Diagnostic Microbiology and Infectious Disease 57 (2007) 399 404

www.elsevier.com/locate/diagmicrobio

Antifungal susceptibility of 1000 Candida bloodstream isolates to

5 antifungal drugs: results of a multicenter study conducted in
Sao Paulo, Brazil, 19952003
Daniel Archimedes da Mattaa, Leila Paula de Almeidaa, Antonia Maria Machadoa,
Ana Carolina Azevedoa, Elisa Junko Ura Kusanob, Norma Fracalanza Travassosc,
Reinaldo Salomaoa,d, Arnaldo Lopes Colomboa,4
a
Division of Infectious Diseases, Universidade Federal de Sao Paulo, SP 04023-062, Brazil
Microbiology Section, Hospital do Servidor Publico Estadual de Sao Paulo, SP 04038-034, Brazil
c
Microbiology Section, Hospital Beneficencia Portuguesa, SP 01323-000, Brazil
d
Division of Infectious Diseases, Hospital e Maternidade Santa Marcelina, SP 08270-070, Brazil
Received 12 July 2006; accepted 21 October 2006

Abstract
We evaluated all Candida sp. bloodstream isolates obtained from patients admitted to 4 tertiary care hospitals between 1995 and 2003 in
the city of Sao Paulo, Brazil. Susceptibility to amphotericin B, 5-fluorocytosine, fluconazole (FCZ), itraconazole (ITZ), and voriconazole
(VCZ) was determined using the Clinical Laboratory Standards Institute broth microdilution method. We tested a total of 1000 strains,
including 400 strains of Candida albicans (40%), 243 of Candida tropicalis (24.3%), 238 of Candida parapsilosis (23.8%), 44 of C.
glabrata (4.4%), 30 of Candida guilliermondii (3%), and 25 of Candida rugosa (2.5%). Only 1.9% of the strains tested were susceptible in a
dose-dependent manner, and 0.2% of them were resistant to FCZ. Almost 100% of the strains were susceptible to VCZ. Despite that azole
resistance was a rare finding, a trend toward increased resistance among C. rugosa strains to FCZ and ITZ was noted.
D 2007 Elsevier Inc. All rights reserved.
Keywords: Candida spp.; Candidemia; Antifungal susceptibility testing; Resistance

1. Introduction
A progressive increase in the frequency of candidemia
has been observed worldwide, particularly among patients
receiving antibiotics, immunosuppressive therapy, or parenteral nutrition, as well as among patients exposed to invasive
medical procedures (Verduyn Lunel et al., 1999). Studies
conducted in tertiary care hospitals in different countries of
Europe and in the United States have shown incidence rates
of candidemia ranging from 0.17 to 0.76 and 0.28 to 0.96
per 1000 admissions, respectively (Kao et al., 1999;
Marchetti et al., 2004; Diekema et al., 2002; Richet et al.,
2002). It is worth mentioning that candidemia leads to an

4 Corresponding author. Tel.: +55-11-5081-3240; fax: +55-11-50830806.

E-mail address: colomboal@terra.com.br (A.L. Colombo).
0732-8893/$ see front matter D 2007 Elsevier Inc. All rights reserved.
doi:10.1016/j.diagmicrobio.2006.10.011

increased time of hospitalization and has a mortality rate of

about 50% (Gudlaugsson et al., 2003).
Antimicrobial resistance is a concern regarding human
pathogens including fungi. Antifungal resistance surveillance programs have been conducted recently by different
groups, and there is mounting evidence suggesting that the
emergence of invasive infections due to Candida nonalbicans (CNA) spp. resistant to fluconazole (FCZ) may be
an increasing problem in several medical centers in the
world. The resistance rates of Candida glabrata bloodstream isolates to FCZ range from 7% to 14% in American
hospitals and from 3.7% to 40% in European hospitals
(Chryssanthou, 2001; Diekema et al., 2002; OstroskyZeichner et al., 2003; Hajjeh et al., 2004; Cuenca-Estrella
et al., 2005; Tortorano et al., 2006).
The surveillance programs focused on candidemia in
South American hospitals remain limited. In addition, there
are few studies extensive enough to provide temporal and

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D.A. da Matta et al. / Diagnostic Microbiology and Infectious Disease 57 (2007) 399 404

geographic trends in terms of the emergence of antifungal

resistance in our region. In the study described here, we
provided data on the trend of species distribution and azole
resistance among 1000 Candida bloodstream isolates
obtained from patients admitted to 4 medical centers from
1995 to 2003.

