Antifungal Susceptibility Testing Of Candida Research Articles

Evaluation of the Vitek 2 system for antifungal susceptibility testing of Candida auris using a representative international panel of clinical isolates: overestimation of amphotericin B resistance and underestimation of fluconazole resistance.

Although the Vitek 2 system is broadly used for antifungal susceptibility testing of Candida spp., its performance against Candida auris has been assessed using limited number of isolates recovered from restricted geographic areas. We therefore compared Vitek 2 system with the reference Clinical and Laboratory Standards Institute (CLSI) broth microdilution method using an international collection of 100 C. auris isolates belonging to different clades. The agreement ±1 twofold dilution between the two methods and the categorical agreement (CA) based on the Centers for Disease Control and Prevention's (CDC's) tentative resistance breakpoints and Vitek 2-specific wild-type upper limit values (WT-ULVs) were determined. The CLSI-Vitek 2 agreement was poor for 5-flucytosine (0%), fluconazole (16%), and amphotericin B (29%), and moderate for voriconazole (61%), micafungin (67%), and caspofungin (81%). Significant interpretation errors were recorded using the CDC breakpoints for amphotericin B (31% CA, 69% major errors; MaEs) and fluconazole (69% CA, 31% very major errors; VmEs), but not for echinocandins (99% CA, 1% MaEs for both micafungin and caspofungin) for which the Vitek 2 allowed correct categorization of echinocandin-resistant FKS1 mutant isolates. Discrepancies were reduced when the Vitek 2 WT-ULV of 16 mg/L for amphotericin B (98% CA, 2% MaEs) and of 4 mg/L for fluconazole (96% CA, 1% MaEs, 3% VmEs) were used. In conclusion, the Vitek 2 system performed well for echinocandin susceptibility testing of C .auris. Resistance to fluconazole was underestimated whereas resistance to amphotericin B was overestimated using the CDC breakpoints of ≥32 and ≥2 mg/L, respectively. Vitek 2 minimun inhibitory concentrations (MICs) >4 mg/L indicated resistance to fluconazole and Vitek 2 MICs ≤16 mg/L indicated non-resistance to amphotericin B.

Speciation and Antifungal Susceptibility Testing of Candida isolated from Immunocompromised Patients of a Tertiary Care Centre in Gujarat, India

Candida species are one of the most common causes of opportunistic infections in immunocompromised patients. An upsurge in incidence of less common species of Candida have been documented since last few years as the major cause of candidemia all over the world and they are also less susceptible to azoles, particularly fluconazole, than C. albicans. The purpose of study was speciation and antifungal susceptibility testing of Candida isolates, obtained from immunocompromised patients. The study included 150 consecutive immunocompromised patients and was initiated after the ethical approval from Sumandeep Vidyapeeth Institutional Ethical Committee (SVIEC). Informed consent was obtained from all and a Detailed Questionnaire regarding the Patient’s history and clinical findings were noted. All the specimens were subjected to a battery of microbiological examination for isolation, identification, and antifungal susceptibility testing. In our study, the incidence of candidiasis in immunocompromised patients was43.1%.C.tropicalis(n=23,37.09%) was the most common species isolated followed by C. albicans (n=20, 32.25%), C. glabrata (n=15,24.19%) and C. parapsilosis (n=4, 6.45%). The isolates showed 100% sensitivity to Amphotericin B and Nystatin, whereas 37.09% sensitivity to Ketoconazole, 20.9% sensitivity to clotrimazole, 19.35% sensitivity to itraconazole and 14.5% sensitivity to Fluconazole. The study undoubtedly indicates a substantial move in the species from C. albicans to Non-albicans Candida and with added resistance to common antifungal drugs.

