Rev Inst Med Trop Sao Paulo
Revista do Instituto de Medicina Tropical de São
Paulo
Rev. Inst. Med. Trop. São
Paulo
1678-9946
0036-4665
Instituto de Medicina Tropical
As elevadas taxas de mortalidade associadas com episódios de
candidemia e a emergência da resistência aos antifúngicos,
requerem o monitoramento da suscetibilidade de Candida spp.,
isoladas das candidemias, frente aos agentes antifúngicos. Os novos
breakpoints, chamados
“espécie-específicos,” foram recentemente aprovados
(M27-S4) requerendo, pois, cuidadosa interpretação e
comparações com aqueles até agora utilizados (M27-A3);
ambos são propostos pelo Clinical Laboratory Standard
Institute (CLSI). O presente estudo avaliou a
suscetibilidade de espécies de Candida isoladas de
candidemias baseando-se nestes dois breakpoints. Quatrocentos e
vinte e dois isolados de Candida foram identificados e assim
distribuídos: C. parapsilosis (48,68%),
C. albicans (35,78%), C.
tropicalis (9,71%), C. glabrata
(3,55%), C. lusitaniae (1,65%),
C. guilliermondii (1,65%), C.
krusei (0,94%). Com base nos critérios do
M27-A3, um total de 33 (7,81%) isolados foram julgados
não-sensíveis, dos quais 16 (3,79%) como resistentes
aos antifúngicos. De acordo com os breakpoints
espécie-específicos (M27-S4) um total de 80
(18,95%) isolados foram considerados não-sensíveis, dos
quais 10 (2,36%) resistentes a algum dos antifúngicos
testados. Com base nos novos breakpoints
espécie-específicos, o número de isolados não-sensíveis
foi 2,4 vezes maior do que o número de não-sensíveis detectado
pelos breakpoints do documento M27-A3. A detecção de
um elevado número de isolados não-sensíveis através dos
breakpoints propostos pelo M27-S4 destaca a
importância dos testes de suscetibilidade, os quais trarão impactos no
reconhecimento de isolados de Candida spp.
não-sensíveis em episódios de candidemias, requerendo, portanto,
continua avaliação.
INTRODUCTION
Candidemia occupies a prominent place among the invasive fungal
infections1,2,3,6,20. This infection is among the most common fungal
infections in hospitalized patients and leads to a long hospital stay, increased
hospital costs14 and a mortality
rate reaching 61% in Brazil10.
Several conditions are associated with the development of candidemia, such
as the following: a) the use of antibacterial agents; b) the presence of a
central venous catheter; c) the use of type 2 histamine receptor blockers
(H2); d) total parenteral nutrition; e) admission
at an intensive care unit (ICU); f) the use of corticosteroids;
g) surgeries; h) previous hospitalization; and i) colonization by
Candida2,3,9,16.
Among the causes of high mortality rates that are observed for candidemia
is the failure of antifungal therapies, which is often due to the emergence of
resistance10.
Similar to the resistance phenomena that are observed when using
antibacterial agents, antifungal resistance can be innate or secondary to the
antifungal agents that are used13.
Additionally, the limited number of systemic antimycotics that are available has
contributed to resistance, first against flucytosine and then against fluconazole.
Furthermore, multiple studies have shown that cross-resistance may cover other azole
class antifungals18.
The spectrum of Candida species isolated from hospitals
is directly linked to the type of patient, geographic location and most commonly
used procedures; and, overall, it can define the susceptibility profile to
antifungal agents6,23.
From a temporal perspective, antifungal agents used for candidemia have
included amphotericin B, flucytosine associated with amphotericin B, fluconazole
and, more recently, voriconazole and echinocandins15.
Since 1997, susceptibility tests of Candida to antifungal
agents have been in use due to the standardization developed by the National
Committee for Clinical Laboratory Standards (NCCLS-M27-A)13. The Antifungal Susceptibility
Testing Subcommittee of the European Committee on Antibiotic Susceptibility Testing
(EUCAST)25 also
has a reference method for antifungal susceptibility testing that is a modification
of the CLSI method4. Isolates
derived from important clinical situations or sterile sites should be evaluated so
that their susceptibility agents can be determined4. However, CLSI4 and EUCAST25 standardized antifungal susceptibility tests define resistance
or susceptibility based on different breakpoints.
