showed good in vitro activity against C.diffluens strains, even those with elevated MICs to amphotericin B and/or established azoles. Most of the isolates were inhibited by 0.5 microg/ml of both VRC and PSC. A clinical isolate showing phenotypic switching exhibited elevated MICs to both agents, i.e., VRC (>16 microg/ml) and PSC (>8 microg/ml).

Comparison between E-test and CLSI broth microdilution method for antifungal susceptibility testing of Candida albicans oral isolates

Thirty Candida albicans isolated from oral candidosis patients and 30 C. albicans isolated from control individuals were studied. In vitro susceptibility tests were performed for amphotericin B, fluconazole, 5-flucytosine and itraconazole through the Clinical and Laboratorial Standards Institute (CLSI) reference method and E test system. The results obtained were analyzed and compared. MIC values were similar for the strains isolated from oral candidosis patients and control individuals. The agreement rate for the two methods was 66.67% for amphotericin B, 53.33% for fluconazole, 65% for flucytosine and 45% for itraconazole. According to our data, E test method could be an alternative to trial routine susceptibility testing due to its simplicity. However, it can not be considered a substitute for the CLSI reference method.

Colorimetric broth microdilution method for the antifungal screening of plant extracts against yeasts

Screening plant extracts for antifungal activity is increasing due to demand for new antifungal agents, but the testing methods present many challenges. Standard broth microdilution methods for antifungal susceptibility testing of available antifungal agents are available now, but these methods are optimised for single compounds instead of crude plant extracts. In this study we evaluated the standard NCCLS method as well as a modification which uses spectrophotometric determination of the end-points with a plate reader. We also evaluated another standard method, the EUCAST method, which is a similar microdilution assay to the NCCLS method, but uses a larger inoculum size and a higher glucose concentration in the medium as well as spectrophotometric end-point determination. The results showed that all three methods had some drawbacks for testing plant extracts and thus we modified the NCCLS broth microdilution method by including a colorimetric indicator-resazurin for end-point determination. This modified method showed good reproducibility and clear-cut end-point, plus the end-point determination needed no instruments. It enabled us to evaluate the activity of a selection of extracts from six Combretaceous plants against three Candida spp. and thus provided pharmacological evidence for some traditional uses of these plants while assisting the identification of the active ingredients.

Recent developments in pradimicin-benanomicin and triazole antibiotics

Fungal infections are on the rise as the number of patients with compromised immune systems continues to increase. The need for safer and more effective antifungals has resulted in the search for novel drug classes and for modifications to existing classes, with the aim of enhancing their antifungal spectra and potency. In this review, two classes of antifungals are discussed: the pradimicin-benanomicin antibiotics and the newer triazole derivatives. These have activity against Candida spp., Cryptococcus neoformans and Aspergillus spp., as well as variable activity against other less commonly encountered fungi including Pneumocystis carinii. Pradimicins-benanomicins are generally fungicidal, whereas the newer azoles appear to be selectively fungicidal to Cryptococcus neoformans and Aspergillus spp. Pradimicin-benanomicin acts by binding to mannan and alters membrane integrity. One water-soluble pradimicin candidate, BMS-181184, has been selected for clinical development. The triazoles act by inhibiting cytochrome P450 sterol 14a-demethylase. Four triazoles either currently in clinical development (voriconazole and D0870) or being considered as clinical candidates (ER-30346 and Sch 56592) will be discussed. The antifungal spectra, pharmacokinetic and toxicologic data in animals, and efficacy results in experimental infection models will be reviewed for BMS-181184 and the four newer triazoles. Results from the early clinical trials for voriconazole and D0870 will also be discussed.

Antifungal susceptibility testing of Candida albicans by flow cytometry

Antifungal susceptibilities of 28 Candida albicans isolates and two quality control strains to amphotericin B and fluconazole were determined by flow cytometry and microdilution method. Minimum inhibitory concentrations (MICs) obtained by flow cytometry were compared with the results obtained by The National Committee for Clinical Laboratory Standards Subcommittee (NCCLS) broth microdilution method. The agreement of results (within two dilution) obtained was found as 96 and 93% for amphotericin B and fluconazole, respectively. At least 24 h incubation was required for reading the microdilution assays. Four hours of incubation was required for fluconazole, whereas 2-h incubation was sufficient for amphotericin B to provide MIC by flow cytometry. Results of this study show that flow cytometry provides a rapid and sensitive in vitro method for antifungal susceptibility testing of Candida albicans isolates.

