Antifungal Susceptibility Patterns, In Vitro Production of Virulence Factors, and Evaluation of Diagnostic Modalities for the Speciation of Pathogenic Candida from Blood Stream Infections and Vulvovaginal Candidiasis
Candida spp. have emerged as successful pathogens in both invasive and mucosal infections. Varied virulence factors and growing resistance to antifungal agents have contributed to their pathogenicity. We studied diagnostic accuracy of HiCrome Candida Differential Agar and Vitek 2 Compact system for identification of Candida spp. in comparison with species-specific PCR on 110 clinical isolates of Candida from blood stream infections (54, 49%) and vulvovaginal candidiasis (56, 51%). C. albicans (61%) was the leading pathogen in VVC, while C. tropicalis (46%) was prominent among BSIs. HiCrome Agar and Vitek 2 Compact had good measures of agreement (κ) 0.826 and 0.895, respectively, in comparison with PCR. We also tested these isolates for in vitro production of proteinase, esterase, phospholipases, and biofilms. Proteinase production was more among invasive isolates ( ), while phospholipase production was more among noninvasive isolates ( ). There was an overall increase in the production of virulence factors among non-albicans Candida. Identification of clinical isolates of Candida up to species level either by chromogenic agar or by Vitek 2 Compact system should be routinely done to choose appropriate therapy. 1. Introduction The opportunistic yeasts belonging to the genus Candida have been associated with a wide range of human infections and significant mortality and morbidity. The clinical manifestations range from infections of the superficial skin and its appendages to deep-seated or disseminated candidiasis. Estimates suggest that Candida spp. have been the third most common nosocomial pathogens associated with blood stream infections (BSIs) [1]. Among noninvasive infections, vulvovaginal candidiasis (VVC) affects approximately 75% of the women with at least one episode during their lifetime [2]. Though C. albicans has been associated mostly with human infections, there has been an increase in the prevalence of infections due to non-albicans Candida in the recent past [3, 4]. Of the many pathogenic non-albicans species known, C. tropicalis, C. parapsilosis, C. kefyr, C. krusei, and C. guilliermondii are mostly associated with human infections. Candida spp. have grown from successful commensals to pathogens in various body sites with the help of many virulence determinants. Though non-albicans Candida have proven to be common pathogens in most invasive infections, little attention is given to their virulence attributes. Adherence to host tissue, response to environmental changes, secretion of hydrolases, and biofilm production are a few of the most
References
[1]
J. Perlroth, B. Choi, and B. Spellberg, “Nosocomial fungal infections: epidemiology, diagnosis, and treatment,” Medical Mycology, vol. 45, no. 4, pp. 321–346, 2007.
[2]
D. Wilson, S. Thewes, K. Zakikhany et al., “Identifying infection-associated genes of Candida albicans in the postgenomic era,” FEMS Yeast Research, vol. 9, no. 5, pp. 688–700, 2009.
[3]
I. Xess, N. Jain, F. Hasan, P. Mandal, and U. Banerjee, “Epidemiology of candidemia in a tertiary care centre of North India: 5-Year study,” Infection, vol. 35, no. 4, pp. 256–259, 2007.
[4]
J. Chander, N. Singla, S. K. Sidhu, et al., “Epidemiology of Candida blood stream infections: experience of a tertiary care centre in North India,” The Journal of Infection in Developing Countries, vol. 7, pp. 670–675, 2013.
[5]
K. Haynes, “Virulence in Candida species,” Trends in Microbiology, vol. 9, no. 12, pp. 591–596, 2001.
[6]
M. D. Zilberberg, M. H. Kollef, H. Arnold et al., “Inappropriate empiric antifungal therapy for candidemia in the ICU and hospital resource utilization: a retrospective cohort study,” BMC Infectious Diseases, vol. 10, article 150, 2010.
[7]
M. D. Englen and L. C. Kelley, “A rapid DNA isolation procedure for the identification of Campylobacter jejuni by the polymerase chain reaction,” Letters in Applied Microbiology, vol. 31, no. 6, pp. 421–426, 2000.
[8]
M. M. Rad, A. S. Zafarghandi, M. A. Zabihi, M. Tavallaee, and Y. Mirdamadi, “Identification of Candida species associated with vulvovaginal candidiasis by multiplex PCR,” Infectious Diseases in Obstetrics and Gynecology, vol. 2012, Article ID 872169, 5 pages, 2012.
[9]
F. Staib, “Serum-proteins as nitrogen source for yeast like fungi,” Sabouraudia, vol. 4, pp. 187–193, 1965.
[10]
Y. H. Samaranayake, R. S. Dassanayake, J. A. M. S. Jayatilake et al., “Phospholipase B enzyme expression is not associated with other virulence attributes in Candida albicans isolates from patients with human immunodeficiency virus infection,” Journal of Medical Microbiology, vol. 54, no. 6, pp. 583–593, 2005.
[11]
W. Rudek, “Esterase activity in Candida species,” Journal of Clinical Microbiology, vol. 8, no. 6, pp. 756–759, 1978.
[12]
G. Ramage, K. V. Walle, B. L. Wickes, and J. L. López-Ribot, “Standardized method for in vitro antifungal susceptibility testing of Candida albicans biofilms,” Antimicrobial Agents and Chemotherapy, vol. 45, no. 9, pp. 2475–2479, 2001.
