Oral candidiasis in liver transplant patients: species identification and antifungal susceptibility profile.

OBJECTIVE: This study aimed to verify oral candidiasis, identify the causative species, and investigate the antifungal susceptibility of yeasts isolated from liver transplant patients. METHODS: A descriptive analysis of 97 patients who underwent liver transplantation was conducted at a hospital. Two clinical examinations (Collections A and B) of the oral cavity were performed. Oral material was collected from all patients, inoculated in Sabouraud Dextrose Agar, and incubated at 35℃ for 48 hours. Samples were identified by molecular sequencing of the internal trascribed space region of rDNA. RESULTS: An antifungal susceptibility test with fluconazole, amphotericin B, and micafungin was performed using the Clinical and Laboratory Standards Institute yeast broth microdilution method. Among the patients, 15 presented with oral candidiasis: eight in Collection A and seven in Collection B. The primary type of candidiasis was atrophic, followed by pseudomembranous candidiasis. The most prevalent species was Candida albicans (nine), followed by Candida glabrata (three), Candida tropicalis (two), and Candida dubliniensis (one). Regarding susceptibility to fluconazole, of the 15 samples, 11 were susceptible, three were susceptible in a dose-dependent manner, and one was resistant. CONCLUSION: The most commonly identified type of candidiasis was atrophic, with C. albicans and C. glabrata being the most prevalent causative species. One fluconazole-resistant isolate each of C. tropicalis and C. albicans were identified.

Oral candidiasis in liver transplant patients: species identification and antifungal susceptibility profile

ABSTRACT Objective This study aimed to verify oral candidiasis, identify the causative species, and investigate the antifungal susceptibility of yeasts isolated from liver transplant patients. Methods A descriptive analysis of 97 patients who underwent liver transplantation was conducted at a hospital. Two clinical examinations (Collections A and B) of the oral cavity were performed. Oral material was collected from all patients, inoculated in Sabouraud Dextrose Agar, and incubated at 35℃ for 48 hours. Samples were identified by molecular sequencing of the internal trascribed space region of rDNA. Results An antifungal susceptibility test with fluconazole, amphotericin B, and micafungin was performed using the Clinical and Laboratory Standards Institute yeast broth microdilution method. Among the patients, 15 presented with oral candidiasis: eight in Collection A and seven in Collection B. The primary type of candidiasis was atrophic, followed by pseudomembranous candidiasis. The most prevalent species was Candida albicans (nine), followed by Candida glabrata (three), Candida tropicalis (two), and Candida dubliniensis (one). Regarding susceptibility to fluconazole, of the 15 samples, 11 were susceptible, three were susceptible in a dose-dependent manner, and one was resistant. Conclusion The most commonly identified type of candidiasis was atrophic, with C. albicans and C. glabrata being the most prevalent causative species. One fluconazole-resistant isolate each of C. tropicalis and C. albicans were identified.

Neonatal fungemia caused by Lodderomyces elongisporus: first case report in Latin America.

Premature hospitalized neonates have a greater risk for candidemia, however, fungemia due to rare opportunistic yeasts have been recently reported and is associated with high mortality rates. We herein report the first case in Latin America of Lodderomyces elongisporus fungemia in a premature neonate with a fatal outcome.

Emergence of cryptic species and clades of Meyerozyma guilliermondii species complex exhibiting limited in vitro susceptibility to antifungals in patients with candidemia.

