Correlation between adhesion, enzyme production, and susceptibility to fluconazole in Candida albicans obtained from denture wearers

Comparative effectiveness of interventions for the treatment of denture stomatitis: A systematic review with network meta-analysis

STATEMENT OF PROBLEM

Symptomatic denture stomatitis (DS) is a painful oral mucosal disorder that can impair quality of life in denture wearers. A complete cure of DS is difficult to achieve, and the most efficacious regimen to treat DS has not yet been conclusively established.

PURPOSE

The purpose of this network meta-analysis was to assess the comparative efficacy of interventions used for the treatment of DS.

MATERIAL AND METHODS

A search was conducted for trials published in Medline, Scopus, PubMed, and Cochrane Central Register of Controlled Trials from inception until February 2022 (PROSPERO Reg no: CRD42021271366). Network meta-analysis was performed on data from randomized controlled trials that assessed the comparative efficacy of any form of intervention for the treatment of DS in denture wearers. Agents were ranked according to their effectiveness in the treatment of DS based on outcomes using surface under the cumulative ranking (SUCRA).

RESULTS

A total of 25 articles were included in the quantitative analysis. Topical antifungal agents (risk ratio [RR]=4.37[95% confidence interval [CI]: 2.15,8.90), topical antimicrobial agents used along with systemic antifungal agents (RR=4.25[95% CI: 1.79,10.33]), systemic antifungal agents (RR=4.25[95% CI: 1.79,10.10]), photodynamic therapy (RR=4.25[95% CI: 1.75,8.98]), and topical plant products (RR=3.40[95% CI: 1.59,7.26]) were found to effectively improve DS. Microwave disinfection concurrently administered with topical antifungal agents (RR=7.38(95% CI: 2.75,19.81), microwave disinfection 7.38[95% CI: 2.75,19.81]), topical antifungal agents (RR=4.88[95% CI: 1.92,12.42]), topical plant products (RR=4.49[95% CI: 1.70,11.82]), systemic antifungal agents together with topical antimicrobial agents (RR=3.85[95% CI: 1.33,11.10]), topical antimicrobial agents (RR=3.39[95% CI: 1.17,9.81]), systemic antifungal agents (RR=3.37[95% CI: 1.21,9.34]), and photodynamic therapy or photochemotherapy (PDT) (RR=2.93[95% CI: 1.01,8.47]) were found to effectively resolve mycological DS. Topical antifungals ranked highest in the SUCRA ranking for clinical improvement, whereas microwave disinfection concurrently administered with topical antifungal agents ranked highest for mycological resolution. None of the agents demonstrated significant side effects except for topical antimicrobial agents which demonstrated altered taste and staining of oral structures.

CONCLUSIONS

Available evidence suggests that topical antifungals, microwave, and systemic antifungals are effective in the treatment of DS, but confidence in these findings is low because of the limited number of studies and a high risk of bias. Additional clinical trials are needed on photodynamic therapy, topical plant products, and topical antimicrobials.

Dynamics and metabolic profile of oral keratinocytes (NOK-si) and Candida albicans after interaction in co-culture

Understanding the interaction between oral keratinocytes (NOK-si) and Candida albicans is fundamental for the development of prevention strategies and new therapies for oral candidiasis. This study evaluated the dynamics and metabolic profile of these cells growing in co-culture by means of cell metabolism, number of CFU ml^-1, and production of enzymes, cytokines, and metabolites. The data were analyzed by ANOVAs and post hoc tests (α = 0.05). In co-cultures, there were significant decreases in the cell metabolism of NOK-si and C. albicans and increases in the CFU ml^-1 values of C. albicans biofilm. There were also significant increases in the production of cytokines by NOK-si and proteinase by C. albicans biofilm after their interaction. The metabolic balance of the main metabolites, amino acids, and extracellular and intracellular metabolites was shifted in favor of the co-cultures, while aromatic alcohols were secreted in higher amounts by the biofilm of C. albicans. It was concluded that the interaction of cells in co-culture influenced their dynamics over time.

Epidemiological factors associated with Candida albicans in patients using complete denture: a scoping review

Objective: This study undertakes a scoping review of research on epidemiological factors of Candida albicans in patients using complete denture (CD). Methods: PubMed, LILACS, Embase, SciELO, Web of Science, and Scopus databases were used. Searches were conducted in December 2020. Keywords used in this search were Candida albicans, Complete Denture, Mouth, and Microbiology. Results: Initially, 89 articles were identified; 19 of these comprised the final sample after applying the exclusion/inclusion criteria. There was a greater tendency for females to use DC. In addition, among all samples evaluating the incidence of the fungus (n = 2,724), approximately 44.7% (n = 1,218) had C. albicans-associated prosthetic stomatitis. Conclusion: Prosthetic stomatitis is a condition that mainly affects women aged 50–70 years and has a multifactorial predisposition. Also, Newton's classification proposed in 1962 is the most used for the clinical diagnosis of oral candidiasis. The CD's hygiene status is a crucial factor for the progression of candidosis, in the same way that the C. albicans fungus plays an important role in the progression of this pathogenesis in the host.

Targeting adhesion in fungal pathogen Candida albicans

Fungal infections with increasing resistance to conventional therapies are a growing concern. Candida albicans is a major opportunistic yeast responsible for mucosal and invasive infections. Targeting the initial step of the infection process (i.e., C. albicans adhesion to the host cell) is a promising strategy. A wide variety of molecules can interfere with adhesion processes via an assortment of mechanisms. Herein, we focus on how small molecules disrupt biosynthesis of fungal cell wall components and membrane structure, prevent the localization of GPI-anchor proteins, inhibit production of enzymes involved in adhesion, downregulate genes encoding adhesins and competitively inhibit receptor interactions. As a result, adhesion of C. albicans to host cells is reduced, paving the way to new classes of antifungal agents.

Antifungal Activity Directed Toward the Cell Wall by 2-Cyclohexylidenhydrazo- 4-Phenyl-Thiazole Against Candida albicans

BACKGROUND

The increasing incidence of invasive forms of candidiasis and resistance to antifungal therapy leads us to seek new and more effective antifungal compounds.

OBJECTIVE

To investigate the antifungal activity and toxicity as well as to evaluate the potential targets of 2- cyclohexylidenhydrazo-4-phenyl-thiazole (CPT) in Candida albicans.

METHODS

The antifungal activity of CPT against the survival of C. albicans was investigated in Caenorhabditis elegans. Additionally, we determined the effect of CPT on the inhibition of C. albicans adhesion capacity to buccal epithelial cells (BECs), the toxicity of CPT in mammalian cells, and the potential targets of CPT in C. albicans.

