[Diagnosing dermatomycoses in a clinical mycology laboratory: guidelines proposed by the Czech Society for Medical Microbiology Working Group on Mycology]

This draft of guidelines for the laboratory diagnosis of dermatomycoses was developed based on discussion among members of the Czech Society for Medical Microbiology Working Group on Mycology. The document Guidelines for the Laboratory Diagnosis of Dermatomycoses was published for discussion on the Czech Society for Medical Microbiology website on 23 March 2020. Until recently, recommendations concerning this area of laboratory diagnosis in mycology were only limited to information in manuals and no comprehensive and systematic document concerning these issues was available. In an effort to fill the gap, members of the working group developed recommendations covering various laboratory aspects of mycology, from obtaining a proper history, to adequate sampling techniques, sample analyses using conventional microscopy and culture techniques, to interpretation of results. Additional information was on the diagnostic potential of novel, modern technology, in particular molecular genetic methods and mass spectrometry. The recently developed European standards for testing the susceptibility of dermatophytes to antifungals were also included in the recommendations. The document will be regularly updated based on new findings.

Unambiguous determination of farnesol and tyrosol in vaginal fluid using fast and sensitive UHPLC-MS/MS method

The new ultra-high performance liquid chromatography method with tandem mass spectrometry detection (UHPLC-MS/MS) has been optimized to allow fast, selective, and high-throughput analysis of two Candida albicans quorum sensing molecules (QSM), farnesol and tyrosol. The problem of the presence of the interference in the samples and system was successfully solved by careful optimization of chromatographic conditions. Charged hybrid stationary phase modified with pentafluorophenyl group and optimized gradient elution provided adequate separation selectivity and peak shapes. The impurity was identified as dibutyl phthalate and had the same m/z ions as farnesol leading to an important interference on selected reaction monitoring channel. Two different types of biological matrices originating from vaginal fluid, supernatant and sediment, were analysed. Micro-solid phase extraction in pipette tips was optimized for the selective isolation of QSM from the supernatant. The insufficient retention of farnesol on the extraction sorbent was improved when 1% of organic solvent was added prior to extraction, while the retention of tyrosol was only possible when using combined C8 and polymer sorbent type. Strong retention of farnesol had to be solved by increasing elution solvent strength and volume up to 600 μL. However, this approach did not allow the pretreatment of sediment samples due to the sorbent clogging. Therefore, our previously developed protein precipitation method was modified and validated to analyse the sediments. New developed UHPLC-MS/MS method provided suitable accuracy and precision for the determination of QSM in vaginal fluid while using only 50 μL sample volume and two different sample preparation methods.

[Pets (dogs/cats) as a possible source of opportunistic pathogenic fungi in humans]

INTRODUCTION

The microbiological aspect of a relationship between pets (dogs/cats) and their owners is mainly concerned with the incidence of the shared fungal species that can be potential pathogens. Since sharing homes with pets is very popular in the Czech Republic, there is an increased possibility of communication between microbiota of the two macroorganisms (the pet and the owner). The aim of the study was to determine, based on the close relationship between pets and humans, the biodiversity of shared fungi, also with respect to previous antimicrobial therapy.

METHODS

A total of 103 samples were collected from 20 pairs (20 owners, 16 dogs and 4 cats). All owners completed a questionnaire with their pets' veterinarians. In owners, swabs were collected from the nasal mucosa, armpit and interdigital spaces of the foot. In pets, swabs were obtained from the external auditory meatus and nasal mucosa. In individuals with skin lesions, samples were also collected from the affected areas. Fungal species were identified by culture and microscopy methods and confirmed by matrix-assisted laser desorption/ionization - time of flight (MALDI-TOF) mass spectrometry. Statistical methods were used to correlate the closeness of relationship with the number of shared fungal species and to correlate previous antimicrobial therapy with the number of shared species of microscopic fungi.

RESULTS

Analysis of the questionnaire found that 65 % of owners who participated in the study kept more pets at home than only the tested one. In the previous year, 5 % of pets and 5 % of owners received antimicrobial therapy. As many as 45 % of dogs or cats slept in their owners' beds and 80 % rested on a sofa together with their owners. Also, 45 % of owners had their faces licked by pets. Eighty percent of pets were fed with several types of food (dry food and cooked food). Further, 70 % of pets lived permanently with their owners in the same household. A total of 45 microscopic fungi species were isolated, of which 15 species occurred in both macroorganisms (pets and humans). Thirty-two species were identified from human and 28 species from animal samples. The most frequent species was the yeast Candida albicans, isolated from 30 samples. From the human nasal mucosa, only four species were isolated. The richest biodiversity was observed in interdigital space samples (26 fungal species). Once again, the most frequent fungal species was C. albicans (8 cases). The most numerous animal samples were obtained from the external auditory meatus. There, the most frequent species was Malassezia pachydermatis (17 cases). In seven pairs, microscopic fungi were shared. Of those, two pairs shared two spe-cies and five pairs shared one species. A total of five fungal species were shared, most often the yeasts C. albicans and Geotrichum candidum.

CONCLUSION

The closeness of the human-pet relationship apparently does not influence the number of shared fungal species. The yeast Candida albicans was most frequently isolated from owners as well as from the nasal mucosa in pets. The lipophilic yeast M. pachydermatis most commonly occurred in the material from the external auditory meatus and skin scales from dogs and cats.

Vaginal microbiome

OBJECTIVE

Presentation of complex information about the vaginal microbiota from historical view to current concepts with focus on latest findings on the structure and functioning of the vaginal microbiome.

DESIGN

Review article.

