id000020
10.3205/id000020
urn:nbn:de:0183-id0000200
Research Article
Parallel and cross-resistances of clinical yeast isolates determined by susceptibility pattern analysis
Schmalreck
Schmalreck
Arno F.
AF
Mikrobiologische Beratung und Service (MBS), München, Germany
author
Willinger
Willinger
Birgit
B
Division of Clinical Microbiology, Department of Laboratory Medicine, University Vienna, Austria
author
Idelevich
Idelevich
Evgeny A.
EA
Institute of Medical Microbiology, University Hospital Münster, Germany
author
Fegeler
Fegeler
Christian
C
Medical Informatics, Faculty of Informatics, University Heilbronn, Germany
author
Lass-Flörl
Lass-Flörl
Cornelia
C
Section Hygiene and Medical Microbiology, Medical University Innsbruck, Austria
author
Fegeler
Fegeler
Wolfgang
W
Institute of Medical Microbiology, University Hospital Münster, Germany
author
Becker
Becker
Karsten
K
Institute of Medical Microbiology, University Hospital Münster, Domagkstr. 10, 48149 MünsterInstitute of Medical Microbiology, University Hospital Münster, Germany
kbecker@uni-muenster.de
author
German Medical Science GMS Publishing House
Düsseldorf
610
Candida
antifungals
flucytosine
amphotericin B
fluconazole, voriconazole
posaconazole, caspofungin
micafungin
anidulafungin
susceptibility testing
susceptibility pattern analysis
parallel resistance
cross-resistance
20160607
engl
This is an Open Access article distributed under the terms of the Creative Commons Attribution 4.0 License.
Dieser Artikel ist ein Open-Access-Artikel und steht unter den Lizenzbedingungen der Creative Commons Attribution 4.0 License (Namensnennung).
2195-8831
4
GMS Infectious Diseases
GMS Infect Dis
02
For calculated initial antifungal therapy, knowledge on parallel and cross-resistances are vitally important particularly in the case of multiresistant isolates. Based on a strain collection of 1,062 yeast isolates from a German/Austrian multicentre study, susceptibility pattern analysis (SPA) was used to determine the proportion of parallel and cross-resistances to eight antifungal agents (AFAs) encompassing flucytosine, amphotericin B, azoles (fluconazole, voriconazole and posaconazole) and echinocandins (caspofungin, micafungin and anidulafungin). A total of 414 (39.0%) isolates were resistant for one or more of the AFAs. Resistance to one AFA was shown for 18.1% of all isolates. For 222 isolates (20.9%), resistance to two to seven AFAs was noted (7.7%; 7.7%; 3.6%; 1.0%; 0.7% and 0.2% to 2, 3, 4, 5, 6 and 7 antifungal compounds, respectively). Partial parallel resistances within the azole and echinocandin classes, respectively, were found for 81 (7.6%) and 70 (6.6%) isolates. Complete parallel resistances for azoles, echinocandins and combined for both classes were exhibited by 93 (8.8%), 18 (1.7%) and 6 (0.6%) isolates, respectively. Isolates displaying cross-resistances between azoles and echinocandins were infrequently found. Highly resistant isolates (resistance to ≥6 AFAs) were almost exclusively represented by Candida albicans. Highly standardized testing of AFAs in parallel and from the same inocula followed by SPA allows detailed insights in the prevalence and distribution of susceptibility patterns of microbial isolates.
BackgroundTreatment options for invasive fungal infections are restricted by a very limited number of applicable antifungal agent (AFA) classes. Due to extensive worldwide use of fluconazole in the past decades, azole resistance has been significantly emerged, often associated with clinical failure , , , . Also for the other AFA classes, resistances with substantial consequences for treatment and patient outcome have been increasingly reported , , , , , . There is mounting evidence that the serious phenomenon of multi-resistance has reached also infections due to fungal pathogens. While reports on testing susceptibilities of yeast isolates to individual antifungals are available for many parts of the world , , , , systematic data on parallel and cross-resistances of Candida and other yeast isolates towards azoles, echinocandins, polyenes and flucytosine are still rare . Of note, the terms “parallel resistances” and “cross-resistances” are often undifferentiated and/or varyingly used today. Here, parallel resistance (PR) was defined as resistance of a given isolate to all antifungal agents within an antifungal class and cross-resistance (CR) as resistance of a given isolate to antifungal agents belonging to different classes of antifungals.Previously, we have analyzed the AFA susceptibilities of 1,062 yeast isolates recovered from clinical specimens within a collaborative study including 17 participating medical centres mainly by standard susceptibility testing analyses . Here, susceptibility pattern (SP) analysis (SPA) was applied allowing a highly standardized analysis and true comparison of antifungal susceptibilities based on determined individual SP of each single isolate . Based on this, we determined the proportion of parallel, cross- and multi-resistances for the clinically most prevalent Candida species, but also for rare yeast species of interest, isolate- and species-specifically stratified for azoles, echinocandins, flucytosine and amphotericin B.
MethodsYeast isolatesA total of 1,062 clinical yeast isolates (species distribution, see Table 1 ) were recovered from clinical relevant routine samples of hospitalized patients and tested for susceptibility within a German/Austrian collaborative study comprising 17 study centres . Details regarding species-specific resistance profiles and AFA-related resistance prevalences have been previously reported . Briefly, 184 (17.3%) specimens were recovered from blood and other normally sterile sites and 878 (82.7%) specimens comprised those from non-sterile sites, such as specimens from lower respiratory tract (n=299; 34.1%), mouth and throat (n=126; 14.4%), urinary tract (n=166; 18.9%); female genital tract (n=35; 4.0%), gastro-intestinal tract (n=61; 6.9%)] and other sites (n=191; 21.7%).AFA and susceptibility testingSusceptibility testing was performed as previously published according to DIN (Deutsches Institut für Normung e.V., i.e. the German Institute for Standardization) . Briefly, antifungal agents were tested in parallel in yeast sensitivity test (YST) as log2-dilution-rows in ready-to-use microdilution trays manufactured by Merlin GmbH (Bornheim-Hersel, Germany) comprising the following range of antifungal concentrations (in mg l-1): amphotericin B (AMB), 0.008–8.0; flucytosine (FCY), 0.31–32.0; fluconazole (FLC), 0.063–64.0; posaconazole (POS), voriconazole (VOR), anidulafungin (ANI), caspofungin (CAS), and micafungin (MCA), 0.008–8.0. YST medium, which corresponds to the modified HR medium according to DIN 58940-8415 , was manufactured by Sifin GmbH (Berlin, Germany). Endpoint reading was performed at 24 h and the MICs were controlled after 48 h incubation at 35°–37°C. Minimal inhibitory concentrations (MICs) were determined according to German DIN standards, i.e. the assumed endpoint was the lowest concentration which shows agitated a significant less turbidity than those of 80%-inhibitions control by visual inspection , .Statistical analysis was performed with SAS® software (SAS Institute, Cary, NC, USA). The antilog of the calculations was displayed as MICs from calculated results. Differences were assessed by using Chi squared test; <![CDATA[P values</PlainText></TextGroup> lower than 0.05 were considered statistically significant.</Pgraph><SubHeadline>MICs and MIC interpretive criteria</SubHeadline><Pgraph>Details of the <Mark2>in vitro</Mark2> susceptibilities of yeast isolates collected within the multicenter study towards eight antifungal agents have been reported before <TextLink reference="12"></TextLink>. Briefly, all drug classes demonstrated multi-modular, at least bi-modular MIC distributions. The geometric means of MICs for FLC, POS, VOR, ANI, CAS, MCA, AMB, and FCY for <Mark2>Candida albicans</Mark2> strains (n=573; mg l<Superscript>-1</Superscript>) were 0.6, 0.5, 2.0, 0.1, 0.1, 0.03, 0.1 and 0.03 and for non-<Mark2>C. albicans</Mark2> strains (n=473; mg l<Superscript>-1</Superscript>): 0.8, 0.9, 8.2, 1.3, 0.4, 0.4, 0.2 and 0.04, respectively.