RESULTS

CPT exhibited a minimum inhibitory concentration (MIC) value of 0.4-1.9 µg/mL. Furthermore, CPT at high concentrations (>60 x MIC) showed no or low toxicity in HepG2 cells and <1% haemolysis in human erythrocytes. In addition, CPT decreased the adhesion capacity of yeasts to the BECs and prolonged the survival of C. elegans infected with C. albicans. Analysis of CPT-treated cells showed that their cell wall was thinner than that of untreated cells, especially the glucan layer. We found that there was a significantly lower quantity of 1,3-β-D-glucan present in CPT-treated cells than that in untreated cells. Assays performed on several mutant strains showed that the MIC value of CPT was high for its antifungal activity on yeasts with defective 1,3-β-glucan synthase.

CONCLUSION

In conclusion, CPT appears to target the cell wall of C. albicans, exhibits low toxicity in mammalian cells, and prolongs the survival of C. elegans infected with C. albicans.

Virulence factors of Candida spp. obtained from blood cultures of patients with candidemia attended at tertiary hospitals in Northeast Brazil

BACKGROUND

Yeasts of the Candida genus are one of the most common causes of bloodstream infections associated with high rates of morbidity and mortality, mainly affecting immunocompromised patients. We aimed to identify yeasts obtained from blood cultures of patients interned at tertiary hospitals in Brazil.

METHODS

We evaluated some of the major virulence factors of Candida spp., including the ability to adhere to human buccal epithelial cells, biofilm formation, hemolytic and phospholipase activity.

RESULTS

We analyzed 70 isolates of Candida spp. obtained from March 2011 and March 2015. Candida spp. showed different peculiarities in terms of expression of virulence factors evaluated in vitro. C. albicans strains were more adherent to HBEC than all the other Candida species. C. tropicalis strains were considered strong biofilm producers. Strains belonging to the C. parapsilosis species complex were able to produce hemolysins, while C. glabrata was also able to lyse erythrocytes and to produce phospholipase.

CONCLUSION

These results suggest that Non-Candida albicans Candida species are also able to express virulence factors which play an important role in bloodstream infectious caused by these yeasts.

Candida sp. Infections in Patients with Diabetes Mellitus

Candidiasis has increased substantially worldwide over recent decades and is a significant cause of morbidity and mortality, especially among critically ill patients. Diabetes mellitus (DM) is a metabolic disorder that predisposes individuals to fungal infections, including those related to Candida sp., due to a immunosuppressive effect on the patient. This review aims to discuss the latest studies regarding the occurrence of candidiasis on DM patients and the pathophysiology and etiology associated with these co-morbidities. A comprehensive review of the literature was undertaken. PubMed, Scopus, Elsevier’s ScienceDirect, and Springer’s SpringerLink databases were searched using well-defined search terms. Predefined inclusion and exclusion criteria were applied to classify relevant manuscripts. Results of the review show that DM patients have an increased susceptibility to Candida sp. infections which aggravates in the cases of uncontrolled hyperglycemia. The conclusion is that, for these patients, the hospitalization periods have increased and are commonly associated with the prolonged use of indwelling medical devices, which also increase the costs associated with disease management.

Yeasts isolated from tropical fruit ice creams: diversity, antifungal susceptibility and adherence to buccal epithelial cells

Abstract Fruit-based ice creams are products widely consumed in tropical countries and, because of their composition, can be a good source for microbial growth, including opportunistic pathogens. The aims of this study were to characterize the yeast populations present in Brazilian fruit-based ice creams, and to investigate the antifungal susceptibility to amphotericin B, fluconazole and itraconazole, and the ability of the isolates that were able to grow at 37 ºC to adhere to buccal epithelial cells (BEC). Two hundred and sixty-seven yeast isolates obtained from the ice cream samples were identified as belonging to 29 species, with counts that ranged from 1.5 to 5.2 log CFU/mL. The predominant species were Candida intermedia, Torulaspora delbrueckii, C. parapsilosis, Clavispora lusitaniae, Saccharomyces cerevisiae and Pichia kudriavzevii. At least 16 yeast species isolated in this study have been reported as opportunistic pathogens. Forty-one yeast isolates showed resistance or dose-dependent susceptibility to at least one of the antifungal drugs tested. One isolate of C. parapsilosis was resistant to all the antifungals tested and showed ability to adhere to BEC. The percentage of adhesion to BEC was high mainly for isolates of P. kudriavzevii, Meyerozyma guilliermondii, C. parapsilosis, S. cerevisiae and Debaromyces hansenii. The data suggest that the presence of these opportunistic yeasts as contaminants in ice creams may represent a potential risk to the final consumer, especially to immunocompromised individuals who may consume these products.

Cytokine gene polymorphism in denture stomatitis patients: A clinical study

OBJECTIVE

This clinical study investigated the association between cytokine gene polymorphism and Candida growth in denture stomatitis (DS) patients.

SUBJECTS AND METHODS

Saliva and blood samples of 160 complete denture wearers (80 healthy controls and 80 with DS) were collected for mycological and gene polymorphism testing, respectively. Salivary Candida growth and TNF-α, TGF-β, IL-6, and IL-10 genotypes were investigated. Data were analyzed using Student's t test, Mann-Whitney U test, chi-square analysis, and continuity (yates) correction tests (p < .05).

RESULTS

Candida albicans colony counts in saliva were significantly higher in the DS group and in the TNF-α GG genotype (p < .05). TGF-β TC GG and TGF-β CC GG haplotypes were significantly higher in DS and control groups, respectively (p < .05). C. albicans colony counts were significantly higher in control group in the TGF-β TC GG haplotype (p < .05). Candida glabrata colony counts were significantly higher in the DS group than the control group in IL-6 GG genotype (p < .05). The difference between DS types in IL-6 genotypes was significant with lower expression level in DS type 3 than DS type 1 and also type 2 (p ≤ .01).

CONCLUSION

The significant differences in some genotypes of the TNF-α, TGF-β, and IL-6 in DS patients are promising in understanding the host defense in DS.