Datasets that correlate CLSI and EUCAST MICs with outcomes revealed lower
response rates when MICs were> 4 µg/mL for C.
albicans, C.tropicalis and C.
parapsilosis and> 16 µg/mL for C.
glabrata. These findings led to the CLSI Subcommittee on Antifungal
Susceptibility testing in an effort to harmonize the CLSI and EUCAST breakpoints for
some Candida species. The new approved breakpoints
(SS-CBPs) provide consistency with the EUCAST breakpoints and should be
more sensitive in the detection of emerging resistance among
Candida spp8,22.
Here, these two criteria for Candida spp. isolates were
compared in cases of candidemia that occurred between 1995 and 2009 and were
registered at the University Hospital of Santa Maria (HUSM), Santa Maria,
RS, Brazil.
METHODS
1. Period of evaluation: This study evaluated the
susceptibility of Candida species isolated from episodes of
candidemia over 15 years (1995 to 2009).
2. Microorganisms: Four hundred and twenty-two
Candida spp. strains isolated from episodes of candidemia that
occurred at the University Hospital of Santa Maria (HUSM); Santa Maria,
Rio Grande do Sul, Brazil. HUSM is a public, tertiary care teaching hospital with
328 beds and 10300 admissions, including adults and children, per year. The samples
(blood) were collected from different wards, including adult, pediatric
and neonatal intensive care units (ICU). Only one isolate of a candidemia
case was included in this study.
3. Identification: Blood cultures were performed using an
automated BACTEC 9120 (Becton Dickinson). Candida spp.
isolated from blood agar plates were identified using standard methods, such as
chlamydospore production, germ tube assays, micro-morphology studies in
corn-meal-Tween 80 agar and biochemical tests using the commercial system ID32C
(bioMérieux Marcy l'Etoile, France). The isolates were stored in
BHI with 20% glycerol and 0.2% agar suspensions and frozen at -70°C
until processed for the study. Before testing, each isolate was cultured on
Sabouraud dextrose agar and CHROMagar to ensure purity and viability.
4. Susceptibility tests to antifungal agents: Assays for
susceptibility were performed using broth microdilution according to the M27-A3
protocol of the Clinical and Laboratory Standards Institute
(CLSI)4. All
isolates were tested against amphotericin B (Sigma Chemical Co., St Louis,
Mo), fluconazole (Sigma Chemical Co, St Louis, Mo), itraconazole
(Janssen-Cilag Pharmaceutica; Belgium), flucytosine (Sigma Chemical
Co), voriconazole (Pfizer, Inc) and caspofungin (Merck, Rahway,
NJ), which were obtained from pure powder and prepared at the indicated
concentrations according to the procedures of protocol M27-A34. The tests were performed in
microdilution plates in which 0.1 mL of antifungal 2X concentrate was used. The
microplates were then sealed with Parafilm and frozen at -70°C until use. The
inocula were prepared from 24-48 h cultures in Sabouraud dextrose agar by suspending
the fungal cells in sterile, distilled water, and the turbidity was
spectrophotometrically fixed according to M27-A3. Lastly, the antifungal drugs were
diluted in RPMI-1640 buffered with morpholinepropanesulfonic acid (MOPS).
On the day of testing, microdilution plates containing 100 µL of RPMI-1640 with
different concentrations of antifungals were inoculated with 100 µL of diluted
culture, resulting in 0.5 x 103 to 2.5 x 103 cells/mL in
each well. The addition of this volume resulted in the required final concentration
of the antifungal agents and, at the same time, the correct number of cells that
were recommended in each well. The plates were closed and incubated at 35°C for
24-48 h, and the MIC endpoint was determined according to document M27-A3. The
susceptibility tests were interpreted according to two criteria: a) CLSI
(M27-A3) and b) SS-CBPs (CLSI M27-S4)5,24 as shown in Table 1.
Candida parapsilosis ATCC 22019 and Candida
krusei ATCC 6258 were included for quality control tests, sterility
control of the medium and control of the medium with antifungals5.