</Pgraph><Pgraph>MIC categorisation was performed as published by applying interpretative criteria for AMB as published by EUCAST <TextLink reference="20"></TextLink> and for FLC as published by DIN <TextLink reference="17"></TextLink>. For POS, ANI, CAS, and MCA interpretative criteria published by Pfaller et al. were used <TextLink reference="21"></TextLink>, <TextLink reference="22"></TextLink>. CLSI criteria were applied for FCY and VOR <TextLink reference="23"></TextLink>. Interpretative criteria for susceptible (S) and resistant (R) were: AMB: S≤1.0, R>1.0; FCY, FLC: S≤4.0, R>16.0; POS, VOR: S≤1.0, R>2; and ANI, CAS MCA: S≤2, R>2.0. If appropriate, the values in between were used as intermediate (I). Species-specific breakpoints were not applied.</Pgraph><Pgraph>SPs representing sequences of interpretative categories (S, I or R) in a prefixed order of the test results were determined by SPA as described, here in an adaptation for fungal microorganisms <TextLink reference="16"></TextLink>. An SP as applied here contains the number of members of antifungal class and the S-I-R categorization (<Mark2>e.g.</Mark2> for a given isolate with complete azole resistance to FLC, POS and VOR: 3R=R-R-R or for an isolate tested susceptible to all eight AFAs included: 8S=S-S-S-S-S-S-S-S).</Pgraph><SubHeadline>Resistance definitions</SubHeadline><Pgraph>Definitions were applied according to DIN 58940-1 and as published elsewhere <TextLink reference="12"></TextLink>, <TextLink reference="17"></TextLink>. Briefly, multiple resistance (MR) was defined in this study, when two or more antifungal agents independently of any substance class were tested resistant in the same isolate,<Mark2> i.e.</Mark2> representing a random susceptibility pattern. Parallel resistance (PR) was defined as resistance of a given isolate to all (complete PR) or more than one, but not all (partial PR) AFAs within a class of antifungals. Cross-resistance (CR) was defined as resistance of a given isolate to two or more AFAs belonging to different classes of antifungals. </Pgraph></TextBlock>
<TextBlock linked="yes" name="Results">
<MainHeadline>Results</MainHeadline><Pgraph>A total of 1,062 clinical yeast isolates (<Mark2>C. albicans</Mark2>, n=573; 54.0%; non-<Mark2>albicans Candida</Mark2> spp., n=473; 44.5%; other yeasts, n=16; 1.5%; further details in Table 1 <ImgLink imgNo="1" imgType="table"/>) were enrolled for SPA evaluating their parallel and cross-resistance patterns. Unless otherwise stated, all results given in the text and the tables are based on the application of YST medium and endpoint reading after 48 h.</Pgraph><Pgraph>For FCY, FLC, VOR and POS, a threefold categorization (S, I and R) was used and a twofold categorization (S and R) was applied for AMB, CAS, MCA and ANI. Thus, the individual SP of a given isolate represents one SP out of a variety of 1,296 theoretically possible SPs. However, only a limited amount of SPs were found, nevertheless, demonstrating numerous parallel and/or cross-resistant strains. Consequently, only a selection of relevant data restricted (i) to clinically most prevalent <Mark2>Candida</Mark2> species or (ii) to rare yeast species with noticeable SPs has been included in Table 1 <ImgLink imgNo="1" imgType="table"/>, Table 2 <ImgLink imgNo="2" imgType="table"/>, Table 3 <ImgLink imgNo="3" imgType="table"/>, Table 4 <ImgLink imgNo="4" imgType="table"/>, Table 5 <ImgLink imgNo="5" imgType="table"/>, Table 6 <ImgLink imgNo="6" imgType="table"/> and Table 7 <ImgLink imgNo="7" imgType="table"/>. Overall, 62 SPs and 117 SPs were found after 24 h and after 48 h incubation using YST medium. In contrast, applying RPMI medium, the amount of SPs gained after 24 h (n=54) as well as after 48 h (n=86) incubation were less than applying YST medium. However, only the medium-caused difference of SP numbers observed after 48 h reached significance (p<0.05) (data not shown).</Pgraph><Pgraph>Standard susceptibility testing analysis neglecting the individual patterns of susceptibility was compared with SPAs considering isolate-specifically resistances within AFA classes and in between different AFA classes (<TextGroup><PlainText>Table 2 </PlainText></TextGroup><ImgLink imgNo="2" imgType="table"/>), thus, allowing inferences to all naturally occurring SPs in detail. Similar analyses are given for echinocandins and, where appropriate, for FCY and AMB (<TextGroup><PlainText>Table 2 </PlainText></TextGroup><ImgLink imgNo="2" imgType="table"/>). Considering isolates exhibiting exclusive resistance to only one of the AFAs tested, but otherwise tested susceptible (1R7S SP), 93 isolates were found to meet this condition. Including also those isolates otherwise tested susceptible or intermediate (1R7S/I SP), this condition was fulfilled by 192 isolates. While 113 (10.6%) isolates were found to be VOR-resistant by standard analysis, SPA demonstrated that none of these isolates showed exclusive VOR resistance (1R SP) analyzing those isolates tested resistant towards the three azoles included. In contrast, 21 (2.0%) and 23 (2.2%) isolates, respectively, exhibited sole resistance towards FLC and POS, but were tested susceptible towards the other azole agents (Table 2 <ImgLink imgNo="2" imgType="table"/>). Considering all AFAs tested, only five (0.5%) isolates were characterized by exclusive resistance to VOR (Table 2 <ImgLink imgNo="2" imgType="table"/>).</Pgraph><Pgraph>Overall, this strain collection comprised 519 (48.9%) yeast isolates tested susceptible to all AFAs included. Regarding azoles and echinocandins, respectively, entire susceptibility were noted for 619 isolates (58.3%) and 974 isolates (91.7%). For the most prevalent species, this 3S SP varied for azoles and echinocandins, respectively, as follows: <Mark2>C. albicans</Mark2>, 77.5% and 91.8%; <Mark2>Candida glabrata</Mark2>, 23.5% and 97.9%; <Mark2>Candida krusei</Mark2>, 4.3% and 100%; <Mark2>Candida parapsilosis</Mark2>, 67.2% and 73.4% and <Mark2>Candida tropicalis</Mark2>, 45.9% and 96.7%.</Pgraph><Pgraph>Partial parallel resistances (SPs: RSS, RRS, SSR, SRR, SRS and RSR; unconsidering further SPs containing “I” categorization) within the azole and echinocandin classes, respectively, were found for 81 (7.6%) and 70 (6.6%) isolates.</Pgraph><Pgraph>The percentage of complete parallel resistance to all azoles (3R) was 8.8%, while it was 1.7% to all echinocandins (Table 1 <ImgLink imgNo="1" imgType="table"/>, Table 3 <ImgLink imgNo="3" imgType="table"/>, Table 4 <ImgLink imgNo="4" imgType="table"/>). A complete resistance towards all azoles combined with cross-resistance either to FCY or AMB occurred in 1.7 % or 2.2% of the isolates. For echinocandins, this 3R SP together with cross-resistance to FCY and AMB, respectively, was 0.1% and 0.4% (Table 1 <ImgLink imgNo="1" imgType="table"/>). </Pgraph><Pgraph>The proportion of complete parallel resistance varied species-specifically. Of particular interest, complete parallel echinocandin resistance was observed for 23.8% of all <Mark2>Candida dubliniensis</Mark2> isolates (Table 1 <ImgLink imgNo="1" imgType="table"/>). A respective echinocandin 3R SP was also documented for <Mark2>Candida sake</Mark2> (50%) and both <Mark2>Geotrichum</Mark2> species included, however, here, a very limited number of isolates enrolled should be taken in consideration. In contrast, <Mark2>C. albicans</Mark2> and <Mark2>C. tropicalis</Mark2> exhibited this 3R-SP for less than 2% of the isolates. However, within the azole class, 3.1%, 6.1%, 12.5%, 14.1%, 14.8%, 15.4%, 23.7 and 50.0% of the <TextGroup><Mark2>C. parapsilosis</Mark2></TextGroup>, <Mark2>C. albicans</Mark2>, <Mark2>Candida guilliermondii</Mark2> <TextGroup><PlainText>(only n=8)</PlainText></TextGroup>, <Mark2>C. glabrata</Mark2>, <Mark2>C. tropicalis</Mark2>, <Mark2>Saccharomyces cerevisiae</Mark2>, <Mark2>C. krusei</Mark2> and <Mark2>Candida melibiosica</Mark2> (only n=2) isolates, respectively, showed a complete parallel resistance. Of interest, 1.8% of the <Mark2>C. albicans</Mark2> isolates showing complete parallel azole resistance exhibited also AMB resistance, while only 0.4% of complete echinocandin-resistant isolates of this species were tested also AMB-resistant. Other cross-resistance patterns towards AMB and FCY for complete azole- and echinocandin-resistant isolates, respectively, are given in Table 1 <ImgLink imgNo="1" imgType="table"/>.