SETTING

Department of Clinical Microbiology, University Hospital and Faculty of Medicine in Hradci Králové, Charles University in Prague.

METHODS

Literature review using the databases (PubMed, Web of Science, Ovid, etc.) with keywords (vaginal microbiota/ microbiom; vaginal discharge; bacterial vaginosis; vulvovaginitis; vaginal Lactobacillus).

RESULTS

The vaginal microbiome is a specific compartment of the human microbiome. Unique conditions of the vagina are characterized by a few microbial species, usually lactobacilli, which are able to utilize glycogen, which is under control of estrogens. Lactobacilli and other fermentative bacteria together with vaginal epithelial cells produce lactic acid and are responsible for acidifying vaginal milieu. Lactic acid occurs in two isomeric forms, and their relative ratio is likely to give the vaginal microbiota a certain degree of stability and ability to withstand some infections. This microbiota is manifested by a low degree of diversity and by the high dynamics of changes of its composition under the influence of various exogenous and endogenous factors. Increase in diversity can be paradoxically associated with a dysbiosis such as bacterial vaginosis. Individual species of lactobacilli mainly Lactobacillus crispatus characterize the main community state types in the vagina. Apart from lactobacilli, healthy women may be colonized with a non-lactobacillary microbiota whose rate is dependent on ethnicity.

CONCLUSION

The definition of vaginal microbiota cannot be only related to the presence or absence of individual microorganisms, although the incidence of some of them can be correlated with dysbiosis or eubiosis. The composition of microbiota is important, but it is only one of the basic attributes of normal vaginal microbiota, but not sufficient; that is the functional definition of vaginal microbiota in relation to its structure and dynamics, including the influence of ethnicity, physiological status of the vagina, and genetic disposition of woman.

Comparison of two long-term gestagen regimens in the management of recurrent vulvovaginal candidiasis: A pilot study

Vulvovaginal candidiasis (VVC) is a hormonal-dependent infection but in contrast to sporadic VVC, therapy of recurrent vulvovaginal candidiasis (RVVC) is still unsolved. Long-term administration of medroxyprogesterone acetate was evaluated for the management of RVVC. Overall, 20 patients were treated with Depo-Provera; 14 patients were treated with Provera. Gestagen therapy was evaluated based on visual analogue scale (VAS), the frequency of attacks, the side effects of gestagens and the consumption of antifungals. There was a reduced symptomatology in both of the groups and substantial reduction in antifungal drug consumption during the second year of gestagen use. Twenty-four patients (70.6%) evaluated their condition regarding the vulvovaginal area as improvement (VAS decrease of 3-5 points). Five patients (14.7%) mentioned minimal or no improvement. Further, a number of antifungal drug-treated episodes dropped dramatically during the study period. Both regimes provided similar results, but five patients from the Depo-Provera group had to withdraw from gestagen therapy. Gestagen supplementation ameliorated the quality of life for the majority of patients with RVVC and suggested a potential role in the management of this syndrome, even if beneficial effect was evident after longer application, and some patients met with side effects that led to an interruption of therapy.

[Contemporary technicqes in diagnostic patients with vaginal microbiota]

OBJECTIVE

Review of literature dealing with the specificity of the vagina from the standpoint of microbial colonization.

DESIGN

Literature review.

SETTING

Department of Obstetrics and Gynecology, Department of Clinical Microbiology, University Hospital and Medical Faculty in Hradec Kralove, Charles University Prague.

METHODS

Analysis of the literature review and personal experience dealing with vaginal microbiota.

High frequency of Candida fabianii among clinical isolates biochemically identified as Candida pelliculosa and Candida utilis

Clinical yeast isolates belonging to Candida pelliculosa, Candida utilis and Candida fabianii are difficult to distinguish in a routine mycology laboratory using common biochemical tests. The aims of this study were to determine the prevalence of C. pelliculosa, C. utilis and C. fabianii in clinical samples and to compare their minimum inhibitory concentrations (MICs) to systemic antifungals. Two hundred and forty-eight clinical yeast isolates obtained from eight large hospitals in the Czech Republic were included in this study. Identification was performed biochemically using ID 32C kit and by MALDI-TOF MS. MICs were determined using colorimetric broth dilution Sensititre YeastOne panels. From a total number of 248 isolates, 175 were identified as C. pelliculosa and 73 as C. utilis using the biochemical kit. In contrast, MALDI-TOF MS identified 222 isolates as C. fabianii, 20 as C. pelliculosa and 6 as C. utilis. The highest mean MICs were found in C. fabianii and, regardless of the studied species, in isolates from blood cultures and central venous catheters. MALDI-TOF MS revealed C. fabianii to be most prevalent in clinical samples as compared with the other studied species. Higher MIC values in C. fabianii support the importance of correct identification of this species.

Healthcare-associated infections in gynecology and obstetrics at a university hospital in the Czech Republic

OBJECTIVE

To determine the spectrum of etiology and the incidence of healthcare-associated infections (HAIs) among gynecologic and obstetric patients.

METHODS

In a descriptive survey, data were analyzed from in-patients at the Department of Gynecology and Obstetrics, University Hospital and Faculty of Medicine in Hradec Králové, Czech Republic, between January 2007 and December 2011.

RESULTS

Among 21 937 patients treated during the study period, there were 189 (0.86%) cases of HAI. Gynecologic patients had a higher incidence of HAIs (1.31%) compared with pregnant women (0.60%). The incidence of HAI was 0.13% after laparoscopic surgery, 0.63% after a minor gynecologic intervention, and 3.73% after major surgery. Vaginal delivery (0.36%) represented a low risk of HAI. Compared with vaginal delivery, the incidence of HAI increased twofold for planned cesarean delivery (0.64%), and tenfold for emergency cesarean delivery (3.63%). The majority of causative microorganisms (72.7%) were susceptible to penicillin antibiotics. None of the patients died as a result of HAI.