ACTIVITY OF TRIAZOLES AND ECHINOCANDINS AGAINST CANDIDA BLOODSTREAM ISOLATES AT PHRAMONGKUTKLAO HOSPITAL, THAILAND

Background: Candidemia is a major cause of morbidity and mortality which can be treated using antifungal agents, triazoles and echinocandins.
 Objectives: We aimed to determine Candida species and their sensitivities to triazoles (fluconazole, itraconazole, voriconazole, and posaconazole) and echinocandins (caspofungin, micafungin, and anidulafungin) among patients with candidiasis to guide future treatment of patients with candidemia or invasive candidiasis.
 Methods: All firstly isolated Candida spp. from patients admitted at Phramongkutklao Hospital, Bangkok, Thailand from January 2012 to December 2013 were included in this study. The antifungal susceptibility testing of Candida spp. isolates was assessed based on micro-dilution method.
 Results: During the 24-month study period, a total of 66 Candida isolates from 66 patients were identified. Of the 66 isolates, 35 (53%) were C. albicans, 18 (27.3%) were C. tropicalis, 10 (15.2%) were C. glabrata and 3 (4.5%) were C. parapsilosis. Fluconazole resistant Candida isolates were found in C. glabrata (100%), C. albicans (14.3%), C. tropicalis (22.2%) and C. parapsilosis (66.7%). Most Candida spp. isolates were mainly susceptible to echinocandins (>90%). Notably, 10%-20% of C. glabrata isolates showed resistance to echinocandins.
 Conclusion: Fluconazole, an empirical therapy, has been cautiously used due to resistant non-albicans Candida species especially, C. glabrata, C. tropicalis and C. parapsilosis. However, the emerging echinocandins resistant C. glabrata isolates need to be closely monitored.

Antifungal susceptibility testing of candida – Methods and issues in current practice

Despite the availability of many antifungal drugs in clinical practice, the occurrence of antifungal drug resistance is on the rise. Since the antifungal susceptibility testing (AFST) is not done routinely in many of the microbiology laboratories, it is very difficult to determine which antifungal agent is very effective for a particular infection. There is a real need for precise, reproducible and extrapolative antifungal susceptibility testing methods to aid the therapeutic management. The practice of empirical treatment for fungal infections further promotes the emergence of resistant strains. The AFST practice would essentially help the clinicians in appropriate decision making. Although conventional AFST methods are somewhat cumbersome, many novel AFST methods are currently available in many laboratory settings which would provide a quicker result many times. In essence, the application of AFST along with identification of the fungus up to species level would definitely be very helpful in selecting the primary antifungal agents for treatment especially in difficult to manage and invasive fungal infections. This review will throw light on the various AFST methods available and their issues in the current practice.

In vitro activity of micafungin against biofilms of Candida albicans, Candida glabrata, and Candida parapsilosis at different stages of maturation

Candida spp. is able to form a biofilm, which is considered resistant to the majority of antifungals used in medicine. The aim of this study was to evaluate the in vitro activity of micafungin against Candida spp. biofilms at different stages of their maturation (2, 6, and 24h). We assessed the inhibitory effect of micafungin against 78 clinical isolates of Candida spp., growing as planktonic or sessile cells, by widely recommended broth microdilution method. The in vitro effect on sessile cells viability was evaluated by colorimetric reduction assay. All examined strains were susceptible or intermediate to micafungin when growing as planktonic cells. At the early stages of biofilm maturation, from 11 (39.3%) to 20 (100%), tested strains, depending on the species, exhibited sessile minimal inhibitory concentrations (SMICs) of micafungin at ≤2mg/L. For 24-h-old Candida spp. biofilms, from 3 (10.7%) to 20 (100%) of the tested strains displayed SMICs of micafungin at ≤2mg/L. Our findings confirm that micafungin exhibits high potential anti-Candida-biofilm activity. However, this effect does not comprise all Candida species and strains. All strains were susceptible or intermediate to micafungin when growing as planktonic cells, but for biofilms, micafungin displays species- and strain-specific activity. Paradoxical growth of C. albicans and C. parapsilosis was observed. Antifungal susceptibility testing of Candida spp. biofilms would be the best solution, but to date, no reference method is available. The strongest antibiofilm activity of micafungin is observed at early stages of biofilm formation. Possibly, micafungin could be considered as an effective agent for prevention of biofilm-associated candidiasis, especially catheter-related candidaemia.

Antifungal Susceptibility Testing of Candida and Cryptococcus Species and Mechanisms of Resistance: Implications for Clinical Laboratories