2. Materials and methods

2.1. Samples
We evaluated all Candida sp. bloodstream isolates
obtained from patients admitted to 4 tertiary care hospitals
between January 1995 and December 2003 in the city of
Sao Paulo, Brazil: Hospital Sao Paulo, Hospital do Servidor
Publico Estadual, Casa de Saude Santa Marcelina, and
Hospital da Beneficencia Portuguesa. The isolates of
Candida spp. recovered from blood cultures from each
center were sent to the Special Mycology Laboratory, at the
Universidade Federal de Sao Paulo, for further species
identification and antifungal susceptibility testing. Isolates
were stored on YPD glycerol (1% yeast extract, 2%
peptone, 2% dextrose, and 3% glycerol) at 70 8C for
different periods before they were tested.
2.2. Yeast identification procedures
The isolates were plated onto CHROMagar Candida
(CHROMagar Microbiology, Paris, France) to check the
purity and viability of all original yeast cultures. C. albicans
isolates were identified if they exhibited green colonies on
CHROMagar Candida and formed chlamydospores on corn
meal-Tween 80 agar. CNA species isolates were identified
on the basis of their micromorphology on corn meal-Tween
80 agar and biochemical tests performed with the commercial system ID 32C (bioMerieux Marcy lEtoile, France)
(Warren and Hazen, 1999).
2.3. In vitro susceptibility testing
Antifungal susceptibility testing was performed using the
Clinical Laboratory Standards Institute (CLSI, 2002,
formerly National Committee for Clinical Laboratory
Standards) broth microdilution assay method. The following antifungal drugs, supplied by the manufacturers as pure
standard compounds, were tested: amphotericin B (AMB)
and 5-fluorocytosine (5FC) (Sigma Chemical, St. Louis,
MO), FCZ and voriconazole (VCZ) (Pfizer, New York,
NY), and itraconazole (ITZ) (Janssen Pharmaceutica, Titusville, NJ). Briefly, the medium used was RPMI-1640
(Sigma Chemical), with l-glutamine, without bicarbonate,
and buffered at pH 7.0 with 3-(N-morpholino)propanesulfonic acid (0.165 mol/L, Sigma Chemical). The yeast
inoculum suspension was prepared by using a spectrophotometer to obtain a final yeast concentration containing 0.5
to 2.5  103 cells/mL. The plates were incubated at 35 8C
for 48 h. Quality control was ensured by testing the CLSIrecommended strains, Candida krusei ATCC 6258 and

C. glabrata ATCC 22019. The MIC for AMB was

considered the lowest tested concentration able to prevent
any visible growth. The MICs for each azole and 5FC were
defined as the lowest concentration resulting in a
prominent inhibition of growth (~50%) compared with the
control growth (CLSI, 2002).
The breakpoints for azoles and 5FC MICs were those
suggested by the CLSI (2002) M27-A2 document and Pfaller
et al. (2006a). Because of the lack of consensus about the
definition of MIC breakpoints for AMB, arbitrary values
suggested by a previous study were used by Nguyen et al.
(1998). Isolates with MICs V 1 Ag/mL for AMB, V 4 Ag/mL
for 5FC, V 8 Ag/mL for FCZ, V 0.125 Ag/mL for ITZ, and
V 1 Ag/mL for VCZ were considered susceptible. Isolates
with MICs from 8 to 16 Ag/mL were classified as intermediate to 5FC. Isolates with MICs from 16 to 32 Ag/mL for
FCZ, 0.25 to 0.5 Ag/mL for ITZ, and 2 Ag/mL for VCZ were
considered as susceptible in a dose-dependent manner
(SDD). MICs z 2 Ag/mL for AMB, z 32 Ag/mL for 5FC,
z 64 Ag/mL for FCZ, z 1 Ag/mL for ITZ, and z 4 Ag/mL for
VCZ were considered resistant.
Analysis of the temporal influence on species distribution
and antifungal susceptibility pattern was arbitrarily performed considering 2 different intervals: 1995 to 1999
(period 1) and 2000 to 2003 (period 2). Statistical analysis
was performed by using v 2 and KruskalWallis test when
appropriated with the software SPSS 11.0.1 software (SPSS,
Chicago, IL).

3. Results
3.1. Distribution of Candida spp.
Table 1 summarizes the distribution of 1000 Candida sp.
bloodstream isolates. Only a single candidemic episode for
each patient was considered for the study. Four hundred of
them were C. albicans (40%), 243 Candida tropicalis
(24.3%), 238 C. parapsilosis (23.8%), 44 C. glabrata

Table 1
Species distribution of 1000 Candida bloodstream isolates stratified in 2
periods: 1995 to 1999 and 2000 to 2003
Candida spp.