Multicenter evaluation of the reproducibility of the proposed antifungal susceptibility testing method for fermentative yeasts of the Antifungal Susceptibility Testing Subcommittee of the European Committee on Antimicrobial Susceptibility Testing (AFST-EUCAST)

OBJECTIVE

To evaluate the intra- and inter-laboratory reproducibility of a new standard for susceptibility testing of fermentative yeasts. This standard is based on the M27-A procedure of the National Committee for Clinical Laboratory Standards (NCCLS), but incorporates several modifications, including spectrophotometric growth-dependent endpoint reading.

METHODS

Nine laboratories participated in the study. Common material lots were used to test six Candida species (one each of C. albicans, C. tropicalis, C. parapsilosis, C. glabrata, C. krusei, and C. lusitaniae), and two quality control strains (C. krusei ATCC6258 and C. parapsilosis ATCC22019). Triplicate testing on three separate days was performed in microtiter format with RPMI-2% glucose, pH 7.0. Flucytosine, fluconazole and itraconazole were tested. In total, 3888 MIC values were included in the analyses. Reproducibility was calculated by means of agreement (percentage of MICs within one two-fold dilution of the mode) and intraclass correlation coefficient (ICC, maximum value of 1).

RESULTS

The average intra-laboratory agreements were 99% and 96% after 24 h and 48 h of incubation, respectively, with ICCs of 0.98 and 0.97 (P < 0.05). Two strains exhibiting a trailing effect showed intra-laboratory agreement of 92% and ICCs of < 0.91 at 48 h. The inter-laboratory agreement was 94% and 88% after 24 h and 48 h, respectively, with ICCs of 0.93 and 0.91 (P < 0.05). Lower values of agreement and ICCs were obtained for strains exhibiting trailing after 48 h of incubation. Itraconazole yielded the lowest values of reproducibility.

CONCLUSION

The new procedure of EUCAST for antifungal susceptibility testing is a reproducible method within and between laboratories and offers several advantages over the NCCLS approved method.

Susceptibility testing of fungi--current status and open questions

The increase of fungal infections and the improvement of therapeutical options demand reliable antifungal susceptibility testing. In vitro susceptibility testing of fungi--in contrast to bacteria--is not yet established as a routine method. The NCCIS (National Committee for Clinical Laboratory Standards) guidelines for susceptibility testing of yeasts (and proposed for hyphomycetes) are most important for standardization. Meanwhile, essential parts of this test procedure are accepted, but it should still be improved. The concept of using only one test medium for all drugs and test organisms is not realized so far. There are also some test situations that prevent the NCCLS standard from being applied. Based on our experience, this article describes the NCCLS methods and their modifications. It places emphasis on lipophilic drugs showing controversies despite standardization. Furthermore, the prediction of MICs on the clinical outcome is discussed. Since there are some pitfalls in testing antifungals, this should be done in experienced laboratories only. The MIC has to be regarded as only one, but an important, factor in the management of fungal diseases. Host-, drug-, and pathogen-specific data should be considered simultaneously.

Comparative evaluation of a new fluorescent carboxyfluorescein diacetate-modified microdilution method for antifungal susceptibility testing of Candida albicans isolates

This report presents a fluorescent carboxyfluorescein diacetate (CFDA)-modified microdilution method used for the susceptibility testing of Candida albicans to amphotericin B, fluconazole, ketoconazole, itraconazole, voriconazole, and flucytosine. Four different broth microdilution susceptibility testing methods were simultaneously evaluated at 24 and 48 h. The MICs determined using the CFDA-modified method (MIC(cfda)) were compared to those obtained by the standard broth microdilution method (MIC(visual)) and a procedure employing the indicator Alamar blue (MIC(alamar)). The reference MIC was determined visually as recommended by the NCCLS M27-A protocol, and then quantified spectrophotometrically following agitation (MIC(spec)). The CFDA-modified microdilution method was demonstrated to effectively determine the MICs for all the antifungal drugs tested at both 24 and 48 h. The results from both the MIC(spec) and MIC(cfda) methods yielded >80% agreement within +/-1 dilution and >90% agreement within +/-2 dilutions at 24 h in comparison to the reference MIC(visual) method, respectively. The trailing growth phenomenon that occurs with azole antifungal drugs and many strains of C. albicans did not inhibit the effectiveness of the MIC(spec) and MIC(cfda) methods. The MIC(spec) and MIC(cfda) methods shared 92.8% agreement within +/-1 dilution at 24 h and 87.6% agreement within +/-1 dilution at 48 h.

