Comparative evaluation of E-test and CLSI methods for Itraconazole,Fluconazole and Ketoconazole susceptibilities of Microsporum canis strains

The incidence of resistance to antifungal agents for dermatophytes is increasing, but most of the methods currently available to test the antifungal susceptibility of Microsporum canis still require standardization. The aims of this study were: (i) to evaluate the antifungal susceptibility of M. canis strains recovered from animals to ketoconazole (KTZ), fluconazole (FLZ) and itraconazole (ITZ) using a modified CLSI broth microdilution (CLSI M38-A2-BMD) and the E-test® protocols and (ii) to estimate the agreement between the methods. Tentative azole epidemiological cutoff values (ECVs) were also proposed in order to interpret the results of in vitro susceptibility tests and to establish the agreement between the E-test and CLSI BMD methods. A total of forty clinical M. canis strains from animals with skin lesions were tested, and the essential (EA) and categorical agreement (CA) between the two methods were determined. KTZ displayed the lowest MIC values, while ITZ and FLZ the highest. The ECV for KTZ and ITZ were 4 μg/ml, while those of FLZ was 64 μg/ml. Based on ECVs, about 88% of M. canis strains were susceptible to all azoles being a cross-resistance with ITZ-FLZ registered for one strain. A total of five M. canis strains showed MIC?>?ECV for FLZ using CLSI, while one strain showed MIC?>?ECV for ITZ using both tests. KTZ, ITZ and FLZ showed EA ranging from 92.5 to 95%, for all azoles and CA?>?97% except for FLZ (87.5%). The good CA between the E-test and the CLSI BMD provides evidence of the reliability of the former method to test the antifungal susceptibility of M. canis for ITZ and KTZ and not for FLZ.

     

ATB FUNGUS2法在念珠菌属和新生隐球菌抗真菌药敏试验中应用的评价

目的评价ATBFUNGUS2半固体培养基法在测定念珠菌属和新生隐球菌对4种常用抗真菌药物敏感性中的应用价值。方法利用CLSIM27．A2微量液基稀释法和ATBFUNGUS2法同时测定131株念珠菌和20株新生隐球菌对两性霉素B（AmB）、氟康唑（FLC）、氟胞嘧啶（5-Fc）和伊曲康唑（ITC）的敏感性。结果①两种方法对于AmB、5-FC、FLC和ITC的一致性分别为98％、89．4％、78．8％和78．1％;②所有受试菌株中两种方法的一致性为80％,但ATBFUNGUS2法将2／5株M27-A2法检查为FLC耐药的白念珠菌判断为敏感或剂量依赖,将8／10株M27-A2法检查为FLC剂量依赖的白念珠菌判断为敏感或耐药。③ATBFUNGUS2法中AmB的MIC值判读范围偏高,以致于实际工作中不能读出准确的值。结论ATBFUNGUS2半固体培养基法在测定念珠菌属和新生隐球菌对4种常用抗真菌药物的敏感性时不失为简单、快速而且重复性好的方法。     

Terbinafine inhibits Cryptococcus neoformans growth and modulates fungal morphology

Cryptococcus neoformans is an encapsulated fungus that causes cryptococcosis. Central nervous system infection is the most common clinical presentation followed by pulmonary, skin and eye manifestations. Cryptococcosis is primarily treated with amphotericin B (AMB), fluconazole (FLC) and itraconazole (ITC). In the present work, we evaluated the in vitro effect of terbinafine (TRB), an antifungal not commonly used to treat cryptococcosis. We specifically examined the effects of TRB, either alone or in conjunction with AMB, FLC and ITC, on clinical C. neoformans isolates, including some isolates resistant to AMB and ITC. Broth microdilution assays showed that TRB was the most effective drug in vitro. Antifungal combinations demonstrated synergism of TRB with AMB, FLC and ITC. The drug concentrations used for the combination formulations were as much as 32 and 16-fold lower than the minimum inhibitory concentration (MIC) values of FLC and AMB alone, respectively. In addition, calcofluor white staining revealed the presence of true septa in hyphae structures that were generated after drug treatment. Ultrastructural analyses demonstrated several alterations in response to drug treatment, such as cell wall alterations, plasma membrane detachment, presence of several cytoplasmic vacuoles and mitochondrial swelling. Therefore, we believe that the use of TRB alone or in combination with AMB and azoles should be explored as an alternative treatment for cryptococcosis patients who do not respond to standard therapies.     