</Pgraph><Pgraph>A more detailed overview of cross-resistances for those yeasts exhibiting a complete parallel resistance pattern to all azoles (3R; 8.8%) and echinocandins (3R; 1.7%), respectively, is given in Table 3 <ImgLink imgNo="3" imgType="table"/> and Table 4 <ImgLink imgNo="4" imgType="table"/>. Overall, 19.4 and 24.7% of complete azole-resistant yeast isolates were tested resistant also towards FCY and AMB, respectively. Regarding echinocandins, 7.5%, 12.9% and 14.0% of these isolates showed resistance to MCA, CAS and ANI, respectively. Of interest, while all full azole-resistant <TextGroup><Mark2>C. glabrata</Mark2></TextGroup> and <Mark2>C. krusei</Mark2> isolates were still susceptible towards all echinocandins, 31.4%, 28.6% and 20.0% of full azole-resistant <Mark2>C. albicans</Mark2> isolates showed cross resistance to CAS, ANI and MCA (Table 3 <ImgLink imgNo="3" imgType="table"/>).</Pgraph><Pgraph>A complete parallel resistance to echinocandins was observed for only 18 yeast isolates. Of these, 16/1046 (1.5%) were represented by species of the <Mark2>Candida genus</Mark2>. Also both <Mark2>Geotrichum</Mark2> isolates included exhibited this SP (Table 4 <ImgLink imgNo="4" imgType="table"/>). Overall, 5.6% and 22.2% of complete echinocandin-resistant yeast isolates were tested resistant also towards FCY and AMB, respectively. Noteworthy, 33.3%, 38.9% and 44.4% of these isolates were also categorized as resistant to VOR, FLC and POS, respectively. For complete echinocandin-resistant <Mark2>C. albicans</Mark2> isolates (n=10/57; 1.7%), 60% were tested resistant also towards each of the azoles included. All <Mark2>C. dubliniensis</Mark2> isolates of this category (n=5) were susceptible to VOR, while one isolate demonstrated partial parallel resistance to FLC and POS (Table 4 <ImgLink imgNo="4" imgType="table"/>).</Pgraph><Pgraph>SPA results for rare yeast species, defined in this study as <Mark2>Candida</Mark2> and non-<Mark2>Candida</Mark2> yeast species comprising equal or less than five isolates, are given in Table 5 <ImgLink imgNo="5" imgType="table"/>. AMB-resistant isolates (each one isolate) were found for <Mark2>Candida lipolytica</Mark2>, <Mark2>C. melibiosica</Mark2>, <Mark2>C. sake</Mark2> and <Mark2>Geotrichum</Mark2> <Mark2>candidum</Mark2>. One <Mark2>C. melibiosica</Mark2> isolate showed complete parallel resistance to all azoles, but was susceptible to AMB, FCY and all echinocandins. The two <Mark2>Candida norvegensis</Mark2> isolates were tested resistant and intermediate, respectively, to FLC, but showed each a one-step more susceptible categorization towards VOR and POS. Both <Mark2>C. sake</Mark2> isolates offered resistances to echinocandins, one with complete parallel resistance and one remaining susceptible to MCA. A full echinocandin resistance was also noted for the <Mark2>G. candidum</Mark2> and <Mark2>Geotrichum capitatum</Mark2> isolates. The <Mark2>Kodamaea ohmeri</Mark2> isolate was tested susceptible to all AFAs with the exception of FLC (tested intermediate). </Pgraph><Pgraph>Overall, complete susceptible SPs to all AFAs tested (<TextGroup><PlainText>8S-SP</PlainText></TextGroup>) were shown for 519/1062 isolates (48.9%) whereas 414 (39.0%) isolates were characterized by resistance to at least one of the AFAs included (≥1R) (Figure 1 <ImgLink imgNo="1" imgType="figure"/>). The remaining 129 isolates (12.1%) without resistances demonstrated in one or more cases intermediate susceptibilities distributed to seven different SPs.</Pgraph><Pgraph>Comparing the proportion of a species within the total amount of study isolates versus its proportion within those isolates exhibiting a complete susceptible phenotype (<TextGroup><PlainText>8S SP</PlainText></TextGroup>), <Mark2>C. albicans</Mark2> isolates showed significantly higher an <TextGroup><PlainText>8S SP</PlainText></TextGroup> (54.0% vs. 75.9% 8S-SP; P<0.01), whereas respective isolates of <Mark2>C. glabrata</Mark2> (22.0% vs. 9.6% 8S-SP; P<0.01), <Mark2>C. krusei</Mark2> (4.3% vs. 0.2%; P<0.01) and <TextGroup><Mark2>C. tropicalis</Mark2></TextGroup> (5.7% vs. 2.5%; P<0.01) displayed significantly less this phenotype. </Pgraph><Pgraph>For 122 (11.5% of total isolates) of the 129 intermediate-tested isolates comprising those without any result categorized as resistant, intermediate azole susceptibility was found as follows: FLC, n=43; POS, n=54; FLC and POS, n=20; FCY and FLC, n=3; FCY and POS, n=1; FCY, FLC and POS, n=1. Intermediate FCY susceptibility was noted for <Mark2>C. albicans</Mark2> (n=5) and <Mark2>Candida kefyr</Mark2> (n=2).</Pgraph><Pgraph>Overall, 222 (20.9%) isolates contained 81 SPs with more than one “R” within the pattern. No isolate was found to be resistant to all eight AFAs tested at 24 h and 48 h endpoint reading, respectively. Resistance limited to a single AFA was found in 192 (18.1%) isolates. In <TextGroup><PlainText>222 isolates</PlainText></TextGroup> (20.9%), resistance patterns to 2–7 AFAs (2-7R) were noted. The distribution of isolates exhibiting resistance to ≥2 AFAs was as follows: 2R, n=82 (7.7%); 3R, n=82 (7.7%); 4R, n=38 (3.6%); 5R, n=11 (1.0%); 6R, n=7 (0.7%), and 7R, n=2 (0.2%). SPs with ≥5R reflecting pronounced multi-resistance are given in Table 6 <ImgLink imgNo="6" imgType="table"/> and Figure 1 <ImgLink imgNo="1" imgType="figure"/>. Of 140 isolates (13.2%) characterized by a 3–7-fold AFA resistance, 97 (9.1%) possessed a complete parallel resistance consisting of 79 (7.4%), 12 (1.1%) and 6 (0.6) isolates showing this SP against all azoles, echinocandins and both AFA classes, respectively. Of note, highly resistant isolates exhibiting 7R- and 6R-patterns were almost exclusively represented by <Mark2>C. albicans</Mark2> with one exception by <Mark2>C. guilliermondii</Mark2>. The two 7R <Mark2>C. albicans</Mark2> strains were still susceptible to flucytosine (Table 6 <ImgLink imgNo="6" imgType="table"/>).</Pgraph><Pgraph>The proportion of still susceptible AFAs in relation to AFA-stratified resistances has been calculated in Table 7 <ImgLink imgNo="7" imgType="table"/> for the clinically most relevant <Mark2>Candida</Mark2> species. As shown in Table 7 <ImgLink imgNo="7" imgType="table"/>, FLC-resistant <Mark2>C. albicans</Mark2> isolates (n=46) displayed susceptibility to one of the echinocandins in more than 76% (CAS, 76.1%; ANI, 78.3% and MCA, 84.8%), but only 13.0% of these FLC-resistant isolates were also susceptible to VOR. Noteworthy, for <Mark2>C. glabrata</Mark2>, this analysis demonstrated that almost all FLC- (n=55), VOR- (n=35) and POS- (n=104) resistant isolates were tested susceptible to all echinocandins with the exception of two CAS-resistant isolates.</Pgraph><Pgraph>While those <Mark2>C. krusei</Mark2> isolates tested resistant to FCY, AMB and/or one of the azoles revealed susceptibility to all echinocandins, respective <Mark2>C. parapsilosis</Mark2> isolates varied in the echinocandin susceptibility (Table 7 <ImgLink imgNo="7" imgType="table"/>). Except one ANI-resistant <Mark2>C. tropicalis</Mark2> isolate, almost all isolates of this species exhibiting complete parallel resistance to the azole class were tested susceptible to all echinocandins included (Table 3 <ImgLink imgNo="3" imgType="table"/> and Table 7 <ImgLink imgNo="7" imgType="table"/>).</Pgraph></TextBlock>
<TextBlock linked="yes" name="Discussion">