Resistance to antifungal drugs amongst Candida species is a growing concern, and azole resistance may be emerging in Cryptococcus species. This review provides a contemporary perspective, relevant to the clinical mycology laboratory, of antifungal susceptibility testing of these fungi, focussing on the challenges of phenotypic and genotypic methodologies to detect drug resistance. Standardised CLSI and EUCAST broth microdilution (BMD) susceptibility testing methods are the benchmark to determine clinical breakpoints (CBPs) and/or epidemiological cut-off values (ECVs) MICs for Candida and Cryptococcus spp. Commercial methods may be used but caution is required when employing BMD CBPs/ECVs to interpret results. Species-specific CBPs/ECVs for Candida spp. generally correlate well with predicting likelihood of therapeutic failure or of presence of a drug resistance mechanism with the exception of the echinocandins where the presence of specific FKS gene mutations and not the MIC correlates most accurately with clinical outcome. The relationship of presence of one or more mechanisms of azole resistance and drug MICs is uncertain. Next generation sequencing technology is offering insights into the relationships between susceptibility results obtained by phenotypic and genotypic methods. For Cryptococcus spp., CBPs are not established but species- and genetic type-specific EVCs are useful for guiding therapy where clinically indicated. Isolates of genotype VGII appear to exhibit the highest MICs. Antifungal susceptibility testing of yeasts is important to detect drug resistance. For Candida spp., MICs have clinical utility for the azoles but detecting echinocandin resistance by genotypic methods is preferred. For Cryptococcus spp., ECVs are useful in guiding therapy.

Multicenter Comparison of the Etest and EUCAST Methods for Antifungal Susceptibility Testing of Candida Isolates to Micafungin.

In vitro susceptibility of 933 Candida isolates, from 16 French hospitals, to micafungin was determined using the Etest in each center. All isolates were then sent to a single center for determination of MICs by the EUCAST reference method. Overall essential agreement between the two tests was 98.5% at ±2 log2 dilutions and 90.2% at ±1 log2 dilutions. Categorical agreement was 98.2%. The Etest is a valuable alternative to EUCAST for the routine determination of micafungin MICs in medical mycology laboratories.

Comparison of two antifungal susceptibility testing of Candida sp. isolates using agar diffusion method: Neo-sensitabs® tablets and Bio-rad® disks

The aim of our study was to evaluate the concordance between the two antifungal susceptibility testing of Candida sp. isolates using agar diffusion method: Neo-Sensitabs(®) tablets and Bio-Rad(®) disks. This is a prospective study conducted in the Laboratory of Parasitology and Mycology of the Mohammed V military teaching hospital from February to August 2012. Upon receiving blood cultures and peripheral sites samples, the identification of Candida isolates performed using routine phenotypic standard tests and the realization of the antifungal susceptibility was carried out on Neo-sensitabs(®) tablets and Bio-Rad(®) disks. A total of 38 Candida strains were isolated: 15 C. albicans (39%), 13 C. glabrata (34%), 5 C. tropicalis (13%), 4 C. krusei (11%) and 1 C. dubliniensis (3%). There were no significant difference (P>0.05) in susceptibility rate between both methods for all antifungal agents tested except for 5-fluorocytosine. The concordance percentage between two methods was 100% for amphotericin B, 97.4% for fluconazole, 94.7% for voriconazole and 73% for 5-fluorocytosine. Both methods are easy to perform, rapid and cost effective. Our results showed the best agreement between the two methods for testing the susceptibility of Candida isolates to amphotericin B, fluconazole and voriconazole while for the 5-fluorocytosine, the concordance rate was low.

Evaluation of the "Dip Effect" Phenomenon in Antifungal Susceptibility Testing of Candida spp. against Echinocandins by Use of Gradient Concentration Strips.

The "dip effect" phenomenon complicates antifungal susceptibility testing with gradient concentration strips. Of 60 Candida isolates tested with the three echinocandins, this phenomenon was observed only for caspofungin with most (>90%) Candida albicans, Candida glabrata, and Candida tropicalis isolates and for isolates with CLSI MICs of ≤0.25 mg/liter. In order to facilitate MIC determination, a practical approach was developed using the inhibition zones at 32, 8, 2, and 1 mg/liter, increasing the agreement with the CLSI method >86%.

Antifungal susceptibility testing of Candida in the Clinical Laboratory: how to do it, when to do it, and how to interpret it

Significant changes in the management of fungaemia have occurred in the last decade with increased use of fluconazole prophylaxis, of empirical treatment and of echinocandins as first-line agents for documented disease. The emergence of drug resistance in fungal pathogens has a profound impact on human health given limited number of antifungal drugs. Antifungal resistance in Candida may be either intrinsic or acquired and may be encountered in the antifungal drug exposed but also the antifungal drug naive patient The variation in resistance rates between centers emphasizes that it is essential to have knowledge of the local Candida species distribution and antifungal resistance rates to guide initial therapy for Candida BSI. Moreover, all Candida isolates from blood and normally sterile sites should be identified to the species level. The Clinical and Laboratory Standards Institute and European Committee on Antimicrobial Susceptibility Testing have developed breakpoints and epidemiological cutoff values that are now established for Candida spp. Clinical microbiology laboratories will be employed commercial susceptibility assays, rather than reference broth microdilution methods and comparative studies are particularly important. Vitek 2®, Etest® and Sensititre YeastOne® provided a high degree of essential agreement and comparable sensitivity and specificity to BMD-RPMI for identifying resistance to azole and echinocandins in Candida spp.