Table 1
Interpretative breakpoints according to the MICs
(µg/mL) from the M27-S4 and M27-A3 CLSI
documents
Candida Species
Antifungal agents*
M27-S4 breakpoints
M27-A3 breakpoints
S
SDD
R
S
SDD
R
C. albicans
FLZ
≤ 2.0
4.0
≥ 8.0
≤ 8.0
16-32
≥ 64
VOR
≤ 0.12
0.25-0.5
≥ 1.0
≤ 1.0
2.0
≥ 4.0
CAS
≤ 0.25
0.5
≥ 1.0
≤ 2.0
--
--
C. glabrata
FLZ
--
≤ 32
≥ 64
≤ 8.0
16-32
≥ 64
VOR
--
--
--
≤ 1.0
2.0
≥ 4.0
CAS
≤ 0.12
0.25
≥ 0.5
≤ 2.0
--
--
C. krusei
FLZ
--
--
--
≤ 8.0
16-32
≥ 64
VOR
≤ 0.5
1.0
≥ 2.0
≤ 1.0
2.0
≥ 4.0
CAS
≤ 0.25
0.5
≥ 1.0
≤ 2.0
--
--
C. parapsilosis
FLZ
≤ 2.0
4.0
≥ 8.0
≤ 8.0
16-32
≥ 64
VOR
≤ 0.12
0.25-0.5
≥ 1.0
≤ 1.0
2.0
≥ 4.0
CAS
≤ 2.0
4.0
≥ 8.0
≤ 2.0
--
--
C. tropicalis
FLZ
≤ 2.0
4.0
≥ 8.0
≤ 8.0
16-32
≥ 64
VOR
≤ 0.12
0.25-0.5
≥ 1.0
≤ 1.0
2.0
≥ 4.0
CAS
≤ 0.25
0.5
≥ 1.0
≤ 2.0
--
> 2.0
C.guilliermondii
CAS
≤ 2.0
4.0
≥ 8.0
≤ 2.0
--
> 2.0
(*)FLZ = fluconazole; VOR = voriconazole;
CAS = caspofungin; (--) breakpoints not provided by
CLSI documents M27-S4 and M27-A3.
5. Statistical analysis: The Wilcoxon nonparametric test was
used to compare two variables. Values of p ≤ 0.05 were
considered significant.
RESULTS
The study of the susceptibility of Candida spp. isolated
from episodes of candidemia that occurred between 1995 and 2009 included 422
isolates that were distributed as follows: C. parapsilosis
(197/46.68%), C. albicans
(151/35.78%), C. tropicalis
(41/9.71%), C. glabrata
(15/3.55%), C. lusitaniae
(7/1.65%), C. guilliermondii
(7/1.65%) and C. krusei
(4/0.94%). Two hundred and seventy-one (64.21%)
isolates were grouped as Candida non-albicans
species. The parameters for evaluating antifungal susceptibility (range: of
susceptibility, MIC50 and MIC90) as well as the percentage of resistance that
was obtained using the CLSI criteria according to M27-A3 and M27-S4
(SS-CBPs) are found in Tables 2
and 3.
Table 2
Susceptibility profile of Candida spp. isolated from
blood cultures in 1995-2009. Detection of non-susceptible isolates based
on the breakpoints from CLSI M27-A3 and species-specific clinical
breakpoints from CLSI M27-S4
Species
N
ATF*
MIC (µg/mL)
CLSI M27-A3 Breakpoints (n)
CLSI M27-S4 Breakpoints (n)
Range
MIC 50%
MIC 90%
R
SDD/I
R
SDD/I
C. parapsilosis
197
AMB
0.06-0.5
0.125
0.25
0
0
--
--
FLZ
0.125-4.0
1.0
4.0
0
0
0
14
ITZ
0.03-0.5
0.125
0.5
0
0
--
--
5FC
0.03-16.0
0.5
2.0
0
1
--
--
VOR
0.03-0.5
0.125
0.25
0
0
0
7
CAS
0.03-2.0
0.5
2.0
0
0
0
0
C. albicans
151
AMB
0.06-1.0
0.25
0.5
0
0
--
--
FLZ
0.125-4.0
0.25
4.0
0
0
0
15
ITZ
0.015-1.0
0.25
0.5
3
0
--
--
5FC
0.03-4.0
1.0
4.0
0
0
--
--
VOR
0.015-0.5
0.125
0.5
0
0
0
4
CAS
0.03-0.5
0.125
0.25
0
0
0
0
C. tropicalis
41
AMB
0.125-1.0
0.125
0.5
0
0
--
--
FLZ
0.25-32.0
2.0
8.0
0
1
3
8
ITZ
0.03-2.0
0.125
0.5
1
0
--
--
5FC
0.125-4.0
1.0
4.0
0
0
--
--
VOR
0.03-2.0
0.25
0.5
0
0
2
5
CAS
0.03-0.25
0.06
0.25
0
0
0
0
C. glabrata
15
AMB
0.125-0.5
0.5
1.0
0
0
--
--
FLZ
0.5-64.0
8.0
32.0
1
5
1
14
ITZ
0.03-2.0
0.5
1.0
4
3
--
--
5FC
0.125-16.0
4.0
16.0
0
4
--