Period 1
(19951999),
n (%)

Period 2
(20002003),
n (%)

Total,
n (%)

C. albicans
C. tropicalis
C. parapsilosis
C. glabrata
C. guilliermondii
C. rugosa
C. krusei
Other Candida spp.
Total

129 (43)
74 (24.7)
58 (19.5)
16 (5.5)
12 (4)
6 (2)
1 (0.3)
3a (1)
299

271 (38.6)
169 (24.1)
180 (25.6)
28 (4)
18 (2.7)
19 (2.7)
5 (0.7)
11b (1.6)
701

400 (40)
243 (24.3)
238 (23.8)
44 (4.4)
30 (3)
25 (2.5)
6 (0.6)
14 (1.4)
1000

.18
.82
.03
.33
.22
.51
.47
.48

C. pelliculosa (2) and C. zeylanoides (1).

C. lusitaniae (5); C. pelliculosa (4); C. famata (1), and
C. lipolytica (1).
b

D.A. da Matta et al. / Diagnostic Microbiology and Infectious Disease 57 (2007) 399 404

401

Table 2
In vitro susceptibilities of 1000 Candida bloodstream isolates tested against FCZ, ITZ, and VCZ
Candida spp. (n)

C. albicans (400)
C. tropicalis (243)
C. parapsilosis (238)
C. glabrata (44)
C. guilliermondii (30)
C. rugosa (25)
C. krusei (6)d
Othere (14)
Total (1000)
a
b
c
d
e

FCZ

ITZ

VCZ

Ag/mL

Ag/mL

Ag/mL

MIC50/MIC90

Sa/SDDb/Rc

MIC50/MIC90

S/SDD/R

MIC50/MIC90

S/SDD/R

0.25/0.5
0.5/1
0.5/2
4/8
2/4
2/32
16/
2/2
0.5/2

100/0/0
100/0/0
100/0/0
93.2/2.3/4.5
96.7/3.3/0
56/44/0
0/100/0
100/0/0
97.9/1.9/0.2

0.03/0.06
0.03/0.06
0.03/0.06
0.25/1
0.25/0.25
0.03/0.5
0.25/
0.03/0.125
0.03/0.125

99.5/0.5/0
98.4/1.6/0
98.8/0.8/0.4
34.1/50/15.9
43.4/50/6.6
68/32/0
33.5/66.5/0
92.9/7.1/0
93.2/5.8/1

0.03/0.03
0.03/0.06
0.03/0.03
0.125/0.25
0.06/0.125
0.25/0.5
0.25/
0.03/0.06
0.03/0.06

100/0/0
100/0/0
100/0/0
93.2/2.3/4.5
100/0/0
100/0/0
100/0/0
100/0/0
99.7/0.1/0.2

Percentage of isolates susceptible to azoles by using CLSI (2002).

Percentage of isolates susceptible-dose dependent to azoles by using CLSI (2002).
Percentage of isolates resistant to azoles by using CLSI (2002).
Isolates of C. krusei should be always assumed to be intrinsically resistant to fluconazole (CLSI, 2002).
C. pelliculosa (6), C. lusitaniae (5), C. famata (1), C. lipolytica (1), and C. zeylanoides (1).

(4.4%), 30 Candida guilliermondii (3%), 25 Candida rugosa

(2.5%), 6 C. krusei and Candida pelliculosa (0.6%), and
5 Candida lusitaniae (0.5%), and there was 1 isolate of each
species of Candida famata, Candida lipolytica, and Candida
zeylanoides (0.1%). The species distribution throughout the
9-year period was stratified by 2 different intervals: 1995 to
1999 (period 1) and 2000 to 2003 (period 2). The rank order
of Candida sp. distribution was relatively stable over the
9-year period of study, except for the increased number of
C. parapsilosis strains isolated in the 2nd period (19.5 
25.6, P = .03). Except for the 25 strains of C. rugosa that
were isolated from patients admitted in a single institution,
the rank order of Candida sp. distribution was basically the
same within the 4 medical centers.
3.2. Antifungal susceptibility testing
MIC values of 1000 strains of Candida spp. ranged
from 0.06 to 1 Ag/mL for AMB, 0.125 to z 64 Ag/mL for
5FC and FCZ, 0.03 to 8 Ag/mL for ITZ, and 0.03 to 4 Ag/
mL for VCZ. Table 2 summarizes the MICs at which 50%
(MIC50) and 90% (MIC90) of the isolates tested were
inhibited for each drug and the susceptibility categories to
FCZ, ITZ, and VCZ according to CLSI (2002) and Pfaller
et al. (2006a).