Candida species biotypes in the oral cavity of infants and children with orofacial clefts under surgical rehabilitation

Patients with orofacial clefts present various risk factors for oral infectious diseases, resulting from anatomical and physiological changes and those resulting from rehabilitating therapeutic interventions. The incidence of Candida species in groups of babies and children with orofacial clefts, during pre- and post-operative periods and until return to first consultation, and the profiles for antifungal sensitivity and virulence in vitro were investigated. Oral samples were collected at different times over the surgical procedures and post-surgical clinical consultation and seeded in chromogenic culture media CHROMagar Candida^®. Candida biotypes were identified by accessing species-specific genomic DNA sequences by PCR techniques and electrophoretic procedures. Antifungal susceptibility testing was performed by the method of microdilution in broth using the antifungals amphotericin B (AP), nystatin (NYS) and fluconazole (FLC). SAP and PL exoenzyme activities were determined by classical microbiological methods. Some orofacial clefts occurred preferentially in male or female. Low incidence (39.1%) of oral colonization by Candida species (C. albicans, C. krusei, C. tropicalis and Candida spp.) was reported in patient admission to surgical ward, with no correlation to orofacial cleft types or surgical history. Significant reduction in frequencies of Candida and changes of species, over sampling periods, showed dynamic patterns of oral colonization: elimination, maintenance or neocolonization of the biotypes. These biotypes showed sensitivity to AP (100%), partial resistance to FLC (<10%) and variable MICs for NYS (0.125-4 μg/mL), in addition to strong exoenzyme activities, especially for SAP. Clinical and therapeutic conducts for surgical rehabilitation, anatomical and physiological characteristics of patients with orofacial clefts, and cultural behavior and regionalism of the patient population served could influence the frequencies and dynamics of oral colonization by Candida species. The data showed Candida biotypes resistant to FLC and sensitive (AP) or clinically compatible (NYS) to polyenes, especially C. albicans, in the oral cavity of patients predisposed to oral colonization and candidiases, contributing to clinical conducts in possible antifungal therapies. These biotypes were considered potentially virulent and able to partially modulate their virulence factors, especially SAP, under the conditions favored by host.

Development and characterization of a 3D oral mucosa model as a tool for host-pathogen interactions

The aim of this study was to (i) design, develop and validate a practical and physiologically relevant reconstituted in vitro oral mucosa tissue model and (ii) to assess its applicability in in vitro host-pathogen interactions with C. albicans and S. aureus. Co-culture organotypic constructions were created by incorporating specific numbers of keratinocytes (NOK-si) onto cellularised, collagen gel scaffolds containing human gingival fibroblasts incubated in KGM media and cultured for 14 days. The detection of the appropriate oral mucosa/epithelial structure was evaluated by histology (hematoxylin and eosin (HE), periodic acid-Schiff (P.A.S.) and Picrosirius red), and immunocytochemistry (cytokeratin 13, cytokeratin 14, Ki-67 and collagen IV) compared to a normal human gingiva. The morphology of the reconstituted tissue was analyzed by Transmission Electron Microscopy. To further quantitate tissue damage, lactate dehydrogenase (LDH) was measured in the tissue supernatant. NOK-si grown upon a gingival scaffold provided an organotypic model in an in vitro setting and exhibited structural characteristics typically associated with normal oral mucosa. Immunocytochemistry revealed the detection of epithelial cytokeratins 13 and 14, Col IV and Ki-67 in the reconstituted oral mucosa model. Infection was detected after 8 h and 16 h. This study presents an in vitro cellularised, organotypic model of reconstituted oral mucosa, which enables close control and characterization of its structure and differentiation over a mid-length period of time in culture.

An Update on Candida tropicalis Based on Basic and Clinical Approaches

Candida tropicalis has emerged as one of the most important Candida species. It has been widely considered the second most virulent Candida species, only preceded by C. albicans. Besides, this species has been recognized as a very strong biofilm producer, surpassing C. albicans in most of the studies. In addition, it produces a wide range of other virulence factors, including: adhesion to buccal epithelial and endothelial cells; the secretion of lytic enzymes, such as proteinases, phospholipases, and hemolysins, bud-to-hyphae transition (also called morphogenesis) and the phenomenon called phenotypic switching. This is a species very closely related to C. albicans and has been easily identified with both phenotypic and molecular methods. In addition, no cryptic sibling species were yet described in the literature, what is contradictory to some other medically important Candida species. C. tropicalis is a clinically relevant species and may be the second or third etiological agent of candidemia, specifically in Latin American countries and Asia. Antifungal resistance to the azoles, polyenes, and echinocandins has already been described. Apart from all these characteristics, C. tropicalis has been considered an osmotolerant microorganism and this ability to survive to high salt concentration may be important for fungal persistence in saline environments. This physiological characteristic makes this species suitable for use in biotechnology processes. Here we describe an update of C. tropicalis, focusing on all these previously mentioned subjects.

Soluble factors from biofilm of Candida albicans and Staphylococcus aureus promote cell death and inflammatory response

Background

The objective of this study was to better understand the effects of soluble factors from biofilm of single- and mixed-species Candida albicans (C. albicans) and methicillin-sensitive Staphylococcus aureus (MSSA) cultures after 36 h in culture on keratinocytes (NOK-si and HaCaT) and macrophages (J774A.1). Soluble factors from biofilms of C. albicans and MSSA were collected and incubated with keratinocytes and macrophages, which were subsequently evaluated by cell viability assays (MTT). Lactate dehydrogenase (LDH) enzyme release was measured to assess cell membrane damage to keratinocytes. Cells were analysed by brightfield microscopy after 2 and 24 h of exposure to the soluble factors from biofilm. Cell death was detected by labelling apoptotic cells with annexin V and necrotic cells with propidium iodide (PI) and was visualized via fluorescence microscopy. Soluble factors from biofilm were incubated with J774A.1 cells for 24 h; the subsequent production of NO and the cytokines IL-6 and TNF-α was measured by ELISA.

Results

The cell viability assays showed that the soluble factors of single-species C. albicans cultures were as toxic as the soluble factors from biofilm of mixed cultures, whereas the soluble factors of MSSA cultures were less toxic than those of C. albicans or mixed cultures. The soluble factors from biofilm of mixed cultures were the most toxic to the NOK-si and HaCaT cells, as confirmed by analyses of PI labelling and cell morphology. Soluble factors from biofilm of single-species MSSA and mixed-species cultures induced the production of IL-6, NO and TNF-α by J744A.1 macrophages. The production of IL-6 and NO induced by the soluble factors from biofilm of mixed cultures was lower than that induced by the soluble factors from biofilm of single-species MSSA cultures, whereas the soluble factors from biofilm of C. albicans cultures induced only low levels of NO.

Conclusions

Soluble factors from 36-h-old biofilm of C. albicans and MSSA cultures promoted cell death and inflammatory responses.

Oral candidal speciation, virulence and antifungal susceptibility in type 2 diabetes mellitus

OBJECTIVES

To determine the oral candidal carriage (OCC), activity of virulent factors and fluconazole susceptibility in subjects with type 2 diabetes mellitus (T2DM) and investigate their association with HbA1c measurements.