Members of the Meyerozyma guilliermondii species complex are able to cause superficial and life-threatening systemic infections with low susceptibility to azoles and echinocandins. We tested 130 bloodstream M. guilliermondii complex isolates collected from eight Latin American medical centers over 18 years (period 1 = 2000-2008 and period 2 = 2009-2018) to investigate trends in species distribution and antifungal resistance. The isolates were identified by rDNA ITS region sequencing, and antifungal susceptibility tests were performed against fluconazole, voriconazole, anidulafungin, and amphotericin B using the CLSI microbroth method. M. guilliermondii sensu stricto (s.s.; n = 116) was the most prevalent species, followed by Meyerozyma caribbica (n = 12) and Meyerozyma carpophila (n = 2). Based on rDNA ITS identification, three clades within M. guilliermondii sensu stricto were characterized (clade 1 n = 94; clade 2 n = 19; and clade 3 n = 3). In the second period of study, we found a substantial increment in the isolation of M. caribbica (3.4% versus 13.8%; P = 0.06) and clade 2 M. guilliermondii s.s. exhibiting lower susceptibility to one or more triazoles. IMPORTANCE Yeast-invasive infections play a relevant role in human health, and there is a concern with the emergence of non-Candida pathogens causing disease worldwide. There is a lack of studies addressing the prevalence and antifungal susceptibility of different species within the M. guilliermondii complex that cause invasive infections. We evaluated 130 episodes of M. guilliermondii species complex candidemia documented in eight medical centers over 18 years. We detected the emergence of less common species within the Meyerozyma complex causing candidemia and described a new clade of M. guilliermondii with limited susceptibility to triazoles. These results support the relevance of continued global surveillance efforts to early detect, characterize, and report emergent fungal pathogens exhibiting limited susceptibility to antifungals.

Increasing Prevalence of Multidrug-Resistant Candida haemulonii Species Complex among All Yeast Cultures Collected by a Reference Laboratory over the Past 11 Years.

There is worldwide concern with the increasing rates of infections due to multiresistant Candida isolates reported in tertiary medical centers. We checked for historical trends in terms of prevalence rates and antifungal susceptibility of the Candida haemulonii species complex in our yeast stock culture collected during the last 11 years. The isolates were identified by sequencing the rDNA internal transcribed spacer (ITS) region, and antifungal susceptibility tests for amphotericin B, voriconazole, fluconazole, anidulafungin, and 5-fluorocytosine were performed by the Clinical and Laboratory Standards Institute (CLSI) microbroth method. A total of 49 isolates were identified as Candida haemulonii sensu stricto (n = 21), followed by C. haemulonii var. vulnera (n = 15) and C. duobushaemulonii (n = 13), including 38 isolates cultured from patients with deep-seated Candida infections. The prevalence of the C. haemulonii species complex increased from 0.9% (18 isolates among 1931) in the first period (December 2008 to June 2013) to 1.7% (31 isolates among 1868) in the second period (July 2014 to December 2019) of analysis (p = 0.047). All isolates tested exhibited high minimum inhibition concentrations for amphotericin B and fluconazole, but they remained susceptible to 5-fluorocytosine and anidulafungin. We were able to demonstrate the increased isolation of the multiresistant Candida haemulonii species complex in our culture collection, where most isolates were cultured from patients with deep-seated infections.

Evaluation of (1 → 3)-ß-D-glucan assay for diagnosing paracoccidioidomycosis.

BACKGROUND: Paracoccidioidomycosis (PCM) is highly prevalent in Latin America, but no commercial system is available for diagnosing this endemic mycosis. OBJECTIVES: To check the performance of (1 â†’ 3)-ß-D-glucan assay (BDG) for diagnosing  PCM in 29 patients with proven fungal disease and compared with double immunodiffusion assay for detecting anti-Paracoccidioides antibodies. PATIENTS AND METHODS: We selected 52 serum samples sequentially obtained from 29 patients with active PCM (12 chronic and 17 acute form). Samples were collected at baseline, and for 16 patients, additional serum levels were obtained after 3 and 6 months of antifungal treatment. Detection of BDG in serum was performed by using the Fungitell® assay. For the double immunodiffusion assay, Paracoccidioides exoantigen was used in latex agglutination tests to detect serum anti-Paracoccidioides antibodies. RESULTS: Despite exhibiting good sensitivity in the diagnosis of patients with PCM, we failed to demonstrate any correlation between the postdiagnosis kinetic profile of BDG serum levels and clinical response to antifungal therapy. This finding may be related to the maintenance of quiescent foci of fungal infection in several organs and tissues, a phenomenon that has been previously reported by other authors and helps to understand why so many relapses are documented in patients treated for short periods of time. Finally, we did not find any correlation between BDG quantification and specific anti-P brasiliensis antibodies serum titres in patients with PCM. CONCLUSIONS: In conclusion, BDG is detected in serum samples of most patients with PCM but is probably not useful for predicting clinical response to antifungal therapy.