3.3. Amphotericin B
None of the strains showed MIC values z 2 Ag/mL for
AMB, including the 5 strains of C. lusitaniae.
3.4. 5-Fluorocytosine
Twenty-five isolates (2.5%) were resistant to 5FC,
including 13 strains of C. tropicalis, 7 of C. albicans, 4
of C. parapsilosis, and 1 of C. krusei.
3.5. Fluconazole
All strains of C. albicans, C. tropicalis, C. parapsilosis,
C. pelliculosa , C. lusitaniae , C. zeylanoides, and
C. lipolytica strains had MIC values V 8 Ag/mL and were
classified as susceptible to FCZ. A total of 19 (1.9%) isolates
were considered SDD to FCZ, including 11 strains of
C. rugosa, 6 of C. krusei, 1 of C. guilliermondii, and 1 of
C. glabrata. Only 2 (0.2%) C. glabrata isolates were
resistant to this antifungal agent (MIC z 64 Ag/mL).
3.6. Itraconazole
A total of 58 (5.8%) isolates were SDD to ITZ, including
22 strains of C. glabrata, 15 of C. guilliermondii, 8 of
C. rugosa strains, 4 of C. krusei, 4 of C. tropicalis, 2 of

Table 3
Susceptibility profile of 1000 Candida bloodstream isolates tested against 5 antifungal drugs
Candida spp. (n1/n2)

% Susceptible isolates tested during time intervals: 19951999/20002003

AMB

5-Fluorocytosine

FCZ

ITZ

VCZ

C. albicans (129/271)
C. tropicalis (74/169)
C. parapsilosis (58/180)
C. glabrata (16/28)
C. guilliermondii (12/18)
C. rugosa (6/19)
Total (299/701)

100/100
100/100
100/100
100/100
100/100
100/100
100/100

96.9/98.9
97.3/91.1
98.3/97.2
100/100
100/100
100/100
97.4/96.3

100/100
100/100
100/100
100/89.3a
91.7/100
100/42b
99.3/97.3

99.2/99.6
97.3/98.8
96.5/99.5
50/28.6a
50/59
100/57.9b
93/93.3

100/100
100/100
100/100
100/89.3
100/100
100/100
100/99.6

a
b

Diferences were not statistically significant to fluconazole ( P = .55) and itraconazole ( P = .16).
Diferences were statistically significant to fluconazole ( P = .01) and itraconazole ( P = .06).

402

D.A. da Matta et al. / Diagnostic Microbiology and Infectious Disease 57 (2007) 399 404

C. parapsilosis, 2 of C. albicans, and 1 of C. pelliculosa.

Seven strains of C. glabrata, 2 of C. guilliermondii, and 1 of
C. parapsilosis were resistant to this antifungal drug.
3.7. Voriconazole
All the isolates that were susceptible in vitro to FCZ and
ITZ were also susceptible to VCZ. Among the 19 isolates
classified as SDD to FCZ, only 1 of them was SDD to VCZ.
The 2 C. glabrata strains resistant to FCZ were classified as
SDD and resistant to VCZ.
3.8. Analysis of the temporal influence on the azole
antifungal susceptibility
Table 3 summarizes the susceptibilities in vitro of
5 antifungal agents against 1000 Candida sp. strains tested
throughout the 2 intervals: 1995 to 1999 (period 1) and 2000
to 2003 (period 2). Isolates remained highly susceptible to
AMB (100%), 5FC (~97%), FCZ (9997%), ITZ (~93%),
and VCZ (10099.7%) over the entire 9-year period. Only
isolates of C. rugosa and C. glabrata spp. showed a trend to
increased resistance to azoles in the 2nd period. The rates of
susceptibility of C. rugosa strains decrease from 100% to
42% to FCZ ( P = .01) and 100% to 58.1% to ITZ ( P = .06)
throughout the period. Despite that some differences were
noted on the susceptibility of C. glabrata strains throughout
the period of the study, the values were not statistically
significant.
4. Discussion
This study represents the largest series published on the
microbiologic profile of candidemia episodes in Brazilian
hospitals. Our data confirm the results previously published
on the high prevalence of C. tropicalis and C. parapsilosis
among CNA species associated with candidemia in Brazil
(Colombo et al., 1999; Costa et al., 2000; Goldani and
Mario, 2003; Antunes et al., 2004; Colombo et al., 2006).
On the other hand, our results point to a trend of decreased
susceptibility to FCZ in C. rugosa strains isolated in a
single institution.
Although C. albicans remains the most frequently isolated
species in this series, CNA isolates accounted for 60% of all
candidemic episodes. Unlike the epidemiology of North
Hemisphere countries, in Brazil, there is still a predominance
of CNA species susceptible to FCZ represented by
C. parapsilosis and C. tropicalis strains (Colombo et al.,
1999; Antunes et al., 2004; Aquino et al., 2005; Colombo et
al., 2006). According to our findings, candidemia due to
C. glabrata persists at a low frequency in Brazilian hospitals
accounting for less than 5% of the candidemic episodes. By
analyzing the data obtained throughout the 9-year period,
excluding the rising incidence of C. parapsilosis strains from
1995 to 2003 (19% versus 25%, P = .03), there were no
changes in distribution pattern of Candida spp.
It is worth mentioning that the 25 episodes of fungemia
due to C. rugosa were documented in a single institution.