MATERIALS AND METHODS

A cross sectional study was conducted on 100 diabetics and 100 healthy volunteers. The virulence was assessed by measuring the phospholipase activity and proteolysis index. Fluconazole susceptibility was performed using the gradient diffusion method. The OCC, virulence factors and antifungal susceptibility were correlated with patients' HbA1c measurements.

RESULTS

The OCC and candidal density carriage was significantly higher in diabetics. Candida albicans (C. albicans) was the most frequently isolated species followed by Candida tropicalis (C. tropicalis). Relatively uncommon species, Candida lusitaniae (C. lusitaniae) and Candida lipolytica (C. lipolytica) were isolated from the diabetics. Prevalence of virulence factor, proteinase, was greater in diabetic group (p<0.05). Reduced fluconazole susceptibility was noted among the isolates from diabetics; however it was not statistically significant (p=0.593). Except one, all the susceptible-dose dependent and resistant isolates were Candida no-albicans (C. non-albicans).

CONCLUSION

C. albicans remains the predominant pathogen in diabetics, although other species are on the rise. Compared to control group, the isolated species from T2DM group had higher proteinase activity. Resistance to fluconazole was considerably greater among the C. non-albicans isolates from T2DM group. These findings warrant effective treatment modalities to reduce the occurrence of oropharyngeal candidiasis.

Evaluation of Virulence Factors In vitro, Resistance to Osmotic Stress and Antifungal Susceptibility of Candida tropicalis Isolated from the Coastal Environment of Northeast Brazil

Several studies have been developed regarding human health risks associated with the recreational use of beaches contaminated with domestic sewage. These wastes contain various micro-organisms, including Candida tropicalis. In this context, the objective of this study was to characterize C. tropicalis isolates from the sandy beach of Ponta Negra, Natal, Rio Grande do Norte, Brazil, regarding the expression of in vitro virulence factors, adaptation to osmotic stress and susceptibility to antifungal drugs. We analyzed 62 environmental isolates and observed a great variation among them for the various virulence factors evaluated. In general, environmental isolates were more adherent to human buccal epithelial cells (HBEC) than C. tropicalis ATCC13803 reference strain, and they also showed increased biofilm production. Most of the isolates presented wrinkled phenotypes on Spider medium (34 isolates, 54.8%). The majority of the isolates also showed higher proteinase production than control strains, but low phospholipase activity. In addition, 35 isolates (56.4%) had high hemolytic activity (hemolysis index > 0.55). With regard to C. tropicalis resistance to osmotic stress, 85.4% of the isolates were able to grow in a liquid medium containing 15% sodium chloride. The strains were highly resistant to the azoles tested (fluconazole, voriconazole and itraconazole). Fifteen strains were resistant to the three azoles tested (24.2%). Some strains were also resistant to amphotericin B (14 isolates; 22.6%), while all of them were susceptible for the echinocandins tested, except for a single strain of intermediate susceptibility to micafungin. Our results demonstrate that C. tropicalis isolated from the sand can fully express virulence attributes and showed a high persistence capacity on the coastal environment; in addition of showing high minimal inhibitory concentrations to several antifungal drugs used in current clinical practice, demonstrating that environmental isolates may have pathogenic potential.

Reliability of the agar based method to assess the production of degradative enzymes in clinical isolates of Candida albicans

The aim of this study was to establish a reproducible protocol using the methodology of hyaline zones around the colonies on specific agar plates for phospholipase and proteinase production. This was an in vitro double-blind experiment, in which the dependent variables were the enzymatic activity measurements (Pz) for the production of phospholipase (Pz-ph) and the production of secreted aspartyl proteinases (Pz-sap). Three independent variables give rise to different measurement protocols. All measurements were carried out at two different moments by four examiners (E1, E2, E3, and E4). The minimum sample size was 30 Candida albicans clinical isolates. Specific agar plates for phospholipase and SAPs production were prepared according the literature. The intra-and inter-examiner reproducibility for each protocol was estimated using the Intraclass Correlation Coefficient (ICC) and its confidence interval (95% CI). Based on the results obtained for both phospholipase and SAPs, there appears to be no consensus on the protocol chosen for each particular examiner. Measuring the colonies in triplicate may be the main factor associated with the increase in measurement accuracy and should therefore take precedence over measuring only one colony. When only one examiner is responsible for taking measurements, a standard protocol should be put in place and the statistical calibration of this researcher should be done prior to data collection. However, if two or more researchers are involved in the assessment of agar plates, our results suggest that the protocols using software to undertake plate reading is preferred.

Dynamics of biofilm formation and the interaction between Candida albicans and methicillin-susceptible (MSSA) and -resistant Staphylococcus aureus (MRSA)

Polymicrobial biofilms are an understudied and a clinically relevant problem. This study evaluates the interaction between C. albicans, and methicillin- susceptible (MSSA) and resistant (MRSA) S. aureus growing in single- and dual-species biofilms. Single and dual species adhesion (90 min) and biofilms (12, 24, and 48 h) were evaluated by complementary methods: counting colony-forming units (CFU mL-1), XTT-reduction, and crystal violet staining (CV). The secretion of hydrolytic enzymes by the 48 h biofilms was also evaluated using fluorimetric kits. Scanning electron microscopy (SEM) was used to assess biofilm structure. The results from quantification assays were compared using two-way ANOVAs with Tukey post-hoc tests, while data from enzymatic activities were analyzed by one-way Welch-ANOVA followed by Games-Howell post hoc test (α = 0.05). C. albicans, MSSA and MRSA were able to adhere and to form biofilm in both single or mixed cultures. In general, all microorganisms in both growth conditions showed a gradual increase in the number of cells and metabolic activity over time, reaching peak values between 12 h and 48 h (ρ<0.05). C. albicans single- and dual-biofilms had significantly higher total biomass values (ρ<0.05) than single biofilms of bacteria. Except for single MRSA biofilms, all microorganisms in both growth conditions secreted proteinase and phospholipase-C. SEM images revealed extensive adherence of bacteria to hyphal elements of C. albicans. C. albicans, MSSA, and MRSA can co-exist in biofilms without antagonism and in an apparent synergistic effect, with bacteria cells preferentially associated to C. albicans hyphal forms.

Extracellular enzymes and susceptibility to fluconazole in Candida strains isolated from patients with vaginitis and healthy individuals

BACKGROUND

Extracellular phospholipase, proteinase, and coagulase are accounted as the major virulence factors in Candida albicans. Several reports showed that the incidence of resistance to fluconazole has risen during last two decades.