<MainHeadline>Discussion</MainHeadline><Pgraph>In addition to antibiotic resistance towards bacterial and other pathogens, nowadays, also resistance to AFAs has emerged as one of the international health challenges to be addressed. AFA-resistant phenotypes may develop in yeast populations due to mutations, selection processes and alternative mechanisms (e.g. biofilm formation) and <Mark2>a priori</Mark2>-resistant species and strains exist <TextLink reference="24"></TextLink>. Moreover, recombination may play also a role in fungi <TextLink reference="25"></TextLink>. The fundamental “answer” of the fungal pathogens to the selection pressure by an increasing use of AFAs, however, is represented by shifts in the species and strain distribution towards those species characterized by intrinsic resistances or increased capabilities to express resistance mechanisms <TextLink reference="25"></TextLink>. While a shift toward infections caused by non-<Mark2>albicans Candida</Mark2> species have been globally reported <TextLink reference="26"></TextLink>, <TextLink reference="27"></TextLink>, <TextLink reference="28"></TextLink>, a systematic review by Falagas et al. covering the period between 1996 and 2009, showed significant geographic, study design and setting variations of the relative frequency of <Mark2>Candida</Mark2> spp. among cases of candidemia in different parts of the world, consequently, local epidemiological data continue to be of major significance <TextLink reference="29"></TextLink>.</Pgraph><Pgraph>Here, eight AFAs were tested in parallel, at the same time, in same assay, with the same inocula, thus, all assay-specific parameters were equal for all AFAs allowing a unique, highly standardized evaluation of the isolates’ susceptibilities. Considering pharmacological and pharmacodynamic aspects by a clinical breakpoint based categorisation (S-I-R), the results were arranged to individual SPs reflecting a resistance “fingerprint” for each single isolate, but embedded in the analysis of a large, recent multicentre isolate collection. Defining a fixed AFA sequence for SPA, SPs of different isolates can be easily compared and the frequencies of different SPs are determinable. Depending on the number of AFAs tested in parallel and the amount of parameters compared (<Mark2>e.g.</Mark2> methods, endpoint determinations, breakpoints, MIC-categorizations), a multitude of different SPs may have gained allowing detailed analyses of susceptibility distributions, for example, dependent on the methodical approaches used.</Pgraph><Pgraph>While standard descriptive methods and resulting data are the essential basis for questioning resistance preferentially for epidemiologically aspects, clinically and therapeutically relevant problems require comparative susceptibility evaluation methods. For this purpose, comparative AFA evaluation of individual isolate-specific susceptibilities may be useful, <Mark2>e.g.</Mark2> for determination of the prevalence of multi-resistant pathogens or to discover the susceptibility loss to complete AFA classes (<Mark2>e.g.</Mark2> azoles and echinocandins). For that purpose, SPA may act as useful tool allowing analyses of large strain collections down to the level of individual isolate-specific conclusions <TextLink reference="30"></TextLink>. The data gained in this study by analyses of cross-susceptibility and -resistance patterns, respectively, are in particular relevant for treatment-related decisions. Here, of utmost clinical interest are those isolates exhibiting a complete parallel resistance to the entire azole class, in particular, if this is accompanied by a partial or, even worse, a complete echinocandin parallel resistance (Table 5 <ImgLink imgNo="5" imgType="table"/> and Table 6 <ImgLink imgNo="6" imgType="table"/>). In contrast to earlier presumptions that no complete echinocandin cross-resistance exists or that there would be only a low potential for the resistance development to echinocandins <TextLink reference="8"></TextLink>, <TextLink reference="31"></TextLink>, we could clearly demonstrate by SPA approach that complete parallel resistance within all echinocandins occurs, here found in 1.7% of the clinical routine isolates included. In comparison, the amount of complete parallel resistance within the azole class was 8.8% characterized by species-specific variations.</Pgraph><Pgraph>Although it is reported that clinical isolates with high echinocandin MICs tend to be low <TextLink reference="32"></TextLink>, isolates with echinocandin MICs of ≥4 mg/L were noted from <TextGroup><PlainText>17 c</PlainText></TextGroup>entres of this study comprising 88 isolates exhibiting those increased MICs for CAS (n=59; 5.6%), ANI (n=55; 5.2%) and MCA (n=26; 2.5%). Increased echinocandin MICs towards one, two and three AFAs of this class were displayed by 54/88 (61.4%), 16/88 (18.1%) and <TextGroup><PlainText>18/88 (20.5%)</PlainText></TextGroup> of the isolates, respectively.</Pgraph><Pgraph>Complete echinocandin parallel resistance has been noted following prolonged use of these compounds for treatment of <Mark2>C. albicans</Mark2> and <Mark2>C. parapsilosis</Mark2> infections <TextLink reference="33"></TextLink>, <TextLink reference="34"></TextLink>. Here, simultaneous presence of echinocandin- and species-dependent cross-resistance with azoles was found up to 30% depending on candidal species (<TextGroup><PlainText>Table 3 </PlainText></TextGroup><ImgLink imgNo="3" imgType="table"/> and Table 4 <ImgLink imgNo="4" imgType="table"/>).</Pgraph><Pgraph>Selection pressure due to continuous exposure appears to play a crucial role in the emergence of azole resistance, thus, high parallel resistance rates for the azoles have to be noted as shown also in this study (8.8% of all isolates). This pattern is aggravated by cross-resistances of azole-resistant isolates to other AFA groups. In previous studies, none of 315 FLC-resistant <Mark2>Candida</Mark2> isolates demonstrated cross-resistance to ANI, whereas cross-resistance to CAS was rarely found (n=4; 1.1%) <TextLink reference="35"></TextLink>, <TextLink reference="36"></TextLink>. In contrast, elevated cross-resistance frequencies of FLC-resistant yeast isolates (n=173) were found in this study for two echinocandins, ANI (n=18; 10.4%) and CAS (n=17; 9.8%). Cross-resistance between azoles and echinocandins, i.e. multi-resistance with different substance classes, may be caused by common resistance mechanisms such as over-expression of genes encoding efflux pumps, multi-drug transport systems, lipid-associated membrane (protein) functions and/or membrane fluidity <TextLink reference="1"></TextLink>, <TextLink reference="37"></TextLink>, <TextLink reference="38"></TextLink>, <TextLink reference="39"></TextLink>.</Pgraph><Pgraph>Complete azole-resistant yeast isolates of this study showed cross-resistance to AMB (n=23; 2.2%) and FCY (n=18; 1.7%). In contrast, cross-resistance of the echinocandin-resistant isolates to AMB (n=4; 0.4%) and FCY (n=1; 0.1%) was much rarer. As determined by SPA, a <TextGroup><Mark2>C. sake</Mark2></TextGroup> isolate showed parallel resistance to all echinocandins and cross-resistance simultaneously to AMB and FCY. Of note, this is the first report to our knowledge of those cross-resistance patterns.</Pgraph><Pgraph>Here, testing more than thousand clinical yeast isolates recovered within the course of a multicentre study to eight AFAs, a wide variety of SPs occurring was found. When tested highly standardized in parallel and from the same inoculum, evaluation of different AFA substances by SPA analysis allows detailed insights in the prevalence and distribution of susceptibility patterns of fungal isolates. Since the SPA approach enables a precise description of both known and so far unknown patterns of cross and parallel resistances, it may reflect the resistance situation in a given setting more comprehensively and more detailed compared to data based on standard susceptibility analyses. Consequently, deductions for treatment strategies based on species-specific SPs may be gained for improvement of calculated antifungal chemotherapy.</Pgraph></TextBlock>
<TextBlock linked="yes" name="Notes">
<MainHeadline>Notes</MainHeadline><SubHeadline>Acknowledgements</SubHeadline><Pgraph>The authors would like to thank all members of the Antifungal Susceptibility Testing (AFST) Study Group involved in the German/Austrian multicenter study: F. Albert and C. Schoerner (Universitätsklinikum Erlangen, Institut für Klinische Mikrobiologie, Immunologie und Hygiene); <TextGroup><PlainText>O. Bader</PlainText></TextGroup> and M. Weig (Institut für Medizinische Mikrobi<TextGroup><PlainText>ol</PlainText></TextGroup>ogie, Universitätsklinikum Göttingen); S. Crusius and A. Podbielski (Institut für Medizinische Mikrobiologie und Hygiene, Universität Rostock); V. Czaika (Dept. of Dermatology, Internal Medicine, Helios Kliniken, Bad Saarow); A. Haas (Institut für Medizinische Mikrobiologie der Ludwig-Maximilians-Universität München); G. Haase (Institut für Medizinische Mikrobiologie, RWTH Universitätsklinik, Aachen); M. Klotz and M. Herrmann (Institut für Mikrob<TextGroup><PlainText>io</PlainText></TextGroup>logie, Universitätsklinikum des Saarlandes, Homburg/Saar); K. Hochauf (Institut für Medizinische Mikrob<TextGroup><PlainText>io</PlainText></TextGroup>logie und Hygiene, Medizinische Fakultät, Technische Universität Dresden); H. Hof (Institut für Medizinische Mikrobiologie und Hygiene, Universitätsklinikum Mannheim); A. Rodloff (Institut für Medizinische Mikrobiologie und Infektionsepidemiologie, Universitätsklinikum Leipzig); M. Ruhnke (Medizinische Klinik und Poliklinik II, Onkologie und Hämatologie, Campus Charité Mitte, Humboldt-Universität, Berlin); U. Schumacher (Institut für Medizinische Mikrobiologie und Krankenhaushygiene, Universität Tübingen); L. Sedlacek and S. Suerbaum (Institut für Mikrobiologie und Krankenhaushygiene, Medizinische Hochschule Hannover); I. Sobottka (Institut für Medizinische Mikrobiologie, Virologie und Hygiene, Universitätsklinikum Hamburg-Eppendorf); G. Valenca and M. Abele-Horn (Institut für Hygiene und Mikrobiologie der Universität Würzburg).