X-Plate Technology: a new method for detecting fluconazole resistance in Candida species

Candida species are responsible for many opportunistic fungal infections. Fluconazole is a well-tolerated antifungal drug, commonly used in the treatment of candidiasis. However, with fluconazole resistance ever increasing, rapid detection and antifungal susceptibility testing of Candida is imperative for proper patient treatment. This paper reports a cost-effective, simple and rapid chromogenic agar dilution method for simultaneous Candida species identification and fluconazole susceptibility testing. The results obtained by X-Plate Technology were in absolute concordance with standard microbroth dilution assays. Analysis of 1383 clinical patient samples with suspected vulvovaginal candidiasis revealed that this technology was able to detect and speciate the Candida isolate and determine the fluconazole susceptibility. The prevalence and susceptibility profiles of the clinical isolates using this method were highly similar to published reports using the microbroth dilution method.

Progress in Antifungal Susceptibility Testing of Candida spp. by Use of Clinical and Laboratory Standards Institute Broth Microdilution Methods, 2010 to 2012

Antifungal susceptibility testing of Candida has been standardized and refined and now may play a useful role in managing Candida infections. Important new developments include validation of 24-h reading times for all antifungal agents and the establishment of species-specific epidemiological cutoff values (ECVs) for the systemically active antifungal agents and both common and uncommon species of Candida. The clinical breakpoints (CBPs) for fluconazole, voriconazole, and the echinocandins have been revised to provide species-specific interpretive criteria for the six most common species. The revised CBPs not only are predictive of clinical outcome but also provide a more sensitive means of identifying those strains with acquired or mutational resistance mechanisms. This brief review serves as an update on the new developments in the antifungal susceptibility testing of Candida spp. using Clinical and Laboratory Standards Institute (CLSI) broth microdilution (BMD) methods.

Advances in Antifungal Susceptibility Testing of Candida, 2010–2012

Antifungal susceptibility testing of Candida has been standardized and refined and now may play an important role in managing Candida infections. Important new developments include the establishment of species-specific epidemiological cutoff values (ECVs) for the systemically active antifungal agents and both common and uncommon species of Candida. The clinical breakpoints (CBPs) for fluconazole, voriconazole, and the echinocandins have been revised to provide species-specific interpretive criteria for the six most common species that not only are predictive of clinical outcome but also provide a more sensitive means of identifying those strains with acquired or mutational resistance mechanisms. Collaborative work by the CLSI and EUCAST organizations has made major advances in the harmonization of these two international standards. The impact of the recent changes in the CBPs on commercial MIC methods does not appear to be major but additional studies with well defined resistant populations are necessary to confirm the ability of these systems to detect emerging resistance.