OBJECTIVES

The present study has investigated the extracellular enzymes of C. albicans and non-albicans species isolated from both patients with vaginitis and healthy women. In addition, susceptibility of the isolates was evaluated against fluconazole.

PATIENTS AND METHODS

Vaginal samples were collected using sterile cotton swabs and inoculated on CHROMagar Candida. Routine morphological tests and ID 32C and API 20C AUX Kits were used to identify species. Phospholipase, proteinase, and coagulase activity were determined by standard methods. Susceptibility to fluconazole was also evaluated using ATB Fungus 3 Kits.

RESULTS

The phospholipase activity was detected in 66.7% of the tested isolates recovered from patients with vaginitis. In the present study, phospholipase activity with higher Pz values (< 0.70) was more common in patients with vaginitis (28 of 66 isolates) whereas this rate in the normal individual was 13 of 42. Proteinase activity was detected in 74.2% and 61.9% of tested isolates recovered from patients and normal individuals, respectively. All tested isolates were negative for coagulase activity. In the present study, resistance to fluconazole was found in 34.8% of isolates. C. dubliniensis was the most common isolate (6 out of 11 isolates) that showed resistance to fluconazole.

CONCLUSIONS

Our results showed that C. albicans was the most frequently isolated from both patients with vaginitis and normal individual. In the present study, we could not find any correlation between extracellular activities and sources of isolates (patients and normal flora) and sensitivity or resistance to fluconazole.

In vivo evaluation of photodynamic inactivation using Photodithazine® against Candida albicans

The use of animal models for PDI evaluation is an important step to prove the in vivo effectiveness of a treatment and may provide outcomes that are close to clinical situations, in comparison with in vitro studies.

Current treatment of oral candidiasis: A literature review

Candidiasis or oral candidosis is one of the most common human opportunistic fungal infections of the oral cavity. This pathology has a wide variety of treatment which has been studied until these days. The present study offers a literature review on the treatment of oral candidiasis, with the purpose of establish which treatment is the most suitable in each case. Searching the 24 latest articles about treatment of candidiasis it concluded that the incidence depends on the type of the candidiasis and the virulence of the infection. Although nystatin and amphotericin b were the most drugs used locally, fluconazole oral suspension is proving to be a very effective drug in the treatment of oral candidiasis. Fluconazole was found to be the drug of choice as a systemic treatment of oral candidiasis. Due to its good antifungal properties, its high acceptance of the patient and its efficacy compared with other antifungal drugs. But this drug is not always effective, so we need to evaluate and distinguish others like itraconazole or ketoconazole, in that cases when Candida strains resist to fluconazole.

Key words:Candidiasis, treatment, miconazole, fluconazole, nystatin.

In vitro combination therapy using low dose clotrimazole and photodynamic therapy leads to enhanced killing of the dermatophyte Trichophyton rubrum

Background

Superficial infections of the skin and mucous membranes caused by dermatophyte fungi are amongst the most common and challenging infections to treat. Previously we demonstrated the phototoxic effects of photodynamic therapy (PDT) towards Trichophyton rubrum, using a green laser to photoactivate Rose Bengal (RB). The aim of this study was to evaluate whether we could; (1) achieve a similar effect using an inexpensive light-emitting diode (LED) to photoactivate RB and (2) to evaluate whether our PDT regime could be combined with standard antifungal drug therapy and increase its effectiveness.

Methods

We designed and built our own inexpensive green (530 nm) LED source and tested its efficacy as part our RB-PDT regime in vitro against T. rubrum. We also examined the potential benefits of incorporating PDT as part of combination therapy and whether the order in which this was done had an impact. First we subjected spore suspensions to sub-inhibitory concentrations of a number of antifungal agents (CLT, MCZ and TRB) for 72 hours followed by RB-PDT. Secondly we subjected spore suspensions to sub-inhibitory PDT followed by drug treatment and evaluated if there were any changes to the minimum inhibitory concentrations (MICs) of the drugs tested.

Results

The optimal conditions for photoinactivation of T. rubrum using RB-PDT alone were 140 μM of RB and 24 J/cm² of LED (equating to a 30-minute exposure). These parameters also caused a 100% reduction in the viability of the pathogenic yeast Candida albicans and the model fungus Saccharomyces cerevisiae. By combining our RB-PDT regime as an adjunct to antifungal drugs we were able to dramatically reduce the exposure times. Treatment of spore suspensions using a sub-inhibitory dose of clotrimazole (CLT) followed by RB-PDT, this order was critical, significantly reduced the exposure times required to achieve 100% inhibition of T. rubrum to 15 minutes as compared to RB-PDT alone.

Conclusions

The combination of antifungal drug and RB-PDT represents an attractive alternative to the current antifungal therapies used to treat superficial fungal diseases. Our approach has the potential to reduce treatment times and drug dosages which can also reduce drug toxicity and improve patient compliance.

Electronic supplementary material

The online version of this article (doi:10.1186/s12866-014-0261-z) contains supplementary material, which is available to authorized users.

In vitro evaluation of the enzymatic activity profile of non-albicans Candida species isolated from patients with oral candidiasis with or without diabetes

OBJECTIVE

To evaluate the expression of phospholipase (PL) and secreted aspartyl proteinase (SAP) by Candida glabrata and C tropicalis obtained from the denture biofilms of healthy participants (16 isolates), patients with oral candidiasis with diabetes (10 isolates), and patients with oral candidiasis without diabetes (25 isolates).

STUDY DESIGN

After incubation, the supernatants and pellets of the isolates were used for the enzymatic assays and quantification of colony-forming units (CFU), respectively. Colorimetric tests were used with phosphatidylcholine as a substrate for PL and azocasein as a substrate for SAP, and the absorbances of the samples were measured. Enzymatic rates were calculated, and values were normalized by CFU. Results were analyzed with factorial analyses of variance (α = .05).

RESULTS

C tropicalis and C glabrata were proteolytic and phospholipolytic. The clinical sources of isolates had no significant effect on the enzymatic activities (P > .05). C tropicalis had significantly higher enzymatic activity for both PL and SAP (P < .001) than did C glabrata.

CONCLUSIONS

C tropicalis isolates produced significantly higher amounts of both enzymes than did the C glabrata isolates.

