Abstract
The present study examines the trend in distribution of Candida species and their antifungal resistance patterns in hospitals across Haryana, a North Indian state with poorly addressed epidemiology of fungal infections. In our collection of 228 Candida isolates, Candida albicans dominated in both high vaginal swab (HVS) and urine samples while Candida glabrata and Candida tropicalis were the second-highest non-albicans Candida species (NAC), respectively. Of note, in blood samples, C. tropicalis and C. albicans were present in equal numbers. All 228 isolates were subjected to antifungal susceptibility tests, whereby 51% of C. albicans recovered from HVS samples displayed fluconazole resistance. To understand its mechanistic basis, expression profiling of efflux pump genes CDR1, CDR2, MDR1 and azole drug target, ERG11 was performed in 20 randomly selected resistant isolates, wherein many isolates elicited higher expression. Further, ERG11 gene sequencing suggested that most of the isolates harbored mutations, which are not reported with azole resistance. However, one isolate, RPCA9 (MIC 64 μg/mL) harbored triple mutation (Y132C, F145L, A114V), wherein Y132 and F145 sites were previously implicated in azole resistance. Interestingly, one isolate, (RPCA61) having MIC > 128 μg/mL harbored a novel mutation, G129R. Of note, HVS isolates RPCA 21, RPCA 22, and RPCA 44 (MICs 64 to > 128 μg/mL) did not show any change in alteration in ERG11 or overexpression of efflux pump genes. Together, this study presents a first report of Candida infections in selected hospitals of Haryana State.
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Abbreviations
- HVS:
-
High vaginal swab
- NAC:
-
Non-albicans Candida
- RT-PCR:
-
Reverse transcriptase polymerase chain reaction
- YEPD:
-
Yeast Extract Peptone Dextrose
- SDA:
-
Sabouraud dextrose agar
- BAL:
-
Bronchoalveolar lavage
- CSF:
-
Cerebrospinal fluid
- VVC:
-
Vulvo-vaginal candidiasis
References
Balkan C, Ercan I, Isik E et al (2019) Genomewide elucidation of drug resistance mechanisms for systemically used antifungal drugs amphotericin B, caspofungin, and voriconazole in the budding yeast. Antimicrob Agents Chemother. https://doi.org/10.1128/AAC.02268-18
Bitar I, Khalaf RA, Harastani H, Tokajian S (2014) Identification, typing, antifungal resistance profile, and biofilm formation of Candida albicans isolates from Lebanese hospital patients. Biomed Res Int 2014:931372. https://doi.org/10.1155/2014/931372
Branco J, Silva AP, Silva RM, Silva-Dias A, Pina-Vaz C, Butler G, Rodrigues AG, Miranda IM (2015) Fluconazole and voriconazole resistance in Candida parapsilosis is conferred by gain-of-function mutations in MRR1 transcription factor gene. Antimicrob Agents Chemother 59:6629–6633. https://doi.org/10.1128/AAC.00842-15
Brown GD, Denning DW, Gow NAR et al (2012) Hidden killers: human fungal infections. Sci Transl Med 4:165rv13. https://doi.org/10.1126/scitranslmed.3004404
Chakrabarti A, Chatterjee SS, Shivaprakash MR (2008) Overview of opportunistic fungal infections in India. Nippon Ishinkin Gakkai Zasshi 49:165–172. https://doi.org/10.3314/jjmm.49.165
Chakrabarti A, Sood P, Rudramurthy SM, Chen S, Kaur H, Capoor M, Chhina D, Rao R, Eshwara VK, Xess I, Kindo AJ, Umabala P, Savio J, Patel A, Ray U, Mohan S, Iyer R, Chander J, Arora A, Sardana R, Roy I, Appalaraju B, Sharma A, Shetty A, Khanna N, Marak R, Biswas S, Das S, Harish BN, Joshi S, Mendiratta D (2015) Incidence, characteristics and outcome of ICU-acquired candidemia in India. Intensive Care Med 41:285–295. https://doi.org/10.1007/s00134-014-3603-2
Chi H-W, Yang Y-S, Shang S-T et al (2011) Candida albicans versus non-albicans bloodstream infections: the comparison of risk factors and outcome. J Microbiol Immunol Infect 44:369–375. https://doi.org/10.1016/j.jmii.2010.08.010
Chouhan S, Kallianpur S, Prabhu KT et al (2019) Candidal prevalence in diabetics and its species identification. Int J Appl Basic Med Res 9:49–54. https://doi.org/10.4103/ijabmr.IJABMR_259_18
