The isolation and identification of Candida glabrata from avian species and a study of the antibacterial activities of Chinese herbal medicine in vitro.

Previously, a fungus was isolated from a diseased pigeon group clinically suspected of being infected with Candida. The fungus was subsequently identified as Candida glabrata using morphology, physiology, biochemistry, and molecular biology testing methods. In the present study, to determine the controlling effects of Chinese herbal medicine for C. glabrata, the bacteriostatic effects of the ethanol extracts Acorus gramineus, Sophora flavescens, Polygonum hydropiper, Cassia obtusifolia, Pulsatilla chinensis, Dandelion, and Cortex phellodendri on C. glabrata in vitro were analyzed. The results showed that the minimum inhibitory concentrations (MIC80) of Cortex phellodendri was 0.25 µg/µL. Meanwhile, that of S. flavescens was 32 µg/µL; C. obtusifolia was 56 µg/µL; A. gramineus and Polygonum hydropiper was 64 µg/µL; and P. chinensis was 112 µg/µL. However, MIC80 for Dandelion was undetectable. In addition, improved drug sensitivity tests revealed that colonies had grown after 24 h in the blank group, as well as the Polygonum hydropiper, P. chinensis, Dandelion, and ethanol groups. The colonies first appeared at the 48-hour point in the other drug-sensitive medium of Chinese herbal medicine. However, no colony growth was found in Cortex phellodendri medium, and the formation of the maximum colony diameter in that group was later than the blank group (e.g., 96 h in the blank group and 120 h in the Chinese herbal medicine group). It was observed that only 17 colony-forming units had grown in 125 µg/µL of the S. flavescens medium, which was significantly different from other groups. Also, the final colony diameter was significantly smaller than that of the other experimental groups. Therefore, it was determined that the A. gramineus, S. flavescens, Polygonum hydropiper, Cassia obtusifolia, P. chinensis, and Cortex phellodendri had certain inhibitory effects on the growth of the C. glabrata. Among those, it was observed that the Cortex phellodendri had the strongest inhibitory effects, followed by the S. flavescens. In the future, these Chinese herbal medicines are expected to be used to treat the fungal infections related to C. glabrata in poultry to improve production performance.

Microbiology and clinical characteristics of industrial oil burns.

INTRODUCTION: Infections complicating burns generally transition from Gram-positive to Gram-negatives over the first couple weeks, but this depends on multiple factors. The microbiology of infections complicating crude oil (CO) and hydraulic fracturing (FRAC) burns is unknown. METHODS: We performed a retrospective study of patients with industrial thermal burns hospitalized >2 days with ≥1 day in the ICU between 4/2011-11/2016. Burns were oil-related (ORB; CO or FRAC) or non-oil related (NORB). Epidemiology and microbiology during the first 15 hospital days was compared. RESULTS: 149 patients were included, with 11 FRAC and 24 CO. CO burns were more severely burned than those with FRAC and NORB (p<0.05). Mortality was 17% and 18% for CO and FRAC burns compared to 3% in NORB (p<0.01). More cultures were obtained from ORB than NORB (p<0.05). ORB were associated with Stenotrophomonas maltophilia and FRAC associated with Serratia marcescens and Candida glabrata. Patients with FRAC, CO and NORB had a median of 13, 3.5, and 4 days to first positive culture respectively (p=0.03). CONCLUSION: ORB were associated with more severe burns and unique microbiology. FRAC burns had longer to initial positive culture, potentially suggesting our current methodology is inadequate to diagnose infections associated with FRAC.

Species distribution and antifungal drug susceptibilities of yeasts isolated from the blood samples of patients with candidemia.

Candida albicans is the most frequently isolated fungal species in hospital settings worldwide. However, non-albicans Candida species with decreased susceptibility to antifungals have emerged as an important cause of fungemia. The aims of this study were to determine the species distribution of fungi isolated from the blood samples of patients at a Swedish University Hospital and to define the in vitro susceptibilities of these isolates to nine antifungal agents. In total, 233 yeast isolates from 143 patients were included in this study. Antifungal susceptibility testing was performed using broth dilution Sensititre YeastOne panels, which comprised amphotericin B, 5-flucytosine, fluconazole, itraconazole, voriconazole, posaconazole, anidulafungin, micafungin, and caspofungin. The most common species in all age groups was C. albicans (n = 93, 65%), followed by C. glabrata (n = 27, 19%) and C. parapsilosis (n = 15, 10%). C. glabrata was mostly found in elderly individuals, while C. parapsilosis was found mainly in young children (p = 0.008). Antifungal resistance was low in the Candida species, except for reduced susceptibility to fluconazole among C. glabrata strains. C. albicans is the most frequent colonizer of Swedish patients. In general antifungal resistance is uncommon in Candida species. Nevertheless, reduced susceptibilities to fluconazole and echinocandins were found in C. glabrata and C. parapsilosis, respectively.