Enzymatic activity profile of a Brazilian culture collection of Candida albicans isolated from diabetics and non-diabetics with oral candidiasis

The secretion of hydrolytic enzymes is a fundamental virulence factor of Candida albicans to develop disease. The objective of this study was to characterise the virulence of 148 clinical isolates of C. albicans from oral candidiasis by assessing the expression of phospholipase (PL) and secreted aspartyl proteinase (SAP). Isolates were obtained from healthy subjects (HS) and diabetics (DOC) and non-diabetics with oral candidiasis (NDOC). An aliquot (5 μl) of each cell suspension was inoculated on PL and SAP agar plates and incubated. Enzymes secretion was detected by the formation of an opaque halo around the colonies and enzymatic activity (PZ) was determined by the ratio between colony diameter and colony diameter plus the halo zone. Statistical comparisons were made by a one-way anova followed by Tukey's post hoc test (α = 0.05). The clinical sources of C. albicans had significant effect (P < 0.001) on the PZ values of both enzymes. For PL, clinical isolates from NDOC and DOC had highest enzymatic activity than those from HS (P < 0.05), with no significant differences between them (P = 0.506). For SAP, C. albicans from NDOC showed the lower enzymatic activity (P < 0.001). There were no significant differences between isolates from HS and DOC (P = 0.7051). C. albicans isolates from NDOC and DOC patients showed an increased production of PL.

Dietary carbohydrates modulate Candida albicans biofilm development on the denture surface

The purpose of this study was to investigate whether dietary carbohydrates can modulate the development of Candida albicans biofilms on the denture material surface. Poly (methyl methacrylate) acrylic resin discs were fabricated and had their surface roughness measured. Biofilms of C.albicans ATCC 90028 were developed on saliva-coated specimens in culture medium without (control) or with carbohydrate supplementation by starch, starch+sucrose, glucose, or sucrose for 72 h. The cell count, metabolic activity, biovolume, average thickness, and roughness coefficient were evaluated at the adhesion phase (1.5 h) and after 24, 48, and 72 h. The secretion of proteinases and phospholipases, cell surface energy, and production of extra/intracellular polysaccharides were analyzed after 72 h of biofilm development. Data were analyzed by one- and two-way ANOVA followed by Tukey’s test at 5% significance level. In the early stages of colonization (adhesion and 24 h), the glucose group showed the highest cell counts and metabolic activity among the groups (p<0.05). After maturation (48 and 72 h), biofilms exposed to glucose, sucrose, or starch+sucrose showed higher cell counts and metabolic activity than the control and starch groups (p<0.001). Compared to the control group, biofilms developed on starch or starch+sucrose had more proteinase activity (p<0.001), whereas biofilms developed on glucose or sucrose had more phospholipase activity (p<0.05). Exposure to starch+sucrose increased the production of extracellular and intracellular polysaccharides (p<0.05). Biofilms developed on starch or without carbohydrate supplementation presented cells with more hydrophobic behavior compared to the other groups. Confocal images showed hyphae forms on biofilms exposed to starch or starch+sucrose. Within the conditions studied, it can be concluded that dietary carbohydrates can modulate biofilm development on the denture surface by affecting virulence factors and structural features.

Virulence attributes and genetic variability of oral Candida albicans and Candida tropicalis isolates

The wide spectrum of candidiasis and its clinical importance encourage the research with the purpose of clarifying the mechanisms of pathogenicity and identification of virulence factors of Candida sp. Therefore, the aim of this study was to verify the adhesion capacity, protease activity and genotypic diversity of oral C. albicans and C. tropicalis isolates. The adhesion ability to the extracellular matrix glycoproteins laminin and fibronectin was evaluated using the ELISA technique. The research of proteases was carried out in agar plate containing bovine albumin and through a quantitative method in buffer solution containing haemoglobin. Intra and interspecies polymorphisms was verified through random amplified polymorphic DNA (RAPD) technique. All C. albicans and C. tropicalis isolates binded to immobilised laminin and fibronectin. Ca33 and Ct13 isolates had relative adhesion index significantly higher than the other isolates for both glycoproteins (P < 0.001). Protease activity was observed in all isolates of C. albicans using either the semi-quantitative or quantitative assay. The protease activity of C. tropicalis was better detected through the quantitative assay. The genotypic diversity by RAPD revealed a heterogeneous population in both species. Nevertheless, C. tropicalis presented higher genetic variability than C. albicans strains.

Correlation between phospholipase of Candida albicans and resistance to fluconazole

The objective of this study was to compare phospholipase production between fluconazole-resistant and fluconazole-susceptible strains of Candida albicans in order to explore the relationship between resistance to antifungal drugs and virulence of C. albicans. Fifteen each of fluconazole-resistant (MIC ≥ 64 μg ml(-1)) and fluconazole-susceptible (MIC ≤ 8 μg ml(-1)) strains of C. albicans were incubated on egg yolk agar to detect phospholipase activity. Virulence of C. albicans was assessed by the average survival time of infected mice. Expression of phospholipase B1 mRNA and protein were detected by RT-PCR and Western blot method. Significant differences between the two groups of Candida strains were observed in phospholipase activity and average survival time of infected mice. The expression of phospholipase B1 mRNA and protein (both of secreted and intracellular forms) were higher in resistant strains than in susceptible strains. The results indicate that the phospholipase activity of C. albicans may be related to its resistance to antifungal drugs.

Investigating biofilm production, coagulase and hemolytic activity in Candida species isolated from denture stomatitis patients

OBJECTIVE

Oral candidiasis, in the form of Candida-associated denture stomatitis, represents a common disease in a large percentage of denture wearers, and Candida albicans remains the most commonly isolated species. In this study, we aimed to evaluate biofilm production, coagulase and hemolytic activity of Candida species isolated from denture stomatitis patients.

MATERIALS AND METHODS

This study included 70 patients (31 female, 39 male). Forty-eight of the patients were found to have a positive culture. A total of 48 Candida isolates representing five species, C. albicans (n=17), C. glabrata (n=10), C. krusei (n=9), C. kefyr (n=7) and C. parapsilosis (n=5), were tested. Their coagulase activities were evaluated by a classical tube coagulase test with rabbit plasma. A blood plate assay on 3% enriched sheep blood Sabouraud-dextrose agar (SDA) was used to determine their in vitro hemolytic activities. Biofilm production was determined by a visual tube method.

RESULTS

Twenty-one Candida isolates exhibited coagulase activity, and the coagulase activities of the C. albicans (64.7%) isolates were higher than other species. C. albicans, C. glabrata, C. kefyr and C. krusei species demonstrated beta hemolysis. C. parapsilosis strains failed to demonstrate any hemolytic activities. Fifteen (88.0%) of the C. albicans strains were biofilm positive. Six (35.2%) of these strains were strongly positive, 8 (47.0%) C. albicans strains were moderately positive and 1 (5.8%) C. albicans strain was weakly positive. Sixteen (51.6%) of the non-albicans Candida strains were biofilm positive while 15 (48.3%) did not produce biofilms.