CONCLUSION

The incidence of HAIs at a university hospital in the Czech Republic was very low. Antibiotic resistance was only a minor problem, and the incidence of multiresistant strains was rare.

Outbreak of fungal endophthalmitis due to Fusarium oxysporum following cataract surgery

Outbreak of exogenous Fusarium endophthalmitis after cataract surgery was evaluated. Twenty patients developed postoperative endophthalmitis. In 19 eyes, pars plana vitrectomy (PPV) was performed, in 14 cases (74 %) with primary intraocular lens explantation. In one case, the PPV was not performed because of poor general condition of the patient. Symptoms of endophthalmitis (damaged vision, iritis, tyndallization in anterior chamber, hypopyon) occurred at intervals of 16-79 days (mean 31.3 days). Fungal etiology was documented in 12 eyes (60 %). Fusarium oxysporum was evidenced by culture and/or microscopy and confirmed by PCR and sequencing analysis. Eighteen (90 %) patients were treated with oral voriconazole (400 mg/day) for a period of 4-6 weeks. The final visual acuity was 6/15 in 1 case (5 %), 6/60 and worse in 17 eyes (85 %), and in 2 cases (10 %), enucleation had to be performed. Viscoelastic filling material was suggested the most likely source of infection. Endophthalmitis caused by Fusarium spp. are a potentially big threat for patients with serious impact on vision. Successful management of the infection is highly dependent on early diagnosis including species identification and antifungal susceptibility testing, and on aggressive and long-term treatment.

[Is diabetes mellitus a risk factor in genital yeast infections?]

OBJECTIVE

To analyze experimental and clinical data on diabetes mellitus (DM) related to infections with focus on vaginal mycosis. To evaluate a role of DM in the epidemiology of vulvovaginal candidiasis.

DESIGN

Review.

SETTING

Department of Clinical Microbiology, Department of Biological and Medical Sciences, Faculty of Pharmacy, Department of Obstetrics and Gynecology, Charles University in Prague, Faculty of Medicine and University Hospital Hradec Kralove.

METHODS

Review of literature data.

RESULTS

DM is a risk factor for fungal infections caused by yeasts (Candida albicans), members of Mucorales fungi, some dimorphic fungi (Coccidioides) and agents of onychomycosis. DM is usually associated only with increased colonization of the anatomical sites (oral cavity, vagina), and/ or with an intensified symptomatology of infection (onychomycosis, mucormycosis). Diabetic patients with oropharyngeal and vulvovaginal candidiasis have frequently changed etiology spectrum. The patients with VVC and DM, especially of older age or with prone to relapses, have tendency to shift of the spectrum to non-albicans species, mainly C. glabrata. Treatment of VVC in diabetic patients can be complicated owing to unfavourable antifungal susceptibility profile (C. glabrata) and/ or adverse interactions between some azole antifungals and sulfonylurea-based antidiabetics.

CONCLUSION

Diabetes mellitus is often cited as a risk factor, although in many cases there is a lack of reliable and clinically relevant information. This does not mean that this disease can be underestimated. On the contrary, it is necessary to get the DM as soon as possible under control and thus prevent complications when infection develops. Individual approach should be applied to the diabetic patients at risk of an infection. Yeast colonization and development of vaginal infection is complex process primarily dependent on sexual hormones, indigenous microbiota and finely tuned mechanisms of local immunity. Role of DM consists in the fact that it is one of the important co-factors that can change the setup of the vaginal environment in favour of yeasts and thus promote or facilitate the development of VVC.

[What is the current stage of vulvovaginal discomfort diagnostics in the Czech Republic? Pilot analysis]

OBJECTIVE

To find out the level of the diagnostic effort of gynaecologists which is focused on the issue of vulvovaginal discomfort.

DESIGN

Pilot questionnaire study.

SETTINGS

Department of Obstetrics and Gynecology, Department of Clinical Microbiology, University Hospital and Medical Faculty Hradec Králové, Charles University, Prague, Department of Biological and Medici Sciences, FaF UK in Hradec Králové.

METHODS AND RESULTS

The evaluation of selected parametres of entrance questionnaire in patients with chronic vulvovaginal discomfort (itching, burning, discharge, vulvodynia more than 4 times a year). It has been confirmed, with the questionnaires, that almost no gynaecologists are interested in the issue of this matter.

CONCLUSION

After evaluating the questionnaires a diversion of patient-tailored attitude has been found out, which can lead to negative consequences, particularly, in the future. Overuse of antibacterial and antimycotic medication and blind treatment have been prevailing.

In vitro antibacterial and antifungal activity of salicylanilide pyrazine-2-carboxylates

The development of new antimicrobial agents for the treatment of infectious diseases remains challenging due to the increasing impact of antibiotic resistance. Since salicylanilides and esters of pyrazine-2-carboxylic acid have been described as potential antimicrobials, we have designed and synthesized a series of 2-(phenylcarbamoyl)phenyl pyrazine-2-carboxylates. These were evaluated in vitro for the activity against fungi and Gram-positive and Gram-negative bacteria. All derivatives showed significant antibacterial activity against Gram-positive strains (MIC ≥ 0.98 μmol/L) including methicillin-resistant Staphylococcus aureus. The most active molecule was 5-chloro-2-(3-chlorophenylcarbamoyl)phenyl pyrazine-2-carboxylate. With one exception these esters were at least partly active against fungi tested strains, in particular against mould strains (MIC ≥ 1.95 μmol/L). The most active antifungal agent overall proved to be 2-(4-bromophenylcarbamoyl)-4-chlorophenyl pyrazine-2-carboxylate.

