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Mechanism of Increased Fluconazole Resistance in Candida glabrata during Prophylaxis
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Candida glabrata can become resistant to fluconazole, causing persistent colonization and invasive infection during prolonged exposure to the drug. To determine the mechanism of resistance in this setting, weekly oropharyngeal cultures for C. glabrata were obtained over a 2-year period from hematopoietic stem cell transplant recipients who were receiving fluconazole prophylaxis. In 20 patients from whom at least two isolates of the same karyotype were obtained more than two weeks apart, fluconazole MICs doubled every 31 days on average. The mechanism of fluconazole resistance in isolates from the 14 of the 20 patients studied in whom MICs changed at least fourfold was studied. Cellular resistance was accompanied by increased drug efflux as measured by decreased accumulation of fluconazole and rhodamine 6G and increased abundance of transcripts from two drug transporters, CgCDR1 and PDH1. The rapidity and regularity of the rising resistance indicated that C. glabrata is able to upregulate drug efflux without losing the ability to maintain colonization.
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“Other transporter genes have been reported to be upregulated in azole-resistant C. glabrata (CgCDR1, CgCDR2 (formerly named PDH1) and CgSNQ2 (another ABC transporter)) [100–102], C. dubliniensis (CdCDR1 and CdCDR2) [103], C. krusei (ABC1 and 2) [104, 105], and C. tropicalis (CDR1-homologue) isolates [44].”
From Candida Infections, Causes, Targets, and Resistance Mechanisms: Traditional and Alternative Antifungal Agents (2013) · cites this paper as [102]
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“…decreased susceptibility in the absence of HST1 The overexpression of ABC efflux pumps represents the major mechanism responsible for high-level azole resistance in C. glabrata isolates (Bennett et al., 2004; Brun et al., 2004; Borst et al., 2005; Cannon et al., 2009; Ferrari et al., 2009).”
BackgroundA Novel Antifungal Plasma-Activated Hydrogel
Liu, Z., Zheng, Y., Dang, J., Zhang, J., Dong, F., Wang, K., & Zhang, J. (2019) · ACS Applied Materials & Interfaces · doi:10.1021/acsami.9b04700 · Cited by 62
Whaley, S. G., Zhang, Q., Caudle, K. E., & Rogers, P. D. (2018) · Antimicrobial Agents and Chemotherapy · doi:10.1128/aac.01070-18 · Cited by 59
“A third study of resistant clinical isolates found CDR1 or PDH1 overexpression in the resistant isolate of 12 of 14 matched clinical isolates (20).”
BackgroundSkn7p is involved in oxidative stress response and virulence of Candida glabrata
Saijo, T., Miyazaki, T., Izumikawa, K., Mihara, T., Takazono, T., Kosai, K., Imamura, Y., Seki, M., Kakeya, H., Yamamoto, Y., et al. (2010) · Mycopathologia · doi:10.1007/s11046-009-9233-5 · Cited by 59
“RNA preparation was performed as described previously [ 6 , 33] with a few modification.”
MethodSelf-citationPathogenesis and Antifungal Drug Resistance of the Human Fungal Pathogen Candida glabrata
Tscherner, M., Schwarzmüller, T., & Kuchler, K. (2011) · Pharmaceuticals · doi:10.3390/ph4010169 · Cited by 60
“glabrata azole resistance: Cdr1, Cdr2 (Pdh1) and Snq2 [25,92,93].”
Multidrug transporters of Candida species in clinical azole resistance
Prasad, R., Nair, R., & Banerjee, A. (2019) · Fungal Genetics and Biology · doi:10.1016/j.fgb.2019.103252 · Cited by 60
Azole‐resistant Candida spp. – emerging pathogens?
