The Journal of Antibiotics (2015) 68, 556–561 & 2015 Japan Antibiotics Research Association All rights reserved 0021-8820/15 www.nature.com/ja ORIGINAL ARTICLE Antifungal susceptibilities of Candida, Cryptococcus neoformans and Aspergillus fumigatus from the Asia and Western Pacific region: data from the SENTRY antifungal surveillance program (2010–2012) Michael A Pfaller, Shawn A Messer, Ronald N Jones and Mariana Castanheira The SENTRY Antifungal Surveillance Program monitors global susceptibility rates of newer and established antifungal agents. We report the in vitro activity of seven antifungal agents against 496 contemporary clinical isolates of yeasts and molds. The isolates were obtained from 20 laboratories in the Asia-Western Pacific (APAC) region during 2010 through 2012. Anidulafungin, caspofungin, micafungin, fluconazole, itraconazole, posaconazole and voriconazole were susceptibility tested using CLSI methods and species-specific interpretive criteria. Sequencing of fks hot spots was performed for echinocandin-resistant strains. Isolates included 13 species of Candida (n = 460), 5 species of non-Candida yeasts (21), 5 species of Aspergillus (11) and 4 other molds. Echinocandin resistance was uncommon among eight species of Candida and was only detected in three isolates of Candida glabrata, two from Australia harboring mutations in fks1 (F625S) and fks2 (S663P). Resistance to the azoles was much more common and was observed among all species with the exception of Candida dubliniensis. Fluconazole resistance rates observed with C. glabrata (6.8%) was comparable to that seen with Candida parapsilosis (5.7%) and Candida tropicalis (3.6%). Cross resistance among the triazoles was seen with each of these three species. The mold-active azoles and the echinocandins were all active against isolates of Aspergillus fumigatus. Azole resistance was not detected among the isolates of Cryptococcus neoformans. Antifungal resistance is uncommon among isolates of fungi causing invasive fungal infections in the APAC region. As in other regions of the world, emerging resistance to the echinocandins among invasive isolates of C. glabrata bears close monitoring. The Journal of Antibiotics (2015) 68, 556–561; doi:10.1038/ja.2015.29; published online 22 April 2015 INTRODUCTION different countries or cities. The SENTRY Antimicrobial Surveillance Surveillance programs devoted to tracking the occurrence of invasive Program is a survey that has been active since 1997 and has reported fungal infections (IFI) have provided a wealth of information the frequency of pathogen occurrence and the susceptibilities to regarding emerging species and the frequency of antifungal various antifungal agents on a global scale.7,28 In the present study, resistance.1–9 The increasing incidence of IFIs in the Asia and Western we summarize the results of the APAC component of the SENTRY Pacific (APAC) regions have resulted in both small- and large-scale Program for the years 2010 through 2012, comparing the activities of surveillance efforts in Australia,10,11 India,12,13 Japan,14 Korea,15–18 three echinocandins and four triazoles tested against a collection of Malaysia,19 Singapore,20 Taiwan21–27 and several other areas.8,9 In 496 isolates of Candida (460 isolates, 13 species), non-Candida yeasts contrast to data from North America and Europe,1,7 Candida glabrata (21 isolates, 3 species), Aspergillus (11 isolates, 5 species) and and Candida krusei are much less prominent as causes of IFI than non-Aspergillus molds (4 isolates, 4 species). Data from institutions either Candida tropicalis or Candida parapsilosis in several areas of the in China are summarized in a separate publication (Pfaller et al.,29,30). APAC region. Furthermore, resistance to fluconazole is much more We have used molecular methods to confirm the identification of the common in isolates of C. tropicalis from Asia (11–15%) than in those less common species of Candida, as well as those of the non-Candida from North America (2.7%) or Europe (1.1%).7,22,27 yeasts and all of the filamentous fungi. Furthermore, we applied the One of the limitations of the existing surveillance data from the newly revised clinical breakpoints for the echinocandins, fluconazole APAC region is that most reports have not used the new species- and voriconazole to determine the resistance profiles of various specific interpretive criteria for the azoles and echinocandins against Candida species31 and the epidemiological cutoff values (ECVs) for Candida and Aspergillus. In addition, many of these reports are limited these agents, as well as itraconazole and posaconazole, to detect to a single institution and most fail to compare results across several emerging, resistance among less common species of Candida31 