Comparison of microdilution method and E-test procedure in susceptibility testing of caspofungin against Candida non-albicans species

It is widely known that systemic and mucosal candidiasis caused by Candida non-albicans strains endangers the lives of hospitalised patients since these pathogens are extremely difficult to defeat by commonly used antifungal agents. The present study determined the in vitro activities of a novel antimicotic drug - caspofungin - against 76 Candida non-albicans isolates by means of the CLSI reference method for broth dilution antifungal susceptibility testing of yeasts and the E-test procedure for comparison. Caspofungin was efficacious against the majority of strains tested, with the average MICs90 evaluated by the microdilution method and E-tests amounting to 1 mg/l and 0.5 mg/l, respectively. Since the agreement between MICs within +/-2 dilutions obtained by these two techniques was 92% (Kappa coefficient of 0.92), the E-test procedure seems to be a reliable alternative to the broth microdilution method and may provide another choice for clinical laboratories.     

In vitro activity of the synthetic lipopeptide PAL-Lys-Lys-NH(2) alone and in combination with antifungal agents against clinical isolates of Cryptococcus neoformans

The in vitro activity of the lipopeptide PAL-Lys-Lys-NH(2) (PAL), alone or combined with either fluconazole (FLU) or amphotericin B (AMB), was investigated against 14 Cryptococcus neoformans isolates. PAL MICs ranged from 1.0 to 4.0 microg/ml. Fungicidal activity was observed. Synergy, defined as a fractional inhibitory concentration (FIC) index of < or =0.5, was observed in 21.4% of PAL/AMB interactions. Antagonism (FIC index>4) was never observed. The broad antifungal activity and the positive interactions with AMB suggest that PAL can represent a promising candidate in infections due to C. neoformans.     

Antifungal susceptibility profiles of <Emphasis Type="Italic">Coccidioides immitis</Emphasis> and <Emphasis Type="Italic">Coccidioides posadasii</Emphasis> from endemic and non-endemic areas

Coccidioidomycosis is a systemic fungal infection endemic in Southwestern United States, Mexico, Central and South America. The causal agents are Coccidioides immitis and C. posadasii. A large number of cases of coccidioidomycosis in New York State residents were identified. We compared susceptibility profiles of these isolates and of C. immitis isolates from California using mycelial phase inoculum and CLSI (NCCLS) M38–A broth microdilution protocol. Minimum fungicidal concentrations (MFC) were also determined. Results indicated that geometric mean MICs of amphotericin B (AMB, 0.06 μg/ml), fluconazole (FLC, 8.0 μg/ml), itraconazole (ITC, 0.07 μg/ml), ketoconazole (KTC, 0.04 μg/ml), voriconazole (VRC, 0.04 μg/ml), posaconazole (PSC, 0.17 μg/ml) and caspofungin (CSP, 0.15 μg/ml) were in susceptible range as per breakpoints published for pathogenic Candida species. However, geometric MFC for FLC was relatively higher (52.4 μg/ml). Also, no significant difference in MIC and MFC values was evident for C. immitis and C. posadasii isolates. In conclusion, current methods for antifungal susceptibility testing yield reproducible profiles for Coccidioides species, which appear to be highly susceptible to most antifungal agents.     

Comparative evaluation of standard dilution method and commercial kit for frozen plate antifungal susceptibility testing of yeasts using 200 clinical isolates

A comparative evaluation of standard microdilution methods and a commercial kit for frozen plate antifungal susceptibility testing of yeasts was performed using amphotericin B, flucytosine, fluconazole, miconazole, and itraconazole on 200 yeast isolates. The isolates included 100 strains of Candida albicans, eight of C. tropicalis, twelve of C. parapsilosis, eight of C. glabrata, five of Cryptococcus neoformans, thirteen of Trichosporon asahii, and 54 other strains of seven other species of ascomycotic yeasts. Microdilution testing was performed according to the standard method for antifungal susceptibility testing published by the Japanese Society for Medical Mycology (JSMM), which are a modification of the method developed by the National Committee for Clinical Laboratory Standards (NCCLS) M27-P. The commercial kit was prepared according to the manufacturer's instructions. The degree of agreement within +/-1 dilution for 200 clinical isolates against five antifungal agents was excellent with values for amphotericin B, flucytosine, fluconazole, miconazole, and itraconazole of 100%, 99.0%, 97.5%, 97.0%, and 97.0%, respectively. Overall, the frozen plate antifungal susceptibility testing kit provided convenient and reproducible results comparable to those obtained with the JSMM standard method.     