Correlation between antifungal consumption and the distribution of Candida species in different hospital departments of a Lebanese medical Centre.

BACKGROUND: In recent years, there has been a significant increase in the incidence of fungal infections attributed to Candida species worldwide, with a major shift toward non-albicans Candida (NAC). In this study, we have described the distribution of Candida species among different hospital departments and calculated the antifungal consumption in our facility. We also correlated the consumption of certain antifungals and the prevalence of specific Candida species. METHODS: This was a retrospective review of all the Candida isolates recovered from the computerised microbiology laboratory database of Makassed General Hospital, a tertiary care centre in Beirut, Lebanon, between January 2010 and December 2015. Data on antifungal consumption between January 2008 and December 2015 were extracted from the hospital pharmacy electronic database. We used Spearman's coefficient to find a correlation between Candida species distribution and antifungal consumption. RESULTS: Between 2008 and 2015, we observed that the highest antifungal consumption was in the haematology/oncology department (days of therapy/1000 patient days = 348.12 ± 85.41), and the lowest was in the obstetrics/gynaecology department (1.36 ± 0.47). In general, the difference in antifungal consumption among various departments was statistically significant (P < 0.0001). Overall, azoles were the most common first-line antifungals in our hospital. Echinocandins and amphotericin B were mostly prescribed in the haematology/oncology department. As for Candida species distribution, a total of 1377 non-duplicate isolates were identified between 2010 and 2015. A non-homologous distribution of albicans vs. non-albicans was noted among the different departments (P = 0.02). The most commonly isolated NAC was Candida glabrata, representing 14% of total Candida species and 59% of NAC. Candida famata (9% of NAC), Candida parapsilosis (3.6% of NAC) and Candida krusei (3% of NAC) were recovered unequally from the different departments. The total antifungal consumption correlated positively with the emergence of NAC. The use of azoles correlated positively with Candida glabrata, while amphotericin B formulations correlated negatively with it. None of these correlations reached statistical significance. CONCLUSION: Different Candida species were unequally distributed among different hospital departments, and this correlated with consumption of antifungals in respective departments, highlighting the need for antifungal stewardship.

Estudio clínico y micológico de otomicosis en diabéticos: una serie de 17 casos / Clinical and mycological study of otomycosis in diabetics: series of 17 cases

RESUMEN Introducción: La otomicosis en pacientes inmunosuprimidos esta caracterizada por ser bilateral y ser causada por candida. Pocos estudios comparan las características micológicas encontradas en la microscopía directa y el cultivo. Objetivo: Identificar las características clínicas y micológicas de la otomicosis en pacientes diabéticos. Material y método: Estudio transversal en centro hospitalario de segundo nivel. Criterios de inclusión: pacientes diabéticos con diagnóstico clínico de otomicosis. Intervención: la muestra se examinó directamente bajo el microscopio y se cultivó. Resultados: Se incluyeron 17 pacientes, 10 mujeres y 7 hombres con una edad media de 47,5 años. Los síntomas predominantes fueron hipoacusia en 91,4% (n =16), prurito en 82,4% (n =14), otorrea en 76,5% (n=13)y otalgia en 70,6% (n =12). Afección bilateral se encontró en 47,1% (n =8). Estudio directo al microscopio mostró levaduras en 94,1% (n =16) y 5,9% mostró aspergillus (n =1). Cándida fue el género más comúnmente encontrado en los cultivos y en el examen directo microscópico con 94,1% (n =16) y Candida albicans la especie más común con 88,2% (n =15). Conclusión: Candida albicans es el agente etiológico más común en pacientes diabéticos con otomicosis. Su presentación clínica más frecuente es hipoacusia, prurito y otorrea. El examen directo identificó adecuadamente a los géneros fúngicos.