</Pgraph><Pgraph>The antifungal agents anidulafungin, fluconazole and voriconazole were provided free of charge by Pfizer GmbH (Germany) as were caspofungin by MSD (Germany), posaconazole by Essex (Germany) and miconazole by Astellas Pharma GmbH (Germany). This work was supported by a grant from Pfizer GmbH (Germany) for purchase and manufacturing of culture media, ready-to-use microdilution trays with the antifungal agents and transport material for collected strains. The opinions expressed in this article are those of the authors and do not necessarily represent those of the pharmaceutical companies.</Pgraph><SubHeadline>Conflict of interest</SubHeadline><Pgraph>K.B. has received research support from Pfizer as well as lecture, travel and other fees from Cubist Pharmaceuticals, MSD Sharp & Dohme, Novartis Pharma and Pfizer. Ch.F. has received lecture, travel and other fees from <TextGroup><PlainText>Pfizer</PlainText></TextGroup>. B.W. has received research support from Pfizer as well as lecture, travel and other fees from Astellas Pharma GmbH, MSD Sharp & Dohme, and Pfizer. All other authors have no conflicts of interest to declare.</Pgraph></TextBlock>
<References linked="yes">
<Reference refNo="1">
<RefAuthor>Kohli A</RefAuthor>
<RefAuthor>Smriti</RefAuthor>
<RefAuthor>Mukhopadhyay K</RefAuthor>
<RefAuthor>Rattan A</RefAuthor>
<RefAuthor>Prasad R</RefAuthor>
<RefTitle>In vitro low-level resistance to azoles in Candida albicans is associated with changes in membrane lipid fluidity and asymmetry</RefTitle>
<RefYear>2002</RefYear>
<RefJournal>Antimicrob Agents Chemother</RefJournal>
<RefPage>1046-52</RefPage>
<RefTotal>Kohli A, Smriti, Mukhopadhyay K, Rattan A, Prasad R. In vitro low-level resistance to azoles in Candida albicans is associated with changes in membrane lipid fluidity and asymmetry. Antimicrob Agents Chemother. 2002 Apr;46(4):1046-52. DOI: 10.1128/AAC.46.4.1046-1052.2002</RefTotal>
<RefLink>http://dx.doi.org/10.1128/AAC.46.4.1046-1052.2002</RefLink>
</Reference>
<Reference refNo="2">
<RefAuthor>Cannon RD</RefAuthor>
<RefAuthor>Lamping E</RefAuthor>
<RefAuthor>Holmes AR</RefAuthor>
<RefAuthor>Niimi K</RefAuthor>
<RefAuthor>Baret PV</RefAuthor>
<RefAuthor>Keniya MV</RefAuthor>
<RefAuthor>Tanabe K</RefAuthor>
<RefAuthor>Niimi M</RefAuthor>
<RefAuthor>Goffeau A</RefAuthor>
<RefAuthor>Monk BC</RefAuthor>
<RefTitle>Efflux-mediated antifungal drug resistance</RefTitle>
<RefYear>2009</RefYear>
<RefJournal>Clin Microbiol Rev</RefJournal>
<RefPage>291-321</RefPage>
<RefTotal>Cannon RD, Lamping E, Holmes AR, Niimi K, Baret PV, Keniya MV, Tanabe K, Niimi M, Goffeau A, Monk BC. Efflux-mediated antifungal drug resistance. Clin Microbiol Rev. 2009 Apr;22(2):291-321, DOI: 10.1128/CMR.00051-08</RefTotal>
<RefLink>http://dx.doi.org/10.1128/CMR.00051-08</RefLink>
</Reference>
<Reference refNo="3">
<RefAuthor>Slavin MA</RefAuthor>
<RefAuthor>Sorrell TC</RefAuthor>
<RefAuthor>Marriott D</RefAuthor>
<RefAuthor>Thursky KA</RefAuthor>
<RefAuthor>Nguyen Q</RefAuthor>
<RefAuthor>Ellis DH</RefAuthor>
<RefAuthor>Morrissey CO</RefAuthor>
<RefAuthor>Chen SC</RefAuthor>
<RefAuthor> Australian Candidemia Study</RefAuthor>
<RefAuthor>Australasian Society for Infectious Diseases</RefAuthor>
<RefTitle>Candidaemia in adult cancer patients: risks for fluconazole-resistant isolates and death</RefTitle>
<RefYear>2010</RefYear>
<RefJournal>J Antimicrob Chemother</RefJournal>
<RefPage>1042-51</RefPage>
<RefTotal>Slavin MA, Sorrell TC, Marriott D, Thursky KA, Nguyen Q, Ellis DH, Morrissey CO, Chen SC; Australian Candidemia Study, Australasian Society for Infectious Diseases. Candidaemia in adult cancer patients: risks for fluconazole-resistant isolates and death. J Antimicrob Chemother. 2010 May;65(5):1042-51. DOI: 10.1093/jac/dkq053</RefTotal>
<RefLink>http://dx.doi.org/10.1093/jac/dkq053</RefLink>
</Reference>
<Reference refNo="4">
<RefAuthor>Schmalreck AF</RefAuthor>
<RefAuthor>Lackner M</RefAuthor>
<RefAuthor>Becker K</RefAuthor>
<RefAuthor>Fegeler W</RefAuthor>
<RefAuthor>Czaika V</RefAuthor>
<RefAuthor>Ulmer H</RefAuthor>
<RefAuthor>Lass-Flörl C</RefAuthor>
<RefTitle>Phylogenetic relationships matter: antifungal susceptibility among clinically relevant yeasts</RefTitle>
<RefYear>2014</RefYear>
<RefJournal>Antimicrob Agents Chemother</RefJournal>
<RefPage>1575-85</RefPage>
<RefTotal>Schmalreck AF, Lackner M, Becker K, Fegeler W, Czaika V, Ulmer H, Lass-Flörl C. Phylogenetic relationships matter: antifungal susceptibility among clinically relevant yeasts. Antimicrob Agents Chemother. 2014;58(3):1575-85. DOI: 10.1128/AAC.01799-13</RefTotal>
<RefLink>http://dx.doi.org/10.1128/AAC.01799-13</RefLink>
</Reference>
<Reference refNo="5">
<RefAuthor>Pfaller MA</RefAuthor>
<RefTitle>Antifungal drug resistance: mechanisms, epidemiology, and consequences for treatment</RefTitle>
<RefYear>2012</RefYear>
<RefJournal>Am J Med</RefJournal>
<RefPage>S3-13</RefPage>
<RefTotal>Pfaller MA. Antifungal drug resistance: mechanisms, epidemiology, and consequences for treatment. Am J Med. 2012 Jan;125(1 Suppl):S3-13. DOI: 10.1016/j.amjmed.2011.11.001</RefTotal>
<RefLink>http://dx.doi.org/10.1016/j.amjmed.2011.11.001</RefLink>
</Reference>
<Reference refNo="6">
<RefAuthor>Chen SC</RefAuthor>
<RefAuthor>Slavin MA</RefAuthor>
<RefAuthor>Sorrell TC</RefAuthor>
<RefTitle>Echinocandin antifungal drugs in fungal infections: a comparison</RefTitle>
<RefYear>2011</RefYear>
<RefJournal>Drugs</RefJournal>
<RefPage>11-41</RefPage>
<RefTotal>Chen SC, Slavin MA, Sorrell TC. Echinocandin antifungal drugs in fungal infections: a comparison. Drugs. 2011 Jan;71(1):11-41. DOI: 10.2165/11585270-000000000-00000</RefTotal>
<RefLink>http://dx.doi.org/10.2165/11585270-000000000-00000</RefLink>
</Reference>
<Reference refNo="7">
<RefAuthor>Montravers P</RefAuthor>
<RefAuthor>Jabbour K</RefAuthor>
<RefTitle>Clinical consequences of resistant Candida infections in intensive care</RefTitle>
<RefYear>2006</RefYear>
<RefJournal>Int J Antimicrob Agents</RefJournal>
<RefPage>1-6</RefPage>
<RefTotal>Montravers P, Jabbour K. Clinical consequences of resistant Candida infections in intensive care. Int J Antimicrob Agents. 2006 Jan;27(1):1-6. DOI: 10.1016/j.ijantimicag.2005.11.002</RefTotal>
<RefLink>http://dx.doi.org/10.1016/j.ijantimicag.2005.11.002</RefLink>
</Reference>
<Reference refNo="8">
<RefAuthor>Perlin DS</RefAuthor>
<RefTitle>Resistance to echinocandin-class antifungal drugs</RefTitle>
<RefYear>2007</RefYear>
<RefJournal>Drug Resist Updat</RefJournal>
<RefPage>121-30</RefPage>
<RefTotal>Perlin DS. Resistance to echinocandin-class antifungal drugs. Drug Resist Updat. 2007 Jun;10(3):121-30. DOI: 10.1016/j.drup.2007.04.002</RefTotal>
<RefLink>http://dx.doi.org/10.1016/j.drup.2007.04.002</RefLink>
</Reference>
<Reference refNo="9">
<RefAuthor>Gugnani HC</RefAuthor>
<RefAuthor>Becker K</RefAuthor>
<RefAuthor>Fegeler W</RefAuthor>
<RefAuthor>Basu S</RefAuthor>
<RefAuthor>Chattopadhya D</RefAuthor>
<RefAuthor>Baveja U</RefAuthor>
<RefAuthor>Satyanarayana S</RefAuthor>
<RefAuthor>Kalghatgi T</RefAuthor>
<RefAuthor>Murlidhar A</RefAuthor>
<RefTitle>Oropharyngeal carriage of Candida species in HIV-infected patients in India</RefTitle>
<RefYear>2003</RefYear>
<RefJournal>Mycoses</RefJournal>
<RefPage>299-306</RefPage>
<RefTotal>Gugnani HC, Becker K, Fegeler W, Basu S, Chattopadhya D, Baveja U, Satyanarayana S, Kalghatgi T, Murlidhar A. Oropharyngeal carriage of Candida species in HIV-infected patients in India. Mycoses. 2003 Sep;46(8):299-306. DOI: 10.1046/j.1439-0507.2003.00896.x</RefTotal>
<RefLink>http://dx.doi.org/10.1046/j.1439-0507.2003.00896.x</RefLink>
</Reference>
<Reference refNo="10">
<RefAuthor>Czaika V</RefAuthor>
<RefAuthor>Nenoff P</RefAuthor>
<RefAuthor>Glöckner A</RefAuthor>
<RefAuthor>Becker K</RefAuthor>
<RefAuthor>Fegeler W</RefAuthor>
<RefAuthor>Schmalreck AF</RefAuthor>