In vitro antibacterial and antifungal activity of salicylanilide benzoates

The resistance to antimicrobial agents brings a need of novel antimicrobial agents. We have synthesized and found the in vitro antibacterial activity of salicylanilide esters with benzoic acid (2-(phenylcarbamoyl)phenyl benzoates) in micromolar range. They were evaluated in vitro for the activity against eight fungal and eight bacterial species. All derivatives showed a significant antibacterial activity against Gram-positive strains with minimum inhibitory concentrations ≥0.98 μmol/L including methicillin-resistant Staphylococcus aureus strain. The most active compounds were 5-chloro-2-(3,4-dichlorophenylcarbamoyl)phenyl benzoate and 4-chloro-2-(4-(trifluoromethyl)phenylcarbamoyl)phenyl benzoate. The antifungal activity is significantly lower.

[Pitfalls of the current laboratory diagnosis and treatment of vulvovaginal candidiasis]

Vulvovaginal candidiasis remains one of the most frequently diagnosed inflammatory diseases of the vagina, which affects most sexually active women. In most patients, it is manifested as acute inflammation which is easy to diagnose and treat. However, in the susceptible population, it may be characterized by recurrent episodes, usually with an unknown cause or exacerbating moment. These facts complicate the diagnosis and therapy. This is highlighted by both non-specific symptoms shared with many other vaginal infections and paucity of reliable signs for diagnosis. Under these circumstances, it is difficult to associate vaginal complaints with yeasts and, vice versa, the presence of yeasts does not necessarily confirm fungal aetiology. Therefore, it is better to regard the condition as a syndrome and the chronic problems as vulvovaginal discomfort. It is a prerequisite for an unbiased diagnostic approach, increasing the probability of finding the real cause of the problem and the chances of treating or even curing the disease. The article is concerned with controversial and problematic aspects of diagnosis and treatment of vulvovaginal candidiasis with a focus on laboratory diagnosis, terminology, epidemiology and ecology of yeasts in relation to vaginal microbiota and, last but not least, on alternative therapeutic approaches.

[Vulvodynia and the possibility of its management]

OBJECTIVE

A study of vulvodynia and the possibility of its management.

SUBJECT

Original study.

SETTING

Department of Obstetrics and Gynecology, Teaching Hospital and Medical Faculty Hradec Králové, Charles University, Prague. Department of Neurology, Teaching Hospital and Medical Faculty Hradec Králové, Charles University, Prague. Outpatient psychiatric department Galenus, Hradec Králové. Department of Clinical Microbiology, Teaching Hospital and Medical Faculty Hradec Králové, Charles University, Prague. Department of Biological and Medical Sciences, Faculty of Pharmacy Hradec Králové, Charles University, Prague.

METHODS

Analysis and discussion focused on our experience in a long time follow-up of patients with chronic vulvovaginal discomfort and vulvodynia.

CONCLUSION

Especially the management of indolent form of vulvodynia would be taken into consideration of idiopathic origin and problematic management. Our study emphasizes the necessity of individual approach. The goal of therapy in this most problematic form is the improving of the actual quality of life. In the case of idiopathic forms of vulvodynia.

[Possibilities of diagnostics yeasts in gynecologist patients]

Problem of mycoses in gynecology is considered very frequent and yeasts are traditionally described as most common cause of vulvovaginal disorders. While acute disorders can be promptly cured in most cases, there is a group of women suffering from those repeatedly. Following article refers to a group of patients in long-term follow-up and shows realistic possibilities of diagnostics, available to out-patient gynecologist. Preliminary results of our pilot project do not confirm yeasts have to be the primary etiologic factor, nevertheless it is logical to be in search of them in these patients.

Ultra high performance liquid chromatography tandem mass spectrometry analysis of quorum-sensing molecules of Candida albicans

Candida albicans is generally one of the most commonly isolated fungal pathogen from human body. It is a frequent cause of nosocomial infections, bloodstream infections, urinary infections and mucosal infections of oral cavity and vagina C. albicans can grow as hyphae, pseudohyphae, or budding yeast. Morphological conversion of a yeast form to pseudohyphal or hyphal one is often characterized by the change of commensal status to an invasive form. Farnesol and tyrosol can participate in these transformation processes as quorum sensing molecules together with some physical-chemical factors. A new analytical method for identification and quantification of biologically active substances farnesol and tyrosol using ultra high performance liquid chromatography (UHPLC) in connection with tandem mass spectrometry was developed. The analytes were separated on Acquity BEH C18 analytical column using binary mobile phase consisting of acetonitrile and formic acid 0.075% (75:25) at flow-rate 0.20 ml/min. SRM (selected reaction monitoring) mode was applied in order to ensure sufficient selectivity and sensitivity using the first most intensive transition as a quantitative (121>77 and 205>121) and second one for the confirmation purposes (121>93 and 205>109). The method was validated in terms of linearity (>0.9994), precision (0.5-3.8% RSD), accuracy (78.9-106.0%), LOD (limit of detection) and LOQ (limit of quantitation). The method can serve as an analytical tool for the detection and determination of quorum-sensing molecules in biological samples.

[Penetration of ceftriaxone into the cerebrospinal fluid and its relationship to inflammatory markers during bacterial meningitis]

AIM

To evaluate the penetration of ceftriaxone into the cerebrospinal fluid (CSF) in patients with invasive bacterial infection and to define correlation between the penetration and laboratory markers of inflammation.