ABSTRACT Introduction: Otomycosis in immunocompromised patients is characterize by its bilateral course and the predominant etiologic agent is Candida. Few studies compare the mycological features between microscopic direct exam and culture. Aim: To identify the clinical and mycological characteristics of otomycosis in diabetic patients. Material and method: Transversal study. Secondary care center. Inclusion criteria: diabetic patients with clinical diagnosis of otomycosis. Intervention: Direct examination under a microscope of the ear sample and culture. Results: We included 17 patients, 10 women, 7 men with a mean age of 47.5 years. Symptoms were hearing loss 94.1% (n = 16), pruritus 82.4% (n =14) otorrhoea 76.5% (n =13) and otalgia 70.6% (n =12). Bilateral involvement was found in 47.1% (n =8). Direct microscopic study found 94.1% of yeast (n =16) and 5.9% of Aspergillus (n =1). Candida was the most common fungal genus in culture and microscopic exam with 94.1% (n =16) of cases and Candida albicans was the most common species in 88.2% (n =15) cases. Conclusion: Candida albicans is the most common etiologic agent in diabetic patients with otomycosis. Main symptoms were hearing loss, itching and otorrhea. Direct exam correctly identified the fungal genus.

Boric Acid and Commercial Organoboron Products as Inhibitors of Drug-Resistant Candida albicans.

Clinical use of boric acid as a topical antifungal in women who have failed standard antifungal therapy with azole drugs has been used sporadically for decades. Our previous in vitro work showing inhibition of Candida albicans growth was conducted on clinical isolates without antifungal drug susceptibility profiling. Here, we report that boric acid restricts growth of drug-resistant Candida albicans and inhibits hyphal growth and diminishes cell volume. The availability of over-the-counter organoboron compounds intended for use as oral nutritional supplements led us to determine if these also were inhibitory toward resistant Candida and show here that they also possess antifungal activity. Candida glabrata was also found to be inhibited by boric acid and organoboron compounds. Further development of organoboron compounds as topical therapeutics is of potential value.

Risk factors and outcomes of candidemia caused by Candida parapsilosis complex in a medical center in northern Taiwan.

To investigate the risk factors and outcomes associated with Candida parapsilosis candidemia, a retrospective study was conducted at a tertiary medical center in northern Taiwan. Patients with C. parapsilosis candidemia and corresponding controls with C. albicans candidemia were chosen and their demographics, comorbidities, risk factors, and clinical outcomes were reviewed. Antifungal susceptibility tests were performed using the Sensititre YeastOne colorimetric system. Matrix-assisted laser desorption ionization-time of flight mass spectrometry was used to classify the genomic species. Of the 270 candidemias found in 253 patients, C. albicans was the most common Candida species isolated (43.0%), followed by C. parapsilosis (22.6%), C. tropicalis (17.4%), and C. glabrata (10.0%). The 30-day mortality of C. parapsilosis candidemia was significantly lower than that of C. albicans candidemia (21.7% vs. 53.9%, P<0.001). C. parapsilosis was positively associated with antifungal agent exposure [OR 7.261 (95% CI, 1.603-32.879), P=0.010], but negatively associated with Candida colonization [OR 0.303 (95% CI, 0.123-0.745), P=0.009], and immunosuppressant use [OR 0.264 (95% CI, 0.099-0.705), P=0.008]. In-hospital mortality was associated with the Sequential Organ Failure Assessment Score [OR 1.255 (95% CI, 1.002-1.573), P=0.048]. The clinical outcomes did not differ across genomic species and in the minimum inhibitory concentrations of fluconazole.

Impact of inappropriate antifungal therapy according to current susceptibility breakpoints on Candida bloodstream infection mortality, a retrospective analysis.