Comparison of visual and spectrophotometric methods of broth microdilution MIC end point determination and evaluation of a sterol quantitation method for in vitro susceptibility testing of fluconazole and itraconazole against trailing and nontrailing Candida isolates

Visual determination of MIC end points for azole antifungal agents can be complicated by the trailing growth phenomenon. To determine the incidence of trailing growth, we performed testing of in vitro susceptibility to fluconazole and itraconazole using the National Committee for Clinical Laboratory Standards broth microdilution M27-A reference procedure and 944 bloodstream isolates of seven Candida spp., obtained through active population-based surveillance between 1998 and 2000. Of 429 C. albicans isolates, 78 (18.2%) showed trailing growth at 48 h in tests with fluconazole, and 70 (16.3%) showed trailing in tests with itraconazole. Of 118 C. tropicalis isolates, 70 (59.3%) showed trailing growth in tests with fluconazole, and 35 (29.7%) showed trailing in tests with itraconazole. Trailing growth was not observed with any of the other five Candida spp. tested (C. dubliniensis, C. glabrata, C. krusei, C. lusitaniae, and C. parapsilosis). To confirm whether or not isolates that showed trailing growth in fluconazole and/or itraconazole were resistant in vitro to these agents, all isolates that showed trailing growth were retested by the sterol quantitation method, which measures cellular ergosterol content rather than growth inhibition after exposure to azoles. By this method, none of the trailing isolates was resistant in vitro to fluconazole or itraconazole. For both agents, a 24-h visual end point or a spectrophotometric end point of 50% reduction in growth relative to the growth control after 24 or 48 h of incubation correlated most closely with the result of sterol quantitation. Our results indicate that MIC results determined by either of these end point rules may be more predictive of in vivo outcome for isolates that give unclear visual end points at 48 h due to trailing growth.

Clinical evaluation of a frozen commercially prepared microdilution panel for antifungal susceptibility testing of seven antifungal agents, including the new triazoles posaconazole, ravuconazole, and voriconazole

A commercially prepared frozen broth microdilution panel (Trek Diagnostic Systems, Westlake, Ohio) was compared with a reference microdilution panel for antifungal susceptibility testing of two quality control (QC) strains and 99 clinical isolates of Candida spp. The antifungal agents tested included amphotericin B, flucytosine, fluconazole, itraconazole, posaconazole, ravuconazole, and voriconazole. Microdilution testing was performed according to NCCLS recommendations. MIC endpoints were read visually after 48 h of incubation and were assessed independently for each microdilution panel. The MICs for the QC strains were within published limits for both the reference and Trek microdilution panels. Discrepancies among MIC endpoints of no more than 2 dilutions were used to calculate the percent agreement. Acceptable levels of agreement between the Trek and reference panels were observed for all antifungal agents tested against the 99 clinical isolates. The overall agreement for each antifungal agent ranged from 96% for ravuconazole to 100% for amphotericin B. The Trek microdilution panel appears to be a viable alternative to frozen microdilution panels prepared in-house.

Potato dextrose agar antifungal susceptibility testing for yeasts and molds: evaluation of phosphate effect on antifungal activity of CMT-3

The broth macrodilution method (BMM) for antifungal susceptibility testing, approved by the National Committee for Clinical Laboratory Standards (NCCLS), was found to have deficiencies in testing of the antifungal activity of a new type of antifungal agent, a nonantibacterial chemically modified tetracycline (CMT-3). The high content of phosphate in the medium was found to greatly increase the MICs of CMT-3. To avoid the interference of phosphate in the test, a new method using potato dextrose agar (PDA) as a culture medium was developed. Eight strains of fungi, including five American Type Culture Collection strains and three clinical isolates, were used to determine the MICs of amphotericin B and itraconazole with both the BMM and the PDA methods. The MICs of the two antifungal agents determined with the PDA method showed 99% agreement with those determined with the BMM method within 1 log(2) dilution. Similarly, the overall reproducibility of the MICs with the PDA method was above 97%. Three other antifungal agents, fluconazole, ketoconazole, and CMT-3, were also tested in parallel against yeasts and molds with both the BMM and the PDA methods. The MICs of fluconazole and ketoconazole determined with the PDA method showed 100% agreement within 1 log(2) dilution of those obtained with the BMM method. However, the MICs of CMT-3 determined with the BMM method were as high as 128 times those determined with the PDA method. The effect of phosphate on the antifungal activity of CMT-3 was evaluated by adding Na2HPO4 to PDA in the new method. It was found that the MIC of CMT-3 against a Penicillium sp. increased from 0.5 microg/ml (control) to 2.0 microg/ml when the added phosphate was used at a concentration of 0.8 mg/ml, indicating a strong interference of Na2HPO4 with the antifungal activity of CMT-3. Except for fluconazole, all the other antifungal agents demonstrated clear end points among the yeasts and molds tested. Nevertheless, with its high reproducibility, good agreement with NCCLS proposed MIC ranges, and lack of interference of phosphate, the PDA method shows promise as a useful assay for antifungal susceptibility testing and screening for new antifungal agents, especially for drugs that may be affected by high (supraphysiologic) phosphate concentrations.