A consensus document for the clinical management of invasive fungal diseases in pediatric patients with hematologic cancer and/or undergoing hematopoietic stem cell transplantation in Brazilian medical centers

ABSTRACT In the present paper we summarize the suggestions of a multidisciplinary group including experts in pediatric oncology and infectious diseases who reviewed the medical literature to elaborate a consensus document (CD) for the diagnosis and clinical management of invasive fungal diseases (IFDs) in children with hematologic cancer and those who underwent hematopoietic stem-cell transplantation. All major multicenter studies designed to characterize the epidemiology of IFDs in children with cancer, as well as all randomized clinical trials addressing empirical and targeted antifungal therapy were reviewed. In the absence of randomized clinical trials, the best evidence available to support the recommendations were selected. Algorithms for early diagnosis and best clinical management of IFDs are also presented. This document summarizes practical recommendations that will certainly help pediatricians to best treat their patients suffering of invasive fungal diseases.

A consensus document for the clinical management of invasive fungal diseases in pediatric patients with hematologic cancer and/or undergoing hematopoietic stem cell transplantation in Brazilian medical centers.

In the present paper we summarize the suggestions of a multidisciplinary group including experts in pediatric oncology and infectious diseases who reviewed the medical literature to elaborate a consensus document (CD) for the diagnosis and clinical management of invasive fungal diseases (IFDs) in children with hematologic cancer and those who underwent hematopoietic stem-cell transplantation. All major multicenter studies designed to characterize the epidemiology of IFDs in children with cancer, as well as all randomized clinical trials addressing empirical and targeted antifungal therapy were reviewed. In the absence of randomized clinical trials, the best evidence available to support the recommendations were selected. Algorithms for early diagnosis and best clinical management of IFDs are also presented. This document summarizes practical recommendations that will certainly help pediatricians to best treat their patients suffering of invasive fungal diseases.

Epidemiology and prognostic factors of nosocomial candidemia in Northeast Brazil: A six-year retrospective study.

Candidemia has been considered a persistent public health problem with great impact on hospital costs and high mortality. We aimed to evaluate the epidemiology and prognostic factors of candidemia in a tertiary hospital in Northeast Brazil from January 2011 to December 2016. Demographic and clinical data of patients were retrospectively obtained from medical records and antifungal susceptibility profiling was performed using the broth microdilution method. A total of 68 episodes of candidemia were evaluated. We found an average incidence of 2.23 episodes /1000 admissions and a 30-day mortality rate of 55.9%. The most prevalent species were Candida albicans (35.3%), Candida tropicalis (27.4%), Candida parapsilosis (21.6%) and Candida glabrata (11.8%). Higher mortality rates were observed in cases of candidemia due to C. albicans (61.1%) and C. glabrata (100%), especially when compared to C. parapsilosis (27.3%). Univariate analysis revealed some variables which significantly increased the probability of death: older age (P = 0.022; odds ratio [OR] = 1.041), severe sepsis (P < 0.001; OR = 8.571), septic shock (P = 0.035; OR = 3.792), hypotension (P = 0.003; OR = 9.120), neutrophilia (P = 0.046; OR = 3.080), thrombocytopenia (P = 0.002; OR = 6.800), mechanical ventilation (P = 0.009; OR = 8.167) and greater number of surgeries (P = 0.037; OR = 1.920). Multivariate analysis showed that older age (P = 0.040; OR = 1.055), severe sepsis (P = 0.009; OR = 9.872) and hypotension (P = 0.031; OR = 21.042) were independently associated with worse prognosis. There was no resistance to amphotericin B, micafungin or itraconazole and a low rate of resistance to fluconazole (5.1%). However, 20.5% of the Candida isolates were susceptible dose-dependent (SDD) to fluconazole and 7.7% to itraconazole. In conclusion, our results could assist in the adoption of strategies to stratify patients at higher risk for developing candidemia and worse prognosis, in addition to improve antifungal management.

