Doi:10.1016/j.ijantimicag.2009.08.009

International Journal of Antimicrobial Agents 35 (2010) 85–88 International Journal of Antimicrobial Agents Infections due to Candida haemulonii: species identification, antifungalsusceptibility and outcomes Sheng-Yuan Ruan , Yao-Wen Kuo , Chun-Ta Huang , Han-Chung Hsiue , Po-Ren Hsueh a Department of Internal Medicine, National Taiwan University Hospital Yun-Lin Branch, Yun-Lin, Taiwanb School of Medicine, National Taiwan University College of Medicine, Taipei, Taiwanc Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwand Department of Laboratory Medicine, National Taiwan University Hospital, Taipei, Taiwan Here we report the clinical features and treatment outcomes of three patients with Candida haemulonii infection. Candida haemulonii was confirmed by sequence analysis of the internal transcribed spacer (ITS) regions of the rRNA genes and the 18S rRNA genes. Two of the three isolates were associated with fun-gaemia and reduced susceptibility to fluconazole [minimum inhibitory concentrations (MICs) of 16 mg/L] and amphotericin B (MICs of 2 mg/L). However, one of these two patients responded to fluconazole ther- apy. Echinocandins, voriconazole and posaconazole demonstrated excellent in vitro potency against the 2009 Elsevier B.V. and the International Society of Chemotherapy. All rights reserved.
1. Introduction
for progressive abdominal fullness and postprandial vomiting.
Adhesion ileus due to previous operation and radiotherapy was Candida haemulonii rarely causes human disease, but an out- diagnosed by imaging studies. Cefmetazole was administered for break of fungaemia among neonates has been reported suspected intra-abdominal infection. The symptoms were not experience with invasive C. haemulonii infection is limited. The relieved by fasting, parenteral nutrition and prokinetic treatment.
paucity of reports in the past may be partly due to failure to identify Surgical intervention was performed and the patient was trans- this unusual Candida sp. by conventional yeast identification sys- ferred to the Intensive Care Unit (ICU) for post-operative care.
tems molecular methods have shown promising results Ventilator support was continued in the ICU. High fever with in identifying Candida spp. can be used to verify the iden- leukocytosis developed following admission to the ICU. Cefmeta- tification results of conventional methods. Antifungal susceptibility zole was changed to imipenem, and fluconazole (400 mg/day) was is another concern in managing invasive C. haemulonii infection administered empirically. Blood cultures from the peripheral vein because C. haemulonii has been reported to be less susceptible to and arterial line both yielded Candida sp. (Isolate A) identified using commonly used antifungal agents we report two cases the VITEK 1 system (bioMérieux, Marcy l’Etoile, France) and the of C. haemulonii fungaemia and one case with positive wound cul- API 32C system (bioMérieux) (Fluconazole was replaced ture for C. haemulonii. Patient characteristics, treatment outcomes with micafungin (100 mg/day) 10 days later owing to persistent and the results of species identification by commercial yeast iden- candidaemia. After 3 weeks of micafungin treatment, the patient tification systems and molecular methods are provided. Antifungal recovered well and subsequent blood cultures were negative for susceptibility testing was also performed.
yeasts. Owing to advanced age and co-morbidities, the patient wasstill ventilator-dependent after the infection had been controlled.
2. Case presentation
A 79-year-old man with a history of hypertension was referred An 85-year-old man with advanced rectal adenocarcinoma to NTUH owing to pneumonia with respiratory failure and left was admitted to National Taiwan University Hospital (NTUH) pneumothorax. Before transfer to our hospital he had receivedpiperacillin/tazobactam treatment for 1 week and imipenem foranother 1 week. High fever with leukocytosis was noted after being ∗ Corresponding author. Tel.: +886 2 2312 3456x5355; fax: +886 2 2322 4263.
admitted to the ICU. Blood culture from the peripheral vein yielded Candida sp. (Isolate B) Cultures of sputum, urine and the 0924-8579/$ – see front matter 2009 Elsevier B.V. and the International Society of Chemotherapy. All rights reserved.
S.-Y. Ruan et al. / International Journal of Antimicrobial Agents 35 (2010) 85–88 central catheter tip were all negative for fungus. The candidaemia was cured by 2 weeks of fluconazole treatment (400 mg/day). The patient was subsequently referred to a specialised weaning unit owing to difficulty in weaning off ventilator support.