<RefTitle>Detection of azole susceptibility patterns in clinical yeast strains isolated from 1998 to 2008</RefTitle>
<RefYear>2014</RefYear>
<RefJournal>New Microbiol</RefJournal>
<RefPage>465-94</RefPage>
<RefTotal>Czaika V, Nenoff P, Glöckner A, Becker K, Fegeler W, Schmalreck AF. Detection of azole susceptibility patterns in clinical yeast strains isolated from 1998 to 2008. New Microbiol. 2014 Oct;37(4):465-94.</RefTotal>
</Reference>
<Reference refNo="11">
<RefAuthor>Pfaller MA</RefAuthor>
<RefAuthor>Messer SA</RefAuthor>
<RefAuthor>Moet GJ</RefAuthor>
<RefAuthor>Jones RN</RefAuthor>
<RefAuthor>Castanheira M</RefAuthor>
<RefTitle>Candida bloodstream infections: comparison of species distribution and resistance to echinocandin and azole antifungal agents in Intensive Care Unit (ICU) and non-ICU settings in the SENTRY Antimicrobial Surveillance Program (2008-2009)</RefTitle>
<RefYear>2011</RefYear>
<RefJournal>Int J Antimicrob Agents</RefJournal>
<RefPage>65-9</RefPage>
<RefTotal>Pfaller MA, Messer SA, Moet GJ, Jones RN, Castanheira M. Candida bloodstream infections: comparison of species distribution and resistance to echinocandin and azole antifungal agents in Intensive Care Unit (ICU) and non-ICU settings in the SENTRY Antimicrobial Surveillance Program (2008-2009). Int J Antimicrob Agents. 2011 Jul;38(1):65-9. DOI: 10.1016/j.ijantimicag.2011.02.016</RefTotal>
<RefLink>http://dx.doi.org/10.1016/j.ijantimicag.2011.02.016</RefLink>
</Reference>
<Reference refNo="12">
<RefAuthor>Schmalreck AF</RefAuthor>
<RefAuthor>Willinger B</RefAuthor>
<RefAuthor>Haase G</RefAuthor>
<RefAuthor>Blum G</RefAuthor>
<RefAuthor>Lass-Flörl C</RefAuthor>
<RefAuthor>Fegeler W</RefAuthor>
<RefAuthor>Becker K</RefAuthor>
<RefAuthor> Antifungal Susceptibility Testing-AFST Study Group</RefAuthor>
<RefTitle>Species and susceptibility distribution of 1062 clinical yeast isolates to azoles, echinocandins, flucytosine and amphotericin B from a multi-centre study</RefTitle>
<RefYear>2012</RefYear>
<RefJournal>Mycoses</RefJournal>
<RefPage>e124-37</RefPage>
<RefTotal>Schmalreck AF, Willinger B, Haase G, Blum G, Lass-Flörl C, Fegeler W, Becker K; Antifungal Susceptibility Testing-AFST Study Group. Species and susceptibility distribution of 1062 clinical yeast isolates to azoles, echinocandins, flucytosine and amphotericin B from a multi-centre study. Mycoses. 2012 May;55(3):e124-37. DOI: 10.1111/j.1439-0507.2011.02165.x</RefTotal>
<RefLink>http://dx.doi.org/10.1111/j.1439-0507.2011.02165.x</RefLink>
</Reference>
<Reference refNo="13">
<RefAuthor>Chen PL</RefAuthor>
<RefAuthor>Lo HJ</RefAuthor>
<RefAuthor>Wu CJ</RefAuthor>
<RefAuthor>Lee HC</RefAuthor>
<RefAuthor>Chang CM</RefAuthor>
<RefAuthor>Lee NY</RefAuthor>
<RefAuthor>Wang AH</RefAuthor>
<RefAuthor>Lin WL</RefAuthor>
<RefAuthor>Ko NY</RefAuthor>
<RefAuthor>Lee CC</RefAuthor>
<RefAuthor>Ko WC</RefAuthor>
<RefTitle>Species distribution and antifungal susceptibility of blood Candida isolates at a tertiary hospital in southern Taiwan, 1999-2006</RefTitle>
<RefYear>2011</RefYear>
<RefJournal>Mycoses</RefJournal>
<RefPage>e17-23</RefPage>
<RefTotal>Chen PL, Lo HJ, Wu CJ, Lee HC, Chang CM, Lee NY, Wang AH, Lin WL, Ko NY, Lee CC, Ko WC. Species distribution and antifungal susceptibility of blood Candida isolates at a tertiary hospital in southern Taiwan, 1999-2006. Mycoses. 2011 Jul;54(4):e17-23. DOI: 10.1111/j.1439-0507.2009.01818.x</RefTotal>
<RefLink>http://dx.doi.org/10.1111/j.1439-0507.2009.01818.x</RefLink>
</Reference>
<Reference refNo="14">
<RefAuthor>Czaika V</RefAuthor>
<RefAuthor>Nenoff P</RefAuthor>
<RefAuthor>Glöckner A</RefAuthor>
<RefAuthor>Fegeler W</RefAuthor>
<RefAuthor>Becker K</RefAuthor>
<RefAuthor>Schmalreck AF</RefAuthor>
<RefTitle>Epidemiology and changes in patient-related factors from 1997 to 2009 in clinical yeast isolates related to dermatology, gynaecology, and paediatrics</RefTitle>
<RefYear>2013</RefYear>
<RefJournal>Int J Microbiol</RefJournal>
<RefPage>703905</RefPage>
<RefTotal>Czaika V, Nenoff P, Glöckner A, Fegeler W, Becker K, Schmalreck AF. Epidemiology and changes in patient-related factors from 1997 to 2009 in clinical yeast isolates related to dermatology, gynaecology, and paediatrics. Int J Microbiol. 2013;2013:703905. DOI: 10.1155/2013/703905</RefTotal>
<RefLink>http://dx.doi.org/10.1155/2013/703905</RefLink>
</Reference>
<Reference refNo="15">
<RefAuthor>Pfaller MA</RefAuthor>
<RefAuthor>Castanheira M</RefAuthor>
<RefAuthor>Lockhart SR</RefAuthor>
<RefAuthor>Ahlquist AM</RefAuthor>
<RefAuthor>Messer SA</RefAuthor>
<RefAuthor>Jones RN</RefAuthor>
<RefTitle>Frequency of decreased susceptibility and resistance to echinocandins among fluconazole-resistant bloodstream isolates of Candida glabrata</RefTitle>
<RefYear>2012</RefYear>
<RefJournal>J Clin Microbiol</RefJournal>
<RefPage>1199-203</RefPage>
<RefTotal>Pfaller MA, Castanheira M, Lockhart SR, Ahlquist AM, Messer SA, Jones RN. Frequency of decreased susceptibility and resistance to echinocandins among fluconazole-resistant bloodstream isolates of Candida glabrata. J Clin Microbiol. 2012 Apr;50(4):1199-203. DOI: 10.1128/JCM.06112-11</RefTotal>
<RefLink>http://dx.doi.org/10.1128/JCM.06112-11</RefLink>
</Reference>
<Reference refNo="16">
<RefAuthor>Fegeler W</RefAuthor>
<RefAuthor>Lintz D</RefAuthor>
<RefAuthor>Ritzerfeld W</RefAuthor>
<RefTitle>Resistance-pattern-analysis – a step toward predictable differentiated antibiotic therapy</RefTitle>
<RefYear>1988</RefYear>
<RefJournal>Zentralbl Bakteriol Mikrobiol Hyg A</RefJournal>
<RefPage>153-9</RefPage>
<RefTotal>Fegeler W, Lintz D, Ritzerfeld W. Resistance-pattern-analysis – a step toward predictable differentiated antibiotic therapy. Zentralbl Bakteriol Mikrobiol Hyg A. 1988 Nov;270(1-2):153-9. DOI: 10.1016/s0176-6724(88)80152-4</RefTotal>
<RefLink>http://dx.doi.org/10.1016/s0176-6724(88)80152-4</RefLink>
</Reference>
<Reference refNo="17">
<RefAuthor>Normenausschuss Medizin (NAMed) im DIN Deutsches Institut für Normung e.V.</RefAuthor>
<RefTitle></RefTitle>
<RefYear>2002</RefYear>
<RefBookTitle>DIN 58940-84:2002-10. Medical microbiology – Susceptibility testing of microbial pathogens to antimicrobial agents – Part 84: Microdilution. Special requirements for testing of fungi against antifungal agents</RefBookTitle>
<RefPage></RefPage>
<RefTotal>Normenausschuss Medizin (NAMed) im DIN Deutsches Institut für Normung e.V. DIN 58940-84:2002-10. Medical microbiology – Susceptibility testing of microbial pathogens to antimicrobial agents – Part 84: Microdilution; Special requirements for testing of fungi against antifungal agents. Berlin: Beuth Verlag; 2002.</RefTotal>
</Reference>
<Reference refNo="18">
<RefAuthor>Clinical and Laboratory Standards Institute</RefAuthor>
<RefTitle></RefTitle>
<RefYear>2002</RefYear>
<RefBookTitle>Reference Method for Broth Dilution Antifungal Susceptibility Testing of Yeasts; Approved Standard M27-A2</RefBookTitle>
<RefPage></RefPage>
<RefTotal>Clinical and Laboratory Standards Institute. Reference Method for Broth Dilution Antifungal Susceptibility Testing of Yeasts; Approved Standard. M27-A2. Wayne, PA: Clinical and Laboratory Standards Institute; 2002.</RefTotal>
</Reference>
<Reference refNo="19">
<RefAuthor>Anonym</RefAuthor>
<RefTitle></RefTitle>
<RefYear>2007</RefYear>
<RefBookTitle>Rationale für Bewertungskriterien für minimale Hemmkonzentrationen (MHK) und Hemmzonendurchmesser (HZD) von Fluconazol entsprechend DIN 58940 bei klinisch relevanten Sprosspilzen, sowie Festlegung von Fluconazol-(Grenz-)Kontrollwerten für Kontrollstämme</RefBookTitle>
<RefPage></RefPage>
<RefTotal>Rationale für Bewertungskriterien für minimale Hemmkonzentrationen (MHK) und Hemmzonendurchmesser (HZD) von Fluconazol entsprechend DIN 58940 bei klinisch relevanten Sprosspilzen, sowie Festlegung von Fluconazol-(Grenz-)Kontrollwerten für Kontrollstämme [Rationale for assessment criteria for minimum inhibitory concentration (MIC) and inhibition zone diameter (IZD) of fluconazole according to DIN 58940 for clinically relevant yeasts, and specification of fluconazole control limits for control strains]. Berlin: Beuth Verlag; 2007. (DIN-Fachbericht; 157).</RefTotal>
</Reference>
<Reference refNo="20">
<RefAuthor>European Committee on Antimicrobial Susceptibility Testing</RefAuthor>
<RefTitle></RefTitle>
<RefYear>2010</RefYear>
<RefBookTitle>Amphotericin B: Rationale for the clinical breakpoints</RefBookTitle>