Clsi C (2012) Reference method for broth dilution antifungal susceptibility testing of yeasts; Fourth Informational Supplement. CLSI document M27-S4 (Draft4). Wayne: Clinical and Laboratory Standards Institute
Deorukhkar SC, Saini S, Mathew S (2014) Non-albicans Candida infection: an emerging threat. Interdiscip Perspect Infect Dis 2014:615958. https://doi.org/10.1155/2014/615958
Fernandes JAL, Prandini THR, Castro M d CA et al (2016) Evolution and application of inteins in Candida species: a review. Front Microbiol 7:1585. https://doi.org/10.3389/fmicb.2016.01585
Flowers SA, Colón B, Whaley SG, Schuler MA, Rogers PD (2015) Contribution of clinically derived mutations in ERG11 to azole resistance in Candida albicans. Antimicrob Agents Chemother 59:450–460. https://doi.org/10.1128/AAC.03470-14
Gerald S, Swaminathan KR, Devi M et al (2017) Prevalence of vulvovaginal candidiasis in the women of the reproductive age, in rural India. Int J Clin Obstet Gynaecol 1(2):37–39
Giri S, Kindo AJ (2012) A review of Candida species causing blood stream infection. Indian J Med Microbiol 30:270–278. https://doi.org/10.4103/0255-0857.99484
Hiller D, Sanglard D, Morschhäuser J (2006) Overexpression of the MDR1 gene is sufficient to confer increased resistance to toxic compounds in Candida albicans. Antimicrob Agents Chemother 50:1365–1371. https://doi.org/10.1128/AAC.50.4.1365-1371.2006
Hu L, Du X, Li T et al (2014) Genetic and phenotypic characterization of Candida albicans strains isolated from infectious disease patients in Shanghai. J Med Microbiol 64(Pt 1):74–83. https://doi.org/10.1099/jmm.0.080200-0
Kalaiarasan K, Singh R, Chaturvedula L (2017) Fungal profile of vulvovaginal candidiasis in a tertiary care hospital. J Clin Diagn Res 11:DC06–DC09. https://doi.org/10.7860/JCDR/2017/23578.9475
Kaur H, Chakrabarti A (2017) Strategies to reduce mortality in adult and neonatal candidemia in developing countries. JoF 3:41. https://doi.org/10.3390/jof3030041
Kaur R, Dhakad MS, Goyal R, Kumar R (2016) Emergence of non-albicans Candida species and antifungal resistance in intensive care unit patients. Asian Pac J Trop Biomed 6:455–460. https://doi.org/10.1016/j.apjtb.2015.12.019
Khadka S, Sherchand JB, Pokhrel BM, Parajuli K, Mishra SK, Sharma S, Shah N, Kattel HP, Dhital S, Khatiwada S, Parajuli N, Pradhan M, Rijal BP (2017) Isolation, speciation and antifungal susceptibility testing of Candida isolates from various clinical specimens at a tertiary care hospital, Nepal. BMC Res Notes 10:218. https://doi.org/10.1186/s13104-017-2547-3
Manastır L, Ergon MC, Yücesoy M (2011) Investigation of mutations in Erg11 gene of fluconazole resistant Candida albicans isolates from Turkish hospitals. Mycoses 54:99–104. https://doi.org/10.1111/j.1439-0507.2009.01766.x
Mohammadi R, Mirhendi H, Rezaei-Matehkolaei A, Ghahri M, Shidfar MR, Jalalizand N, Makimura K (2013) Molecular identification and distribution profile of Candida species isolated from Iranian patients. Med Mycol 51:657–663. https://doi.org/10.3109/13693786.2013.770603
Mullick JB, Majumdar T, Ray J, Sil SK (2015) Changing trends of candida isolates and their antifungal susceptibility pattern in vulvovaginal candidiasis cases of Tripura, Northeast India. JEMDS 4:15918–15922. https://doi.org/10.14260/jemds/2015/2317
Pfaller MA, Diekema DJ (2004) Rare and emerging opportunistic fungal pathogens: concern for resistance beyond Candida albicans and Aspergillus fumigatus. J Clin Microbiol 42:4419–4431. https://doi.org/10.1128/JCM.42.10.4419-4431.2004
Pfaller MA, Andes DR, Diekema DJ, Horn DL, Reboli AC, Rotstein C, Franks B, Azie NE (2014) Epidemiology and outcomes of invasive candidiasis due to non-albicans species of Candida in 2,496 patients: data from the Prospective Antifungal Therapy (PATH) registry 2004-2008. PLoS One 9:e101510. https://doi.org/10.1371/journal.pone.0101510
Queiroz PA, Godoy JSR, Mendonça P d SB et al (2015) Adhesion and biofilm formation in artificial saliva and susceptibility of yeasts isolated from chronic kidney patients undergoing haemodialysis. J Med Microbiol 64:960–966. https://doi.org/10.1099/jmm.0.000122
