Epidemiology, management, and risk factors for death of invasive Candida infections in critical care: a multicenter, prospective, observational study in France (2005-2006). Crit Care Med. 2009;37:1612-1618. [PMID: 19325476 DOI: 10.1097/ccm.0b013e31819efac0]

Fungal bloodstream infections in tertiary care hospitals in Colombia

BACKGROUND

Fungal infections have increased in critical care patients, causing high morbidity and mortality.

AIMS

Describe the frequency and responsible fungal species involved in bloodstream fungal infection from 2001 to 2007 in tertiary care level hospitals belonging to a surveillance network in Colombian cities.

METHODS

Data were collected from a microbiology surveillance network based on 27 hospital laboratories in five Colombian cities. Data were entered into a Whonet® version 5.4 database. Fungemia data were analyzed according to location (Intensive care unit -ICU- vs. non-ICU services). Frequency over time was also described.

RESULTS

Fungal infections corresponded to 4.1% of all bloodstream infections. Candidemia represented 3.7% and 5.2% of all isolates in non-ICU and ICU services, respectively. Over 99% of the isolates were yeasts, and Candida albicans was the most frequently isolated organism in and out of the ICU, showing a decreasing trend in the last few years. In the adult ICU and non-ICU services, the second organism most frequently isolated was C. tropicalis, while C. parapsilopsis was the most frequent in the pediatric and neonatal ICU, also showing an overall decreasing trend. Cryptococcus neoformans was the fourth mycotic organism most frequently identified.

CONCLUSIONS

In Colombia, epidemiology of fungal infections seems to be changing. C. albicans is the principal agent causing bloodstream fungal infection, but an increase of non-albicans species has been observed as well as high frequency of C. neoformans.

How I manage haematology patients with septic shock

Patients with a variety of haematological conditions are at risk of infection and its most serious complication: septic shock. Mortality for septic shock remains high and especially so in patients with haematological malignancy and following bone marrow transplantation. However, advances in the treatment of severe sepsis have improved mortality rates even though evidence for the management of severe sepsis in haematology patients is limited. Wherever possible this review will concentrate on evidence directly applicable to haematology patients but inevitably will have to extrapolate evidence from other patient groups. The Surviving Sepsis Guidelines 2008 provide information on best practice in the management of patients with severe sepsis and septic shock and are broadly applicable though not specific to haematology patients. This review summarizes a practical approach to the management of severe sepsis in haematology patients and highlights areas of research which may bring new treatments in the future. The review is limited to the management and initial resuscitation of septic shock in adult haematology patients and will not address the detailed intensive care management of these patients or the management of severe sepsis in children.

Prevalent nosocomial clusters among causative agents for candidemia in Hamilton, Canada

In Canada, the incidence of candidemia, the bloodstream infection caused by Candida species, varied from 1.2-5.1 cases/100,000, representing the third most common type of bloodstream infections in intensive care unit patients. However, the relative contributions of nosocomial transmission in candidemia remain poorly understood. In this study, we investigated the prevalence of nosocomial clusters among the causative agents for candidemia in Hamilton, Ontario, Canada, during a period from January 2005 to February 2009. We genotyped 134 isolates from 125 unrelated patients with candidemia, among which were 87 C. albicans, 20 C. parapsilosis, 11 C. glabrata, 15 C. tropicalis, and one C. krusei. Our PCR fingerprinting analyses using three highly polymorphic primers identified a total of 99 genotypes, with 18 of them shared by 44 independent isolates. Nine pairs of isolates were obtained from the same patients at the same time and each pair had identical fingerprints. Interestingly, all 44 independent strains belonging to each of the shared genotypes were isolated from patients within 3-months stay in the Hamilton hospitals. Both inter- and intra-ward clusters were found, including one that contained strains from intensive care units in two hospitals. Our results indicated that 33% of the patients with candidemia were infected by nosocomial clusters and suggested that measures should be taken in hospitals to prevent nosocomial acquisition of Candida infections.

Candida tropicalis in human disease

Candida tropicalis is one of the more common Candida causing human disease in tropical countries; the frequency of invasive disease varies by geography causing 3--66% of candidaemia. C. tropicalis is taxonomically close to C. albicans and shares many pathogenic traits. C. tropicalis is particularly virulent in neutropenic hosts commonly with hematogenous seeding to peripheral organs. For candidaemia and invasive candidiasis amphotericin B or an echinocandin are recommended as first-line treatment, with extended-spectrum triazoles acceptable alternatives. Primary fluconazole resistance is uncommon but may be induced on exposure. Physicians in regions where C. tropicalis is common need to be mindful of this lesser-described pathogen.