Susceptibility testing of fluconazole by the NCCLS broth macrodilution method, E-test, and disk diffusion for application in the routine laboratory

Antifungal susceptibility testing may be an important aid in the treatment of patients with life-threatening yeast infections. In order to establish the suitability of different susceptibility test methods for fluconazole with yeasts, the Rosco tablet and the E-test were compared with the gold standard NCCLS broth macrodilution method for 106 yeast strains. These included 102 clinical isolates of Candida spp., including Candida glabrata (n = 30), Candida albicans (n = 20), Candida tropicalis (n = 13), Candida parapsilosis (n = 10), Candida krusei (n = 8), plus Cryptococcus neoformans (n = 3), Saccharomyces cerevisiae (n = 2), and 16 strains belonging to other Candida spp. Four American Type Culture Collection strains of Candida were included as quality controls. The NCCLS method was found to be too complex and labor-intensive for routine testing. The E-test is an accurate alternative, but experience in determining MICs and careful attention to procedural details are critically important. The Rosco tablet showed the best agreement with the NCCLS reference method, especially when newly established breakpoints of R < or = 10 mm and S > or = 21 mm were used.

Present status of the detection of antifungal resistance: the perspective from both sides of the ocean

The NCCLS reference methodology for antifungal susceptibility testing is a new milestone of the evolution of medical mycology. The use of this methodology however, is not problem-free. At present, major limitations are a trailing phenomenon with azoles, unreliable detection of resistance to amphotericin B, poor growth of some organisms and unpractical procedures for the clinical laboratory. Herein a overview of NCCLS guidelines for yeasts and filamentous fungi is presented. Likewise, a review of studies conducted trying to overcome the limitations of reference procedures is also included. Several alternative approaches are reviewed as alternative media, inoculum size and incubation time. Modifications of reading procedure and endpoint determination are also evaluated. Agar diffusion methods and other methods for susceptibility testing are cited. Finally, we discuss the data on correlation of the in vitro results with the in vivo activity.

Antifungal susceptibility testing. New technology and clinical applications

The state of the art for susceptibility testing of yeasts is comparable with that of bacteria. Standardized methods for performing antifungal susceptibility testing are reproducible, accurate, and available in clinical laboratories. The development of quality control limits and interpretive criteria for a limited number of antifungal agents provides a basis for the application of this testing in the clinical laboratory. A proficiency testing program is available as a quality assurance measure for laboratories and has documented steady improvement among laboratories using the NCCLS method. As with antibacterial agents, surveillance programs are now in place using reference quality testing methods to monitor antifungal resistance trends on a global scale. It is clear that antifungal susceptibility testing can predict outcome in several clinical situations. Susceptibility testing is most helpful in dealing with infection caused by non-albicans species of Candida, and susceptibility testing of azoles is increasingly important in the management of candidiasis in critically ill patients. Susceptibility testing also has been standardized for filamentous fungi that cause invasive infections. Studies are ongoing to further refine this approach and evaluate the in vivo correlation with the in vitro data for molds. Future efforts must be directed toward establishing and validating interpretive break-points for licensed antifungals such as amphotericin B, and for new antifungals that are not yet licensed. Finally, procedures must be optimized for testing non-Candida yeasts (e.g., C. neoformans) and molds.

Antifungal susceptibility testing: practical aspects and current challenges

Development of standardized antifungal susceptibility testing methods has been the focus of intensive research for the last 15 years. Reference methods for yeasts (NCCLS M27-A) and molds (M38-P) are now available. The development of these methods provides researchers not only with standardized methods for testing but also with an understanding of the variables that affect interlaboratory reproducibility. With this knowledge, we have now moved into the phase of (i) demonstrating the clinical value (or lack thereof) of standardized methods, (ii) developing modifications to these reference methods that address specific problems, and (iii) developing reliable commercial test kits. Clinically relevant testing is now available for selected fungi and drugs: Candida spp. against fluconazole, itraconazole, flucytosine, and (perhaps) amphotericin B; Cryptococcus neoformans against (perhaps) fluconazole and amphotericin B; and Aspergillus spp. against (perhaps) itraconazole. Expanding the range of useful testing procedures is the current focus of research in this area.

In vitro antifungal susceptibility testing

With the rising frequency of fungal infections, as well as increasing reports of resistance to antifungal agents, it is imperative that clinically applicable antifungal susceptibility testing be available. In 1997 the National Committee for Clinical Laboratory Standards published standard guidelines for antifungal susceptibility testing of Candida sp and Cryptococcus neoformans with amphotericin B, flucytosine, fluconazole, itraconazole, and ketoconazole. Although the methods are standard, they are time consuming, can be difficult to interpret, and are approved only for testing limited organisms and drugs. Modifications to the methods and alternative approaches have been proposed to make these tests more convenient and efficient, applicable to a greater number of species, and appropriate for performing in the clinical laboratory.