<RefPage></RefPage>
<RefTotal>European Committee on Antimicrobial Susceptibility Testing. Amphotericin B: Rationale for the clinical breakpoints. Version 1.0. 2010.</RefTotal>
</Reference>
<Reference refNo="21">
<RefAuthor>Pfaller MA</RefAuthor>
<RefAuthor>Messer SA</RefAuthor>
<RefAuthor>Boyken L</RefAuthor>
<RefAuthor>Tendolkar S</RefAuthor>
<RefAuthor>Hollis RJ</RefAuthor>
<RefAuthor>Diekema DJ</RefAuthor>
<RefTitle>Selection of a surrogate agent (fluconazole or voriconazole) for initial susceptibility testing of posaconazole against Candida spp.: results from a global antifungal surveillance program</RefTitle>
<RefYear>2008</RefYear>
<RefJournal>J Clin Microbiol</RefJournal>
<RefPage>551-9</RefPage>
<RefTotal>Pfaller MA, Messer SA, Boyken L, Tendolkar S, Hollis RJ, Diekema DJ. Selection of a surrogate agent (fluconazole or voriconazole) for initial susceptibility testing of posaconazole against Candida spp.: results from a global antifungal surveillance program. J Clin Microbiol. 2008 Feb;46(2):551-9. DOI: 10.1128/JCM.01952-07</RefTotal>
<RefLink>http://dx.doi.org/10.1128/JCM.01952-07</RefLink>
</Reference>
<Reference refNo="22">
<RefAuthor>Pfaller MA</RefAuthor>
<RefAuthor>Boyken L</RefAuthor>
<RefAuthor>Hollis RJ</RefAuthor>
<RefAuthor>Kroeger J</RefAuthor>
<RefAuthor>Messer SA</RefAuthor>
<RefAuthor>Tendolkar S</RefAuthor>
<RefAuthor>Jones RN</RefAuthor>
<RefAuthor>Turnidge J</RefAuthor>
<RefAuthor>Diekema DJ</RefAuthor>
<RefTitle>Wild-type MIC distributions and epidemiological cutoff values for the echinocandins and Candida spp</RefTitle>
<RefYear>2010</RefYear>
<RefJournal>J Clin Microbiol</RefJournal>
<RefPage>52-6</RefPage>
<RefTotal>Pfaller MA, Boyken L, Hollis RJ, Kroeger J, Messer SA, Tendolkar S, Jones RN, Turnidge J, Diekema DJ. Wild-type MIC distributions and epidemiological cutoff values for the echinocandins and Candida spp. J Clin Microbiol. 2010 Jan;48(1):52-6. DOI: 10.1128/JCM.01590-09</RefTotal>
<RefLink>http://dx.doi.org/10.1128/JCM.01590-09</RefLink>
</Reference>
<Reference refNo="23">
<RefAuthor>Clinical and Laboratory Standards Institute</RefAuthor>
<RefTitle></RefTitle>
<RefYear>2011</RefYear>
<RefBookTitle>Reference Method for Broth Dilution Antifungal Susceptibility Testing of Yeasts; Third Informational Supplement. M27-S3</RefBookTitle>
<RefPage></RefPage>
<RefTotal>Clinical and Laboratory Standards Institute. Reference Method for Broth Dilution Antifungal Susceptibility Testing of Yeasts; Third Informational Supplement. M27-S3. Wayne, PA: Clinical and Laboratory Standards Institute; 2011.</RefTotal>
</Reference>
<Reference refNo="24">
<RefAuthor>Sanglard D</RefAuthor>
<RefTitle>Resistance of human fungal pathogens to antifungal drugs</RefTitle>
<RefYear>2002</RefYear>
<RefJournal>Curr Opin Microbiol</RefJournal>
<RefPage>379-85</RefPage>
<RefTotal>Sanglard D. Resistance of human fungal pathogens to antifungal drugs. Curr Opin Microbiol. 2002 Aug;5(4):379-85. DOI: 10.1016/S1369-5274(02)00344-2</RefTotal>
<RefLink>http://dx.doi.org/10.1016/S1369-5274(02)00344-2</RefLink>
</Reference>
<Reference refNo="25">
<RefAuthor>Lott TJ</RefAuthor>
<RefAuthor>Frade JP</RefAuthor>
<RefAuthor>Lockhart SR</RefAuthor>
<RefTitle>Multilocus sequence type analysis reveals both clonality and recombination in populations of Candida glabrata bloodstream isolates from U.S. surveillance studies</RefTitle>
<RefYear>2010</RefYear>
<RefJournal>Eukaryotic Cell</RefJournal>
<RefPage>619-25</RefPage>
<RefTotal>Lott TJ, Frade JP, Lockhart SR. Multilocus sequence type analysis reveals both clonality and recombination in populations of Candida glabrata bloodstream isolates from U.S. surveillance studies. Eukaryotic Cell. 2010 Apr;9(4):619-25. DOI: 10.1128/EC.00002-10</RefTotal>
<RefLink>http://dx.doi.org/10.1128/EC.00002-10</RefLink>
</Reference>
<Reference refNo="26">
<RefAuthor>Ostrosky-Zeichner L</RefAuthor>
<RefAuthor>Pappas PG</RefAuthor>
<RefTitle>Invasive candidiasis in the intensive care unit</RefTitle>
<RefYear>2006</RefYear>
<RefJournal>Crit Care Med</RefJournal>
<RefPage>857-63</RefPage>
<RefTotal>Ostrosky-Zeichner L, Pappas PG. Invasive candidiasis in the intensive care unit. Crit Care Med. 2006 Mar;34(3):857-63. DOI: 10.1097/01.CCM.0000201897.78123.44</RefTotal>
<RefLink>http://dx.doi.org/10.1097/01.CCM.0000201897.78123.44</RefLink>
</Reference>
<Reference refNo="27">
<RefAuthor>Bassetti M</RefAuthor>
<RefAuthor>Righi E</RefAuthor>
<RefAuthor>Costa A</RefAuthor>
<RefAuthor>Fasce R</RefAuthor>
<RefAuthor>Molinari MP</RefAuthor>
<RefAuthor>Rosso R</RefAuthor>
<RefAuthor>Pallavicini FB</RefAuthor>
<RefAuthor>Viscoli C</RefAuthor>
<RefTitle>Epidemiological trends in nosocomial candidemia in intensive care</RefTitle>
<RefYear>2006</RefYear>
<RefJournal>BMC Infect Dis</RefJournal>
<RefPage>21</RefPage>
<RefTotal>Bassetti M, Righi E, Costa A, Fasce R, Molinari MP, Rosso R, Pallavicini FB, Viscoli C. Epidemiological trends in nosocomial candidemia in intensive care. BMC Infect Dis. 2006;6:21. DOI: 10.1186/1471-2334-6-21</RefTotal>
<RefLink>http://dx.doi.org/10.1186/1471-2334-6-21</RefLink>
</Reference>
<Reference refNo="28">
<RefAuthor>Groll AH</RefAuthor>
<RefAuthor>Walsh TJ</RefAuthor>
<RefTitle>Uncommon opportunistic fungi: new nosocomial threats</RefTitle>
<RefYear>2001</RefYear>
<RefJournal>Clin Microbiol Infect</RefJournal>
<RefPage>8-24</RefPage>
<RefTotal>Groll AH, Walsh TJ. Uncommon opportunistic fungi: new nosocomial threats. Clin Microbiol Infect. 2001;7 Suppl 2:8-24. DOI: 10.1111/j.1469-0691.2001.tb00005.x</RefTotal>
<RefLink>http://dx.doi.org/10.1111/j.1469-0691.2001.tb00005.x</RefLink>
</Reference>
<Reference refNo="29">
<RefAuthor>Falagas ME</RefAuthor>
<RefAuthor>Roussos N</RefAuthor>
<RefAuthor>Vardakas KZ</RefAuthor>
<RefTitle>Relative frequency of albicans and the various non-albicans Candida spp among candidemia isolates from inpatients in various parts of the world: a systematic review</RefTitle>
<RefYear>2010</RefYear>
<RefJournal>Int J Infect Dis</RefJournal>
<RefPage>e954-66</RefPage>
<RefTotal>Falagas ME, Roussos N, Vardakas KZ. Relative frequency of albicans and the various non-albicans Candida spp among candidemia isolates from inpatients in various parts of the world: a systematic review. Int J Infect Dis. 2010 Nov;14(11):e954-66. DOI: 10.1016/j.ijid.2010.04.006</RefTotal>
<RefLink>http://dx.doi.org/10.1016/j.ijid.2010.04.006</RefLink>
</Reference>
<Reference refNo="30">
<RefAuthor>Schmalreck AF</RefAuthor>
<RefAuthor>Hof H</RefAuthor>
<RefAuthor>Becker K</RefAuthor>
<RefAuthor>Fegeler W</RefAuthor>
<RefAuthor>Czaika V</RefAuthor>
<RefTitle>Susceptibility patterns and cross-resistance of: antimicrobial peptides (defensins, bacteriocins, ionophores), aminoglycosides, macrolides, penicillins, cephalosporins, and carbapenems in Listeria spp</RefTitle>
<RefYear>2014</RefYear>
<RefJournal>World Res J Antimicrob Agents</RefJournal>
<RefPage>39-61</RefPage>
<RefTotal>Schmalreck AF, Hof H, Becker K, Fegeler W, Czaika V. Susceptibility patterns and cross-resistance of: antimicrobial peptides (defensins, bacteriocins, ionophores), aminoglycosides, macrolides, penicillins, cephalosporins, and carbapenems in Listeria spp. World Res J Antimicrob Agents. 2014;3(1):39-61.</RefTotal>
</Reference>
<Reference refNo="31">
<RefAuthor>Hof H</RefAuthor>
<RefTitle>Is there a serious risk of resistance development to azoles among fungi due to the widespread use and long-term application of azole antifungals in medicine?</RefTitle>
<RefYear>2008</RefYear>
<RefJournal>Drug Resist Updat</RefJournal>
<RefPage>25-31</RefPage>
<RefTotal>Hof H. Is there a serious risk of resistance development to azoles among fungi due to the widespread use and long-term application of azole antifungals in medicine? Drug Resist Updat. 2008 Feb-Apr;11(1-2):25-31. DOI: 10.1016/j.drup.2008.01.001</RefTotal>
<RefLink>http://dx.doi.org/10.1016/j.drup.2008.01.001</RefLink>
</Reference>
<Reference refNo="32">
<RefAuthor>Pfaller MA</RefAuthor>
<RefAuthor>Diekema DJ</RefAuthor>
<RefAuthor>Messer SA</RefAuthor>
<RefAuthor>Hollis RJ</RefAuthor>
<RefAuthor>Jones RN</RefAuthor>
<RefTitle>In vitro activities of caspofungin compared with those of fluconazole and itraconazole against 3,959 clinical isolates of Candida spp., including 157 fluconazole-resistant isolates</RefTitle>
<RefYear>2003</RefYear>
<RefJournal>Antimicrob Agents Chemother</RefJournal>
<RefPage>1068-71</RefPage>