This species of Candida is considered rare among infections

in humans. However, Colombo et al. (2003) documented an
outbreak of fungemia caused by this species in the same
hospital. Having in mind that new isolations occurred after
the outbreak and throughout the year, it is clear that this
pathogenic agent was able to adapt itself to the hospital
environment, causing new episodes of candidemia. Actually, C. rugosa is a fungus that appears to be emerging as a
cause of invasive infection in Latin America as suggested by
Pfaller et al. (2006b).
In accordance with other series published in different
countries, isolates from bloodstream infections caused by
C. albicans, C. parapsilosis, and C. tropicalis spp.
presented high susceptibility to all antifungal agents tested.
Resistance to azoles in C. albicans isolates associated with
fungemia remains low and is mostly limited to immunosuppressed patients with hematologic disorders receiving
prophylaxis with high doses of FCZ (Marr et al., 2000;
Ostrosky-Zeichner et al., 2003; Hajjeh et al., 2004).
All Candida isolates in our investigation had MIC values
V 1 Ag/mL for AMB. Higher AMB MICs were not seen with
our C. lusitaniae strains, a species often considered as less
susceptible to AMB. This finding is in accordance with data
published by Ostrosky-Zeichner et al. (2003). In fact,
resistance to AMB in C. lusitaniae is not still well
understood, although there are data supporting mutations
in sterol pathways and other data supporting phenotypic
switching (Miller et al., 2006).
Although the CLSI method has proven to be reliable and
reproducible, it generates a restricted range of AMB MICs,
precluding discrimination between susceptible and resistant
isolates of Candida spp. (Park et al., 2006). Some studies
have emphasized that the E-test has significant value for the
determination of AMB MICs and represents one of the more
reliable ways to identify resistant isolates (Rex et al., 2001;
McClenny et al., 2002). However, interpretive breakpoints
for AMB susceptibility testing have remained controversial,
and therefore, routine AMB testing for Candida spp.
isolated from the bloodstream is probably not indicated
(Park et al., 2006).
Resistance to 5FC was documented in 2.5% of all the
isolates tested. This finding is in accordance with the data
generated by Pfaller et al. (2002) where only 3% of 8000
isolates tested were resistant to 5FC.
In our study, bloodstream isolates of C. tropicalis proved
to be susceptible to azoles. In other studies, C. tropicalis
strains related to candidemic episodes have shown resistance rates ranging from 0% to 12% (Diekema et al., 2002;
Godoy et al., 2003; Ostrosky-Zeichner et al., 2003; Cheng
et al., 2004; Hajjeh et al., 2004; Colombo et al., 2006). Such
significant variation in resistance rates of C. tropicalis
strains may be in part related to the in vitro phenomenon
known as trailing growth. It is well known that C. tropicalis
and C. albicans strains can exhibit heavy trailing in the
broth microdilution method after 48 h of incubation
(Arthington-Skaggs et al., 2000). It is our belief that only