BACKGROUND: The mortality of Candida Bloodstream Infection (CBSI) remains high. Antifungal susceptibility breakpoints were recently updated for Candida species, the impact remains unknown. In this study we evaluated the impact of inappropriate antifungal treatment according to recent breakpoints on 30-day mortality of CBSI. METHODS: From June 2008 to July 2014, data on CBSI episodes from two tertiary-care centers, treated > 72 h were analyzed. Antifungal therapy and 30-day mortality were registered. Inappropriate antifungal treatment according to current Clinical & Laboratory Standards Institute (CLSI) breakpoints was adjusted with 30-day mortality-related co-variates. RESULTS: One hundred forty-nine episodes of CBSI were analyzed. The most frequent species were: C. albicans (40%), C. tropicalis (23%) and C. glabrata complex (20%). According to the 2012 CLSI, 10.7% received inappropriate treatment. The 30-day mortality was 38%; severe sepsis [Odds ratio (OR) 3.4; 95% CI 1.3-8.4], cirrhosis (OR 36; 95% CI 12.2-605), early central venous catheter removal (OR 0.23; 95% CI 0.08-0.66) and previous antifungal therapy (OR 0.15; 95%CI 0.03-0.62), were associated with 30-day mortality by multivariate analysis. Inappropriate antifungal treatment was not (OR 0.19; 95% CI 0.03-1.2). CONCLUSIONS: Appropriate antifungal therapy according to CLSI 2012 did not have an impact on mortality. Mortality of CBSI remains high due to disease severity and comorbidities; early antifungal therapy and catheter removal may reduce it.

The essential oil of Allium sativum as an alternative agent against Candida isolated from dental prostheses / Aceite esencial de Allium sativum como tratamiento alternativo contra aislamientos de Candida procedentes de prótesis dentales

Background. The colonization of the surfaces of dental prostheses by Candida albicans is associated with the development of denture stomatitis. In this context, the use of fluconazole has been proposed, but its disadvantage is microbial resistance. Meanwhile, the oil of Allium sativum has shown an effect in controlling biofilm formation by C. albicans. Aims. The objective of this study was to determine the antifungal activities of the essential oil of A. sativum and fluconazole against clinical isolates of Candida species obtained from rigid, acrylic-based partial or total dentures and to compare these agents’ effects on both biofilm and planktonic cells. Methods. A total of 48 clinical isolates obtained from the acrylic surface of partial or complete dentures were examined, and the following species were identified: C. albicans, Candida glabrata, Candida tropicalis, and Candida krusei. For each isolate, the antifungal activities of the essential oil of A. sativum and fluconazole against both biofilm and planktonic cells were evaluated using the Clinical & Laboratory Standards Institute (CLSI) M27-A3 method. The isolates were also evaluated by semiquantitative XTT reduction. Results. All planktonic Candida isolates were susceptible to the essential oil of A. sativum, whereas 4.2% were resistant to fluconazole. Regarding susceptibilities in biofilms, 43.8% of biofilms were resistant to A. sativum oil, and 91.7% were resistant to fluconazole. Conclusions. All planktonic cells of the different Candida species tested are susceptible to <1mg/ml A. sativum oil, and the majority are susceptible to fluconazole. Susceptibility decreases in biofilm cells, with increased resistance to fluconazole compared with A. sativum oil. The essential oil of A. sativum is thus active against clinical isolates of Candida species obtained from dentures, with effects on both biofilm and planktonic cells in vitro (AU)

Antecedentes. La colonización por parte de Candida albicans de las superficies de las prótesis dentales se asocia con el desarrollo de estomatitis. Se ha propuesto el uso de fluconazol, pero su desventaja es la resistencia microbiana. El aceite de Allium sativum ha mostrado su efectividad al controlar la formación de biopelícula de objetivos. Objetivos. Determinar la sensibilidad de cepas clínicas de especies de Candida, obtenidas de prótesis dentales parciales o totales rígidas de base acrílica, al aceite esencial de A. sativum y comparar su efecto en células planctónicas y en biopelícula. Métodos. Se incluyeron 48 cepas clínicas de la superficie acrílica de prótesis dentales totales o parciales, identificadas entre las siguientes especies: C. albicans, Candida glabrata, Candida tropicalis y Candida krusei. Se evaluó la sensibilidad de cada una al aceite esencial de A. sativum y al fluconazol mediante la metodología M27-A3 del CLSI, tanto sobre células planctónicas como en biopelícula, y mediante el método semicuantitativo de la reducción de XTT en el último caso. Resultados. Todas las cepas planctónicas de Candida fueron sensibles al aceite esencial de A.sativum, mientras que el 4,2% fue resistente al fluconazol. En cuanto a su sensibilidad en biopelícula, el 43,8% fue resistente a A. sativum y el 91,7% lo fue al fluconazol. Conclusiones. Todas las cepas en forma planctónica de las diferentes especies de Candida fueron sensibles a concentraciones inferiores a 1mg/ml del aceite esencial de A. sativum y en menor proporción a fluconazol. La sensibilidad disminuyó en las células en biopelícula, con mayor resistencia al fluconazol en comparación con el aceite esencial de A. sativum. Por tanto, el aceite esencial de A. sativum es activo frente a cepas clínicas de diferentes especies de Candida, obtenidas de dentaduras, con efectos en biopelícula y células planctónicas in vitro (AU)

Biofilms Formed by Isolates from Recurrent Vulvovaginal Candidiasis Patients Are Heterogeneous and Insensitive to Fluconazole.