A 78-year-old man with hypertension, chronic kidney disease and peripheral vascular occlusive disease (PVOD) visited the hos- pital because of gangrene of the left fifth toe with pus discharge for 3 weeks. The chronic non-healing wound was considered to be PVOD associated. Wound culture yielded Candida sp. (Isolate C) The wound improved with frequent dressing changes without any 3. Materials and methods
All three isolates of Candida spp. were initially identified to species level by standard laboratory procedures, including mor-phological identification, VITEK 1 and API 32C. The species ofthe isolates were further identified using VITEK 2 Yeast cards (bioMérieux), Candida chips sequence analysis of the rRNA gene internal transcribed spacer (ITS) regions 18S rRNAgenes primers ITS1 (5 -TCCGTAGGTGAACCTGCGG-3 ) andITS4 (5 -TCCTCCGCTTATTGATATGC-3 ) were used to amplify the ITS regions by polymerase chain reaction (PCR) as described previouslyprimers 18SF (5 -ATTGGAGGGCAAGTCTGGTG-3 ) and 18SR (5 -CCGATCCCTAGTCGGCATAG-3 ) were used for sequencing the18S rRNA genes. The sequences were compared with sequences available in the GenBank database using the BLAST program. The results of identification are summarised in Antifungal susceptibility testing was performed by the broth microdilution method according to guidelines published by the Clinical and Laboratory Standards Institute inimum inhibitory concentrations (MICs) were determined after incubation for 48 h.
Two reference strains (Candida parapsilosis ATCC 22019 and Can- dida krusei ATCC 6258) were used as quality control strains. The results of susceptibility testing are shown in Antifungal susceptibilities were interpreted as recommended Sus- ceptibility breakpoints were defined as ≤8 mg/L for fluconazole, ≤0.125 mg/L for itraconazole and ketoconazole, ≤4 mg/L for flucy- tosine, ≤1 mg/L for voriconazole, posaconazole and amphotericin B and ≤2 mg/L for caspofungin, anidulafungin and micafungin 4. Results and discussion
The disease presentations of C. haemulonii fungaemia, including high fever and leukocytosis, did not differ from other common nosocomial infections. Regarding patient characteristics, the three reported cases were all of advanced age (78–85 years). In previous reports, patients with C. haemulonii fungaemia were either very old or very young Other frequently reported predisposing factors include central venous catheter insertion, malignancy and mechanical ventilation In our cases, ventilator and central venous catheter use were present in thetwo patients with fungaemia, and the first case had cancer. The characteristics of patients with C. haemulonii fungaemia suggested that invasive C. haemulonii infection usually develops in critically Accurate identification of C. haemulonii is important for clin- icians in choosing optimal therapy, since C. haemulonii had been reported to be resistant to fluconazole and amphotericin B However, conventional yeast identification systems are not reli- able in identifying this rare Candida sp. In this study, we compared the identification results of several conventional yeast S.-Y. Ruan et al. / International Journal of Antimicrobial Agents 35 (2010) 85–88 identification systems and molecular methods. The VITEK 2 system showed high consistency with tested molecular methods in identi-fying C. haemulonii The VITEK 1 system failed to identifyC. haemulonii in all three cases and recognised the isolates as Pichia ohmeri. The API 32C system also failed to identify C. haemulonii and reported the isolates as Candida sake or other Candida spp. Forthe API 32C system, the three C. haemulonii isolates yielded twobiocodes that were different from a previous report of the rarity of the species, the efficacy of commonly used yeast identification systems to identify C. haemulonii has not been well evaluated. The findings of this study suggest that the VITEK 2system, compared with VITEK 1 and API 32C system, is a bettersystem for identifying C. haemulonii. In a recent study, the isolatesidentified as C. haemulonii by VITEK 2 were all confirmed as C.
haemulonii or its closely related species the VITEK 2 system still cannot differentiate C. haemulonii from its closely related species, such as Candida pseudohaemulonii Antifungal resistance is a great concern in the management of patients with invasive candidiasis. Candida haemulonii was previ-ously reported to be resistant to fluconazole and amphotericin B susceptible to caspofungin and micafungin n this study, the isolates obtained from the three patients showed simi-lar susceptibility patterns. Two isolates associated with fungaemiaexhibited amphotericin B MICs of 2 mg/L. Among the five tested azoles, the isolates were less susceptible to fluconazole and itra-conazole. In contrast, voriconazole and posaconazole showed high in vitro potency. Clinically, fluconazole failed to eradicate candi- daemia in the first case but succeeded in the second case. Thehigher fluconazole MIC (16 mg/L in both cases) may account for theuncertainty of treatment outcome. The three tested echinocandinswere highly active against C. haemulonii, especially micafungin and anidulafungin. In the first case, micafungin successfully eradicated C. haemulonii fungaemia, which failed to respond to initial flucona- zole treatment. Flucytosine also showed good in vitro potency. Insummary, fluconazole and amphotericin B are not reliable empir-ical antifungal agents for C. haemulonii fungaemia. Echinocandins or newer triazoles may be better empirical antifungal agents for References
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