--
VOR
0.06-4.0
0.5
2.0
2
0
--
--
CAS
0.06-0.5
0.125
0.25
0
0
0
3
C. guilliermondii
7
AMB
0.125-0.25
0.25
0.25
0
0
--
--
FLZ
0.5-4.0
2.0
4.0
0
0
--
--
ITZ
0.03-0.5
0.06
0.5
0
0
--
--
5FC
0.06-1.0
0.5
1.0
0
0
--
--
VOR
0.06-0.25
0.06
0.06
0
0
--
--
CAZ
0.03-0.25
0.06
0.06
0
0
0
0
C. lusitaniae
7
AMB
0.125-0.5
0.5
0.5
0
0
--
--
FLZ
0.25-4.0
2.0
2.0
0
0
--
--
ITZ
0.03-0.5
0.5
0.5
0
0
--
--
5FC
0.25-2.0
0.5
2.0
0
0
--
--
VOR
0.06-0.25
0.25
0.25
0
0
--
--
CAS
0.06-0.5
0.125
0.25
0
0
--
--
C. krusei
4
AMB
0.125-0.5
0.25
0.5
0
0
--
--
FLZ
4.0-8.0
8.0
8.0
4**
0
4**
0
ITZ
0.25-1.0
0.5
0.5
1
3
--
--
5FC
0.25-2.0
0.5
2.0
0
0
--
--
VOR
0.06-0.25
0.25
0.25
0
0
0
0
CAS
0.06-0.5
0.125
0.25
0
0
0
0
(*) AMB = amphotericin B; FLZ = fluconazole;
ITZ = itraconazole; 5FC = flucytosine; VOR =
voriconazole; CAS = caspofungin; (**)
C. krusei are assumed to be intrinsically
resistant to fluconazole; (--) breakpoints not provided by
CLSI documents M27-S4 and M27-A3.
Table 3
Comparison (number and %) of non-susceptible
Candida spp. to antifungal agents detected using
the CLSI M27-A3 breakpoints and the new species-specific clinical
breakpoints from CLSI M27-S4
Antifungal Agents
M27-A3
M27-S4
SDD
R
SDD
R
Itraconazole
6
9
--
--
Fluconazole
6
5
51
8
Voriconazole
0
2
16
2
Flucytosine
5
0
--
--
Caspofungin
0
0
3
0
Total
17a (4.02%)
16 (3.79%)
70b(16.58%)
10 (2.36%)
33c (7.81%)
80d (18.95%)
(--) antifungal agents not contemplated in M27-S4;
(%) referent to the total of isolates evaluated in
the period (n = 422); (a ≠ b and c
≠ d) p <0.05.
When the susceptibility of all Candida isolates that
were obtained from candidemia cases over 15 years was evaluated based on the CLSI
M27-A3 criteria4, 16 resistant
isolates were identified: itraconazole, n = 9 (C.
albicans = 3; C. glabrata = 4; C.
tropicalis = 1; C. krusei = 1);
fluconazole, n = 5 (C. glabrata = 1; C.
krusei = 4); and voriconazole, n = 2 (C.
glabrata = 2). Using the same criteria, 17
susceptible-dependent-dose (SDD) or intermediate (I) isolates
were found: flucytosine, n = 5 (C. parapsilosis = 1
and C. glabrata = 4); itraconazole, n = 6
(C. glabrata = 3 and C. krusei
= 3); and fluconazole, n = 6 (C. tropicalis
= 1 and C. glabrata = 5). The number of
non-susceptible (SDD or Intermediate plus Resistant) strains was 33
(Tables 2 and 3).
Based on the SS-CBPs (CLSI M27-S4)5, the total number of resistant isolates was 10:
fluconazole, n = 8 (C. tropicalis = 3, C.
glabrata = 1 and C. krusei = 4); and
voriconazole, n = 2 (C. tropicalis). Of the
susceptible dose-dependent (SDD) or Intermediate (I) isolates,
70 (16.58%) were detected and distributed as follows: fluconazole, n
= 51 [C. albicans (15), C.
parapsilosis (14), C. tropicalis
(8) and C. glabrata (14)]; voriconazole, n
= 16 [C. albicans (4), C.
parapsilosis (7) and C. tropicalis
(5)], and caspofungin (n = 3) [C.
glabrata (3)]. The number of non-susceptible (SDD
or Intermediate plus Resistant) strains was 80 (Tables 2 and 3).