Fungal Peritonitis Due to Fusarium solani Species Complex Sequential Isolates Identified with DNA Sequencing in a Kidney Transplant Recipient in Brazil.

Fungal peritonitis is a rare serious complication most commonly observed in immunocompromised patients under peritoneal dialysis. Nevertheless, this clinical condition is more difficult to treat than bacterial peritonitis. Bacterial peritonitis followed by the use of antibiotics is the main risk factor for developing fungal peritonitis. Candida spp. are more frequently isolated, and the isolation of filamentous fungi is only occasional. Here we describe a case of Fusarium solani species complex peritonitis associated with bacterial peritonitis in a female kidney transplant recipient with previous history of nephrotic syndrome. The patient has had Enterobacter sp. endocarditis and was hypertensive and diabetic. Two sequential isolates of F. solani were recovered from cultures and identified with different molecular techniques. She was successfully treated with 50 mg daily amphotericin B for 4 weeks.

Fungemia caused by Candida species in a children's public hospital in the city of São Paulo, Brazil: study in the period 2007-2010.

Candidemia remains a major cause of morbidity and mortality in the health care environment. The epidemiology of Candida infection is changing, mainly in relation to the number of episodes caused by species C. non-albicans. The overall objective of this study was to evaluate the frequency of yeasts of the genus Candida, in a four-year period, isolated from blood of pediatric patients hospitalized in a public hospital of the city of São Paulo, Brazil. In this period, yeasts from blood of 104 patients were isolated and, the identified species of Candida by phenotypic and genotypic methods were: C. albicans (39/104), C. tropicalis (25/104), C. parapsilosis (23/104), Pichia anomala (6/104), C. guilliermondii (5/104), C. krusei (3/104), C. glabrata (2/104) and C. pararugosa (1/104). During the period of the study, a higher frequency of isolates of C. non-albicans (63.55%) (p = 0.0286) was verified. In this study we verified the increase of the non-albicans species throughout the years (mainly in 2009 and 2010). Thus, considering the peculiarities presented by Candida species, a correct identification of species is recommended to lead to a faster diagnosis and an efficient treatment.

FUNGEMIA CAUSED BY Candida SPECIES IN A CHILDREN'S PUBLIC HOSPITAL IN THE CITY OF SÃO PAULO, BRAZIL: STUDY IN THE PERIOD 2007-2010 / Fungemia por espécies de Candida em Hospital Pediátrico da cidade de São Paulo, Brasil: estudo no período de 2007 a 2010

Candidemia remains a major cause of morbidity and mortality in the health care environment. The epidemiology of Candida infection is changing, mainly in relation to the number of episodes caused by species C. non-albicans. The overall objective of this study was to evaluate the frequency of yeasts of the genus Candida, in a four-year period, isolated from blood of pediatric patients hospitalized in a public hospital of the city of São Paulo, Brazil. In this period, yeasts from blood of 104 patients were isolated and, the identified species of Candida by phenotypic and genotypic methods were: C. albicans (39/104), C. tropicalis (25/104), C. parapsilosis (23/104), Pichia anomala (6/104), C. guilliermondii (5/104), C. krusei (3/104), C. glabrata (2/104) and C. pararugosa (1/104). During the period of the study, a higher frequency of isolates of C. non-albicans (63.55%) (p = 0.0286) was verified. In this study we verified the increase of the non-albicans species throughout the years (mainly in 2009 and 2010). Thus, considering the peculiarities presented by Candida species, a correct identification of species is recommended to lead to a faster diagnosis and an efficient treatment.