Molecular identification of closely related Candida species using two ribosomal intergenic spacer fingerprinting methods

Recent changes in the epidemiology of candidiasis highlighted an increase in non- Candida albicans species emphasizing the need for reliable identification methods. Molecular diagnostics in fungal infections may improve species characterization, particularly in cases of the closely related species in the Candida complexes. We developed two PCR/restriction fragment length polymorphism assays, targeting either a part of the intergenic spacer 2 or the entire intergenic spacer (IGS) of ribosomal DNA using a panel of 270 isolates. A part of the intergenic spacer was used for discrimination between C. albicans and C. dubliniensis and between species of the C. glabrata complex (C. glabrata/C. bracarensis/C. nivariensis). The whole IGS was applied to C. parapsilosis, C. metapsilosis, and C. orthopsilosis, and to separate C. famata (Debaryomyces hansenii) from C. guilliermondii (Pichia guilliermondii) and from the other species within this complex (ie, C. carpophila, C. fermentati and C. xestobii). Sharing similar biochemical patterns, Pichia norvegensis and C. inconspicua exhibited specific IGS profiles. Our study confirmed that isolates of C. guilliermondii were frequently mis-identified as C. famata. As much as 67% of the clinical isolates phenotypically determined as C. famata were recognized mostly as true P. guilliermondii. Conversely, 44% of the isolates initially identified as C. guilliermondii were corrected by the IGS fingerprints as C. parapsilosis, C. fermentati, or C. zeylanoides. These two PCR/restriction fragment length polymorphism methods may be used as reference tools [either alternatively or adjunctively to the existing ribosomal DNA (26S or ITS) sequence comparisons] for unambiguous determination of the Candida species for which phenotypic characterization remains problematic.

Outcomes with micafungin in patients with candidaemia or invasive candidiasis due to Candida glabrata and Candida krusei

OBJECTIVES

Infection with Candida glabrata and Candida krusei represents a major challenge. We sought to describe outcomes for patients with candidaemia/invasive candidiasis (C/IC) due to these pathogens who were treated with micafungin.

METHODS

We pooled two randomized trials of micafungin versus comparator. We identified patients infected with either C. glabrata or C. krusei. One trial compared micafungin (100 mg/day with option for dose escalation) with liposomal amphotericin B, while the other compared micafungin (either 100 or 150 mg/day) and caspofungin (NCT00106288 and NCT00105144). Clinical cure was our primary endpoint while 28 day mortality represented a secondary endpoint.

RESULTS

Among 1070 subjects with C/IC, 183 were infected with either C. glabrata (n = 144) or C. krusei (n = 39). One hundred and seventeen received micafungin. Clinical cure rates in those receiving micafungin were similar to those randomized to comparator [73.5% (86/117) versus 62.1% (41/66), P = not significant]. Mortality at 28 days was also similar [29.1% (34/117) with micafungin versus 34.8% (23/66) with comparator, P = not significant]. In logistic regression, treatment agent correlated with neither cure nor mortality. Factors independently linked with lower cure rates included: IC neutropenia; higher severity of illness; and medical admission. Higher severity of illness and failure to remove a central venous catheter were associated with 28 day mortality. Crude and adjusted outcomes were comparable irrespective of micafungin dose administered.

CONCLUSIONS

Micafungin results in similar outcomes to comparators for C/IC due to C. glabrata and C. krusei. The 100 mg/day dose represents an acceptable option in this setting. Patient characteristics and catheter management appear to be more important factors affecting clinical outcomes.

Bench-to-bedside review: therapeutic management of invasive candidiasis in the intensive care unit

Candida is one of the most frequent pathogens in bloodstream infections, and is associated with significant morbidity and mortality. The epidemiology of species responsible for invasive candidiasis, both at local and worldwide levels, has been changing - shifting from Candida albicans to non-albicans species, which can be resistant to fluconazole (Candida krusei and Candida glabrata) or difficult to eradicate because of biofilm production (Candida parapsilosis). Numerous intensive care unit patients have multiple risk factors for developing this infection, which include prolonged hospitalisation, use of broad-spectrum antibiotics, presence of intravascular catheters, parenteral nutrition, high Acute Physiology and Chronic Health Evaluation score, and so forth. Moreover, delaying the specific therapy was shown to further increase morbidity and mortality. To minimise the impact of this infection, several management strategies have been developed - prophylaxis, empirical therapy, pre-emptive therapy and culture-based treatment. Compared with prophylaxis, empirical and pre-emptive approaches allow one to reduce the exposure to antifungals by targeting only the patients at high risk of candidemia, without delaying therapy until the moment blood Candida is identified in blood cultures. The agents recommended for initial treatment of candidemia in critically ill patients include echinocandins and lipid formulation of amphotericin B.