<RefTotal>Pfaller MA, Diekema DJ, Messer SA, Hollis RJ, Jones RN. In vitro activities of caspofungin compared with those of fluconazole and itraconazole against 3,959 clinical isolates of Candida spp., including 157 fluconazole-resistant isolates. Antimicrob Agents Chemother. 2003 Mar;47(3):1068-71. DOI: 10.1128/AAC.47.3.1068-1071.2003</RefTotal>
<RefLink>http://dx.doi.org/10.1128/AAC.47.3.1068-1071.2003</RefLink>
</Reference>
<Reference refNo="33">
<RefAuthor>Laverdière M</RefAuthor>
<RefAuthor>Lalonde RG</RefAuthor>
<RefAuthor>Baril JG</RefAuthor>
<RefAuthor>Sheppard DC</RefAuthor>
<RefAuthor>Park S</RefAuthor>
<RefAuthor>Perlin DS</RefAuthor>
<RefTitle>Progressive loss of echinocandin activity following prolonged use for treatment of Candida albicans oesophagitis</RefTitle>
<RefYear>2006</RefYear>
<RefJournal>J Antimicrob Chemother</RefJournal>
<RefPage>705-8</RefPage>
<RefTotal>Laverdière M, Lalonde RG, Baril JG, Sheppard DC, Park S, Perlin DS. Progressive loss of echinocandin activity following prolonged use for treatment of Candida albicans oesophagitis. J Antimicrob Chemother. 2006 Apr;57(4):705-8. DOI: 10.1093/jac/dkl022</RefTotal>
<RefLink>http://dx.doi.org/10.1093/jac/dkl022</RefLink>
</Reference>
<Reference refNo="34">
<RefAuthor>Moudgal V</RefAuthor>
<RefAuthor>Little T</RefAuthor>
<RefAuthor>Boikov D</RefAuthor>
<RefAuthor>Vazquez JA</RefAuthor>
<RefTitle>Multiechinocandin- and multiazole-resistant Candida parapsilosis isolates serially obtained during therapy for prosthetic valve endocarditis</RefTitle>
<RefYear>2005</RefYear>
<RefJournal>Antimicrob Agents Chemother</RefJournal>
<RefPage>767-9</RefPage>
<RefTotal>Moudgal V, Little T, Boikov D, Vazquez JA. Multiechinocandin- and multiazole-resistant Candida parapsilosis isolates serially obtained during therapy for prosthetic valve endocarditis. Antimicrob Agents Chemother. 2005 Feb;49(2):767-9. DOI: 10.1128/AAC.49.2.767-769.2005</RefTotal>
<RefLink>http://dx.doi.org/10.1128/AAC.49.2.767-769.2005</RefLink>
</Reference>
<Reference refNo="35">
<RefAuthor>Pfaller MA</RefAuthor>
<RefAuthor>Boyken L</RefAuthor>
<RefAuthor>Hollis RJ</RefAuthor>
<RefAuthor>Messer SA</RefAuthor>
<RefAuthor>Tendolkar S</RefAuthor>
<RefAuthor>Diekema DJ</RefAuthor>
<RefTitle>In vitro activities of anidulafungin against more than 2,500 clinical isolates of Candida spp., including 315 isolates resistant to fluconazole</RefTitle>
<RefYear>2005</RefYear>
<RefJournal>J Clin Microbiol</RefJournal>
<RefPage>5425-7</RefPage>
<RefTotal>Pfaller MA, Boyken L, Hollis RJ, Messer SA, Tendolkar S, Diekema DJ. In vitro activities of anidulafungin against more than 2,500 clinical isolates of Candida spp., including 315 isolates resistant to fluconazole. J Clin Microbiol. 2005 Nov;43(11):5425-7. DOI: 10.1128/JCM.43.11.5425-5427.2005</RefTotal>
<RefLink>http://dx.doi.org/10.1128/JCM.43.11.5425-5427.2005</RefLink>
</Reference>
<Reference refNo="36">
<RefAuthor>Pfaller MA</RefAuthor>
<RefAuthor>Messer SA</RefAuthor>
<RefAuthor>Boyken L</RefAuthor>
<RefAuthor>Rice C</RefAuthor>
<RefAuthor>Tendolkar S</RefAuthor>
<RefAuthor>Hollis RJ</RefAuthor>
<RefAuthor>Diekema DJ</RefAuthor>
<RefTitle>Caspofungin activity against clinical isolates of fluconazole-resistant Candida</RefTitle>
<RefYear>2003</RefYear>
<RefJournal>J Clin Microbiol</RefJournal>
<RefPage>5729-31</RefPage>
<RefTotal>Pfaller MA, Messer SA, Boyken L, Rice C, Tendolkar S, Hollis RJ, Diekema DJ. Caspofungin activity against clinical isolates of fluconazole-resistant Candida. J Clin Microbiol. 2003 Dec;41(12):5729-31. DOI: 10.1128/JCM.41.12.5729-5731.2003</RefTotal>
<RefLink>http://dx.doi.org/10.1128/JCM.41.12.5729-5731.2003</RefLink>
</Reference>
<Reference refNo="37">
<RefAuthor>Niimi K</RefAuthor>
<RefAuthor>Maki K</RefAuthor>
<RefAuthor>Ikeda F</RefAuthor>
<RefAuthor>Holmes AR</RefAuthor>
<RefAuthor>Lamping E</RefAuthor>
<RefAuthor>Niimi M</RefAuthor>
<RefAuthor>Monk BC</RefAuthor>
<RefAuthor>Cannon RD</RefAuthor>
<RefTitle>Overexpression of Candida albicans CDR1, CDR2, or MDR1 does not produce significant changes in echinocandin susceptibility</RefTitle>
<RefYear>2006</RefYear>
<RefJournal>Antimicrob Agents Chemother</RefJournal>
<RefPage>1148-55</RefPage>
<RefTotal>Niimi K, Maki K, Ikeda F, Holmes AR, Lamping E, Niimi M, Monk BC, Cannon RD. Overexpression of Candida albicans CDR1, CDR2, or MDR1 does not produce significant changes in echinocandin susceptibility. Antimicrob Agents Chemother. 2006 Apr;50(4):1148-55. DOI: 10.1128/AAC.50.4.1148-1155.2006</RefTotal>
<RefLink>http://dx.doi.org/10.1128/AAC.50.4.1148-1155.2006</RefLink>
</Reference>
<Reference refNo="38">
<RefAuthor>Schuetzer-Muehlbauer M</RefAuthor>
<RefAuthor>Willinger B</RefAuthor>
<RefAuthor>Krapf G</RefAuthor>
<RefAuthor>Enzinger S</RefAuthor>
<RefAuthor>Presterl E</RefAuthor>
<RefAuthor>Kuchler K</RefAuthor>
<RefTitle>The Candida albicans Cdr2p ATP-binding cassette (ABC) transporter confers resistance to caspofungin</RefTitle>
<RefYear>2003</RefYear>
<RefJournal>Mol Microbiol</RefJournal>
<RefPage>225-35</RefPage>
<RefTotal>Schuetzer-Muehlbauer M, Willinger B, Krapf G, Enzinger S, Presterl E, Kuchler K. The Candida albicans Cdr2p ATP-binding cassette (ABC) transporter confers resistance to caspofungin. Mol Microbiol. 2003 Apr;48(1):225-35. DOI: 10.1046/j.1365-2958.2003.03430.x</RefTotal>
<RefLink>http://dx.doi.org/10.1046/j.1365-2958.2003.03430.x</RefLink>
</Reference>
<Reference refNo="39">
<RefAuthor>Paderu P</RefAuthor>
<RefAuthor>Park S</RefAuthor>
<RefAuthor>Perlin DS</RefAuthor>
<RefTitle>Caspofungin uptake is mediated by a high-affinity transporter in Candida albicans</RefTitle>
<RefYear>2004</RefYear>
<RefJournal>Antimicrob Agents Chemother</RefJournal>
<RefPage>3845-9</RefPage>
<RefTotal>Paderu P, Park S, Perlin DS. Caspofungin uptake is mediated by a high-affinity transporter in Candida albicans. Antimicrob Agents Chemother. 2004 Oct;48(10):3845-9. DOI: 10.1128/AAC.48.10.3845-3849.2004</RefTotal>
<RefLink>http://dx.doi.org/10.1128/AAC.48.10.3845-3849.2004</RefLink>
</Reference>
</References>
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<Caption><Pgraph><Mark1>Table 1: Percentages of yeast isolates (n=1,062) showing complete parallel resistance within azoles and echinocandins and their cross resistance patterns towards FCY and AMB</Mark1></Pgraph></Caption>
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<MediaNo>3</MediaNo>
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<Caption><Pgraph><Mark1>Table 3: Proportion of cross resistances of isolates with complete parallel resistance within the azole class</Mark1></Pgraph></Caption>
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<MediaNo>4</MediaNo>
<MediaID>4</MediaID>
<Caption><Pgraph><Mark1>Table 4: Proportion of cross resistances of isolates with complete parallel resistance within the echinocandin class</Mark1></Pgraph></Caption>
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<MediaNo>5</MediaNo>
<MediaID>5</MediaID>
<Caption><Pgraph><Mark1>Table 5: Detailed results of SPA for rare yeast species</Mark1></Pgraph></Caption>
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<MediaNo>6</MediaNo>
<MediaID>6</MediaID>
<Caption><Pgraph><Mark1>Table 6: </Mark1><Mark1><Mark2>Candida</Mark2></Mark1><Mark1> isolates showing multi-resistant AFA patterns</Mark1></Pgraph></Caption>
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<Caption><Pgraph><Mark1>Table 2: Standard analysis and SPA of susceptibility testing of yeast isolates (n=1,062)</Mark1></Pgraph></Caption>
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<MediaNo>7</MediaNo>
<MediaID>7</MediaID>
<Caption><Pgraph><Mark1>Table 7: Proportion of still susceptible AFAs in relation to AFA-stratified resistances</Mark1></Pgraph></Caption>
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<Caption><Pgraph><Mark1>Figure 1: Proportion of major susceptibility patterns of study isolates (n=1,062) showing percentages of isolates (i) tested susceptible to all AFAs included (8S), (ii) non-resistant isolates tested intermediate to one or more AFAs (</Mark1>≥<Mark1>1I) or (iii) tested resistant to one or more AFAs (</Mark1>≥<Mark1>1R). For isolates exhibiting </Mark1>≥<Mark1>1R SP, the percentages of multi-resistant isolates are given (1–4R, resistance to 1 to 4 AFAs; 5R, resistance to 5 AFAs; 6R, resistance to 6 AFAs and 7R, resistance to 7 AFAs).</Mark1></Pgraph></Caption>
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