EUCAST and CLSI: How to Assess in Vitro Susceptibility and Clinical Resistance

There are two different approved reference procedures based on microdilution techniques for antifungal susceptibility testing (AFST) of fungal species, the CLSI and the EUCAST procedures. Although there have always been some methodological differences between them, AFST results are comparable. In addition, current breakpoints values of antifungal compounds to interpret AFST results set by both institutions are very similar with some exceptions. Experts advised AFST should be done with validated commercial techniques for a routine daily practice and discrepant results should be confirmed by reference procedures particularly for isolates with borderline/resistant MIC values. Reference methods by EUCAST and CLSI should be also used in periodical epidemiological studies, to evaluate new antifungal agents, new methods of AFST and to know the susceptibility profile of rare and emerging fungal species.     

The Widely Used ATB FUNGUS 3 Automated Readings in China and Its Misleading High MICs of Candida spp. to Azoles: Challenges for Developing Countries' Clinical Microbiology Labs

The rapid development in the clinical microbiology diagnostic assays presents more challenges for developing countries than for the developed world, especially in the area of test validation before the introduction of new tests. Here we report on the misleading high MICs of Candida spp. to azoles using the ATB FUNGUS 3 (bioMérieux, La Balme-les Grottes, France) with automated readings in China to highlight the dangers of introducing a diagnostic assay without validation. ATB FUNGUS 3 is the most commonly used commercial antifungal susceptibility testing method in China. An in-depth analysis of data showed higher levels of resistance to azoles when ATB FUNGUS 3 strips were read automatically than when read visually. Based on this finding, the performance of ATB FUNGUS 3, read both visually and automatically, was evaluated by testing 218 isolates of five clinically important Candida species, using broth microdilution (BMD) following CLSI M27-A3 as the gold-standard. The overall essential agreement (EA) between ATB visual readings and BMD was 99.1%. In contrast, the ATB automated readings showed higher discrepancies with BMD, with overall EA of 86.2%, and specifically lower EA was observed for fluconazole (80.7%), voriconazole (77.5%), and itraconazole (73.4%), which was most likely due to the trailing effect of azoles. The major errors in azole drug susceptibilities by ATB automated readings is a concern in China that can result in misleading clinical antifungal drug selection and pseudo high rates of antifungal resistance. Therefore, the ATB visual reading is generally recommended. In the meantime, we propose a practical algorithm to be followed for ATB FUNGUS 3 antifungal susceptibility for Candida spp. before the improvement in the automated reading system.     

Comparison of Commercial Methods and the CLSI Broth Microdilution to Determine the Antifungal Susceptibility of Candida parapsilosis Complex Bloodstream Isolates from Three Health Institutions in Rio de Janeiro,Brazil

Two commercial methods, the Etest and Vitek 2, were compared with the Clinical and Laboratory Standards Institute broth microdilution method to determine the susceptibility of Candida parapsilosis complex to amphotericin B, caspofungin, fluconazole, voriconazole, and itraconazole. One-hundred bloodstream isolates of C. parapsilosis complex from three hospitals in Rio de Janeiro city, Brazil, between 1998 and 2006 were analyzed. C. parapsilosis sensu stricto (61 %) was the predominant species, followed by C. orthopsilosis (37 %) and C. metapsilosis (2 %). Most isolates were susceptible to the tested drugs. However, one C. parapsilosis sensu stricto isolate was considered resistant for amphotericin B. The essential agreement was 100 % between the methods, except for itraconazole (96.3 %). The categorical agreement varied for fluconazole and itraconazole by Etest and for amphotericin B and fluconazole by Vitek 2. This study reinforces the suitability of the commercial methods in routine clinical microbiology laboratories for antifungal susceptibility testing.     