Based on the number of Candida spp. that were not
susceptible to antifungal agents, the new SS-CBPs detected 2.4 times the number of
non-susceptible isolates that were detected using the M27-A3 breakpoints (p
<0.05) (Table 3).
DISCUSSION
The study's results indicated minor variations in relation to the
species of Candida involved in the episodes of candidemia:
C. parapsilosis was the most prevalent, followed by C.
albicans and then C. tropicalis. The prevalence of
C. parapsilosis could be associated with the number of
candidemia episodes that were detected in neonates and pediatric patients.
HINRICHSEN et al.10 mainly reported C. parapsilosis in these
patients. Additionally, the Candida non-albicans
was more prevalent than C. albicans. These results were in
accordance with those of many Brazilian studies6,7,10,19 and have
been observed in multicentric, international studies23.
In general, the study's results showed that the detection of
resistant isolates was not a common phenomenon. The definition of in
vitro resistance to antifungal agents is based on the breakpoints that
were established by methods standardized to yeasts in a set of CLSI documents named
M27. Although the technical recommendations for performing these tests have not been
changed, the interpretative breakpoints were redefined. In the CLSI M27-A3
document4, the breakpoints
that define susceptible, SDD, or resistant to each antifungal agent encompass all
Candida species. Recently the Subcommittee on Antifungal
Susceptibility Tests of the CLSI developed new species-specific clinical breakpoints
(SS-CBPs) for some Candida species (CLSI
M27-S45). These new
breakpoints are an attempt to balance the CLSI and EUCAST breakpoints. Thus, they
took into account the distribution of MICs of the wild-type of each
Candida species, the molecular mechanism of resistance, the
categorical agreement between MICs that were generated by both methods (CLSI
and EUCAST), as well as the reassessment of the correlation between MICs and
outcome of candidemias8,24. Due to these recent advances, in
the present study, the susceptibility profiles of Candida were
compared using both parameters.
Based on CLSI M27-A34,
the total number of non-susceptible isolates that were detected throughout the study
was 33 (7.81%), and, using the new breakpoints (SS-CBPs),
80 (18.95%) isolates were non-susceptible; thus, the number of
non-susceptible isolates that were identified by these different criteria differed
by two-fold (Table 3).
By comparing the detection of resistance between the two interpretative
criteria, a major difference in resistance identification was observed for the
M27-A3 breakpoints. However, this difference was due to the presence of
itraconazole, which was absent among the new M27-S4 breakpoints. On the other hand,
the number of susceptible dose-dependent (SDD) or intermediate
(I) isolates was increased 4-fold based on the new SS-CBPs breakpoints.
The majority of susceptible dose-dependent (SDD) or intermediate
(I) isolates occurred against fluconazole, which was in accordance with
previous studies because fluconazole is the most common azole associated with
alterations in susceptibility, and its use as an indicator of resistance to azoles
has been proposed21. In this
study, fluconazole resistance detected by M27-A3 was 1.18%, which was similar
to the results obtained by COLOMBO et al.6; on the other hand, the non-susceptible isolates to
fluconazole totaled 11 (2.60%), which was lower than the 5%
reported by COLOMBO et al.6, but similar to the 2.1% that was reported by DA MATTA
et al.7.
This study detected 0.47% (n = 2) of isolates that
were resistant to voriconazole, which is similar to the 0.2% that was reported
by DA MATTA et al.7 in Brazil, but lower than the percentage reported by other
authors: LYON et al.11 detected 1.1%, and MESSER et al. detected
0.9%12.
The percentage resistant to itraconazole (2.13%) was
greater than that reported by DA MATTA et al.7, but lower than the 11.5% that
was reported by MESSER et al.12 and the 30% that was reported by PEMÁN et
al. in Spain17.
For flucytosine, five isolates (5/1.18%) were
classified as intermediate (I), which is contrary to the results of DA
MATTA et al.7,
where 2.5% of the isolates exhibited resistance to this agent. On the other
hand, most Brazilian studies did not evaluate the susceptibility of flucytosine
because it is only used in combination with amphotericin B once monotherapy is no
longer recommended18.