CO(2) acts as a signalling molecule in populations of the fungal pathogen Candida albicans

When colonising host-niches or non-animated medical devices, individual cells of the fungal pathogen Candida albicans expand into significant biomasses. Here we show that within such biomasses, fungal metabolically generated CO(2) acts as a communication molecule promoting the switch from yeast to filamentous growth essential for C. albicans pathology. We find that CO(2)-mediated intra-colony signalling involves the adenylyl cyclase protein (Cyr1p), a multi-sensor recently found to coordinate fungal responses to serum and bacterial peptidoglycan. We further identify Lys 1373 as essential for CO(2)/bicarbonate regulation of Cyr1p. Disruption of the CO(2)/bicarbonate receptor-site interferes selectively with C. albicans filamentation within fungal biomasses. Comparisons between the Drosophila melanogaster infection model and the mouse model of disseminated candidiasis, suggest that metabolic CO(2) sensing may be important for initial colonisation and epithelial invasion. Our results reveal the existence of a gaseous Candida signalling pathway and its molecular mechanism and provide insights into an evolutionary conserved CO(2)-signalling system.

Recent exposure to caspofungin or fluconazole influences the epidemiology of candidemia: a prospective multicenter study involving 2,441 patients

A prospective multicenter surveillance program on yeast bloodstream infections was implemented in the Paris, France, area without restrictions on ward of hospitalization (intensive care unit, hematology, and surgery) or age (adults and children). The present analysis concerns 2,618 isolates collected over 7 years from 2,441 patients. Centralized species identification and antifungal susceptibility testing using the EUCAST methodology were performed. Almost 10% (232/2,441) of the patients had recently (≤30 days) been treated with antifungal drugs. We analyzed the effect of recent exposure to fluconazole (n = 159) or caspofungin (n = 61) on the proportions of the five major Candida species. For both drugs, preexposure was associated with a decreased prevalence of Candida albicans in favor of less drug-susceptible species (C. glabrata and C. krusei for the former and C. parapsilosis and, to a lesser extent, C. glabrata and C. krusei for the latter; P = 0.001). In the multivariate analysis, the risk of being infected with an isolate with decreased susceptibility to fluconazole was independently associated with an age of ≥15 years (odds ratio [OR] = 2.45; 95% confidence interval [CI] = 1.39 to 4.31; P = 0.002) and with recent exposure to fluconazole (OR = 2.17; 95% CI = 1.51 to 3.13; P < 0.001), while the risk of being infected with an isolate with decreased susceptibility to caspofungin was independently associated with an age <15 years (OR = 2.53; 95% CI = 1.43 to 4.48; P = 0.001) and with recent exposure to caspofungin (OR = 4.79; 95% CI = 2.47 to 9.28; P < 0.001). These findings could influence future recommendations for the management of candidemia.

Candida tropicalis fungaemia: incidence, risk factors and mortality in a general hospital

The risk factors and clinical features of patients with Candida tropicalis fungaemia have not been fully defined. We performed a case-control study comparing 59 cases of C. tropicalis fungaemia with 177 episodes of fungaemia caused by other species of Candida in our hospital over a 24-year period (January 1985 to December 2008). Patients with C. tropicalis fungaemia were more likely to be older (median age, 67 vs. 56 years; p 0.01), to have cancer (45.5% vs. 31.6%, p 0.04), and to have the abdomen as the portal of entry (32.2% vs. 11.9%, p 0.001), and had a higher in-hospital mortality rate (61% vs. 44%, p 0.03). Multivariate analysis showed that the independent risk factors for C. tropicalis fungaemia were cancer (OR 4.5; 95% CI 1.05-3.83; p 0.03) and the abdomen as the portal of entry (OR 13.6; 95% CI 1.9-8.2; p <0.001). When survivors were compared with non-survivors, the risk factors associated with a poor outcome were neutropenia (19.4% vs. 0; p 0.03), corticosteroid treatment (36% vs. 13%; p 0.07), and septic shock (50% vs. 17.4%; p 0.01). The independent risk factors for mortality in the multivariate analysis were corticosteroid treatment (OR 8.2; 95% CI 0.9-27.7; p 0.04) and septic shock (OR 14.6; 95% CI 2.4-90.2; p 0.004), whereas urinary tract infection (OR 0.07; 95% CI 0.01-0.8; p 0.03) and catheter removal (OR 0.06; 95% CI 0.01-0.4; p 0.002) were protective factors. C. tropicalis is the fourth most common cause of fungaemia in our hospital. It is associated with underlying malignancy, the abdomen as the portal of entry, and poor outcome.