Vulvovaginal candidiasis (VVC) is a global health problem affecting ∼75% of women at least once in their lifetime. Here we examined the epidemiology of VVC in a patient cohort to identify the causative organisms associated with VVC. Biofilm-forming capacity and antifungal sensitivity profiles were also assessed. We report a shifting prevalence of Candida species with heterogeneous biofilm-forming capacity, which is associated with altered antifungal drug sensitivity.

Echinocandins Compared to Fluconazole for Candidemia of a Urinary Tract Source: A Propensity Score Analysis.

BACKGROUND: Whether echinocandins could be used to treat candidemia of a urinary tract source (CUTS) is unknown. We aimed to provide current epidemiological information of CUTS and to compare echinocandin to fluconazole treatment on CUTS outcomes. METHODS: A multicenter study of adult patients with candidemia was conducted in 9 hospitals. CUTS was defined as a candidemia with concomitant candiduria by the same organism associated with significant urological comorbidity. The primary outcome assessed was clinical failure (defined by 7-day mortality or persistent candidemia) in patients treated with either an echinocandin or fluconazole. A propensity score was calculated and then entered into a regression model. RESULTS: Of 2176 episodes of candidemia, 128 were CUTS (5.88%). Most CUTS cases were caused by Candida albicans (52.7%), followed by Candida glabrata (25.6%) and Candida tropicalis (16.3%). Clinical failure occurred in 7 patients (20%) treated with an echinocandin and in 15 (17.1%) treated with fluconazole (P = .730). Acute renal failure (adjusted odds ratio [AOR], 3.01; 95% confidence interval [CI], 1.01-8.91; P = .047) was the only independent factor associated with clinical failure, whereas early urinary tract drainage procedures (surgical, percutaneous, or endoscopic) were identified as protective (AOR, 0.08; 95% CI, .02-.31; P < .001). Neither univariate nor multivariate analysis showed that echinocandin therapy altered the risk of clinical failure. CONCLUSIONS: Initial echinocandin therapy was not associated with clinical failure in patients with CUTS. Notably, acute renal failure predicted worse outcomes and performing an early urologic procedure was a protective measure.

The current treatment landscape: candidiasis.

The epidemiology of Candida species infection has changed over recent decades, influenced by local hospital-related factors, patient predisposing conditions and type of antifungal agents administered. A shift from Candida albicans as the predominant pathogen towards an increasing prevalence of the species Candida glabrata and Candida parapsilosis amongst critically ill patients has been documented. Changes in Candida species distribution may impact treatment recommendations due to differences in susceptibility to antifungal agents among species. Previous exposure to antifungal agents has likely contributed to this shift in species distribution. Another evolving epidemiological factor to consider is the global increase in antifungal resistance to certain antifungal drug types, which has been contributed to by the inappropriate use of these agents. Proposed management strategies to optimize treatment of patients with Candida infection include starting prompt 'early' antifungal therapy, early cessation of inappropriate therapy, using an adequate dose and duration of therapy and de-escalating treatment whenever possible. The implementation of institutional antifungal stewardship programmes has the potential to promote appropriate utilization of antifungal agents and to significantly improve the care of patients with Candida infection. However, a cultural change among healthcare providers and authorities is currently needed to improve antifungal use worldwide.

Epidemiology of candidemia and antifungal susceptibility in invasive Candida species in the Asia-Pacific region.