Rapid Identification and Susceptibility Testing of Candida spp. from Positive Blood Cultures by Combination of Direct MALDI-TOF Mass Spectrometry and Direct Inoculation of Vitek 2

Fungaemia is associated with high mortality rates and early appropriate antifungal therapy is essential for patient management. However, classical diagnostic workflow takes up to several days due to the slow growth of yeasts. Therefore, an approach for direct species identification and direct antifungal susceptibility testing (AFST) without prior time-consuming sub-culturing of yeasts from positive blood cultures (BCs) is urgently needed. Yeast cell pellets prepared using Sepsityper kit were used for direct identification by MALDI-TOF mass spectrometry (MS) and for direct inoculation of Vitek 2 AST-YS07 card for AFST. For comparison, MALDI-TOF MS and Vitek 2 testing were performed from yeast subculture. A total of twenty four positive BCs including twelve C. glabrata, nine C. albicans, two C. dubliniensis and one C. krusei isolate were processed. Applying modified thresholds for species identification (score ≥1.5 with two identical consecutive propositions), 62.5% of BCs were identified by direct MALDI-TOF MS. AFST results were generated for 72.7% of BCs directly tested by Vitek 2 and for 100% of standardized suspensions from 24 h cultures. Thus, AFST comparison was possible for 70 isolate-antifungal combinations. Essential agreement (minimum inhibitory concentration difference ≤1 double dilution step) was 88.6%. Very major errors (VMEs) (false-susceptibility), major errors (false-resistance) and minor errors (false categorization involving intermediate result) amounted to 33.3% (of resistant isolates), 1.9% (of susceptible isolates) and 1.4% providing 90.0% categorical agreement. All VMEs were due to fluconazole or voriconazole. This direct method saved on average 23.5 h for identification and 15.1 h for AFST, compared to routine procedures. However, performance for azole susceptibility testing was suboptimal and testing from subculture remains indispensable to validate the direct finding.     

Deletion of Cryptococcus neoformans AIF ortholog promotes chromosome aneuploidy and fluconazole-resistance in a metacaspase-independent manner

Apoptosis is a form of programmed cell death critical for development and homeostasis in multicellular organisms. Apoptosis-like cell death (ALCD) has been described in several fungi, including the opportunistic human pathogen Cryptococcus neoformans. In addition, capsular polysaccharides of C. neoformans are known to induce apoptosis in host immune cells, thereby contributing to its virulence. Our goals were to characterize the apoptotic signaling cascade in C. neoformans as well as its unique features compared to the host machinery to exploit the endogenous fungal apoptotic pathways as a novel antifungal strategy in the future. The dissection of apoptotic pathways revealed that apoptosis-inducing factor (Aif1) and metacaspases (Mca1 and Mca2) are independently required for ALCD in C. neoformans. We show that the apoptotic pathways are required for cell fusion and sporulation during mating, indicating that apoptosis may occur during sexual development. Previous studies showed that antifungal drugs induce ALCD in fungi and that C. neoformans adapts to high concentrations of the antifungal fluconazole (FLC) by acquisition of aneuploidy, especially duplication of chromosome 1 (Chr1). Disruption of aif1, but not the metacaspases, stimulates the emergence of aneuploid subpopulations with Chr1 disomy that are resistant to fluconazole (FLC(R)) in vitro and in vivo. FLC(R) isolates in the aif1 background are stable in the absence of the drug, while those in the wild-type background readily revert to FLC sensitivity. We propose that apoptosis orchestrated by Aif1 might eliminate aneuploid cells from the population and defects in this pathway contribute to the selection of aneuploid FLC(R) subpopulations during treatment. Aneuploid clinical isolates with disomies for chromosomes other than Chr1 exhibit reduced AIF1 expression, suggesting that inactivation of Aif1 might be a novel aneuploidy-tolerating mechanism in fungi that facilitates the selection of antifungal drug resistance.     

Minimal inhibitory concentrations of Candida species to five antifungals by using the reference dilution micromethod and the E-test.