A multicentre study of antifungal strategies and outcome of Candida spp. peritonitis in intensive-care units

Information on the species causing Candida peritonitis, their in vitro susceptibility, antifungal strategies in this setting and patient outcome is still scarce. AmarCand was a prospective, non-interventional study in 271 adult intensive-care unit (ICU) patients with proven invasive Candida infection who received systemic antifungal therapy (France, 2005-2006). Of these ICU patients, 93 (median age 65 years, simplified acute physiology score II 52) had Candida peritonitis, including 73 nosocomial peritonitis, 53 concomitant bacterial peritoneal infections and 26 candidaemias. Candida species were C. albicans (n = 63/108 isolates, 58%), C. glabrata (n = 22, 20%), C. krusei (n = 9), C. kefyr (n = 5), C. parapsilosis (n = 3), C. tropicalis (n = 3), C. ciferii (n = 2) and C. lusitaniae (n = 1). Of tested isolates, 28% were fluconazole-resistant or susceptible dose-dependent (C. albicans 3/32, C. glabrata 9/14, C. krusei 4/4). Empiric antifungal treatment was started 1 day (median) after peritonitis diagnosis, with fluconazole (n = 2 patients), caspofungin (n = 12), voriconazole (n = 3), amphotericin B (n = 2), or a combination (n = 4). Following susceptibility testing, empiric antifungal treatment was judged inadequate in 9/45 (20%) patients and modified in 30 patients (fluconazole was replaced by caspofungin (n = 14) or voriconazole (n = 4)). Mortality in ICU was 38% (35/93) and was not influenced by type of Candida species, fluconazole susceptibility, time to treatment, candidaemia, nosocomial acquisition, or concomitant bacterial infection. No specific factors for death were identified. In summary, a high proportion of fluconazole-resistant or susceptible dose-dependent strains was cultured. These results confirm the high mortality rates of Candida peritonitis and plead for additional investigation in this population. Antifungal treatment for severe cases of Candida peritonitis in ICU patients remains the standard care.

[Management of candidemia and invasive candidiasis]

Candida species is the fourth most common cause of bloodstream infection and is the leading cause of invasive fungal infection among hospitalized patients. Acute disseminated candidiasis remains a life-threatening disease that now occurs mainly in intensive care units hospitalized patients. Delay in treatment of Candida bloodstream infections could be minimized by the development of more rapid and sensitive diagnostic techniques for the identification of Candida bloodstream infections. Current guidelines for the management of invasive candidiasis recommend fluconazole or an echinocandin as the primary therapeutic option. The optimal choice of the antifungal agent should depend on local epidemiology, prior antifungal therapy and patient's characteristics.

Recognition and prevention of nosocomial invasive fungal infections in the intensive care unit

Despite recent advances in antifungal treatments, the morbidity and mortality of fungal infections, especially invasive candidiasis, in patients in the intensive care unit setting remain high. Because of this, there has been a great interest in improving the evaluation, risk assessment, and prevention of fungal infections in the intensive care unit. Some important advances in the diagnosis of invasive candidiasis include rapid species identification and improvements in antigen testing. The introduction of several prediction rules has helped to guide clinicians in the use of prophylaxis or preemptive antifungal therapy in high-risk patients. However, the most immediate benefit has been realized with the introduction of new antifungal agents that have proved to be safer than those available in the past.

Subtelomeric silencing of the MTL3 locus of Candida glabrata requires yKu70, yKu80, and Rif1 proteins

Candida glabrata is a haploid opportunistic fungal pathogen that is phylogenetically related to Saccharomyces cerevisiae. Even though C. glabrata has no known sexual cycle, it contains, like S. cerevisiae, three mating type-like loci (MTL) called MTL1, MTL2, and MTL3, as well as most of the genes required for mating, meiosis, and sporulation. MTL1 is localized at an internal position on chromosome B and is thought to be the locus corresponding to the MAT locus in S. cerevisiae. MTL2 and MTL3 are localized close to two telomeres on different chromosomes (29.4 kb from Chr E-L and 10.5 kb from Chr B-L, respectively). By using URA3 reporter gene insertions at the three MTL loci, we found that in contrast to the case for S. cerevisiae, only MTL3 is subject to transcriptional silencing while MTL2 is transcriptionally active, and this is in agreement with previously reported data. We found that the silencing of MTL3 is nucleated primarily at the left telomere of chromosome B and spreads over 12 kb to MTL3, rather than nucleating at flanking, closely positioned cis-acting silencers, like those flanking HMR and HML of S. cerevisiae. Interestingly, the silencing of MTL3 absolutely requires the yKu70, yKu80, and Rif1 proteins, in sharp contrast to the silencing of the HM loci of S. cerevisiae. In addition, we found that several cell type-specific genes are expressed in C. glabrata regardless of the presence, or even absence, of mating type information at any of the MTL loci.