[13]
F. Hasan, I. Xess, X. Wang, N. Jain, and B. C. Fries, “Biofilm formation in clinical Candida isolates and its association with virulence,” Microbes and Infection, vol. 11, no. 8-9, pp. 753–761, 2009.
[14]
M. Y. Cirak, A. Kalkanci, S. Kustimur, and S. Ku？timur, “Identification of Candida species by Restriction Fragment Length Polymorphism (RFLP) analysis of colony lysates,” Gazi Medical Journal, vol. 14, no. 1, pp. 14–17, 2003.
[15]
S. G. Nadeem, S. T. Hakim, and S. U. Kazmi, “Use of CHROMagar Candida for the presumptive identification of Candida species directly from clinical specimens in resource-limited settings,” Libyan Journal of Medicine, vol. 5, no. 1, pp. 1–6, 2010.
[16]
S. Perea and T. F. Patterson, “Antifungal resistance in pathogenic fungi,” Clinical Infectious Diseases, vol. 35, no. 9, pp. 1073–1080, 2002.
[17]
V. Kumari, T. Banerjee, P. Kumar, et al., “Emergence of non-albicans Candida among Candidal vulvovaginitis cases and study of their potential virulence factors, from a tertiary care center, North India,” Indian Journal of Pathology and Microbiology, vol. 56, pp. 144–147, 2013.
[18]
M. M. de vos, M. Cuenca-Estrella, T. Beokhout et al., “Vulvovaginal candidiasis in a Flemish patient population,” Clinical Microbiology and Infection, vol. 11, no. 12, pp. 1005–1011, 2005.
[19]
K. Zakikhany, J. R. Naglik, A. Schmidt-Westhausen, G. Holland, M. Schaller, and B. Hube, “In vivo transcript profiling of Candida albicans identifies a gene essential for interepithelial dissemination,” Cellular Microbiology, vol. 9, no. 12, pp. 2938–2954, 2007.
[20]
N. Pahwa, R. Kumar, S. Nirkhiwale, et al., “Species distribution and drug susceptibility of candida in clinical isolates from a tertiary care centre at Indore,” Indian Journal of Medical Microbiology, vol. 32, no. 1, pp. 44–48, 2014.
[21]
S. S. Richter, R. P. Galask, S. A. Messer, R. J. Hollis, D. J. Diekema, and M. A. Pfaller, “Antifungal susceptibilities of Candida species causing vulvovaginitis and epidemiology of recurrent cases,” Journal of Clinical Microbiology, vol. 43, no. 5, pp. 2155–2162, 2005.
[22]
J. R. Naglik, S. J. Challacombe, and B. Hube, “Candida albicans secreted aspartyl proteinases in virulence and pathogenesis,” Microbiology and Molecular Biology Reviews, vol. 67, no. 3, pp. 400–428, 2003.
[23]
S. Silva, S. J. Hooper, M. Henriques, R. Oliveira, J. Azeredo, and D. W. Williams, “The role of secreted aspartyl proteinases in Candida tropicalis invasion and damage of oral mucosa,” Clinical Microbiology and Infection, vol. 17, no. 2, pp. 264–272, 2011.
[24]
C. R. Costa, X. S. Passos, L. K. H. Souza, P. D. A. Lucena, O. D. F. L. Fernandes, and M. D. R. R. Silva, “Differences in exoenzyme production and adherence ability of candida spp. isolates from catheter, blood and oral cavity,” Revista do Instituto de Medicina Tropical de Sao Paulo, vol. 52, no. 3, pp. 139–143, 2010.
[25]
A. Felk, M. Kretschmar, A. Albrecht et al., “Candida albicans hyphal formation and the expression of the Efg1-regulated proteinases Sap4 to Sap6 are required for the invasion of parenchymal organs,” Infection and Immunity, vol. 70, no. 7, pp. 3689–3700, 2002.
[26]
M. A. Ghannoum, “Potential role of phospholipases in virulence and fungal pathogenesis,” Clinical Microbiology Reviews, vol. 13, no. 1, pp. 122–143, 2000.
[27]
D. Williams and M. Lewis, “Pathogenesis and treatment of oral Candidosis,” Journal of Oral Microbiology, vol. 3, no. 2011, article 5771, 2011.
[28]
E. Aktaz, N. Yigit, and A. Ayyildiz, “Esterase activity in various Candida species,” Journal of International Medical Research, vol. 30, no. 3, pp. 322–324, 2002.
[29]
C. P. G. Kumar, T. Menon, T. Sundararajan et al., “Esterase activity of Candida species isolated from immunocompromised hosts,” Revista Iberoamericana de Micologia, vol. 23, no. 2, pp. 101–103, 2006.
[30]
M. Tumbarello, B. Posteraro, E. M. Trecarichi et al., “Biofilm production by Candida species and inadequate antifungal therapy as predictors of mortality for patients with candidemia,” Journal of Clinical Microbiology, vol. 45, no. 6, pp. 1843–1850, 2007.