Tobudic, S., Kratzer, C., & Presterl, E. (2012) · Mycoses · doi:10.1111/j.1439-0507.2011.02146.x · Cited by 57
Candida glabrata erg1 Mutant with Increased Sensitivity to Azoles and to Low Oxygen Tension
Tsai, H., Bard, M., Izumikawa, K., Krol, A. A., Sturm, A. M., Culbertson, N. T., Pierson, C. A., & Bennett, J. E. (2004) · Antimicrobial Agents and Chemotherapy · doi:10.1128/aac.48.7.2483-2489.2004 · Cited by 56
“This species is naturally about 8-fold more resistant to fluconazole than Candida albicans, and following drug exposure, the levels of resistance can increase 16-fold more, leading to clinically significant fluconazole resistance (1, 18).”
BackgroundSelf-citationRecent insights into the mechanisms of antifungal resistance
Barker, K. S., & Rogers, P. D. (2006) · Current Infectious Disease Reports · doi:10.1007/s11908-006-0019-3 · Cited by 54
Augmenting Azoles with Drug Synergy to Expand the Antifungal Toolbox
Kane, A., & Carter, D. A. (2022) · Pharmaceuticals · doi:10.3390/ph15040482 · Cited by 56
Salazar, S. B., Simões, R., Pedro, N. A., Pinheiro, M. J. F., Carvalho, M. F. N. N., & Mira, N. P. (2020) · Journal of Fungi · doi:10.3390/jof6010023 · Cited by 58
“It is believed that this growing emergence of resistance to azoles is linked to the massive use of fluconazole in prophylaxis of patients considered at risk of suffering an infection caused by Candida [26-29].”
BackgroundTumbarello, M., Sanguinetti, M., Trecarichi, E. M., La Sorda, M., Rossi, M., de Carolis, E., de Gaetano Donati, K., Fadda, G., Cauda, R., & Posteraro, B. (2008) · Journal of Antimicrobial Chemotherapy · doi:10.1093/jac/dkn381 · Cited by 53
“glabrata isolates from transplant recipients receiving fluconazole prophylaxis showed that the MICs doubled, on average, every 31 days.(5) Expression of CgCDR1, CgCDR2 and CgSNQ2 was up-regulated to different extents in the fluconazole-resistant (6 patients) or fluconazole-SDD (8 patients) isolates, but not in the FS…”
BackgroundCandida glabrata is unusual with respect to its resistance to cationic antifungal proteins
Helmerhorst, E. J., Venuleo, C., Beri, A., & Oppenheim, F. G. (2005) · Yeast · doi:10.1002/yea.1241 · Cited by 53
“Otherwise, it can be hypothesized that the capacity of C. glabrata to upregulate the expression of the drug efflux pumps encoded by CDR1 and PDH1 (Bennett et al., 2004; Vermitsky and Edlind, 2004) may also negatively affect the efficacy and intracellular accumulation of cationic proteins.”
BackgroundUPC2A Is Required for High-Level Azole Antifungal Resistance in Candida glabrata
Whaley, S. G., Caudle, K. E., Vermitsky, J.-P., Chadwick, S. G., Toner, G., Barker, K. S., Gygax, S. E., & Rogers, P. D. (2014) · Antimicrobial Agents and Chemotherapy · doi:10.1128/aac.02217-13 · Cited by 52
“isolates from head and neck radiation patients, stem cell transplant patients, and human immunodeficiency virus (HIV) patients and for vulvovaginal candidiasis (11, 13, 39, 56, 57).”
BackgroundRamos, A., Pintos-Pascual, I., Guinea, J., Gutiérrez‐Villanueva, A., Abreu, E. V. G., Díaz-García, J., Asensio, Á., Iranzo, R., Sánchez‐Romero, I., Muñoz‐Algarra, M., et al. (2022) · Journal of Fungi · doi:10.3390/jof8050451 · Cited by 53
“Previous use of fluconazole has been considered a risk factor for the development of resistance in several Candida species; however, no statistically significant difference was detected in our patients (Tables 3 and 4) [24,25].”