Experimental annotation of the human pathogen Candida albicans coding and noncoding transcribed regions using high-resolution tiling arrays

BACKGROUND

Compared to other model organisms and despite the clinical relevance of the pathogenic yeast Candida albicans, no comprehensive analysis has been done to provide experimental support of its in silico-based genome annotation.

RESULTS

We have undertaken a genome-wide experimental annotation to accurately uncover the transcriptional landscape of the pathogenic yeast C. albicans using strand-specific high-density tiling arrays. RNAs were purified from cells growing under conditions relevant to C. albicans pathogenicity, including biofilm, lab-grown yeast and serum-induced hyphae, as well as cells isolated from the mouse caecum. This work provides a genome-wide experimental validation for a large number of predicted ORFs for which transcription had not been detected by other approaches. Additionally, we identified more than 2,000 novel transcriptional segments, including new ORFs and exons, non-coding RNAs (ncRNAs) as well as convincing cases of antisense gene transcription. We also characterized the 5' and 3' UTRs of expressed ORFs, and established that genes with long 5' UTRs are significantly enriched in regulatory functions controlling filamentous growth. Furthermore, we found that genomic regions adjacent to telomeres harbor a cluster of expressed ncRNAs. To validate and confirm new ncRNA candidates, we adapted an iterative strategy combining both genome-wide occupancy of the different subunits of RNA polymerases I, II and III and expression data. This comprehensive approach allowed the identification of different families of ncRNAs.

CONCLUSIONS

In summary, we provide a comprehensive expression atlas that covers relevant C. albicans pathogenic developmental stages in addition to the discovery of new ORF and non-coding genetic elements.

Prevalence and antifungal drug sensitivity of non-albicans Candida in oral rinse samples of self-caring elderly

AIM

To assess the prevalence and antifungal drug sensitivity of non-albicans Candida (NAC) species in elderly outpatients.

MATERIALS AND METHODS

We investigated oral rinse samples of 194 self-caring elderly population (mean age 83 years) with emphasis on background factors for harbouring NAC. Susceptibility of Candida species to antifungal drugs was determined using standard methodology. Multiple logistic regression analysis was performed taking positive NAC count as the dependent variable and a number of known Candida risk factors as independent variables.

RESULTS

Prevalence of candidal carriage of the population was 78.4%, of which 0.5% of the subjects were NAC positive. Candida dubliniensis was the most prevalent NAC species, followed by Candida glabrata and Candida parapsilosis. The NAC positive elderly were more often edentulous with dental prostheses or had fewer teeth than Candida albicans-positive or yeast-negative subjects. Dental caries slightly increased the risk for having NAC strains (odds ratio 1.08), whilst greater age appeared to lower the risk (odds ratio 0.77). Candida species were susceptible to the commonly used antifungal agents in general, but with considerable variation among species. Occasionally, some NAC exhibited lower antifungal susceptibility.

CONCLUSION

The possibility of oral reservoirs of NAC strains which are resistant to common antifungals should be noted in elderly outpatients.

Comparison of albicans vs. non-albicans candidemia in French intensive care units

Introduction

Candidemia raises numerous therapeutic issues for intensive care physicians. Epidemiological data that could guide the choice of initial therapy are still required. This analysis sought to compare the characteristics of intensive care unit (ICU) patients with candidemia due to non-albicans Candida species with those of ICU patients with candidemia due to Candida albicans.

Methods

A prospective, observational, multicenter, French study was conducted from October 2005 to May 2006. Patients exhibiting candidemia developed during ICU stay and exclusively due either to one or more non-albicans Candida species or to C. albicans were selected. The data collected included patient characteristics on ICU admission and at the onset of candidemia.

Results

Among the 136 patients analyzed, 78 (57.4%) had candidemia caused by C. albicans. These patients had earlier onset of infection (11.1 ± 14.2 days after ICU admission vs. 17.4 ± 17.7, p = 0.02), higher severity scores on ICU admission (SOFA: 10.4 ± 4.7 vs. 8.6 ± 4.6, p = 0.03; SAPS II: 57.4 ± 22.8 vs. 48.7 ± 15.5, P = 0.015), and were less often neutropenic (2.6% vs. 12%, p = 0.04) than patients with candidemia due to non-albicans Candida species.