It is accepted that the frequency of candidosis has increased during the last decade, specially in hospitalized patients. The more frequent use of azole antifungals and the recognition of isolates of Candida sp resistant to these and other drugs such as 5-fluorocytosine constitute a great need for a reproducible and useful C. albicans in vitro susceptibility testing method for monitoring antifungal therapy in clinical mycological laboratories. The E-test is a novel agar diffussion technique for testing the susceptibility of yeasts against a defined continous gradient of drug and could be used by most clinical laboratories. In this study the E-test and the NCCLS reference microbroth method (M27-P guidelines) were used to determine the MICs of amphotericin B, 5-flucytosine, itraconazole, fluconazole and ketoconazole for 50 clinical isolates of Candida albicans, Torulopsis glabrata, C. tropicalis and Hansenula anomala and five reference ATCC strains. The main purpose of the study was to compare the results obtained by the two methods. In general good agreement (+/- 1 dilution) was otained between both methods, despite differences observed for some species-antifungal combinations in which the MICs were lower by the E-test than by the microbroth method. MICs for C. albicans and T. glabrata to amphotericin B were < 0.50 microg/mL. Two isolates of C. albicans and two others of H. anomala, showed MIC < 8 microg/mL for 5- flucytosine. All isolates of T. glabrata and 40% of C. albicans showed MICs > 16 microg/mL for fluconazole. The results of this study indicate that E-test is an alternative for susceptibility testing to the NCCLS reference method. Because its simplicity it seems to be an easier test for routine clinical laboratories.     

Evaluation of Etest Performed in Mueller–Hinton Agar Supplemented with Glucose for Antifungal Susceptibility Testing of Clinical Isolates of Filamentous Fungi

Although reference broth microdilution protocol is currently available for filamentous fungi antifungal susceptibility testing (AFST), simpler alternatives as Etest^® tend to be favoured in clinical routine, making their validation of utmost importance. In this study, Etest^® method using 2 % glucose supplemented Muller–Hinton agar was compared to the Clinical and Laboratory Standards Institute (CLSI) M38-A2 protocol for filamentous fungi AFST. The echinocandins, caspofungin and anidulafungin, the azoles voriconazole and posaconazole, and the polyene amphotericin B were tested against 48 Aspergillus spp., seven Fusarium spp., one Beauveria bassiana and three Paecilomyces lilacinus isolates. The majority of the isolates were susceptible to the antifungals tested, and the overall level of agreement between the CLSI and Etest methods was 71.9 % for one dilution and 99.7 % when using two dilutions. Since interpretative breakpoints for filamentous fungi employing the CLSI or Etest methods are not available yet, the established epidemiological cut-off values for Aspergillus spp. were used to distinguish wild-type isolates from those with acquired resistance mechanisms. Forty-five Aspergillus strains did not evidence resistance mutations.     

Cryptococcus neoformans: The Model Organism for Yeast Antifungal Drug Susceptibility Testing

We describe an approach to antifungal susceptibility testing of the yeast Cryptococcus neoformans that shows promise for predicting the mycological response in patients to treatment. Quantitative cultures of the cerebrospinal fluid provide a direct measure of the patient's mycological response to treatment and have been used in multiple studies to identify the most promising antifungal drugs for subsequent testing in larger clinical studies. Using these quantitative measures of response, a modified macrobroth dilution assay system shows the potential for predicting the response of an individual patient to treatment with amphotericin B, fluconazole, or the combination of amphotericin B plus flucytosine. We describe this modified macrobroth dilution assay method, the statistical approach for assessing susceptibility, and the clinical decisions that can be guided by this in vitro antifungal drug susceptibility testing.     

Comparative evaluation of Trichosporon asahii susceptibility using ASTY colorimetric microdilution and CLSI M27‐A2 broth microdilution reference methods

The in vitro activity of AMPH‐B, 5‐FC, FLCZ, MCZ, ITCZ, and VRCZ against 50 isolates of T. asahii was determined using CLSI M27‐A2 microdilution and ASTY colorimetric methods. Observed agreement ranged from 96 to 100% according to the drug. Overall, the agreement between two methods was 97.7%. The ASTY colorimetric method was thus determined to be comparable to the CLSI reference method when testing the susceptibility of T. asahii to a variety of antifungal agents.     