The susceptibility profile intermediate (I) to caspofungin was
found for three isolates of C. glabrata. Although none of these
were classified as resistant, the finding of this study was in accordance with that
of PFALLER et al.23,24, where C.
krusei and C. glabrata were the most common species,
with resistances to caspofungin of 12.5% and 2.5%, respectively.
In this study, the evaluation of susceptibility allows one to better
understand the local epidemiology of candidemia cases that are resistant to
treatment. Detecting a higher number of non-susceptible species has highlighted the
importance of evaluating susceptibility tests using new SS-CBPs (CLSI
M27-S45), which will
impact the monitoring, selection and use of antifungal agents in the clinic.
ACKNOWLEDGMENTS
To CNPq and FAPERGS (Fundação de Amparo à Pesquisa do
Estado do Rio Grande do Sul).
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Autoria
Edileusa Rosa dos Santos
Post-Graduate Program in Pharmaceutical
Sciences, Health Science Center, Federal University of Santa Maria, Santa
Maria, RS, BrazilFederal University of Santa
MariaBrazilSanta Maria, RS, BrazilPost-Graduate Program in Pharmaceutical
Sciences, Health Science Center, Federal University of Santa Maria, Santa
Maria, RS, Brazil
University Hospital of Santa Maria, Santa
Maria, RS, BrazilUniversity Hospital of Santa
MariaBrazilSanta Maria, RS, BrazilUniversity Hospital of Santa Maria, Santa
Maria, RS, Brazil
Camila F. Dal Forno
University Hospital of Santa Maria, Santa
Maria, RS, BrazilUniversity Hospital of Santa
MariaBrazilSanta Maria, RS, BrazilUniversity Hospital of Santa Maria, Santa
Maria, RS, Brazil
Mari Glei Hernandez
Post-Graduate Program in Pharmaceutical
Sciences, Health Science Center, Federal University of Santa Maria, Santa
Maria, RS, BrazilFederal University of Santa
MariaBrazilSanta Maria, RS, BrazilPost-Graduate Program in Pharmaceutical
Sciences, Health Science Center, Federal University of Santa Maria, Santa
Maria, RS, Brazil
University Hospital of Santa Maria, Santa
Maria, RS, BrazilUniversity Hospital of Santa
MariaBrazilSanta Maria, RS, BrazilUniversity Hospital of Santa Maria, Santa
Maria, RS, Brazil
Thaís Felli Kubiça
Post-Graduate Program in Pharmaceutical
Sciences, Health Science Center, Federal University of Santa Maria, Santa
Maria, RS, BrazilFederal University of Santa
MariaBrazilSanta Maria, RS, BrazilPost-Graduate Program in Pharmaceutical
Sciences, Health Science Center, Federal University of Santa Maria, Santa
Maria, RS, Brazil
Tarcieli P. Venturini
Post-Graduate Program in Pharmaceutical
Sciences, Health Science Center, Federal University of Santa Maria, Santa
Maria, RS, BrazilFederal University of Santa
MariaBrazilSanta Maria, RS, BrazilPost-Graduate Program in Pharmaceutical
Sciences, Health Science Center, Federal University of Santa Maria, Santa
Maria, RS, Brazil
Francieli Chassot
Post-Graduate Program in Pharmaceutical
Sciences, Health Science Center, Federal University of Santa Maria, Santa
Maria, RS, BrazilFederal University of Santa
MariaBrazilSanta Maria, RS, BrazilPost-Graduate Program in Pharmaceutical