In the Asia-Pacific region, Candida albicans is the predominant Candida species causing invasive candidiasis/candidemia in Australia, Japan, Korea, Hong Kong, Malaysia, Singapore and Thailand whereas C. tropicalis is the most frequently encountered Candida species in Pakistan and India. Invasive isolates of C. albicans, C. parapsilosis complex and C. tropicalis remain highly susceptible to fluconazole (>90% susceptible). Fluconazole resistance (6.8-15%), isolates with the non-wild-type phenotype for itraconazole susceptibility (3.9-10%) and voriconazole (5-17.8%), and echinocandin resistance (2.1-2.2% in anidulafungin and 2.2% in micafungin) among invasive C. glabrata complex isolates are increasing in prevalence. Moreover, not all isolates of C. tropicalis have been shown to be susceptible to fluconazole (nonsusceptible rate, 5.7-11.6% in China) or voriconazole (nonsusceptible rate, 5.7-9.6% in China).

Initial antifungal strategy does not correlate with mortality in patients with candidemia.

The incidence of Candida bloodstream infections (BSIs) has increased over time, especially in medical wards. The objective of this study was to evaluate the impact of different antifungal treatment strategies on 30-day mortality in patients with Candida BSI not admitted to intensive care units (ICUs) at disease onset. This prospective, monocentric, cohort study was conducted at an 1100-bed university hospital in Rome, Italy, where an infectious disease consultation team was implemented. All cases of Candida BSIs observed in adult patients from November 2012 to April 2014 were included. Patients were grouped according to the initial antifungal strategy: fluconazole, echinocandin, or liposomal amphotericin B. Cox regression analysis was used to identify risk factors significantly associated with 15-day and 30-day mortality. During the study period, 130 patients with candidemia were observed (58 % with C. albicans, 7 % with C. glabrata, and 23 % with C. parapsilosis). The first antifungal drug was fluconazole for 40 % of patients, echinocandin for 57.0 %, and liposomal amphotericin B for 4 %. During follow-up, 33 % of patients died. The cumulative mortality 30 days after the candidemia episode was 30.8 % and was similar among groups. In the Cox regression analysis, clinical presentation was the only independent factor associated with 15-day mortality, and Acute Physiology and Chronic Health Evaluation (APACHE) II score and clinical presentation were the independent factors associated with 30-day mortality. No differences in 15-day and 30-day mortality were observed between patients with and without C. albicans candidemia. In patients with candidemia admitted to medical or surgical wards, clinical severity but not the initial antifungal strategy were significantly correlated with mortality.

Acquired Flucytosine Resistance during Combination Therapy with Caspofungin and Flucytosine for Candida glabrata Cystitis.

Treatment of Candida glabrata cystitis remains a therapeutic challenge, and an antifungal combination using flucytosine is one option. We describe two patients with refractory C. glabrata cystitis who failed flucytosine combined with caspofungin with early-acquired high-level resistance to flucytosine due to nonsense mutations in the FUR1 gene. Rapidly acquired flucytosine resistance with microbiological failure should discourage combination of caspofungin and flucytosine during urinary candidiasis.

[Yeast species in vulvovaginitis candidosa]. / Vulvovaginitis candidosában eloforduló sarjadzógomba-speciesek.

INTRODUCTION: Vulvovaginal candidiasis is the most common mycosis, however, the available information about antifungal susceptibilities of these yeasts is limited. AIM: To compare the gold standard fungal culture with a new molecular identification method and report the incidence of yeast species in vulvovaginitis candidosa. METHOD: The authors studied 370 yeasts isolated from vulvovaginal candidiasis and identified them by phenotypic and molecular methods. RESULTS: The most common species was Candida albicans (85%), followed by Candida glabrata, and other Candida species. CONCLUSION: At present there are no recommendations for the evaluation of antifungal susceptibility of pathogenic fungal species occurring in vulvovaginal candidiasis and the natural antifungal resistance of the different species is known only. Matrix Assisted Laser Desorption Ionization Time of Flight identification can be used to differentiate the fluconazole resistant Candida dubliniensis and the sensitive Candida albicans strains.

Changes in genotype and fluconazole susceptibility of isolates from patients with Candida glabrata in Tunisia.