Conclusions

Although patients infected with Candida albicans differed from patients infected with non-albicans Candida species for a few characteristics, no clinical factor appeared pertinent enough to guide the choice of empirical antifungal therapy in ICU.

Forward genetics in Candida albicans that reveals the Arp2/3 complex is required for hyphal formation, but not endocytosis

Candida albicans is a diploid fungal pathogen lacking a defined complete sexual cycle, and thus has been refractory to standard forward genetic analysis. Instead, transcription profiling and reverse genetic strategies based on Saccharomyces cerevisiae have typically been used to link genes to functions. To overcome restrictions inherent in such indirect approaches, we have investigated a forward genetic mutagenesis strategy based on the UAU1 technology. We screened 4700 random insertion mutants for defects in hyphal development and linked two new genes (ARP2 and VPS52) to hyphal growth. Deleting ARP2 abolished hyphal formation, generated round and swollen yeast phase cells, disrupted cortical actin patches and blocked virulence in mice. The mutants also showed a global lack of induction of hyphae-specific genes upon the yeast-to-hyphae switch. Surprisingly, both arp2 Delta/Delta and arp2 Delta/Delta arp3 Delta/Delta mutants were still able to endocytose FM4-64 and Lucifer Yellow, although as shown by time-lapse movies internalization of FM4-64 was somewhat delayed in mutant cells. Thus the non-essential role of the Arp2/3 complex discovered by forward genetic screening in C. albicans showed that uptake of membrane components from the plasma membrane to vacuolar structures is not dependent on this actin nucleating machinery.

Reverse genetics in Candida albicans predicts ARF cycling is essential for drug resistance and virulence

Candida albicans, the major fungal pathogen of humans, causes life-threatening infections in immunocompromised individuals. Due to limited available therapy options, this can frequently lead to therapy failure and emergence of drug resistance. To improve current treatment strategies, we have combined comprehensive chemical-genomic screening in Saccharomyces cerevisiae and validation in C. albicans with the goal of identifying compounds that can couple with the fungistatic drug fluconazole to make it fungicidal. Among the genes identified in the yeast screen, we found that only AGE3, which codes for an ADP-ribosylation factor GTPase activating effector protein, abrogates fluconazole tolerance in C. albicans. The age3 mutant was more sensitive to other sterols and cell wall inhibitors, including caspofungin. The deletion of AGE3 in drug resistant clinical isolates and in constitutively active calcineurin signaling mutants restored fluconazole sensitivity. We confirmed chemically the AGE3-dependent drug sensitivity by showing a potent fungicidal synergy between fluconazole and brefeldin A (an inhibitor of the guanine nucleotide exchange factor for ADP ribosylation factors) in wild type C. albicans as well as in drug resistant clinical isolates. Addition of calcineurin inhibitors to the fluconazole/brefeldin A combination only initially improved pathogen killing. Brefeldin A synergized with different drugs in non-albicans Candida species as well as Aspergillus fumigatus. Microarray studies showed that core transcriptional responses to two different drug classes are not significantly altered in age3 mutants. The therapeutic potential of inhibiting ARF activities was demonstrated by in vivo studies that showed age3 mutants are avirulent in wild type mice, attenuated in virulence in immunocompromised mice and that fluconazole treatment was significantly more efficacious when ARF signaling was genetically compromised. This work describes a new, widely conserved, broad-spectrum mechanism involved in fungal drug resistance and virulence and offers a potential route for single or improved combination therapies.

The Ras/cAMP/PKA signaling pathway and virulence in Candida albicans

Candidiasis is the most common cause of fungal infections, and the majority of these are caused by Candida albicans. The protean pathogenic potential of C. albicans includes the capacity to infect diverse mucosal and epidermal surfaces as well as to disseminate via the bloodstream to internal organs, potentially causing system failure in cases of severe immunosuppression. Many environmental niches in the host may be invaded by C. albicans through modulation of gene expression patterns while changing morphology between yeast and hyphal growth forms. The Ras/cAMP/PKA signaling pathway has attracted particular attention for its role in promoting hyphal growth and because of its importance in virulence. Here, we present an overview of the components of the pathway and their functions, how the pathway may be activated in human hosts and recent updates regarding the role of Ras/cAMP/PKA signaling in virulence.