D.A. da Matta et al. / Diagnostic Microbiology and Infectious Disease 57 (2007) 399 404

a limited number of C. tropicalis bloodstream isolates are

able to express the mechanisms of azole resistance already
described by Vandeputte et al. (2005).
We obtained only 2 strains of C. glabrata resistant to
FCZ, representing less than 5% of the C. glabrata strains
tested. This finding suggests that resistance to FCZ against
Candida spp., including C. glabrata strains, is still rare in
clinical isolates from fungemia in Brazil. Recently, Colombo
et al. (2006) reported antifungal susceptibility data of 712
candidemic episodes documented in 11 medical centers from
9 Brazilian cities. The resistance rate to FCZ among C.
glabrata strains in that study was 5.7%. In contrast to our
findings, the resistance rate to FCZ among C. glabrata
isolates in bloodstream infections is higher in the United
States (714%) and Europe (440%) (Chryssanthou, 2001;
Diekema et al., 2002; Ostrosky-Zeichner et al., 2003;
Tortorano et al., 2006; Hajjeh et al., 2004; Cuenca-Estrella
et al., 2005). These differences may be related to the low use
of FCZ in prophylaxis and empirical therapy regimens in
Brazilian public hospitals as compared with American and
European medical centers (Colombo et al., 1999).
In spite of the low occurrence of isolates less susceptible
to FCZ in this series, it should be pointed out that there
was an increase in the isolation of C. rugosa strains
with reduced susceptibility to this drug during the study
(10042%, P = .01). The trend toward increased resistance
among C. rugosa isolates to azoles is interesting and will
require further investigation to determine the factors behind
these observations.
In this study, VCZ was the triazole with the highest in vitro
antifungal activity against all Candida strains with 99.7% of
all the isolates tested susceptible to this antifungal agent. Of
note, 2 C. glabrata isolates resistant to FCZ also exhibited
lower susceptibility or resistance to VCZ. Although VCZ
displayed improved potency compared with FCZ, it is
apparent that cross-resistance to these agents may be
observed among the rare bloodstream infection isolates of
Candida spp. that are resistant to FCZ (Pfaller et al., 2001).
In conclusion, we were able to demonstrate that in
Brazilian hospitals, most CNA species are represented by
C. tropicalis and C. parapsilosis isolates still highly
susceptible to antifungal agents. Otherwise, we noted a
trend toward increased resistance among C. rugosa strains
to azoles in a single institution. Our data highlight the
relevance to continue surveillance programs to evaluate
trends of species distribution and resistance of Candida
isolates to antifungal drugs. This aspect becomes even more
important when we consider that new drugs have been
included in recent years in the therapeutic arsenal of
antifungal agents, and we must monitor their impact in the
epidemiology of candidemia.
Acknowledgments
The authors thank Dr. Beth Arthington-Skaggs for
critical reading of the manuscript.

403

This study was supported by CAPES (Coordenacao de

Aperfeic oamento de Pessoal de Nvel Superior) and
FAPESP (Fundacao de Amparo a` Pesquisa do Estado de
Sao Paulo), Brazil.