MATERIAL AND METHODS

Levels of ceftriaxone in the serum and CSF of 17 patients with purulent meningitis were examined. Serum concentrations of ceftriaxone before and after its administration were measured in 9 patients (18 samples, 52.9 %) by microbiological assay based on the agar diffusion test. In all patients, the CSF/serum quotient for ceftriaxone was calculated and correlated with laboratory markers of inflammation (C-reactive protein, fibrinogen and neutrophils). The CSF from nine patients with positive culture for bacteria was used for a modified bactericidal test.

RESULTS

Ceftriaxone levels in the serum before and after administration (31.2 mg/l -/+ SD 12.29 and 300.0 mg/l -/+ SD 125.9, respectively) were different (p = 0.000156). The decrease of ceftriaxone levels in the CSF was gradual. There was also a significant difference between the levels of inflammatory markers and CSF/serum quotient of ceftriaxone. Patients with the values higher than 0.1 had higher CRP serum levels (p = 0.00192), fibrinogen serum levels (p = 0.0178) as well as neutrophil count in the CSF (p = 0.0112). However, no inflammatory markers (or their combinations) predicted the extent of penetration of ceftriaxone into the CSF.

CONCLUSION

High serum concentration of ceftriaxone causes higher penetration through the inflamed blood-brain barrier. Higher antibiotic penetration correlated with the extent of systemic inflammatory response. However, no inflammatory marker predicted the rate of ceftriaxone crossing the blood-brain barrier. Ceftriaxone penetration, with a 24-hour regimen of administration, remains reliable and efficient therapy of purulent meningitis.

[Infections of the oral mucosa caused by herpes simplex virus]

OBJECTIVES

Recapitulation of our knowledge dealing with diagnosis and therapy of oral mucosal diseases caused by HSV.

MATERIAL AND METHODS

Analysis of a sample of 135 patients coming from Department of Dentistry, Faculty of Medicine in Hradec Králové within 11 years. Statistical evaluation of the data and related associations (clinical diagnosis, age, gender, general health status, treatment mode) were realized by ANOVA analysis, t-test, and Fisher's exact test.

RESULTS

A total sample of 135 individuals (81 women and 54 men) consisted of 49 individuals with primary herpetic gingivostomatitis (37 %) and recurrences with clinical signs of herpetic stomatitis in 68 patients (50 %) and labial herpes simplex in 18 patients (13 %) aged from 1 to 90 years, mean age 40.4 year, with maximal occurrence in the 3rd and 7th decades. The mean age of individuals with herpetic gingivostomatitis was significantly lower (p = 0.0001). The occurrence of herpetic stomatitis was associated with severe concomitant diseases (p = 0,0001). Topical treatment was applied in 73 individuals (54 %), combined mode in 58 individuals (43 %), only systemic therapy in 4 individuals (3 %). In most of individuals with herpetic gingivostomatitis only topical treatment was used (80 %, in most of herpetic recurrences combined therapy was applied (62 %).

CONCLUSIONS

The age of individuals with primary infection and herpetic recurrences was significantly different. Herpetic stomatitis occurred often as an opportunistic viral infection in seriously ill and older patients. Antiseptics with antiviral properties and their combinations with systemic administration of antiviral drugs proved successfully in the treatment.

Cytostatic tetrazole–butenolide conjugates: linking tetrazole and butenolide rings via stille coupling and biological activity of the target substances

A series of tetrazoles linked to the butenolide core via benzene rings were prepared by the Stille coupling reaction of α-(tributylstannyl)butenolides and 5-(alkylsulfanyl)-1-(4-iodophenyl)tetrazoles, and the compounds were tested for antifungal and cytostatic activity. Interesting antifungal activities against the filamentous strain Absidia corymbifera, and cytostatic activities against leukemic cells HL-60 and CCRF-CEM were found. The cytostatic activity requires the presence of both the butenolide ring and the alkylsulfanyl group bound to tetrazole ring. In addition, the feasibility of Pd-coupling reactions with 5-iodotetrazoles was evaluated.

[Treatment of invasive candidiasis--recommendations of professional]

National working group representing clinicians (hematologists, oncologists, infection diseases and ICU specialists), microbiologists, and different special medical societies and working groups prepared evidence-based guidelines for the treatment established fungal infection--invasive candidiasis in the adult hematology and ICU patients. These guidelines updated those published in the Czech Republic in 2003-2004. Evidence criteria of the Infectious Diseases Society of America (IDSA) were used for assessing the quality of clinical trials, and EORTC/MSG Consensus Group for definitions of invasive fungal disease.

[Treatment for invasiveness aspergillosis--recommendations of professionals]

An increasing incidence of invasive aspergillosis is observed in most immunocompromised patients, and especially patients with acute leukemia and after hematopoietic stem cell transplantation. In order to decrease the mortality due to this infection, the clinicians need to optimise their treatment choice. The objective of these guidelines is to summarize the current evidence for treatment of invasive aspergillosis. The recommendations have been developed by an expert panel following an evidence-based search of literature with regard to current recommendation of European Conference in Infections in Leukemia and Infectious Diseases Society of America.