Novel fluorescent broth microdilution method for fluconazole susceptibility testing of Candida albicans

A comparative evaluation of the reference National Committee for Clinical Laboratory Standards (NCCLS) broth microdilution method with a novel fluorescent carboxyfluorescein diacetate (CFDA)-modified microdilution method for the susceptibility testing of fluconazole was conducted with 68 Candida strains, including 53 Candida albicans, 5 Candida tropicalis, 5 Candida glabrata, and 5 Candida parapsilosis strains. We found trailing endpoints and discordant fluconazole MICs of < 8 microg/ml at 24 h and of > or =64 microg/ml at 48 h for 12 of the C. albicans strains. These strains satisfy the definition of the low-high MIC phenotype. All 12 low-high phenotype strains were correctly shown to be susceptible at 48 h with the CFDA-modified microdilution method. For the 41 non-low-high phenotype C. albicans strains, the CFDA-modified microdilution method yielded 97.6% (40 of 41 strains) agreement within +/-1 dilution at 24 h compared with the reference method and 92.7% (38 of 41 strains) agreement within +/-1 dilution at 48 h compared with the reference method. The five strains each from C. tropicalis, C. glabrata, and C. parapsilosis that were tested showed 100% agreement within +/-2 dilutions for the two methods being evaluated.

Prevalence and antifungal susceptibility of 442 Candida isolates from blood and other normally sterile sites: results of a 2-year (1996 to 1998) multicenter surveillance study in Quebec, Canada

During a 2-year surveillance program (1996 to 1998) in Quebec, Canada, 442 strains of Candida species were isolated from 415 patients in 51 hospitals. The distribution of species was as follows: Candida albicans, 54%; C. glabrata, 15%; C. parapsilosis, 12%; C. tropicalis, 9%; C. lusitaniae, 3%; C. krusei, 3%; and Candida spp., 3%. These data, compared to those of a 1985 survey, indicate variations in species distribution, with the proportions of C. glabrata and C. parapsilosis increasing by 9 and 4%, respectively, and those of C. albicans and C. tropicalis decreasing by 10 and 7%, respectively. However, these differences are statistically significant for C. glabrata and C. tropicalis only. MICs of amphotericin B were > or =4 microg/ml for 3% of isolates, all of which were non-C. albicans species. Three percent of C. albicans isolates were resistant to flucytosine (> or =32 microg/ml). Resistance to itraconazole (> or =1 microg/ml) and fluconazole (> or =64 microg/ml) was observed, respectively, in 1 and 1% of C. albicans, 14 and 9% of C. glabrata, 5 and 0% of C. tropicalis, and 0% of C. parapsilosis and C. lusitaniae isolates. Clinical data were obtained for 343 patients. The overall crude mortality rate was 38%, reflecting the multiple serious underlying illnesses found in these patients. Bloodstream infections were documented for 249 patients (73%). Overall, systemic triazoles had been administered to 10% of patients before the onset of candidiasis. The frequency of isolation of non-C. albicans species was significantly higher in this group of patients. Overall, only two C. albicans isolates were found to be resistant to fluconazole. These were obtained from an AIDS patient and a leukemia patient, both of whom had a history of previous exposure to fluconazole. At present, it appears that resistance to fluconazole in Quebec is rare and is restricted to patients with prior prolonged azole treatment.

Synergism of voriconazole and terbinafine against Candida albicans isolates from human immunodeficiency virus-infected patients with oropharyngeal candidiasis

The synergism of voriconazole (VRC) and terbinafine was studied by using 39 genotypically defined clinical Candida albicans isolates that were cross-resistant to fluconazole and VRC and serial isolates that gradually developed azole resistance. Synergy was noticed in 100% (eight of eight) of the strains that were resistant to VRC. Antagonism was not observed.

Influence of glucose supplementation and inoculum size on growth kinetics and antifungal susceptibility testing of Candida spp