and JMI Laboratories, North Liberty, IA, USA Correspondence: Dr MA Pfaller, Microbiology, JMI Laboratories, 345 Beaver Kreek Centre Suite A, North Liberty, IA 52317, USA. E-mail: [email protected] Received 19 November 2014; revised 10 February 2015; accepted 22 February 2015; published online 22 April 2015 Antifungal resistance in the Asia-Pacific MA Pfaller et al 557 among isolates of Aspergillus fumigatus32 and Cryptococcus neofor- isolates), A. clavatus (one isolate), Aspergillus foetidis (one isolate), Aspergillus mans.33 niger species complex (two isolates), Aspergillus section Terrei (one isolate), and four other molds (one Lichtheimia ramosa,oneScedosporium aurantiacum,one MATERIALS AND METHODS Scedosporium prolificans and one Trichoderma longibrachiatum). Organisms A total of 496 clinical isolates from patients with IFI were collected during 2010 Antifungal susceptibility testing through 2012 from 20 different laboratories in Australia (6 sites, 177 isolates), All yeasts were tested for in vitro susceptibility to the echinocandins Hong Kong (1 site, 23 isolates), India (3 sites, 7 isolates), Korea (4 sites, 87 (anidulafungin, caspofungin and micafungin) and the triazoles (fluconazole, isolates), New Zealand (2 sites, 64 isolates), Singapore (1 site, 65 isolates), South posaconazole and voriconazole) using CLSI36 broth microdilution methods. Africa (1 site, 18 isolates), Taiwan (1 site, 3 isolates) and Thailand (1 site, 52 The Minimum inhibitory concentration (MIC) results for all agents were read isolates) as part of the SENTRY Program (Table 1). In each case, collection was following 24 h of incubation when the agents were tested against Candida spp., approved by the appropriate institutional review board. Each participating whereas MIC end points for the triazoles were read after 48 h when the drugs center recovered consecutive, non-duplicated isolates from patients with were tested against non-Candida yeasts.36 In all instances, the MIC values were bloodstream infections, normally sterile body fluids, abscess, and tissue samples determined visually as the lowest concentration of drug that caused significant and respiratory tract infections (Aspergillus and other molds only). Isolates growth diminution levels (⩾ 50% inhibition relative to the growth control).36,37 were identified at the participating institutions using methods routinely In vitro susceptibility testing of Aspergillus spp. and other molds against the used at the submitting laboratory, including Vitek, MicroScan, API and echinocandins and triazoles (itraconazole, posaconazole and voriconazole) was Auxacolor, supplemented by classical methods for yeast and mold performed by broth microdilution as described in CLSI document M38-A2.38 identification.34,35 Isolates were submitted to JMI Laboratories (North Liberty, The triazole MICs and echinocandin minimum effective concentrations were IA, USA), where the identification was confirmed by morphological, biochem- determined as defined in the CLSI reference method.38 ical and molecular methods (all non-Candida yeasts and all molds) as described We used the revised CLSI clinical breakpoint values and epidemiological previously.7,29 cutoff values to differentiate susceptible/wild-type strains from resistant/non- – – Among the 460 isolates of Candida, there were 197 isolates of C. albicans,88 wild-type strains of each species.31 33,36 40 of C. glabrata,88ofC. parapsilosis,55ofC. tropicalis,8ofCandida dubliniensis, Quality control was performed as recommended in CLSI documents M27- 7ofCandida guilliermondii,5ofC. krusei,5ofCandida lusitaniae and 6 of A336 and M38-A238 using the strains C. krusei ATCC 6258 C. parapsilosis ATTC miscellaneous Candida spp. (2 Candida fabianii, 1 Candida haemulonii,1 22019, and A. fumigatus MYA-3626. Candida kefyr,1Candida metapsilosis,and1Candida orthopsilosis). The All isolates of Candida spp. that were resistant to one or more of the collection also included C. neoformans (16 isolates), Lodderomyces elongisporus echinocandins were further characterized regarding the presence or absence of (1 isolate) Rhodotorula mucilaginosa (1 isolate), Saccharomyces cerevisiae (1 mutation in the hot spot regions of fks1 and fks2 (C. glabrata only) as described isolate) and Trichosporon asahii (2 isolates). Molds included A. fumigatus (six previously.41,42 Table 1 Geographic distribution of organisms collected during 2010 to 2012 from Asia-Western Pacific medical centers participating in the SENTRY Antifungal Surveillance Program No. of isolates in each geographic region Organism/organism group AUS HK IND KOR NZ SNG SA TWN TLD Total Total, yeasts 177 23 7 87 64 65 18 3 52 496 All Candida spp. 159 23 7 85 61 65 15 3 42 460 C. albicans 69 11 3 39 28 25 6 3 13 197 C. glabrata 384 1312131 7 88