CONCLUSION

The results of this present study indicate coagulase, hemolytic activity and biofilm production by Candida spp. isolated from patients with denture stomatitis. Investigations of these virulence factors might be helpful in gaining information about the possible virulence of oral Candida species related to denture stomatitis.

Adherence to buccal epithelial cells, enzymatic and hemolytic activities of Candida isolates from HIV-infected individuals

Candida spp., along with other microorganisms are usually found in the normal flora of the human oral mucosa. However in HIV-infected individuals these yeasts can become opportunistic pathogens and lead to mucosal infections. The transformation from a harmless commensal to a virulent pathogen under conditions of dysfunctional host defense system is attributable to an extensive repertoire of selectively expressed virulence determinants. The present study was undertaken to analyze the production of four important virulence factors viz. adherence to buccal epithelial cells (BEC), proteinase activity, phospholipase activity and hemolysis, and to evaluate the correlation between these virulence factors in 65 Candida isolates from HIV-infected individuals with oral candidiasis. A total of 95.3%, 67.7%, 41.5% and 100% of the Candida isolates showed adherence to BEC, and proteinase, phospholipase and hemolytic activities, respectively. Production of proteinase and phospholipase enzymes was seen in 89.7% and 59.0% of C. albicans isolates and 34.6% and 15.4% of non-Candida albicans Candida (NAC) isolates, respectively. C. albicans showed significantly greater level of virulence factor expression with regards to adherence to BEC (P < 0.001), phospholipase production (P < 0.044) and hemolysis (P = 0.037) as compared to NAC. A correlative relationship between proteinase activity and adherence to BEC, as well as phospholipase production was noted.

Enzymatic activity, sensitivity to antifungal drugs and Baccharis dracunculifolia essential oil by Candida strains isolated from the oral cavities of breastfeeding infants and in their mothers' mouths and nipples

Candida strains can cause oral candidosis, as well as nipples candidosis and lead to premature weaning or yeast transmission. The aim of this study was to evaluate 51 Candida isolates obtained from the oral cavities of infants during breastfeeding and mothers' oral cavities and nipples, their enzymatic activity and their sensitivity to amphotericin B, fluconazole and Baccharis dracunculifolia essential oil. Among the studied strains, 96.1% produced phospholipase and 78.4% produced proteinase. The antifungal resistance was only observed among isolates of C. albicans, for which three strains showed a resistant activity to fluconazole and one showed a resistant activity to amphotericin B. All strains were sensitive to B. dracunculifolia essential oil with MIC between 0.2 and 6.25 mg/ml. It was concluded that most of the strains showed significant enzymatic activity and were sensitive to amphotericin B and fluconazole. B. dracunculifolia essential oil inhibited the growth of all strains, including the ones resistant to commercial antifungal agents.

Hydrolytic enzyme production is associated with Candida albicans biofilm formation from patients with type 1 diabetes

Oral candidosis is common in patients with diabetes mellitus, as yeasts, particularly Candida albicans, have the propensity to colonise, form biofilms and release hydrolytic enzymes which cause inflammation. This study aimed to investigate these characteristics in isolates from three groups of patients with type 1 diabetes: individuals with better controlled diabetes (BCD; >or=6 <8%), individuals with poorly controlled diabetes (PCD; >or=8%) and non-diabetics (ND; HbA(1c) <5.9%). The biomass (Bm), phospholipase (P(z)), haemolysin (H(z)) and proteinase (Pr(z)) were assessed using a microtitre biofilm assay and agar-based hydrolytic enzyme assays. Biofilm formation was significantly increased in the PCD group compared to ND and BCD groups (P < 0.05). No significant differences in P(z) levels were observed between groups, whereas both H(z) and Pr(z) were significantly greater in the diabetes groups than in the healthy control group (P < 0.05). Statistically significant correlations were found to exist between the HbA(1c) levels of the patients and the Bm (R = 0.384; P = 0.033), haemolysin activity (R = -0.455; P = 0.010) and proteinase activity (R = -0.531; P = 0.002). There was no apparent correlation between the Bm and P(z) activity (R = -0.305; P = 0.053) or H(z) activity (R = -0.100; P = 0.296). However, a negative correlation was found between Bm and Pr(z) values (R = -0.343; P = 0.030). These data suggest that biofilm formation is likely to play a role in the pathogenicity of oral candidosis, and in patients with diabetes, this may be due to the ability of C. albicans to adapt to the altered physiological environment. The production of hydrolytic enzymes is independently associated with this growth modality.

Susceptibility of Candida albicans to photodynamic therapy in a murine model of oral candidosis

OBJECTIVE

In vivo studies of antimicrobial PDT in animal models of oral candidosis are scarce and the association of porphyrin and LED light has not been evaluated for in vivo photoinactivation of Candida. In this study the effectiveness of photodynamic therapy (PDT) on the inactivation of Candida albicans in vivo was evaluated.

STUDY DESIGN

Seventy-one 6-week-old female Swiss mice were immunosuppressed, provided tetracycline to their drinking water, then orally swabbed with a suspension of C. albicans (10(7) CFU/mL). Four days after oral inoculation, PDT was performed on the dorsum of the tongue after topical administration of Photogem at 400, 500, or 1000 mg/L and followed 30 minutes later by illumination with LED light (305 J/cm(2)) at 455 or 630 nm (n = 5 each). After swabbing to recover yeast from the tongue, the number of surviving yeast cells was determined (CFU/mL) and analyzed by ANOVA and Holm-Sidak tests (P < .05). Animals were humanely killed, and the tongues surgically removed and processed for histological evaluation of presence of yeast and inflammatory reaction.

RESULTS

PDT resulted in a significant reduction in C. albicans recovered from the tongue (P < .001) when compared with mice from the positive control group. There was no difference between the concentrations of Photogem and LED light wavelengths used. Histological evaluation of the tongue revealed that PDT causes no significant adverse effects to the local mucosa.

CONCLUSION

PDT promoted significant reduction in the viability of C. albicans biofilm without harming the tongue tissue.

The effect of gentian violet on virulent properties of Candida albicans

The aim of this study was to evaluate the effect of gentian violet (GV) on phospholipase activity, proteinase activity and germ tube formation rate of Candida albicans. Both 12 phospholipase-positive and 12 proteinase-positive C. albicans isolates with Pz values <or=0.89 were obtained. A yeast suspension (1-3 x 10(7) cfu/ml) of each isolate was prepared. After a brief exposure (60 min) to sub-therapeutic concentrations (0.5 or 2 microg/ml) of GV, Pz value of phospholipase, Pz value of proteinase and germ tube formation rate were determined. Phospholipase activity, proteinase activity and germ tube formation rate in two groups exposed to GV were significantly lower than those in the group unexposed (P < 0.05). The results of this study indicated that sub-therapeutic concentrations of GV may lead to reduction in phospholipase activity, proteinase activity and germ tube formation, and then may suppress virulence and pathogenicity of C. albicans.