Sanches MD, Mimura LAN, Oliveira LRC et al (2018) Differential behavior of non-albicans Candida species in the central nervous system of immunocompetent and immunosuppressed mice. Front Microbiol 9:2968. https://doi.org/10.3389/fmicb.2018.02968
Sheppard DC, Locas M-C, Restieri C, Laverdiere M (2008) Utility of the germ tube test for direct identification of Candida albicans from positive blood culture bottles. J Clin Microbiol 46:3508–3509. https://doi.org/10.1128/JCM.01113-08
Sobel JD (2006) The emergence of non-albicans Candida species as causes of invasive candidiasis and candidemia. Curr Infect Dis Rep 8:427–433
Stefaniuk E, Baraniak A, Fortuna M, Hryniewicz W (2016) Usefulness of CHROMagar Candida medium, biochemical methods—API ID32C and VITEK 2 compact and two MALDI-TOF MS systems for Candida spp. identification. Pol J Microbiol 65:111–114. https://doi.org/10.5604/17331331.1197283
Taei M, Chadeganipour M, Mohammadi R (2019) An alarming rise of non-albicans Candida species and uncommon yeasts in the clinical samples; a combination of various molecular techniques for identification of etiologic agents. BMC Res Notes 12:779. https://doi.org/10.1186/s13104-019-4811-1
Taj-Aldeen SJ, Kolecka A, Boesten R, Alolaqi A, Almaslamani M, Chandra P, Meis JF, Boekhout T (2013) Epidemiology of candidemia in Qatar, the Middle East: performance of MALDI-TOF MS for the identification of Candida species, species distribution, outcome, and susceptibility pattern. Infection 42:393–404. https://doi.org/10.1007/s15010-013-0570-4
Tan BH, Chakrabarti A, Li RY, Patel AK, Watcharananan SP, Liu Z, Chindamporn A, Tan AL, Sun PL, Wu UI, Chen YC, Asia Fungal Working Group (AFWG) (2015) Incidence and species distribution of candidaemia in Asia: a laboratory-based surveillance study. Clin Microbiol Infect 21:946–953. https://doi.org/10.1016/j.cmi.2015.06.010
Wang B, Huang L-H, Zhao J-X et al (2015) ERG11 mutations associated with azole resistance in Candida albicans isolates from vulvovaginal candidosis patients. Asian Pac J Trop Biomed 5:909–914. https://doi.org/10.1016/j.apjtb.2015.08.002
Wisplinghoff H, Bischoff T, Tallent SM et al (2004) Nosocomial bloodstream infections in US hospitals: analysis of 24,179 cases from a prospective nationwide surveillance study. Clin Infect Dis 39:309–317. https://doi.org/10.1086/421946
Xiang M-J, Liu J-Y, Ni P-H, Wang S, Shi C, Wei B, Ni YX, Ge HL (2013) Erg11 mutations associated with azole resistance in clinical isolates of Candida albicans. FEMS Yeast Res 13:386–393. https://doi.org/10.1111/1567-1364.12042
Yan L, Wang X-D, Seyedmousavi S, Yuan JN, Abulize P, Pan WH, Yu N, Yang YL, Hu HQ, Liao WQ, Deng SW (2019) Antifungal susceptibility profile of Candida albicans isolated from vulvovaginal candidiasis in Xinjiang Province of China. Mycopathologia 184:413–422. https://doi.org/10.1007/s11046-018-0305-2
You L, Qian W, Yang Q, Mao L, Zhu L, Huang X, Jin J, Meng H (2017) ERG11 gene mutations and MDR1 up-regulation confer pan-azole-resistance in Candida tropicalis causing disseminated candidiasis while on posaconazole prophylaxis in an acute lymphoblastic leukemia patient. Antimicrob Agents Chemother 61(7). https://doi.org/10.1128/AAC.02496-16
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AKY would like to acknowledge Garima Shahi and Suman Sharma for their insightful suggestions and help during the course of the work.
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RP and AK conceived the ideas. AK and RB collected the data. AK, RN, and MK performed the RT-PCR experiment. AK, RN, AB, and SMR analyzed the data. RP, AC, AK, RN, and AB wrote the manuscript with inputs from AKM and NAG.
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Kumar, A., Nair, R., Kumar, M. et al. Assessment of antifungal resistance and associated molecular mechanism in Candida albicans isolates from different cohorts of patients in North Indian state of Haryana. Folia Microbiol 65, 747–754 (2020). https://doi.org/10.1007/s12223-020-00785-6
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DOI: https://doi.org/10.1007/s12223-020-00785-6