References
Antunes AG, Pasqualotto AC, Diaz MC, dAzevedo PA, Severo LC (2004)
Candidemia in a Brazilian tertiary care hospital: species distribution and
antifungal susceptibility patterns. Rev Inst Med Trop Sao Paulo
46:239 241.
Aquino VR, Lunardi LW, Goldani LZ, Barth AL (2005) Prevalence,
susceptibility profile for fluconazole and risk factors for candidemia in a
tertiary care hospital in southern Brazil. Braz J Infect Dis 9:411 418.
Arthington-Skaggs BA, Warnock DW, Morrison CJ (2000) Quantitation of
Candida albicans ergosterol content improves the correlation between
in vitro antifungal susceptibility test results and in vivo outcome after
fluconazole treatment in a murine model of invasive candidiasis.
Antimicrob Agents Chemother 44:2081 2085.
Cheng MF, Yu KW, Tang RB, Fan YH, Yang YL, Hsieh KS, Ho M, Lo HJ
(2004) Distribution and antifungal susceptibility of Candida species
causing candidemia from 1996 to 1999. Diagn Microbiol Infect Dis
48:33 37.
Colombo AL, Nucci M, Salomao R, Branchini MLM, Richtmann R, Derossi
A, Wey S (1999) High rate of non-albicans candidemia in Brazilian
tertiary care hospitals. Diagn Microbiol Infect Dis 34:281 286.
Colombo AL, Melo AS, Crespo Rosas RF, Salomao R, Briones M, Hollis
RJ, Messer SA, Pfaller MA (2003) Outbreak of Candida rugosa
candidemia: an emerging pathogen that may be refractory to amphotericin B therapy. Diagn Microbiol Infect Dis 46:253 257.
Colombo AL, Nucci M, Park BJ, Nouer SA, Arthington-Skaggs B, da
Matta DA, Warnock D, Morgan J (2006) Epidemiology of candidemia
in Brazil: a nationwide sentinel surveillance of candidemia in eleven
medical centers. J Clin Microbiol 44:2816 2823.
Costa SF, Marinho I, Araujo EAP, Manrique AEI, Medeiros EAS, Levin AS
(2000) Nosocomial fungaemia: a 2-year prospective study. J Infect Dis
45:69 72.
Chryssanthou E (2001) Trends in antifungal susceptibility among
Swedish Candida species bloodstream isolates from 1994 to 1998:
comparison of the E-test and the Sensititre YeastOne Colorimetric
Antifungal Panel with the NCCLS M27-A reference method. J Clin
Microbiol 39:4181 4183.
Cuenca-Estrella M, Rodriguez D, Almirante B, Morgan J, Planes AM,
Almela M, Mensa J, Sanchez F, Ayats J, Gimenez M, Salvado M,
Warnock DW, Pahissa A, Rodriguez-Tudela JL, Barcelona Candidemia
Project Study Group (2005) In vitro susceptibilities of bloodstream
isolates of Candida species to six antifungal agents: results from a
population-based active surveillance programme, Barcelona, Spain,
20022003. J Antimicrob Chemother 55:194 199.
Diekema D, Messer SA, Brueggemann AB, Coffman SL, Doern GV,
Herwaldt LA, Pfaller MA (2002) Epidemiology of candidemia: 3-year
results from the emerging infection and epidemiology of Iowa organism
study. J Clin Microbiol 40:1298 1302.
Godoy P, Tiraboschi IN, Severo LC, Bustamante B, Calvo B, Almeida LP,
Matta DA, Colombo AL (2003) Species distribution and antifungal
susceptibility profile of Candida spp. Bloodstream isolates from Latin
American hospitals. Mem Inst Oswaldo Cruz 98:401 405.
Goldani LZ, Mario PSS (2003) Candida tropicalis in a tertiary care
hospital. J Infect 46:155 160.
Gudlaugsson O, Gillespie S, Lee K, Vande Berg J, Hu J, Messer S,
Herwaldt L, Pfaller M, Diekema D (2003) Attributable mortality of
nosocomial candidemia, revisited. Clin Infect Dis 37:1172 1177.
Hajjeh RA, Sofair AN, Harrison LH, Lyon GM, Arthington-Skaggs BA,
Mirza SA, Phelan M, Morgan J, Lee-Yang W, Ciblak MA, Benjamin
LE, Sanza LT, Huie S, Yeo SF, Brandt ME, Warnock DW (2004)

404

D.A. da Matta et al. / Diagnostic Microbiology and Infectious Disease 57 (2007) 399 404

Incidence of bloodstream infections due to Candida species and in vitro

susceptibilities of isolates collected from 1998 to 2000 in a populationbased active surveillance program. J Clin Microbiol 42:1519 1527.
Kao AS, Brandt ME, Pruitt WR, Conn LA, Perkins BA, Stephens DS,
Baughman WS, Reingold AL, Rothrock GA, Pfaller MA, Pinner RW,
Hajjeh RA (1999) The epidemiology of candidemia in two United
States Cities: results of a population-based active surveillance. Clin
Infect Dis 29:1164 1170.
Marchetti O, Bille J, Fluckiger U, Eggimann P, Ruef C, Garbino J, Calandra
T, Glauser MP, Tauber MG, Pittet D, Fungal Infection Network of
Switzerland (2004) Epidemiology of candidemia in Swiss tertiary care
hospitals: secular trends, 19912000. Clin Infect Dis 38:311 320.
Marr KA, Seidel K, White TC, Bowden RA (2000) Candidemia in
allogeneic blood and marrow transplant recipients: evolution of risk
factors after the adoption of prophylactic fluconazole. J Infect Dis
181:309 316.
McClenny NB, Fei H, Baron EJ, Gales AC, Houston A, Hollis RJ, Pfaller
MA (2002) Change in colony morphology of Candida lusitaniae in
association with development of amphotericin B resistance. Antimicrob
Agents Chemother 46:1325 1328.
Miller NS, Dick JD, Merz WG (2006) Phenotypic switching in Candida
lusitaniae on copper sulfate indicator agar: association with amphotericin B resistance and filamentation. J Clin Microbiol 44:1536 1539.
National Committee for Clinical Laboratory Standards (2002) Reference
Method for Broth Dilution Antifungal Susceptibility Testing of Yeasts.
Approved Standard M27-A2. 2nd ed. Villanova, PA7 National
Committee for Clinical Laboratory Standards.
Nguyen MH, Clancy CJ, Yu VL, Yu YC, Morris AJ, Snydman DR, Sutton
DA, Rinaldi MG (1998) Do in vitro susceptibility data predict the
microbiologic response to amphotericin B? Results of a prospective
study of patients with Candida fungemia. J Infect Dis 177:425 430.
Ostrosky-Zeichner L, Rex JH, Pappas PG, Hamill RJ, Larsen RA, Horowitz
HW, Powderly WG, Hyslop N, Kauffman CA, Cleary J, Mangino JE,
Lee J (2003) Antifungal susceptibility survey of 2,000 bloodstream
Candida isolates in the United States. Antimicrob Agents Chemother
47:3149 3154.
Park BJ, Arthington-Skaggs BA, Hajjeh RA, Iqbal N, Ciblak MA, LeeYang W, Hairston MD, Phelan M, Plikaytis BD, Sofair AN, Harrison
LH, Fridkin SK, Warnock DW (2006) Evaluation of amphotericin B
interpretive breakpoints for Candida bloodstream isolates by correlation with therapeutic outcome. Antimicrob Agents Chemother
50:1287 1292.