Examination of potential virulence factors of Candida tropicalis clinical isolates from hospitalized patients

Candida tropicalis has been reported to be one of the Candida species which is most likely to cause bloodstream and urinary tract infections in hospitalized patients. Accordingly, the aim of this study was to characterize the virulence of C. tropicalis by assessing antifungal susceptibility and comparing the expression of several virulence factors. This study was conducted with seven isolates of C. tropicalis from urine and blood cultures and from central venous catheter. C. tropicalis ATCC 750 was used as reference strain. Yeasts adhered (2 h) to epithelial cells and silicone and 24 h biofilm biomass were determined by crystal violet staining. Pseudohyphae formation ability was determined after growth in fetal bovine serum. Enzymes production (hemolysins, proteases, phospholipases) was assessed by halo formation on agar plates. Susceptibility to antifungal agents was determined by E-test. Regarding adhesion, it can be highlighted that C. tropicalis strains adhered significantly more to epithelium than to silicone. Furthermore, all C. tropicalis strains were able to form biofilms and to express total hemolytic activity. However, protease was only produced by two isolates from urine and by the isolates from catheter and blood. Moreover, only one C. tropicalis (from catheter) was phospholipase positive. All isolates were susceptible to voriconazole, fluconazole and amphotericin B. Four strains were susceptible-dose dependent to itraconazole and one clinical isolate was found to be resistant.

The effect of Dodonaea viscosa var. angustifolia on Candida albicans proteinase and phospholipase production and adherence to oral epithelial cells

AIM OF THE STUDY

This study investigated effect of a crude extract of Dodonaea viscosa on the proteinase and phospholipase production and adherence to epithelial cells by Candida albicans isolated from HIV positive and HIV negative patients.

MATERIALS AND METHODS

Twenty Candida albicans strains isolated from HIV positive and 20 from HIV negative patients were investigated. The isolates were exposed to subinhibitory concentration of crude plant extract and adherence, proteinase and phospholipase production were assessed. The results were analysed using Student's t-test and a two-way ANOVA.

RESULTS

Dodonaea viscosa var. angustifolia inhibited the adherence of Candida albicans to oral epithelial cells (p=<0.01) but no significant effect of the plant extract on proteinase and phospholipase production was observed. Results from Candida albicans strains isolated from HIV positive and HIV negative patients were similar.

CONCLUSIONS

Dodonaea viscosa var. angustifolia inhibited the adherence of Candida albicans to oral epithelial cells, which is the initial step of colonization in the infection process. This plant has a therapeutic potential at subinhibitory concentration.

Curcumin as a promising antifungal of clinical interest

OBJECTIVES

The antifungal activity of curcumin was evaluated against 23 fungi strains and its in vitro inhibitory effect on the adhesion of Candida species to human buccal epithelial cells (BEC) was also investigated.

METHODS

The antifungal susceptibility was evaluated by broth microdilution assay following the CLSI (formerly the NCCLS) guidelines. The inhibitory effect of curcumin on the cell adhesion was performed with Candida species and BEC.

RESULTS

Paracoccidioides brasiliensis isolates were the most susceptible to curcumin while the growth of Aspergillus isolates was not affected. Curcumin was much more efficient than fluconazole in inhibiting the adhesion of Candida species to BEC, particularly those strains isolated from the buccal mucosa of AIDS patients.

CONCLUSIONS

The lack of antifungal compounds with reduced side effects highlights the importance of studying natural products for this purpose. Curcumin was a more potent antifungal than fluconazole against P. brasiliensis, the causal agent of the neglected disease paracoccidioidomycosis. Curcumin dramatically inhibited the adhesion of Candida species isolated from AIDS patients to BEC, demonstrating that curcumin is a promising lead compound that warrants further investigation into its therapeutical use in immunocompromised patients.

Correlation between enzyme production, germ tube formation and susceptibility to fluconazole in Candida species isolated from patients with denture-related stomatitis and control individuals

INTRODUCTION

Phospholipase and proteinase secretion in yeasts of the genus Candida has been described as a relevant virulence factor. Also, germ tube formation by Candida albicans is associated with its invasive capacity and is considered an important pathogenic mechanism.

METHODS

To link the production of hydrolytic enzymes with the capacity to produce infection, 232 clinical isolates of yeasts from the oral cavity of 140 individuals wearing removable maxillary protheses were studied. The sample was composed of 70 patients with denture-related stomatitis (DRS) and 70 individuals with normal palatal mucosa. For strains identified as C. albicans, the correlation between germ tube formation and their capacity to cause infection was studied and the presence of Candida dubliniensis was investigated. Susceptibility to fluconazole was evaluated.

RESULTS

Candida albicans was the only species producing phospholipase and germ tube. We observed a higher level of production of phospholipase in cases of infection compared with commensals. Significant differences between the two groups of C. albicans isolates were observed as to germ tube production. Only, Candida glabrata showed lower susceptibility to fluconazole.

CONCLUSION

The results reinforced the idea that C. albicans is the most frequent and can be the most pathogenic yeast in oral candidosis. However, the strains isolated from DRS patients and healthy individuals showed the same virulence factors. It seems that several virulence attributes are involved in the infective process but no single factor contributes to Candida virulence. Candida dubliniensis was absent in the oral cavity of individuals with and without DRS.

In vitro evaluation of putative virulence attributes of oral isolates of Candida spp. obtained from elderly healthy individuals

Identification of Candida isolates obtained from oral cavity of elderly healthy individuals revealed the predominance of non-albicans Candida species (88.9%) compared to Candida albicans (11%). CHROMagar Candida differential medium and PCR revealed the presence of Candida tropicalis (33.3%), Candida glabrata (27.8%), and Candida krusei (16.7%). We investigated the presence of virulence attributes in a total of 18 isolates, including acid protease and phospholipase production, hemolytic activity, and biofilm production. Extracellular protease was found in five isolates (27.8%) whereas extracellular phospholipase was found in three isolates (17%). All isolates showed hemolytic activity. About 56% of the isolates were weakly positive for biofilm formation (score +) whereas a minority (5.6%) of them showed strong biofilm formation (score 4+). Susceptibility in vitro of the isolates to fluconazole was carried out by microdilution method. Fluconazole showed a strong inhibition against most buccal isolates. The resistant isolates were 2 C. tropicalis, 2 C. glabrata, and 1 C. krusei.