Salicylanilide esters of N-protected amino acids as novel antimicrobial agents

A series of novel, highly antimicrobial salicylanilide esters of N-protected amino acids were synthesized and characterized. Their in vitro antimicrobial activity against eight fungal strains and Mycobacterium tuberculosis was determined. The compounds had the highest level of activity against Aspergillus fumigatus, Absidia corymbifera and Trichophyton mentagrophytes, and these levels were higher than that of the standard drug fluconazole. In addition, three compounds showed interesting antituberculosis activity, with inhibition ranging from 89% to 99%. (S)-4-Chloro-2-(4-trifluoromethylphenylcarbamoyl)-phenyl 2-benzyloxy-carbonylamino-propionate had the highest level of both antifungal and antimycobacterial activity. The structure-activity relationships of the new compounds are discussed.

[Yeasts isolated from the patients of the Department of Dentistry, University Hospital in Hradec Králové in the period of 1996-2007]

PURPOSE OF THE STUDY

The goal was to evaluate the spectrum of yeasts isolated from biological materials from patients treated at the Department of Dentistry, Faculty of Medicine and University Hospital in Hradec Kralove in the years 1996 to 2007. The study focused on the relationships between yeasts and some clinical and epidemiological characteristics.

MATERIAL AND METHODS

The study involved patients with the positive mycological findings attending the Department of Dentistry in the period. Electronic records kept at the Department of Clinical Microbiology were processed and then analyzed statistically by regression analysis and chi2 test.

RESULTS

During the period 1996 to 2007, 530 patients (26.9 %) showed culture-positive yeasts in a total of 713 biological specimens (23.9 %). Mycological findings were more common (chi2 test, p = 0.00003) in women (n = 348; 30.4 %) than in men (n = 182; 22.0 %). The mucous membrane of the mouth and the tongue were most often colonized by yeasts (51.5 %). Candida albicans (93.2 %) predominated among the yeasts isolated. The overall proportion of non-albicans Candida species (C. tropicalis, C. glabrata and C. krusei) was relatively low (24.7 %) and there was no significant trend of changes during the period in the spectrum of yeasts. However, a comparison of the distribution of yeast over the period showed a statistically higher incidence of C. tropicalis in females than in males (13.2 % vs. 6.6 %; chi2 test, p = 0.020) and more frequent positivity of C. krusei in men compared to women (4.9 % vs. 1.1 %; chi2 test, p = 0.007). Majority of yeast isolates was associated with the diagnosis of mucosal infection in the mouth cavity (89.0 %); smaller part represented diseases of teeth and adjacent anatomical sites (periodontium) and uncommon infections (angular cheilitis, salivary gland, Sjögren syndrome).

CONCLUSIONS

The study showed that yeasts were commonly present in the oral cavity either as normal microflora or cause of fungal infections, especially in women. The tongue, the palate and buccal mucosa were most frequent anatomical location with yeasts isolated. Candida albicans remains predominant species, but C. tropicalis and C. glabrata can frequently be isolated. There were no trends in the change of yeast spectrum during that period.

Identification and characterization of thiosemicarbazones with antifungal and antitumor effects: cellular iron chelation mediating cytotoxic activity

Thiosemicarbazones derived from acetylpyrazines were prepared by condensing an acetylpyrazine or a ring-substituted acetylpyrazine with thiosemicarbazide. Using the same procedure, N, N-dimethylthiosemicarbazones were synthesized from acetylpyrazines and N, N-dimethylthiosemicarbazide. A total of 20 compounds (16 novel) were chemically characterized and then tested for antifungal effects on eight strains of fungi and also for antitumor activity against SK-N-MC neuroepithelioma cells. The most effective compound identified in terms of both antifungal and antitumor activity was N, N-dimethyl-2-(1-pyrazin-2-ylethylidene)hydrazinecarbothioamide (5a). The mechanism of action of this and its related thiosemicarbazones was due, at least in part, to its ability to act as a tridentate ligand that binds metal ions. This was deduced from preparation of the related thiosemicarbazones [acetophenone thiosemicarbazone (6) and acetophenone N, N-dimethylthiosemicarbazone (7)] that do not possess a coordinating ring-N, which plays a vital role in metal ion chelation. Furthermore, 5a and several other thiosemicarbazones that showed high antiproliferative activity were demonstrated to have marked iron (Fe) chelation efficacy. In fact, these agents were highly effective at mobilizing (59)Fe from prelabeled SK-N-MC cells and preventing (59)Fe uptake from the serum Fe transport protein, transferrin. In contrast, compounds 6 and 7 that do not possess a tridentate metal-binding site showed little activity. Further studies examining ascorbate oxidation demonstrated that the Fe complexes of the most effective compounds were redox-inactive. Thus, in contrast to other thiosemicarbazones with potent antiproliferative activity, Fe chelation and mobilization rather than free radical generation played a significant role in the cytotoxic effects of the current ligands.

[Recurrent vulvovaginal candidiasis--possibility of its treatment]

OBJECTIVE

A review of recurrent vulvovaginal candidiasis and the possibility of its treatment.

SUBJECT

Original study.

SETTING

Department of Obstetrics and Gynaecology, Medical Faculty Hradec Králové, Charles University, Prague. Department of Clinical Microbiology, Medical Faculty Hradec Králové, Charles University, Prague. Department of Biological and Medical Sciences, Faculty of Pharmacy Hradec Králové, Charles University, Prague. Department of Clinical Imunology and Allergology, Medical Faculty Hradec Králové, Charles University, Prague. Department of Psychiatry, Medical Faculty Olomouc, Palacky University, Olomouc.

METHODS

Analysis and discussion focused especially on our results and experience in a long time followup of patients with confirmed recurrent vulvovaginal candidiasis.

CONCLUSION

Owing to the multifactorial character of etiopathogenesis, the management of recurrent vulvovaginal candidiasis would be taken into consideration the complexity of the disease, not only the treatment of individual episodes with antimycotics.