Fungicidal activity of human lactoferrin-derived peptides based on the antimicrobial αβ region
Kondori, N., Baltzer, L., Dolphin, G. T., & Mattsby‐Baltzer, I. (2010) · International Journal of Antimicrobial Agents · doi:10.1016/j.ijantimicag.2010.08.020 · Cited by 52
“glabrata to histatin 5 suggested that the cellular characteristics providing resistance to azoles were distinct from those of cationic antifungal peptides [15,23,24].”
BackgroundStavrou, A. A., Lackner, M., Lass‐Flörl, C., & Boekhout, T. (2019) · FEMS Yeast Research · doi:10.1093/femsyr/foz037 · Cited by 53
Carvalho, G. G., Felipe, M. P., & Costa, M. S. (2009) · The Journal of Microbiology · doi:10.1007/s12275-009-0059-0 · Cited by 51
Singh, S. T., & Supuran, C. T. (2013) · Journal of Enzyme Inhibition and Medicinal Chemistry · doi:10.3109/14756366.2013.800059 · Cited by 50
Invasive Fungal Infections and Their Epidemiology: Measures in the Clinical Scenario
Bajpai, V. K., Khan, I., Shukla, S., Kumar, P., Rather, I. A., Park, Y.-H., Huh, Y. S., & Han, Y. (2019) · Biotechnology and Bioprocess Engineering · doi:10.1007/s12257-018-0477-0 · Cited by 53
Lee, H., Lamichhane, A. K., Garraffo, H. M., Kwon-Chung, K. J., & Chang, Y. C. (2012) · Molecular Microbiology · doi:10.1111/j.1365-2958.2012.08016.x · Cited by 50
“…characterized in S. cerevisiae and pathogenic Candida species such as C. albicans and C. glabrata (Kontoyiannis et al., 1999; Sanglard and Odds, 2002; White et al., 2002; Bennett et al., 2004; Brun et al., 2004; Akins, 2005; Helmerhorst et al., 2006; Tsai et al., 2006; Lamping et al., 2007).”
Molecular Evolution of Minisatellites in Hemiascomycetous Yeasts
Richard, G., & Dujon, B. (2005) · Molecular Biology and Evolution · doi:10.1093/molbev/msj022 · Cited by 45
“Candida glabrata is a pathogenic yeast, a causative agent of human candidiasis (Bennett, Izumikawa, and Marr 2004).”
BackgroundVullo, D., Leewattanapasuk, W., Mühlschlegel, F. A., Mastrolorenzo, A., Capasso, C., & Supuran, C. T. (2013) · Bioorganic & Medicinal Chemistry Letters · doi:10.1016/j.bmcl.2013.02.092 · Cited by 46
Innocenti, A., Leewattanapasuk, W., Mühlschlegel, F. A., Mastrolorenzo, A., & Supuran, C. T. (2009) · Bioorganic & Medicinal Chemistry Letters · doi:10.1016/j.bmcl.2009.06.048 · Cited by 46
Etiopathology, Epidemiology, Diagnosis, and Treatment of Fungal Keratitis
Bisen, A. C., Sanap, S. N., Agrawal, S., Biswas, A., Mishra, A., Verma, S. K., Singh, V., & Bhatta, R. S. (2024) · ACS Infectious Diseases · doi:10.1021/acsinfecdis.4c00203 · Cited by 49
Posteraro, B., Martucci, R., Sorda, M. L., Fiori, B., Sanglard, D., Carolis, E. D., Florio, A. R., Fadda, G., & Sanguinetti, M. (2009) · Journal of Clinical Microbiology · doi:10.1128/jcm.02070-08 · Cited by 44
Costa, C., Ribeiro, J., Miranda, I. M., Silva-Dias, A., Cavalheiro, M., Costa-de-Oliveira, S., Rodrigues, A. G., & Teixeira, M. C. (2016) · Frontiers in Microbiology · doi:10.3389/fmicb.2016.00526 · Cited by 43
“As expected (Miyazaki et al., 1998; Sanglard et al., 1999; Bennett et al., 2004), the expression of CgCDR1 and CgCDR2 was found to correlate with azole drug resistance in the clinical isolates (Figure 3).”