Candidemia permance como a maior causa de morbidade e mortalidade em ambiente hospitalar. A epidemiologia de infecções por Candida vem se alterando, principalmente em relação ao número de episódios causados por espécies não-albicans. Este estudo teve como objetivo avaliar a frequência, em um período de quatro anos, de leveduras do gênero Candida isoladas de sangue de pacientes pediátricos internados em hospital público da cidade de São Paulo, Brasil. Neste período foram isoladas leveduras de sangue de 104 pacientes, e as espécies de Candida identificadas, por métodos fenotípicos e genotípicos, foram: C. albicans (39/104), C. tropicalis (25/104), C. parapsilosis (23/104), Pichia anomala (6/104), C. guilliermondii (5/104), C. krusei (3/104), C. glabrata (2/104) e C. pararugosa (1/104). Em todo período do estudo foi observada maior frequência de isolamento de C. não-albicans (63,55%) (p = 0,0286). Neste estudo verificou-se aumento das espécies não-albicans ao longo dos anos (principalmente em 2009 e 2010), assim, ressalta-se que correta identificação em nível de espécie é recomendável, para que isso acarrete diagnóstico rápido e tratamento eficaz.

Systematic review and new insights into the molecular characterization of the Candida rugosa species complex.

Recently, Candida rugosa was characterized as a species complex comprising four taxa: C. rugosa sensu stricto, Candida pseudorugosa, Candida neorugosa and Candida mesorugosa. Although considered relatively rare, several clusters of candidemia due to C. rugosa complex had been reported presenting mortality rates close to 70%. In this work we discuss the systematization, phenotyping and molecular methods based on internal transcribed spacer region (ITS) sequencing and proteomic analyses for species identification, as well as clinical aspects of the C. rugosa complex. We performed a Bayesian phylogenetic analysis using 72 ITS sequences representative of C. rugosa complex isolates and related species within the genus. Biochemical, morphological and MALDI-TOF MS analyses were processed with C. rugosa complex type strains and related species isolates. We described that the phylogeny showed four distinct clades inferred with high posterior probabilities, corresponding to the four species within the C. rugosa complex, excluding C. pararugosa. Biochemical and morphological aspects distinguished only C. rugosa sensu stricto but were not sufficient to accurately identify species within the rest of the complex. Protein spectrum profiles differentiated all reference strains from different species analyzed. To our knowledge, we presented the first phylogenetic analysis using a large collection of ITS sequences as well as proteomic profiles generated from isolates of the C. rugosa complex and related species that can enlighten systematics, diagnostics and clinical research fields.

Echinocandin resistance in two Candida haemulonii isolates from pediatric patients.

We report 3 cases of patients with Candida haemulonii isolates that were obtained from hemocultures. In 2 of the 3 cases, isolates exhibited resistance to echinocandins and fluconazole. This is the first report of an echinocandin-resistant species of this fungus in pediatric patients.

Identificação e caracterização de genes diferencialmente expressos em hifas de Candida albicans / Identification and characterization of genes differentially expressed in hypha of Candida albicans

A transição morfológica de levedura para hifa é essencial para a virulência de Candida albicans. Esta transição envolve a expressão de genes hifa-específicos que estão sob o controle de fatores transcricionais. Para descobrir genes hifa-específicos utilizamos um método de triagem diferencial, onde clones de biblioteca de DNA genômico foram hibridizados com sondas de cDNA de levedura e hifa. Dois clones com aumento de expressão em hifa foram selecionados. O sequenciamento dos insertos destes clones permitiu a identificação de dois genes metabólicos importantes: CaHXT7 (high-affinity hexose transporter) e CaYLL34 (da família AAA ATPase). As regiões codificadoras completas destes genes foram caracterizadas e a análise das proteínas hipotéticas revelou que: (1) CaHxt7p tem um domínio de transportador de hexose e (2) CaYll34p tem dois domínios AAA ATPase, com possível papel na fusão de membranas e degradação de proteínas (por exemplo, a valosina humana). Este é o primeiro estudo que demonstra aumento de expressão de genes metabólicos em hifas de C. albicans. CaYLL34 foi inativado por mutagênese insercional, utilizando o cassete HisG-URA3HisG, gerando o mutante M61. Esta linhagem apresentou alterações morfológicas acentuadas como aumento de vacúolo, de tamanho celular e diminuição na taxa de indução de hifa em todas as condições analisadas. Estes resultados mostram que a diminuição parcial dos níveis de CaYll34p celular é suficiente para afetar a morfologia celular característica, porque somente um alelo foi inativado, enquanto o outro continua funcional. Ainda, a associação dos produtos de CaHXT7 e CaYLL34 com a formação de hifas torna estas proteínas potenciais alvos para desenvolvimento de novas drogas antifúngicas

