Azole-Resistant Candida albicans: Report of Two Cases of Resistance to Fluconazole and Review

Abstract

We report the course of oropharyngeal infection by Candida albicans that was refractory to treatment with fluconazole in two patients infected by the human immunodeficiency virus (HIV). We also review the epidemiology of C. albicans with decreased in vitro and in vivo susceptibility to azole antifungal agents, the significance of such isolates, the known mechanisms by which C. albicans may become less susceptible to azole antifungal agents, and the efficacy of various treatments for mucosal candidiasis. The occurrence in HIV-infected patients of mucosal candidiasis that is refractory to therapy with fluconazole and is due to C. albicans that demonstrates decreased in vitro susceptibility to fluconazole has been reported since 1990. Following the release of miconazole and ketoconazole in the late 1970s, C. albicans with decreased in vitro susceptibility to these agents was isolated from patients with chronic mucocutaneous candidiasis who required repeated and prolonged courses of therapy. Subsequently, C. albicans with decreased in vitro-susceptibility to ketoconazole, clotrimazole, and itraconazole has been isolated from HIV-infected patients. Recent reports of the sexual and nosocomial transmission of wild-type C. albicans indicate the possibility of future person-to-person transmission of C. albicans with decreased in vitro susceptibility to azole antifungal agents.

Topical polyene antifungals in hematopoietic cell transplant patients: tolerability and efficacy

“…However, there were no differences between the total number of times the rinse was swallowed following use, and no statistically significant difference in overall tolerability of the rinses was seen. Consistent with previous literature [11,48,58,62,37,31,18,3], there was no evidence of polyene resistance occurring in Candida recovered during the study However, it must be noted that the mean number of days and doses of topical therapy was limited.…”

“…Amphotericin B oral suspension (Fungizone oral suspension, Bristol-Myers Squibb) is a candidate for prophylaxis of oropharyngeal candidiasis. Candida are rarely resistant to amphotericin B, clinically (IV use) or in vitro [11,48,58,62,37,31,18,3]. However, the related topical polyene, nystatin, despite similarly rare in vitro resistance, has demonstrated poor efficacy in these situations [37,31,29,2,52,32,12].…”

A nationwide survey of deep fungal infections and fungal prophylaxis after hematopoietic stem cell transplantation in Japan

“…It has been suggested that long-term use of azole antifungal agents may cause resistance. 32 Additionally, azole antifungal agents are expensive, and long-term use is not economical. 33 On the other hand, for the prophylactic use of antifungal agents in allogeneic transplant, the CDC recommends prophylactic fluconazole 400 mg/day during the neutropenic period following transplantation.…”

Anticandidal activity ofCassia fistulaand its effect on ergosterol biosynthesis

“…In the last 10 years, there has been a considerable increase in mycoses and systemic infections caused by Candida albicans, particularly among immunocompromised patients (Eggimann et al, 2003). Studies have indicated C. albicans resistance to azoles or hepatonephrotoxic or nephrotoxic linked to polyene use, particularly amphotericin-B (White & Goetz, 1994;Rex et al, 1995). Therefore, searching for the sources of new anticandidal is required from the medicinal plant derivatives owing to their versatile application.…”