ResultSTB5 Is a Negative Regulator of Azole Resistance in Candida glabrata
Noble, J. A., Tsai, H., Suffis, S. D., Su, Q., Myers, T. G., & Bennett, J. E. (2012) · Antimicrobial Agents and Chemotherapy · doi:10.1128/aac.01278-12 · Cited by 40
Self-citationRezaei‐Matehkolaei, A., Shafiei, S., & Mahmoudabadi, A. Z. (2016) · PubMed Central · Cited by 41
An Introduction to the Medically Important Candida Species
Moran, G. P., Coleman, D. C., & Sullivan, D. J. (2014) · ASM Press eBooks · doi:10.1128/9781555817176.ch2 · Cited by 51
In VivoandIn VitroAcquisition of Resistance to Voriconazole by Candida krusei
Ricardo, E., Miranda, I. M., Faria‐Ramos, I., Silva, R. M., Rodrigues, A. G., & Pina‐Vaz, C. (2014) · Antimicrobial Agents and Chemotherapy · doi:10.1128/aac.02603-14 · Cited by 40
“, Cdr1p efflux activity contributes more to FLC resistance than Cdr2p (28, 29).”
BackgroundMechanisms of azole resistance in clinical isolates of Candida glabrata from two hospitals in China
Yao, D., Chen, J., Chen, W., Li, Z., & Hu, X. (2019) · Infection and Drug Resistance · doi:10.2147/idr.s202058 · Cited by 39
“11,12 These transporters are regulated by the zinc fi nger transcription factor CgPdr1, which functionally resembles the Saccharomyces cerevisiae Pdr1 (ScPdrl) and ScPdr3 transcription factors.”
Metadata
- Authors
- Bennett, J. E., Izumikawa, K., & Marr, K. A.
- Affiliations
- National Institutes of Health (US)
- University of Washington (US)
- Venue
- Antimicrobial Agents and Chemotherapy
- Publisher
- American Society for Microbiology
- Published
- 2004-05
- Volume
- 48
- Issue
- 5
- Pages
- 1773-1777
- ISSN
- 0066-4804 (ISSN-L)
- 1098-6596
- PMC
- PMC400565
- OpenAlex
- W2108027055
- Cited by
- 217
- References
- 20
- Citations by year
- 2025: 4 · 2024: 5 · 2023: 2 · 2022: 6 · 2021: 7 · 2020: 6 · 2019: 10 · 2018: 11 · 2017: 10 · 2016: 7 · 2015: 10 · 2014: 15 · 2013: 17 · 2012: 11
- FWCI
- 8.64
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Locations
- Antimicrobial Agents and Chemotherapy (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- Funders
- National Institutes of Health (5k08ai001571-02)
- National Institute of Allergy and Infectious Diseases (AI01571)
- Topics
- Health Sciences › Medicine › Infectious Diseases › Antifungal resistance and susceptibility
- Health Sciences › Medicine › Microbiology (medical) › Antibiotic Resistance in Bacteria
- Life Sciences › Agricultural and Biological Sciences › Plant Science › Fungal Plant Pathogen Control
- Keywords
- Candida glabrata, fluconazole resistance, antifungal prophylaxis, hematopoietic stem cell transplant recipients, drug efflux, oropharyngeal colonization, invasive candidiasis
- MeSH terms
- Antifungal Agents, Candidiasis, Fluorescent Dyes, Karyotyping, Rhodamines, Blotting, Northern, Fluconazole, Electrophoresis, Gel, Pulsed-Field, Reverse Transcriptase Polymerase Chain Reaction, Drug Resistance, Fungal, Drug Resistance, Multiple, Fungal, Candida glabrata
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