The influences of inoculum size and glucose supplementation on the growth kinetics of 60 Candida spp. clinical isolates (Candida albicans, Candida tropicalis, Candida parapsilosis, Candida glabrata, Candida krusei, and Candida lusitaniae [10 isolates each]) are assessed. The combined influence of growth and reading method (visual or spectrophotometric) on the determination of the MICs of amphotericin B, flucytosine, fluconazole, itraconazole, ketoconazole, and voriconazole is also analyzed, and the MICs are compared with those determined by the National Committee for Clinical Laboratory Standards standard microdilution method (NCCLS document M27-A). Glucose supplementation and inoculum size had a significant influence on the growth cycles of these yeasts, and a statistically significant denser growth (optical density at 540 nm) was seen for both incubation periods, 24 and 48 h (P < 0.01). A longer exponential phase and shorter lag phase were also observed. The A540 values at 24 h of incubation with medium containing glucose and an inoculum of 10(5) CFU/ml were >0.4 U for all species, with the exception of that for C. parapsilosis (A540 = 0.26 +/- 0.025). The MICs at 24 h determined by testing with 2% glucose and an inoculum of 10(5) CFU/ml showed the strongest agreement (96.83%) with MICs determined by the reference method. MICs were not falsely elevated, and good correlation indexes were obtained. The reproducibility of results with this medium-inoculum combination was high (intraclass correlation coefficient, 0.955). The best agreement and reproducibility of results for spectrophotometric readings were achieved with endpoints of 50% growth inhibition for flucytosine and azoles and 95% for amphotericin B. Supplementation of test media with glucose and an inoculum size of 10(5) CFU/ml yielded a reproducible technique that shows elevated agreement with the reference procedures and a shorter incubation period for obtaining reliable MIC determinations. The spectrophotometric method offers an advantage over the visual method by providing a more objective and automated MIC determination.

Elevated phenotypic switching and drug resistance of Candida albicans from human immunodeficiency virus-positive individuals prior to first thrush episode

Strains of Candida albicans obtained from human immunodeficiency virus (HIV)-positive individuals prior to their first episode of oral thrush were already in a high-frequency mode of switching and were far more resistant to a number of antifungal drugs than commensal isolates from healthy individuals. Switching in these isolates also had profound effects both on susceptibility to antifungal drugs and on the levels of secreted proteinase activity. These results suggest that commensal strains colonizing HIV-positive individuals either undergo phenotypic alterations or are replaced prior to the first episode of oral thrush. They also support the suggestion that high-frequency phenotypic switching functions as a higher-order virulence trait, spontaneously generating in colonizing populations variants with alterations in a variety of specific virulence traits.

Susceptibility testing of voriconazole, fluconazole, itraconazole and amphotericin B against yeast isolates in a Turkish University Hospital and effect of time of reading

Voriconazole is a promising azole effective against a variety of fungi, including yeasts. In this study, we tested in vitro activities of voriconazole, fluconazole, itraconazole and amphotericin B against some ATCC and reference strains and 250 clinical yeast isolates. We also evaluated the effect of time of reading on MIC results. Voriconazole was the most active agent against Candida and Trichosporon isolates, including the putatively fluconazole-resistant C. krusei (MIC(90) 0.25 microg/ml) and C. glabrata (MIC(90) 0.5 microg/ml). Amphotericin B MICs were scattered in a considerably narrow range in both RPMI 1640 and Antibiotic Medium 3. MICs at 24 hours and 48 hours were similar in general for all antifungals tested. The highest percentage of strains that showed 24-hour and 48-hour MICs within +/-1-log(2) dilution was observed for amphotericin B tested in RPMI (99%), and the lowest for amphotericin B tested in Antibiotic Medium 3 (80%). In conclusion, voriconazole is very effective against a wide spectrum of Candida species and 24-hour readings could substitute 48-hour MIC evaluation.

In vitro antifungal susceptibility of clinical isolates of Candida spp. from hospitalized patients

A total of 122 Candida spp. strains, isolated from a group of 100 patients hospitalized in the Santa Casa de Misericordia of Belo Horizonte were assayed for in vitro susceptibility to amphotericin B, fluconazole, itraconazole, ketoconazole and flucytosine using a microbroth technique proposed by the National Committee for Clinical Laboratory Standards. In this study large variations were observed among minimum inhibitory concentration values depending on the species tested. The statistical analysis (Kruskal-Wallis test) showed that itraconazole and flucytosine were the more efficient antifungal drugs for most of species, and amphotericin B and fluconazole were the least efficient.

Comparison of three methods of determining MICs for filamentous fungi using different end point criteria and incubation periods

Three different methods were used to determine the in vitro activities of amphotericin B, ketoconazole, itraconazole, and flucytosine against 30 isolates of different genera of filamentous fungi. MICs were determined visually, with or without agitation, and spectrophotometrically by using a broth microdilution method. For amphotericin B, there was one end point reading criterion (the minimum concentration of antifungal that inhibited 100% of growth), but for azoles and flucytosine there were two (the minimum concentrations that inhibited 50 and 75% of fungal growth, respectively) after 48 and 72 h of incubation. All tests were performed in triplicate. An intraclass correlation coefficient (ICC) was used to evaluate the reproducibility of each of the methods and the correlation among them. The reproducibility of the three methods was very high (ICC of 0.808 to 0.992), particularly in the case of azoles and flucytosine. In general, the degree of reproducibility was highest for azoles and amphotericin B after 72 h of incubation and for flucytosine after 48 h of incubation. The degree of correlation among the three methods was very high (ICC of >0.98) with all of the antifungals under all the conditions tested. The end point reading criteria and the time of incubation affected neither the reproducibility of the methods nor their correlation, and their effect on MICs was statistically significant.