Synthesis, antimycobacterial and antifungal evaluation of 3-arylaminopyrazine-2,5-dicarbonitriles

This paper describes preparation and biological evaluation of pyrazinamide analogues. Pyrazinamide with its simple structure gives a good opportunity for further modification regarding an increase of its antimycobacterial activity. We prepared a series of compounds derived from pyrazine-2,5-dicarbonitrile with arylamino substitution in position 3. All compounds were assayed in vitro against major Mycobacterium and various Fungi species. The best activity was found in 3-{[3-(trifluoromethyl)phenyl]amino}pyrazine-2,5-dicarbonitrile 11 with the value of 6.25 micromol(-1) against M. tuberculosis H(37)Rv and moderate activity against minor Mycobacterium pathogens.

[Multidisciplinary approach to the management of vulvovaginal discomfort]

Vulvovaginal discomfort is generally the most common reason for visiting a gynaecological clinic. The acute complaints are, in most cases, solved by a gynaecologist himself and the decision procedure is based on possibilities arising from outpatient examination. If need be, the evaluation of wet preparation should be carried out. In many cases we have been confronted with discrepant diagnosis where severe difficulties are not accompanied by relevant development of inflammatory changes and thus the diagnosis gives us an impression of quandary. In this case microbiological examination is the logic solution. With regard to changing living conditions we can expect in the future, that clinical symptoms of vulvovaginitis will not be entirely clear. The overview article points out the possibilities, which a gynecologist is able to use within differential diagnosis in the outpatient department. It also emphasis the necessity of interdisciplinary co-operation, particularly in patients with chronic difficulties where erudite evaluation of fixed preparation and culture examination are beneficial.

Comparison of disk diffusion test and Etest for voriconazole and fluconazole susceptibility testing

The distribution for voriconazole and fluconazole susceptibility was determined by Etest and disk diffusion test in 143 clinical isolates. The majority of the strains of Aspergillus spp., Candida krusei, C. inconspicua, C norvegensis and Saccharomyces cerevisiae displayed resistance or decreased susceptibility to fluconazole in contrast to voriconazole. The absolute categorical agreement for voriconazole and fluconazole susceptibility results by the disk method and Etest was 90.5 and 74.8 % respectively. The error rate bounding analysis showed only 0.7 % of false susceptible results ( very major error) with voriconazole, but 2.8 % with fluconazole. Fluconazole can be used as a surrogate factor to predict voriconazole susceptibility but with lower reliability for susceptible-dose dependent and resistance category, especially in Candida glabrata isolates. The results of the disk method were not substantially influenced by the composition of media (Mueller-Hinton agar vs antimycotic Sensitivity Test agar), even if with the latter the results had fewer tendencies to produce false susceptibility of C.glabrata isolates to both of the triazole drugs. Disk test as well as Etest were shown to represent suitable methods for routine evaluation of susceptibility of clinical isolates of pathogenic fungi, including aspergilli, to fluconazole and voriconazole.

Effect of subinhibitory concentration of some established and experimental antifungal compounds on the germ tube formation in Candida albicans

The influence of subinhibitory concentrations of six established and 19 newly synthesized antifungal compounds on the dimorphic transition of three C. albicans strains was evaluated in the filamentation-inducing medium. Amphotericin B was found to produce almost complete inhibition in the germination at a concentration of 1/10 of the corresponding MIC and partial inhibition at a concentration as low as MIC/50. Flucytosine and four azole derivatives were proven ineffective. From the newly synthesized drugs, the incrustoporin derivative LNO6-22, two phenylguanidine derivatives (PG15, PG45), and four thiosalicylanilide derivatives, in particular, showed results comparable to those of amphotericin B, with a high inhibition of germ tube formation at concentrations of MIC/10. In general, concentrations of MIC/50 had no visible effect.

Clinical aspects and luteal phase assessment in patients with recurrent vulvovaginal candidiasis

OBJECTIVE

This study was undertaken to characterize the patients with recurrent vulvovaginal candidiasis.

STUDY DESIGN

Basic data of personal history and history of recurrent vulvovaginal candidiasis, lower genital tract symptoms and signs in 50 patients were analyzed in this longitudinal follow-up study including the determination of midluteal serum progesterone and urinary pregnanediol levels during the luteal phase in 84 cycles (recurrent vulvovaginal candidiasis) and 60 cycles (healthy controls).

RESULTS

All patients suffered primary idiopathic form of recurrent vulvovaginal candidiasis. Frequently, there was a striking discrepancy between severe symptoms and clinical finding, which was often negligible or normal. There was no redness and no or minimum discharge in 52% of culture documented attacks. In contrast to the healthy controls, the patients had significantly lower levels of progesterone (p<0.01) as well as those of urinary pregnanediol (p<0.05).

CONCLUSION

Culture positive attacks in patients with recurrent vulvovaginal candidiasis represented rather a form of vulvovaginal discomfort than attacks of vulvovaginal candidiasis with typical inflammatory changes. Significantly lower progesterone levels in the RVVC patients as compared to the healthy controls suggest a link between an altered hormonal status and one of possible causes of RVVC in these women.