Pfaller MA, Diekema DJ, Jones RN, Sader HS, Fluit AC, Hollis RJ,
Messer SA, SENTRY Participant Group (2001) International surveillance of bloodstream infections due to Candida species: frequency of
occurrence and in vitro susceptibilities to fluconazole, ravuconazole,
and voriconazole of isolates collected from 1997 through 1999 in the
SENTRY antimicrobial surveillance program. J Clin Microbiol
39:3254 3259.
Pfaller MA, Messer SA, Boyken L, Huynh H, Hollis RJ, Diekema DJ
(2002) In vitro activities of 5-fluorocytosine against 8,803 clinical
isolates of Candida spp.: global assessment of primary resistance using
National Committee for Clinical Laboratory Standards susceptibility
testing methods. Antimicrob Agents Chemother 6:3518 3521.
Pfaller MA, Diekema DJ, Rex JH, Espinel-Ingroff A, Johnson EM,
Andes D, Chaturvedi V, Ghannoum MA, Odds FC, Rinaldi MG,
Sheehan DJ, Troke P, Walsh TJ, Warnock DW (2006a) Correlation of
MIC with outcome for Candida species tested against voriconazole:
analysis and proposal for interpretive breakpoints. J Clin Microbiol
44:819 826.
Pfaller MA, Diekema DJ, Colombo AL, Kibbler C, Ng KP, Gibbs DL,
Newell VA (2006b) Candida rugosa, an emerging fungal pathogen with
resistance to azoles: geographic and temporal trends from the
ARTEMIS DISK Antifungal Surveillance Program. J Clin Microbiol
44:3578 3582.
Rex JH, Pfaller MA, Walsh TJ, Chaturvedi V, Espinel-Ingroff A,
Ghannoum MA, Gosey LL, Odds FC, Rinaldi MG, Sheehan DJ,
Warnock DW (2001) Antifungal susceptibility testing: practical aspects
and current challenges. Clin Microbiol Rev 14:643 658.
Richet H, Roux P, Des Champs C, Esnault Y, Andremont A, French
Candidemia Study Group (2002) Candidemia in French hospitals:
incidence rates and characteristics. Clin Microbiol Infect 8:405 412.
Tortorano AM, Kibbler C, Peman J, Bernhardt H, Klingspor L, Grillot R
(2006) Candidaemia in Europe: epidemiology and resistance. Int J
Antimicrob Agents 27:359 366.
Vandeputte P, Larcher G, Berges T, Renier G, Chabasse D, Bouchara JP
(2005) Mechanisms of azole resistance in a clinical isolate of Candida
tropicalis. Antimicrob Agents Chemother 49:4608 4615.
Verduyn Lunel FM, Meis JF, Voss A (1999) Nosocomial fungal infections:
candidemia. Diagn Microbiol Infect Dis 34:213 220.
Warren NG, Hazen KC (1999) Candida, Cryptococcus, and other yeasts of
medical importance. In Manual of Clinical Microbiology. Eds, RP
Murray, EJ Baron, MA Pfaller, FC Tenover and RH Yolken. 7th ed.
Washington, DC7 American Society for Microbiology, pp 1184 1199.