Candida rugosa , an Emerging Fungal Pathogen with Resistance to Azoles: Geographic and Temporal Trends from the ARTEMIS DISK Antifungal Surveillance Program

Abstract

Candida rugosa is a fungus that appears to be emerging as a cause of infection in some geographic regions. We utilized the extensive database of the ARTEMIS DISK Antifungal Surveillance Program to describe the geographic and temporal trends in the isolation of C. rugosa from clinical specimens and the in vitro susceptibilities of 452 isolates to fluconazole and voriconazole. C. rugosa accounted for 0.4% of 134,715 isolates of Candida, and the frequency of isolation increased from 0.03% to 0.4% over the 6.5-year study period (1997 to 2003). C. rugosa was most common in the Latin American region (2.7% versus 0.1 to 0.4%). Decreased susceptibility to fluconazole (40.5% susceptible) was observed in all geographic regions; however, isolates from Europe and North America were much more susceptible (97 to 100%) to voriconazole than those from other geographic regions (55.8 to 58.8%). C. rugosa was most often isolated from blood and urine in patients hospitalized at the Medical and Surgical inpatient services. Notably, bloodstream isolates were the least susceptible to both fluconazole and voriconazole. C. rugosa should be considered, along with the established pathogens Candida krusei and Candida glabrata, as a species of Candida with reduced susceptibility to the azole antifungal agents.

In Vitro Activity of Seven Systemically Active Antifungal Agents against a Large Global Collection of RareCandidaSpecies as Determined by CLSI Broth Microdilution Methods

“…guilliermondii and C. rugosa both appear to be increasing in frequency as causes of invasive candidiasis, especially in Latin America (19,20,68,79,80). Both species have been responsible for clusters of infections in hospital settings, and both demonstrate decreased susceptibilities to amphotericin B, fluconazole, and the echinocandins (Table 2) (19,20,24,26,27,36,48,49,70,79,80).…”

“…Several species, such as C. lusitaniae (6,28,30,65,72), C. guilliermondii (24, 27, 36, 48, 49, 70, 79), C. kefyr (8,88,92), C. famata (106), C. dubliniensis (17,74,99), and C. rugosa (20,26,80,98), have been reported to express resistance to one or more antifungal agents and have occurred in nosocomial clusters, either in association with the selective pressure of an antifungal agent or in relation to intravascular catheters and breaks in infection control procedures (31,77). Thus, although rare, these species of Candida must be considered to be opportunistic pathogens that may pose resistance problems for the currently licensed antifungal agents.…”

Results from the ARTEMIS DISK Global Antifungal Surveillance Study, 1997 to 2007: a 10.5-Year Analysis of Susceptibilities of Candida Species to Fluconazole and Voriconazole as Determined by CLSI Standardized Disk Diffusion

“…Whereas these species, as well as C. krusei, are often seen as colonizers (3,22,58,62), isolates from blood and NSBF are reported in this survey (Table 9) and in other reports in the literature (3,11,34,35,39,40,62). These and other relatively rare species of Candida are unlikely to be familiar to many clinicians and microbiologists, and there are few or no data concerning prognosis or optimal treatment strategies (13,14,25,41,43,47,53,54,65,66). Given the ubiquitous use of azoles in prophylaxis and empirical and directed therapies (4,43,65,66), it is important to know the activities of the systemically active agents, such as fluconazole and voriconazole, against these organisms (65,66).…”

First Case Report of Bloodstream Infection Due to a Candida Species Closely Related to the Novel Species Candida pseudorugosa

“…Candida rugosa has been cited as a potential emerging fungal pathogen (25) that may be most common in Latin America (28,29). Pfaller et al (28) utilized the database of the ARTEMIS DISK Antifungal Surveillance Program to describe 452 isolates of this species.…”

“…Pfaller et al (28) utilized the database of the ARTEMIS DISK Antifungal Surveillance Program to describe 452 isolates of this species. Their findings suggest that this species appears to be developing increased resistance to azole antifungal agents, especially in certain geographic regions, and it most often causes BSI and urinary tract infections in patients hospitalized in the medical and surgical inpatient services.…”