Use of spectrophotometric reading for in vitro antifungal susceptibility testing ofAspergillusspp

A comparative study of visual and spectrophotometric MIC endpoint determinations for antifungal susceptibility testing of Aspergillus species was performed. A broth microdilution method adapted from the National Committee for Clinical Laboratory Standards (NCCLS) was used for susceptibility testing of 180 clinical isolates of Aspergillus species against amphotericin B and itraconazole. MICs were determined visually and spectrophotometrically at 490 nm after 24, 48, and 72h of incubation, and MIC pairs were compared. The agreement between the two methods was 99% for amphotericin B and ranged from 95 to 98% for itraconazole. It is concluded that spectrophotometric MIC endpoint determination is a valuable alternative to the visual reference method for susceptibility testing of Aspergillus species.Key words: antifungal, susceptibility testing, Aspergillus, spectrophotometric reading.

Optimizing voriconazole susceptibility testing of Candida: effects of incubation time, endpoint rule, species of Candida, and level of fluconazole susceptibility

Voriconazole is a new triazole antifungal agent that has potent activity against many isolates of Candida, including Candida krusei and Candida glabrata. In this work, we studied the impact of glucose supplementation, incubation time, agitation of the plates prior to reading, endpoint determination rule, visual versus spectrophotometric reading, Candida species, and fluconazole MIC on the MIC of voriconazole for Candida isolates tested by using the microdilution format assay of the National Committee for Clinical Laboratory Standards (NCCLS) M27-A antifungal susceptibility testing methodology. For both voriconazole and fluconazole, a spectrophotometric endpoint of 50% reduction in turbidity relative to the growth control correlated most closely with the NCCLS-defined visual endpoint of "prominent decrease in turbidity." Correlation was generally better after 24 h of incubation than after 48 h. Supplementation of the medium to contain 20 g of glucose/liter did not alter the MIC significantly but did enhance growth and simplify visual readings. All Candida species appeared potentially susceptible to voriconazole, including isolates of C. krusei. For some isolates for which fluconazole MICs were markedly elevated voriconazole MICs were also elevated, but the clinical significance of these observations remains to be determined.

Multicenter comparison of the sensititre YeastOne Colorimetric Antifungal Panel with the National Committee for Clinical Laboratory standards M27-A reference method for testing clinical isolates of common and emerging Candida spp., Cryptococcus spp., and other yeasts and yeast-like organisms

National Committee for Clinical Laboratory Standards (NCCLS) standard guidelines are available for the antifungal susceptibility testing of common Candida spp. and Cryptococcus neoformans, but NCCLS methods may not be the most efficient and convenient procedures for use in the clinical laboratory. MICs of amphotericin B, fluconazole, flucytosine, itraconazole, and ketoconazole were determined by the commercially prepared Sensititre YeastOne Colorimetric Antifungal Panel and by the NCCLS M27-A broth microdilution method for 1,176 clinical isolates of yeasts and yeast-like organisms, including Blastoschizomyces capitatus, Cryptococcus spp., 14 common and emerging species of Candida, Hansenula anomala, Rhodotorula spp., Saccharomyces cerevisiae, Sporobolomyces salmonicolor, and Trichosporon beigelii. Colorimetric MICs of amphotericin B corresponded to the first blue well (no growth), and MICs of the other agents corresponded to the first purple or blue well. Three comparisons of MIC pairs by the two methods were evaluated to obtain percentages of agreement: 24- and 48-h MICs and 24-h colorimetric versus 48-h reference MICs. The best performance of the YeastOne panel was with 24-h MICs (92 to 100%) with the azoles and flucytosine for all the species tested, with the exception of C. albicans (87 to 90%). For amphotericin B, the best agreement between the methods was with 48-h MIC pairs (92 to 99%) for most of the species tested. The exception was for isolates of C. neoformans (76%). These data suggest the potential value of the YeastOne panel for use in the clinical laboratory.

No increase in frequency of antifungal resistance among yeasts isolated from normally sterile sites in patients at Foothills Hospital from 1993 to 1996

OBJECTIVE

To determine the prevalence of resistance to antifungal drugs among yeasts isolated from sterile sites from patients in one hospital and the relationship of resistance to antifungal use, and to assess whether resistance was increasing.

METHOD

Susceptibility testing performed by National Committee for Clinical Laboratory Standards (NCCLS) (Villanova, Pennsylvania) microdilution method and by E test. Antifungal use was determined by selected chart review and from pharmacy data. SPECIMENS AND SETTING: Tertiary care adult hospital with neonatal intensive care.