Definitions and Epidemiology of Candida Species not Susceptible to Echinocandins

Antifungal susceptibility testing of Candida against the echinocandin antifungal agents (anidulafungin [ANF], caspofungin [CSF], micafungin [MCF]) has been standardized by the Clinical and Laboratory Standards Institute (CLSI) Subcommittee on Antifungal Testing. The CLSI proposed a single set of clinical breakpoints (CBPs) for all three echinocandins and all species of Candida: susceptible, minimum inhibitory concentration (MIC) ≤ 2 μg/mL; nonsusceptible, MIC > 2 μg/mL. Subsequently, these CBPs have been shown to lack sensitivity in detecting strains of Candida with acquired resistance mechanisms associated with treatment failure. Studies using the CLSI method have defined wild-type (WT) MIC distributions and epidemiologic cutoff values (ECVs) for each echinocandin and the common species of Candida. The ECVs serve as a sensitive means of discriminating WT strains from those with acquired resistance mechanisms. WT MIC distributions revealed ECV ranges of 0.03 to 0.25 μg/mL for all major species except C. parapsilosis (1–4 μg/mL) and C. guilliermondii (4–16 μg/mL). These ECVs reliably differentiate WT strains of each species from non-WT strains containing fks mutations. These data, coupled with additional biochemical, clinical, pharmacokinetic, and pharmacodynamic considerations, have resulted in new CBPs of ≤0.25 μg/mL (susceptible), 0.5 μg/mL (intermediate), and ≥1 μg/mL (resistant) for ANF, CSF, and MCF for C. albicans, C. tropicalis, and C. krusei. For these agents and C. parapsilosis, the new CBPs are ≤2 μg/mL (susceptible), 4 μg/mL (intermediate), and ≥8 μg/mL (resistant). For C. glabrata, the CBPs for ANF and CSF are ≤0.12 μg/mL (susceptible), 0.25 μg/mL (intermediate), and ≥0.5 μg/mL (resistant), whereas those for MCF are ≤0.06 μg/mL, 0.12 μg/mL, and ≥0.25 μg/mL, respectively. Application of both ECVs and the lower species-specific CBPs for the echinocandins has proven useful in both resistance surveillance and clinical care and will serve as an important step in international harmonization of in vitro susceptibility testing of this important antifungal class.

Wild-Type MIC Distributions and Epidemiologic Cutoff Values for Fluconazole and Candida: Time for New Clinical Breakpoints?

Antifungal susceptibility testing of Candida against fluconazole has been standardized by both the Clinical and Laboratory Standards Institute (CLSI) and the European Committee on Antimicrobial Susceptibility Testing (EUCAST). Both CLSI and EUCAST have developed clinical breakpoint (CBP) criteria for fluconazole, but these differ in both magnitude and target species. Studies using the EUCAST method have also defined wild-type minimum inhibitory concentration (MIC) distributions and epidemiologic cutoff values (ECVs or ECOFFs) for the common species of Candida. The ECVs serve as a sensitive means of discriminating wild-type strains from those with acquired resistance mechanisms and include MICs of 1 μg/mL for C. albicans, 2 μg/mL for C. tropicalis and C. parapsilosis, 32 μg/mL for C. glabrata, and 128 μg/mL for C. krusei. Because the CLSI CBPs may be too insensitive to detect emerging resistance among strains of C. albicans, C. tropicalis, and C. parapsilosis, and bisect the WT MIC distribution of C. glabrata, we sought to establish the wild-type MIC distribution and ECVs for fluconazole and Candida spp. The establishment of the wild-type MIC distributions and ECVs for fluconazole using CLSI methods will be useful in resistance surveillance and may prove to be an important step in the development of species-specific CBPs for this important antifungal agent.

Antifungal Susceptibility Testing of Candida Isolates from the Candida Surveillance Study

Antifungal Susceptibility Testing of Candida Isolates from the Candida Surveillance Study

New developments in the antifungal susceptibility testing of Candida

Antifungal susceptibility testing of Candida spp has been standardized and refined and now may play an important role in managing Candida infections. Important new developments include standardizing methods for testing echinocandins, fluconazole, and voriconazole and establishing interpretive breakpoints for these agents. Refinements in broth microdilution technology include the ability to read results after 24-hour incubation for several agents, addition of new azoles and echinocandins to commercially available microdilution trays, and automation of the entire testing process. Cross-resistance studies have identified important relationships among the triazole antifungals, and international collaboration offers the promise of harmonization and the development of an international standard for the testing of yeasts.

Antifungal susceptibility testing of Candida spp. by relative growth measurement at single concentrations of antifungal agents.

The relative growth (percentage of growth relative to control growth) of 496 isolates representing six Candida species was assessed as a means of determining in vitro susceptibilities of the isolates in microdilution plate wells containing single concentrations of each of seven antifungal agents. The relative growth data were highly reproducible. With flucytosine and amorolfine they correlated well with MICs, but for an azole antifungal agent, terconazole, they did not correlate with MICs. Distributions of relative growth percentages for different Candida spp. showed significant differences in species susceptibility to individual agents. For example, C. albicans was less susceptible than the other species to amorolfine; C. parapsilosis isolates were particularly susceptible to terbinafine; and C. glabrata, C. guilliermondii, and C. krusei isolates were less susceptible than C. albicans to fluconazole and ketoconazole but equally susceptible as or more susceptible than C. albicans to itraconazole. Differential patterns of susceptibility to individual azole antifungal agents were noted for some individual strains as well as for Candida spp.