Hybrid molecules of estrone: New compounds with potential antibacterial, antifungal, and antiproliferative activities

New hybrid molecules of estrone were synthesized as compounds indicating promising biological activity (antibacterial, antimycobacterial, antifungal, and antiproliferative). The prepared molecules contained various heterocyclic units (pyridine, benzylsulfanyl derivatives of pyridine or derivatives of tetrazole) linked to estrone by n-heptyl bridges. The compounds with charge on molecule (the hybrid pyridinium or benzylsulfanylpyridinium salts) exhibited significant biological activity (antibacterial, antimycobacterial, antifungal, and antiproliferative). On the other hand, the compounds not in the form of salts (omega-(1-phenyl-5-tetrazolylthio)heptylethers of estrone) were inactive. The antimycobacterial activities of three different series of tetrazole derivatives (i.e., the hybrid molecules with estrone, tetrazole-5-thiols, and 5-benzylsulfanyl-1-phenyltetrazoles) with the same substituents on phenyl ring were compared. Amongst them, the 5-benzylsulfanyl-1-phenyltetrazoles were the most potent.

Cryptococcosis-a review of 13 autopsy cases from a 54-year period in a large hospital

From 1952 to 2005, 13 cases of cryptococcosis confirmed by postmortem examination were diagnosed in autopsy material from the University Hospital in Hradec Králové, the Czech Republic. Histologically, Cryptococcus was found in multiple organs (brain and spinal cord, lungs, lymph nodes, spleen, bone marrow, liver, kidneys and adrenal glands). The lungs and CNS were the organs most often involved. Only in two cases was the diagnosis of cryptococcal infection established during the patient's lifetime, in both presenting clinically as meningitis, with positive result of CSF cultivation. Data and issues of diagnostics and treatment of cryptococcosis are discussed.

[Presumptive identification of Candida albicans by rapid diagnostic tests]

PURPOSE OF THE STUDY

The goal of the study was to evaluate the practical value of rapid tests in laboratory diagnostics of pathogenic yeasts with focus on Candida albicans and to elaborate an alternative method of germ tube test in NYP medium.

MATERIAL AND METHODS

200 clinical strains of 12 yeast species isolated in mycology laboratory at the Department of Clinical Microbiology, Teaching Hospital in Hradec Králové were investigated. All these isolates were studied according to their growth onto the two chromogenic media (CandiSelect, Bio-Rad, HiCrome Candida Agar, HiMedia) and the production of germ tubes in serum and NYP medium. The results of identification by the rapid tests were verified by standard methods.

RESULTS

All 100 C. albicans isolates grew on CandiSelect as well as HiCrome Candida agar as characteristically coloured colonies. In case of HiCrome Candida agar, C. tropicalis strains (n = 15) produced typically blue-green colonies. Sensitivity and specifity of both the media was 100%. Germ tubes were observed in serum and NYP medium in all C. albicans strains. Lower proportion of pseudohyphae was noticed in NYP medium than serum particularly in non-albicans Candida strains. Two strains C. tropicalis (13.3 %) produced germ tubes in serum, but not NYP.

CONCLUSIONS

Both CandiSelect and HiCrome Candida Agar identified reliably C. albicans isolates, in case of the latter C. tropicalis as well. The comparison of the production of germ tubes in serum versus NYP medium showed comparable results and lower risk of false positive results in NYP medium which can follow from pseudohyphae formation. All rapid tests studied represent reliable tools for presumptive identification of C. albicans.

Primer R108 performs best in the RAPD strain typing of three Aspergillus species frequently isolated from patients

We evaluated the suitability of various primers for the RAPD (random amplified polymorphic DNA) accurate species identification and strain typing of Aspergillus clinical isolates. Five primers described previously were tested for their discriminatory power in three Aspergillus species (A. fumigatus, A. niger agg. and A. flavus - 23 clinical isolates and 2 reference strains). Clustering of RAPD fingerprints corresponded well with the identification based on morphological features. All isolates were resolved as different strains using the primer R108 and the RAPD protocol optimized for a Robocycler thermal cycler. RAPD with the primer R108 thus can be considered to be a valuable, simple and powerful tool for identification and strain delineation of Aspergillus spp.

Antifungal susceptibility testing by flow cytometry: is it the future?

The current increase in the number and significance of fungal infections, the expanding armamentarium of antifungal agents, and the emergence of the problem of antifungal drug resistance have been intensifying the importance of antifungal susceptibility testing (AST). The Clinical and Laboratory Standards Institute (CLSI, formerly NCCLS) in the United States and the Antifungal Susceptibility Testing Subcommittee of the European Committee on Antimicrobial Susceptibility Testing (AFST-EUCAST) published standard methodologies in order to achieve higher reproducibility and allow direct inter-laboratory comparison of the susceptibility results. Nevertheless, several problems remain unresolved and the methods depend on long incubation periods of a minimum of 24 h (EUCAST) or even 48 h (CLSI). Over the last 15 years, successful applications of flow cytometric techniques to AST of both yeast and moulds have been reported. These techniques are based on the analysis of a great number of fungal cells individually and frequently rely on short incubation times of no more than a few hours. Considering these attributes, flow cytometry (FC) seems to have the potential to achieve clinical usefulness in the near future. The collection of data on the reproducibility of the results and on the correlation with clinical outcomes has barely started, however. Practical validation of the experimental methodologies is not granted before a significant amount of data addressing those questions is available.

Investigation of the mechanism of action of 3-(4-bromophenyl)-5-acyloxymethyl-2,5-dihydrofuran-2-one against Candida albicans by flow cytometry

The mechanism of action of the antifungal agent 3-(4-bromophenyl)-5-acyloxymethyl-2,5-dihydrofuran-2-one against Candida albicans was investigated by flow cytometry, using propidium iodide, DiBAC4(3), and FUN-1 as the fluorescent dyes. A related but less active agent, together with amphotericin B and fluconazole, was tested in parallel for comparison of the results. The incrustoporine derivative was found to have a potent fungicidal activity on C. albicans, resulting in damage of cell membrane.