Role of transcription factor CaNdt80p in cell separation, hyphal growth, and virulence in Candida albicans

The NDT80/PhoG transcription factor family includes ScNdt80p, a key modulator of the progression of meiotic division in Saccharomyces cerevisiae. In Candida albicans, a member of this family, CaNdt80p, modulates azole sensitivity by controlling the expression of ergosterol biosynthesis genes. We previously demonstrated that CaNdt80p promoter targets, in addition to ERG genes, were significantly enriched in genes related to hyphal growth. Here, we report that CaNdt80p is indeed required for hyphal growth in response to different filament-inducing cues and for the proper expression of genes characterizing the filamentous transcriptional program. These include noteworthy genes encoding cell wall components, such as HWP1, ECE1, RBT4, and ALS3. We also show that CaNdt80p is essential for the completion of cell separation through the direct transcriptional regulation of genes encoding the chitinase Cht3p and the cell wall glucosidase Sun41p. Consistent with their hyphal defect, ndt80 mutants are avirulent in a mouse model of systemic candidiasis. Interestingly, based on functional-domain organization, CaNdt80p seems to be a unique regulator characterizing fungi from the CTG clade within the subphylum Saccharomycotina. Therefore, this study revealed a new role of the novel member of the fungal NDT80 transcription factor family as a regulator of cell separation, hyphal growth, and virulence.

A multi-protein complex controls cAMP signalling and filamentation in the fungal pathogen Candida albicans

Candida albicans is an opportunistic fungal pathogen of humans. The ability of the fungus to grow as both yeast and filamentous forms is essential for its pathogenicity. Morphogenesis of C. albicans is largely regulated through the secondary messenger cAMP, produced by the soluble adenylyl cyclase, Cyr1p. Recent evidence suggests that Cyr1p can be directly stimulated by environmental cues to increase cytoplasmic cAMP levels and thus promote hyphal development. In this issue of Molecular Microbiology, Zou et al. demonstrate that, in response to some environmental cues, Cyr1p functions as part of a tripartite complex additionally involving Cap1p and G-actin. All three proteins in the complex are required to raise cytosolic cAMP levels after stimulation with serum and bacterial peptidoglycan. The formation of such a complex highlights the importance of precise regulation of Cyr1p activity in response to host environmental cues.

Candida albicans hyphal formation and virulence assessed using a Caenorhabditis elegans infection model

Candida albicans colonizes the human gastrointestinal tract and can cause life-threatening systemic infection in susceptible hosts. We study here C. albicans virulence determinants using the nematode Caenorhabditis elegans in a pathogenesis system that models candidiasis. The yeast form of C. albicans is ingested into the C. elegans digestive tract. In liquid media, the yeast cells then undergo morphological change to form hyphae, which results in aggressive tissue destruction and death of the nematode. Several lines of evidence demonstrate that hyphal formation is critical for C. albicans pathogenesis in C. elegans. First, two yeast species unable to form hyphae (Debaryomyces hansenii and Candida lusitaniae) were less virulent than C. albicans in the C. elegans assay. Second, three C. albicans mutant strains compromised in their ability to form hyphae (efg1Delta/efg1Delta, flo8Delta/flo8Delta, and cph1Delta/cph1Delta efg1Delta/efg1Delta) were dramatically attenuated for virulence. Third, the conditional tet-NRG1 strain, which enables the external manipulation of morphogenesis in vivo, was more virulent toward C. elegans when the assay was conducted under conditions that permit hyphal growth. Finally, we demonstrate the utility of the C. elegans assay in a screen for C. albicans virulence determinants, which identified several genes important for both hyphal formation in vivo and the killing of C. elegans, including the recently described CAS5 and ADA2 genes. These studies in a C. elegans-C. albicans infection model provide insights into the virulence mechanisms of an important human pathogen.

Hyperglycemia in critical illness: a review

Hyperglycemia is commonplace in the critically ill patient and is associated with worse outcomes. It occurs after severe stress (e.g., infection or injury) and results from a combination of increased secretion of catabolic hormones, increased hepatic gluconeogenesis, and resistance to the peripheral and hepatic actions of insulin. The use of carbohydrate-based feeds, glucose containing solutions, and drugs such as epinephrine may exacerbate the hyperglycemia. Mechanisms by which hyperglycemia cause harm are uncertain. Deranged osmolality and blood flow, intracellular acidosis, and enhanced superoxide production have all been implicated. The net result is derangement of endothelial, immune and coagulation function and an association with neuropathy and myopathy. These changes can be prevented, at least in part, by the use of insulin to maintain normoglycemia.