POPULATION STUDIED

Distinct yeast isolates from sterile site specimens collected during the years 1993 to 1996.

RESULTS

A total of 132 yeast isolates were studied, of which 78 (59%) were Candida albicans. The proportion of C albicans remained steady over the four-year period, and there was no trend to increased resistance among C albicans. The number of isolates of all species with fluconazole microdilution minimum inhibitory concentration (MIC) greater than 8 mg/L in each of the four years were one of 32 in 1996, three of 26 in 1994, six of 33 in 1995, and one of 41 in 1996. A single isolate had an itraconazole microdilution MIC greater than 0.5 mg/L in each year. Prior use of antifungal therapy was rare in this patient population.

CONCLUSIONS

The increase in resistance to antifungal drugs reported by some centres did not occur in this institution over the course of the study. This experience may reflect differences in infection control practices and in patterns of use of antifungal agents. The NCCLS method was found to be superior to the E test as a routine method for testing susceptibility of yeasts.

Influence of incubation time, inoculum size, and glucose concentrations on spectrophotometric endpoint determinations for amphotericin B, fluconazole, and itraconazole

We addressed the influence of the incubation time (24 h versus 48 h), starting inoculum size (standard inoculum size, approximately 10(3) CFU/ml, versus large inoculum size, approximately 10(4) CFU/ml), and supplementation with 2% glucose of RPMI 1640 medium on the spectrophotometric determination of the MICs of amphotericin B, fluconazole, and itraconazole. We compared the MICs determined spectrophotometrically with those determined by the standard broth macrodilution method (National Committee for Clinical Laboratory Standards approved guideline M27-A). The agreement between the results of the spectrophotometric and standard methods for amphotericin B testing was 100%; this agreement was independent of the inoculum size and incubation time. On the other hand, the agreement for the results for fluconazole testing and itraconazole testing was dependent on the inoculum size and incubation time. With large inoculum size, excellent agreement can be achieved at 24 h. With standard inoculum size, acceptable agreement can be achieved only at 48 h. In contrast to previous observations, the addition of 2% glucose did not have any significant impact on the growth density at 24 h, nor did it improve the agreement with the standard method. Furthermore, supplemental glucose might falsely elevate the MIC at 48 h.

Clinical evaluation of the ASTY colorimetric microdilution panel for antifungal susceptibility testing

A method using a commercially prepared colorimetric microdilution panel (ASTY; Kyokuto Pharmaceutical Industrial Co., Ltd.) was compared in four different laboratories with the National Committee for Clinical Laboratory Standards (NCCLS) reference microdilution method by testing 802 clinical isolates of Candida spp. (C. albicans, C. glabrata, C. tropicalis, C. parapsilosis, C. krusei, C. lusitaniae, C. guilliermondii, C. lipolytica, C. rugosa, and C. zeylanoides) against amphotericin B, 5-fluorocytosine (5FC), fluconazole, and itraconazole. Reference MIC endpoints were established after 48 h of incubation, and ASTY endpoints were established after 24 and 48 h of incubation. ASTY endpoints were determined to be the time at which the color of the first well changed from red (indicating growth) to purple (indicating growth inhibition) or blue (indicating no growth). Excellent agreement (within 2 dilutions) between the reference and colorimetric MICs was observed. Overall agreement was 93% at 24 h and 96% at 48 h. Agreement ranged from 90% with itraconazole and 5FC to 96% with amphotericin B at 24 h and from 92% with itraconazole to 99% with amphotericin B and 5FC at 48 h. The ASTY colorimetric microdilution panel method appears to be comparable to the NCCLS reference method for testing the susceptibilities of Candida spp. to a variety of antifungal agents.

Comparison of a 2,3-bis(2-methoxy-4-nitro-5-sulfophenyl)-5-[(phenylamino)carbonyl]-2H-t etrazolium hydroxide (XTT) colorimetric method with the standardized National Committee for Clinical Laboratory Standards method of testing clinical yeast isolates for susceptibility to antifungal agents

MICs for clinical Candida and Cryptococcus isolates were determined by a method incorporating the colorimetric indicator 2,3-bis(2-methoxy-4-nitro-5-sulfophenyl)-5-[(phenylamino)carbonyl] -2H-tetrazolium hydroxide (XTT), and the results were compared with MICs obtained by the National Committee for Clinical Laboratory Standards approved standard method (M27-A). One hundred percent of all isolates demonstrated agreement within 2 dilutions between the MICs of amphotericin B, fluconazole, itraconazole, ketoconazole, and flucytosine obtained by the two methods. These data suggest that an XTT-based method could provide a useful means for the determination of antifungal susceptibility of yeasts.