Sciences, Health Science Center, Federal University of Santa Maria, Santa
Maria, RS, Brazil
Janio M. Santurio
Departament of Microbiology and
Parasitology, Federal University of Santa Maria, Santa Maria, RS,
BrazilFederal University of Santa
MariaBrazilSanta Maria, RS, BrazilDepartament of Microbiology and
Parasitology, Federal University of Santa Maria, Santa Maria, RS,
Brazil
Sydney Hartz Alves
Post-Graduate Program in Pharmaceutical
Sciences, Health Science Center, Federal University of Santa Maria, Santa
Maria, RS, BrazilFederal University of Santa
MariaBrazilSanta Maria, RS, BrazilPost-Graduate Program in Pharmaceutical
Sciences, Health Science Center, Federal University of Santa Maria, Santa
Maria, RS, Brazil
Departament of Microbiology and
Parasitology, Federal University of Santa Maria, Santa Maria, RS,
BrazilFederal University of Santa
MariaBrazilSanta Maria, RS, BrazilDepartament of Microbiology and
Parasitology, Federal University of Santa Maria, Santa Maria, RS,
Brazil
Correspondence to: Prof. Dr. Sydney Hartz Alves, Rua dos
Andradas 1985/201, 97010-033 Santa Maria, RS, Brazil. Phone: +55
3220-8906, E-mail: sydneyalves.ufsm@gmail.com
SCIMAGO INSTITUTIONS RANKINGS
Post-Graduate Program in Pharmaceutical
Sciences, Health Science Center, Federal University of Santa Maria, Santa
Maria, RS, BrazilFederal University of Santa
MariaBrazilSanta Maria, RS, BrazilPost-Graduate Program in Pharmaceutical
Sciences, Health Science Center, Federal University of Santa Maria, Santa
Maria, RS, Brazil
University Hospital of Santa Maria, Santa
Maria, RS, BrazilUniversity Hospital of Santa
MariaBrazilSanta Maria, RS, BrazilUniversity Hospital of Santa Maria, Santa
Maria, RS, Brazil
Departament of Microbiology and
Parasitology, Federal University of Santa Maria, Santa Maria, RS,
BrazilFederal University of Santa
MariaBrazilSanta Maria, RS, BrazilDepartament of Microbiology and
Parasitology, Federal University of Santa Maria, Santa Maria, RS,
Brazil
Table 2
Susceptibility profile of Candida spp. isolated from
blood cultures in 1995-2009. Detection of non-susceptible isolates based
on the breakpoints from CLSI M27-A3 and species-specific clinical
breakpoints from CLSI M27-S4
Table 3
Comparison (number and %) of non-susceptible
Candida spp. to antifungal agents detected using
the CLSI M27-A3 breakpoints and the new species-specific clinical
breakpoints from CLSI M27-S4
table_chartTable 1
Interpretative breakpoints according to the MICs
(µg/mL) from the M27-S4 and M27-A3 CLSI
documents
Candida Species
Antifungal agents*
M27-S4 breakpoints
M27-A3 breakpoints
S
SDD
R
S
SDD
R
C. albicans
FLZ
≤ 2.0
4.0
≥ 8.0
≤ 8.0
16-32
≥ 64
VOR
≤ 0.12
0.25-0.5
≥ 1.0
≤ 1.0
2.0
≥ 4.0
CAS
≤ 0.25
0.5
≥ 1.0
≤ 2.0
--
--
C. glabrata
FLZ
--
≤ 32
≥ 64
≤ 8.0
16-32
≥ 64
VOR
--
--
--
≤ 1.0
2.0
≥ 4.0
CAS
≤ 0.12
0.25
≥ 0.5
≤ 2.0
--
--
C. krusei
FLZ
--
--
--
≤ 8.0
16-32
≥ 64
VOR
≤ 0.5
1.0
≥ 2.0
≤ 1.0
2.0
≥ 4.0
CAS
≤ 0.25
0.5
≥ 1.0
≤ 2.0
--
--
C. parapsilosis
FLZ
≤ 2.0
4.0
≥ 8.0
≤ 8.0
16-32
≥ 64
VOR
≤ 0.12
0.25-0.5
≥ 1.0
≤ 1.0
2.0
≥ 4.0
CAS
≤ 2.0
4.0
≥ 8.0
≤ 2.0
--
--