Transcriptional regulation of carbohydrate metabolism in the human pathogen Candida albicans

Glycolysis is a metabolic pathway that is central to the assimilation of carbon for either respiration or fermentation and therefore is critical for the growth of all organisms. Consequently, glycolytic transcriptional regulation is important for the metabolic flexibility of pathogens in their attempts to colonize diverse niches. We investigated the transcriptional control of carbohydrate metabolism in the human fungal pathogen Candida albicans and identified two factors, Tye7p and Gal4p, as key regulators of glycolysis. When respiration was inhibited or oxygen was limited, a gal4tye7 C. albicans strain showed a severe growth defect when cultured on glucose, fructose or mannose as carbon sources. The gal4tye7 strain displayed attenuated virulence in both Galleria and mouse models as well, supporting the connection between pathogenicity and metabolism. Chromatin immunoprecipitation coupled with microarray analysis (ChIP-CHIP) and transcription profiling revealed that Tye7p bound the promoter sequences of the glycolytic genes and activated their expression during growth on either fermentable or non-fermentable carbon sources. Gal4p also bound the glycolytic promoter sequences and activated the genes although to a lesser extent than Tye7p. Intriguingly, binding and activation by Gal4p was carbon source-dependent and much stronger during growth on media containing fermentable sugars than on glycerol. Furthermore, Tye7p and Gal4p were responsible for the complete induction of the glycolytic genes under hypoxic growth conditions. Tye7p and Gal4p also regulated unique sets of carbohydrate metabolic genes; Tye7p bound and activated genes involved in trehalose, glycogen, and glycerol metabolism, while Gal4p regulated the pyruvate dehydrogenase complex. This suggests that Tye7p represents the key transcriptional regulator of carbohydrate metabolism in C. albicans and Gal4p provides a carbon source-dependent fine-tuning of gene expression while regulating the metabolic flux between respiration and fermentation pathways.

Pathogens must be able to assimilate the carbon sources in their environment to generate sufficient energy and metabolites to survive. Since glycolysis is a central metabolic pathway, it is important for this metabolic flexibility. The most commonly isolated agent in human fungal infections, Candida albicans, depends upon glycolysis for the progression of systemic disease. We investigated glycolytic transcriptional regulation in C. albicans and defined two key regulators of the pathway, Tye7p and Gal4p. We demonstrated that these factors are important for the fermentative growth of C. albicans both in vitro and in vivo and also regulate the input and output fluxes of glycolysis. The gal4tye7 strain showed attenuated virulence in a Galleria and two mouse models, potentially due to the severe growth defect in oxygen-limiting environments. Gal4p and Tye7p represent fungal specific regulators involved in the pathogenicity of the organism that may be exploited in the development of antifungal treatments. Our study describes a fungal glycolytic transcriptional circuit that is fundamentally different from that of the model yeast Saccharomyces cerevisiae, providing further evidence that the transcriptional networks in S. cerevisiae need not be generally representative of the fungal kingdom.

Excess mortality, length of stay and cost attributable to candidaemia

BACKGROUND

There were 1967 reports of Candida species isolated from blood specimens in 2007 in the UK (excluding Scotland). Such infections are particularly common in the intensive care unit (ICU). The impact of candidaemia on mortality, length of stay (LOS) and cost in a UK hospital was examined.

METHODS

A retrospective analysis of candidaemia episodes and appropriate matched controls was undertaken based on data from the ICU, high dependency units and hospital wards at Wythenshawe Hospital in Manchester. The study covered the period November 2003-February 2007.

RESULTS

In total, 48 case-patients of candidaemia and 81 control-patients were identified. The attributable mortality due to candidaemia varied from 21.5% to 34.7%. Candidaemia patients spend on average 5.6 days more in the ICU than matched patients and generate mean additional costs of at least 8252 UK pounds per patient, 16,595 pounds in adults only.

CONCLUSION

Candidaemia remains a severe disease associated with high attributable mortality in the UK. In addition, candidaemia leads to additional ICU length of stay and costs. The implication is an attributable cost of at least 16.2 million UK pounds with 683 deaths attributable to candidaemia per year in the UK.

Report from the European Congress of Clinical Microbiology and Infectious Diseases

With its cool climate, Finland has a lower prevalence of fungal infections than many other European countries that have hosted the annual congress of the European Society of Clinical Microbiology and Infectious Diseases. However, changing patterns of infection and drug resistance, and their impact on treatment decisions, are as important to Nordic infectious disease specialists as to their colleagues in warmer countries. Similarly, developments in diagnostic techniques that enable fungal invasion to be identified before there is clinical evidence of infection will be a major step forward for physicians wherever they practise. It should therefore come as no surprise that this year's European Congress of Clinical Microbiology and Infectious Diseases was as well attended as previous meetings, with over 8000 participants arriving from all parts of Europe.