UNLABELLED: Candida glabrata has emerged as an opportunistic pathogen of considerable importance in invasive and superficial infections. AIMS: To analyze the development of fluconazole resistance in patients under treatment through epidemiological survey in our hospital. PATIENTS AND METHODS: Twenty two patients (89 clinical strains) were collected. Molecular typing of isolates was performed by polymorphic markers. Analysis of gene expression was realized by reverse transcriptase-real time polymerase chain reactions (RT-qPCR). RESULTS: Genetic analysis showed that 63% persists with apparently unchanged strains (n=14). Among them, four showed fluconazole resistance development. A strain replacement was observed in 6 patients and two patients selected more resistant isolates during the course of treatment. An analysis of Candida glabrata cerebellar degeneration-related protein 1 (CgCDR1), Candida glabrata cerebellar degeneration-related protein 2 (CgCDR2) and Candida glabrata sterol 14 alpha-demetylase Erg 11 (CgERG11) expression revealed an over-expression in 10 resistant isolates. CONCLUSION: This study demonstrated that C. glabrata strain undergo frequent changes in vivo. The increase in CgCDR1 and CgCDR2 expression was the most mechanism associated with fluconazole resistance.

Breakthrough invasive Candida glabrata in patients on micafungin: a novel FKS gene conversion correlated with sequential elevation of MIC.

Candida glabrata strains sequentially isolated from blood developed resistance to micafungin (MICs from <0.015 to 4 µg/ml). A novel mutation identified in micafungin-resistant strains at bp 262 of FKS2 (containing a deletion of F659 [F659del]) was inserted into the homologous region in FKS1.

Recurrent arthritis by Candida glabrata, a diagnostic and therapeutic challenge.

Infectious arthritis due to Candida glabrata is very rare. A 40-year-old Iranian man had developed a painful swelling on the left knee since a year ago. A surgery (meniscectomy) was performed on his knee. However, in follow-up visit after 2 months, the patient's condition was deteriorated. Direct examination of synovial fluid with Gram and hematoxylin-eosin stains were negative for any bacterial or fungal infection or crystal elements; however, inoculation into BACTEC™ Mycosis IC/F and Plus Aerobic/F culture bottles led to the isolation of a yeast strain. The macroscopic examination on CHROMagar™ Candida medium combined with microscopical examination on CMT80 agar made a presumptive identification of the isolate to be considered as C. glabrata, and it was later on confirmed by ITS sequencing. Initial empirical treatment was started with intravenous amphotericin B for 4 weeks followed by oral itraconazole which was unsuccessful. Prescription of an oral 150-mg tablet of fluconazole was considered for a 2-month course. All symptoms completely declined, and no recurrence of infection was detected. Antifungal susceptibility testing (AFST) was performed for this isolate, and the result showed sensitivity to both amphotericin B and itraconazole and less susceptibility to fluconazole while clinical recovery was achieved by fluconazole. In any suspected clinical case caused by infectious agents, application of an effective fungal diagnostic test should be considered to avoid complications due to misdiagnosis. The correlation of AFST result with real in vivo therapeutic responses can be strain or patient dependent, and this should be considered for a successive treatment.

Frequency of clinically isolated strains of oral Candida species at Kagoshima University Hospital, Japan, and their susceptibility to antifungal drugs in 2006-2007 and 2012-2013.

BACKGROUND: The isolation frequency and susceptibility to antifungal agents of oral Candida isolates from patients with oral candidiasis (OC) were compared between studies conducted in 2006-2007 and 2012-2013. METHODS: A total158 strains was isolated from 112 patients who visited Kagoshima University Hospital for the treatment of OC during the 14-month period from February 2012 and March 2013, and evaluated on the isolation frequency of each Candida strain and the susceptibility against antifungal drugs as compared to those evaluated in 2006-2007. RESULTS: There was a higher frequency of xerostomia as a chief complaint and of autoimmune disease in the 2012-2013 study than in the 2006-2007 study. More than 95% of Candida isolates were C. albicans and C. glabrata. In addition, the proportion of the latter increased from 12.3% in the 2006-2007 study to 23.4% in the 2012-2013 study, while the proportion of the former decreased from 86.2% to 72.8%, respectively. C. albicans was isolated in almost all patients, while C. glabrata was only isolated concomitantly with C. albicans. Minimal inhibitory concentrations (MICs) were not significantly different between groups with a few exceptions. Candida isolates, of which MICs surpassed break points, apparently increased for miconazole and itraconazole against C. glabrata in the 2012-2013 study, but this was not statistically significant. As a result, more cases of autoimmune disease, a greater number of C. glabrata isolates, and higher resistance to azoles were seen in the 2012-2013 study than in the 2006-2007 study. CONCLUSION: These data indicate that with recent increases in C. glabrata infection, a causative fungus of OC, and in C. glabrata resistance to azoles, caution is needed in the selection of antifungal drugs for the treatment of OC.