C. tropicalis
FLZ
≤ 2.0
4.0
≥ 8.0
≤ 8.0
16-32
≥ 64
VOR
≤ 0.12
0.25-0.5
≥ 1.0
≤ 1.0
2.0
≥ 4.0
CAS
≤ 0.25
0.5
≥ 1.0
≤ 2.0
--
> 2.0
C.guilliermondii
CAS
≤ 2.0
4.0
≥ 8.0
≤ 2.0
--
> 2.0
table_chartTable 2
Susceptibility profile of Candida spp. isolated from
blood cultures in 1995-2009. Detection of non-susceptible isolates based
on the breakpoints from CLSI M27-A3 and species-specific clinical
breakpoints from CLSI M27-S4
Species
N
ATF*
MIC (µg/mL)
CLSI M27-A3 Breakpoints (n)
CLSI M27-S4 Breakpoints (n)
Range
MIC 50%
MIC 90%
R
SDD/I
R
SDD/I
C. parapsilosis
197
AMB
0.06-0.5
0.125
0.25
0
0
--
--
FLZ
0.125-4.0
1.0
4.0
0
0
0
14
ITZ
0.03-0.5
0.125
0.5
0
0
--
--
5FC
0.03-16.0
0.5
2.0
0
1
--
--
VOR
0.03-0.5
0.125
0.25
0
0
0
7
CAS
0.03-2.0
0.5
2.0
0
0
0
0
C. albicans
151
AMB
0.06-1.0
0.25
0.5
0
0
--
--
FLZ
0.125-4.0
0.25
4.0
0
0
0
15
ITZ
0.015-1.0
0.25
0.5
3
0
--
--
5FC
0.03-4.0
1.0
4.0
0
0
--
--
VOR
0.015-0.5
0.125
0.5
0
0
0
4
CAS
0.03-0.5
0.125
0.25
0
0
0
0
C. tropicalis
41
AMB
0.125-1.0
0.125
0.5
0
0
--
--
FLZ
0.25-32.0
2.0
8.0
0
1
3
8
ITZ
0.03-2.0
0.125
0.5
1
0
--
--
5FC
0.125-4.0
1.0
4.0
0
0
--
--
VOR
0.03-2.0
0.25
0.5
0
0
2
5
CAS
0.03-0.25
0.06
0.25
0
0
0
0
C. glabrata
15
AMB
0.125-0.5
0.5
1.0
0
0
--
--
FLZ
0.5-64.0
8.0
32.0
1
5
1
14
ITZ
0.03-2.0
0.5
1.0
4
3
--
--
5FC
0.125-16.0
4.0
16.0
0
4
--
--
VOR
0.06-4.0
0.5
2.0
2
0
--
--
CAS
0.06-0.5
0.125
0.25
0
0
0
3
C. guilliermondii
7
AMB
0.125-0.25
0.25
0.25
0
0
--
--
FLZ
0.5-4.0
2.0
4.0
0
0
--
--
ITZ
0.03-0.5
0.06
0.5
0
0
--
--
5FC
0.06-1.0
0.5
1.0
0
0
--
--
VOR
0.06-0.25
0.06
0.06
0
0
--
--
CAZ
0.03-0.25
0.06
0.06
0
0
0
0
C. lusitaniae
7
AMB
0.125-0.5
0.5
0.5
0
0
--
--
FLZ
0.25-4.0
2.0
2.0
0
0
--
--
ITZ
0.03-0.5
0.5
0.5
0
0
--
--
5FC
0.25-2.0
0.5
2.0
0
0
--
--
VOR
0.06-0.25
0.25
0.25
0
0
--
--
CAS
0.06-0.5
0.125
0.25
0
0
--
--
C. krusei
4
AMB
0.125-0.5
0.25
0.5
0
0
--
--
FLZ
4.0-8.0
8.0
8.0
4**
0
4**
0
ITZ
0.25-1.0
0.5
0.5
1
3
--
--
5FC
0.25-2.0
0.5
2.0
0
0
--
--
VOR
0.06-0.25
0.25
0.25
0
0
0
0
CAS
0.06-0.5
0.125
0.25
0
0
0
0
table_chartTable 3
Comparison (number and %) of non-susceptible
Candida spp. to antifungal agents detected using
the CLSI M27-A3 breakpoints and the new species-specific clinical
breakpoints from CLSI M27-S4
Antifungal Agents
M27-A3
M27-S4
SDD
R
SDD
R
Itraconazole
6
9
--
--
Fluconazole
6
5
51
8
Voriconazole
0
2
16
2
Flucytosine
5
0
--
--
Caspofungin
0
0
3
0
Total
17a (4.02%)
16 (3.79%)
70b(16.58%)
10 (2.36%)
33c (7.81%)
80d (18.95%)
Como citar
Santos, Edileusa Rosa dos et al. Suscetibilidade de|Candidaspp. isoladas de hemocultivos, avaliadas pelos|breakpointsdos documentos M27-A3 e M27-S4 do CLSI. Revista do Instituto de Medicina Tropical de São Paulo [online]. 2014, v. 56, n. 6 [Acessado 9 Abril 2025], pp. 477-482. Disponível em: <https://doi.org/10.1590/S0036-46652014000600004>. ISSN 1678-9946. https://doi.org/10.1590/S0036-46652014000600004.
Instituto de Medicina Tropical de São PauloAv. Dr. Enéas de Carvalho Aguiar, 470, 05403-000 - São Paulo - SP - Brazil, Tel. +55 11 3061-7005 -
São Paulo -
SP -
Brazil E-mail: revimtsp@usp.br
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