Identification of genes differentially expressed in hyphae of Candida albicans

A transição morfológica de levedura para hifa é essencial para a virulência de Candida albicans. Esta transição envolve a expressão de genes hifa-específicos que estão sob o controle de fatores transcricionais. Para descobrir genes hifa-específicos utilizamos um método de triagem diferencial, onde clones de biblioteca de DNA genômico foram hibridizados com sondas de cDNA de levedura e hifa. Dois clones com aumento de expressão em hifa foram selecionados. O sequenciamento dos insertos destes clones permitiu a identificação de dois genes metabólicos importantes: CaHXT7 (high-affinity hexose transporter) e CaYLL34 (da família AAA ATPase). As ORFs completas destes genes foram caracterizadas e a análise das proteínas hipotéticas revelou que: (1) CaHxt7p tem um domínio de transportador de hexose e (2) CaYll34 tem dois domínios AAA ATPase. Este é o primeiro estudo que demonstra aumento de expressão de genes metabólicos em hifas de C. albicans. Ainda, a associação dos produtos de CaHXT7 e CaYLL34 com a formação de hifas torna estas proteínas potenciais novos alvos para drogas antifúngicas.

Identification of genes differentially expressed in hyphae of Candida albicans

The ability to switch from yeast to hyphal forms is essential for Candida albicans virulence. This morphological switch involves the expression of hyphal-specific genes under the control of transcriptional factors. To contribute to the discovery of hyphal-specific genes, we used a differential screening method where clones of a genomic DNA library were hybridized with yeast and hyphal cDNA probes. Two clones with increased expression in hyphae were selected for study. Sequencing these clones, we found that they encoded two important metabolic genes, CaHXT7 (high-affinity hexose transporter) and CaYLL34 (member of the AAA ATPase family). CaHXT7 and CaYLL34 ORFs were completely determined. Analyses of the putative proteins show that: (1) CaHxt7p has one hexose transporter domain and (2) CaYll34p has two AAA ATPase domains. These results show, for the first time, increased expression of metabolic genes in C. albicans hyphae. Also, because the proteins encoded by CaHXT7 and CaYLL34 may be necessary for the switching to hyphae, they could be new targets for antifungal drugs.

A transição morfológica de levedura para hifa é essencial para a virulência de Candida albicans. Esta transição envolve a expressão de genes hifa-específicos que estão sob o controle de fatores transcricionais. Para descobrir genes hifa-específicos utilizamos um método de triagem diferencial, onde clones de biblioteca de DNA genômico foram hibridizados com sondas de cDNA de levedura e hifa. Dois clones com aumento de expressão em hifa foram selecionados. O sequenciamento dos insertos destes clones permitiu a identificação de dois genes metabólicos importantes: CaHXT7 (high-affinity hexose transporter) e CaYLL34 (da família AAA ATPase). As ORFs completas destes genes foram caracterizadas e a análise das proteínas hipotéticas revelou que: (1) CaHxt7p tem um domínio de transportador de hexose e (2) CaYll34 tem dois domínios AAA ATPase. Este é o primeiro estudo que demonstra aumento de expressão de genes metabólicos em hifas de C. albicans. Ainda, a associação dos produtos de CaHXT7 e CaYLL34 com a formação de hifas torna estas proteínas potenciais novos alvos para drogas antifúngicas.