Influence of growth media on vancomycin resistance of Enterococcus isolates and correlation with resistance gene determinants

The effect of Mueller-Hinton (MH), MH+blood or brain heart infusion medium (agar or broth) on 13 Enterococcus isolates was determined, when testing their antibiotic susceptibility. Disk diffusion and Vitek methods were used to determine vancomycin resistance, while broth dilution and E-test methods were used to measure the minimum inhibitory concentration. The data were correlated with the presence of vancomycin resistance genes. A definite correlation pattern could not be established between the presence of van genes and vancomycin resistance in any plating medium, when tested by the disk diffusion assay. The broth dilution, irrespective of the plating medium, and Vitek methods were more reliable than the E-test method in testing isolates with vanA or vanB genes. However, for vanC2/C3 genotypes, the E-test method, irrespective of the plating medium, tested better than the broth dilution assay.     

Species level identification and antifungal susceptibility of yeasts isolated from various clinical specimens and evaluation of Integral System Yeasts Plus

It is essential to use easy, standard, cost-effective and accurate methods for identification and susceptibility testing of yeasts in routine practice. This study aimed to establish the species distribution and antifungal susceptibility of yeast isolates and also to evaluate the performance of the colorimetric and commercially available Integral System Yeasts Plus (ISYP). Yeast isolates (n=116) were identified by conventional methods and ISYP. Antifungal susceptibility testing was performed by the microdilution method according to the standards of CLSI M27-A3 and ISYP. Candida albicans (50%) was the most common species isolated, followed by C. parapsilosis (25%) (mostly in blood samples). According to the CLSI M27-S3 criteria, resistance rates for amphotericin B, flucytosine, fluconazole, itraconazole, and voriconazole were 0%, 0%, 4.6%, 4.5% and 1.8%, respectively. Resistance for miconazole (MIC >1 mg/L) was found as 17.9%. Sixty-two (53.4%) of the isolates which were analyzed by ISYP showed disagreement with those identified by the conventional methods and API ID 32C identification kit or a specific identification code could not be assigned by ISYP. The performance of ISYP could be indicated as low for all antifungal drugs tested according to the ROC analysis (AUC: 0.28-0.56). As the current version of ISYP displays a poor performance, it is recommended to use the other commercial systems whose results are approved as reliable and in agreement with those of the reference methods in identification and susceptibility testing of yeasts.     

Performance of different methods for testing polymyxin B: comparison of broth microdilution,agar dilution and MIC test strip in mcr-1 positive and negative Escherichia coli

Antimicrobial susceptibility testing with the last-resort antibiotics polymyxins (polymyxin B and colistin) is associated with several methodological issues. Currently, broth microdilution (BMD) is recommended for colistin and polymyxin B. BMD is laborious and the utility of alternative methods needs to be evaluated for polymyxin B susceptibility testing. In this study, using BMD as a reference method, the performance of agar dilution (AD) and MIC test strips (MTS) were evaluated in polymyxin B susceptibility testing. BMD, AD and MTS were used to determine MICs of 193 clinical isolates of Escherichia coli. Seventy-nine were positive for the polymyxin resistance gene mcr-1. Method performances were evaluated based on pair-wise agreements with the reference method (BMD) and statistical testing. AD and MTS showed an unacceptable number of very major errors (VMEs) compared with BMD, 9·3 and 10·7%, respectively. The essential agreement (EA) was low for AD (49·7%), but high for MTS (97·8%). However, statistical testing showed that MTS tended to yield a one-step lower MIC (P < 0·01) compared with BMD. The discordances observed with MTS and AD in comparison with BMD for polymyxin B susceptibility testing for E. coli suggest their inapplicability in routine testing. A large number of isolates clustered around the susceptibility breakpoint (2–4 mg l⁻¹) and several mcr-1 positive isolates (17%) were determined as susceptible with BMD. A screening breakpoint for mcr-1 of 2 mg l⁻¹ should also be considered.     

In vitro resistance to fluconazole and itraconazole in clinical isolates of Candida spp and Cryptococcus neoformans

An in vitro susceptibility testing of 181 strains of six species of Candida and 21 strains of Cryptococcus neoformans was carried out in order to investigate the resistance to new antifungal drugs. We have studied clinical isolates from 200 different patients of Hospital del Mar (Barcelona) and Hospital La Inmaculada (Almería). An agar diffusion method (NeoSensitabs, Rosco, Taastrup, Denmark), was employed with fluconazole, itraconazole, and reference drugs amphotericin B, flucytosine, tioconazole and ketoconazole. A high level of susceptibility was found for amphotericin B in C. neoformans strains while 19% of them were resistant to flucytosine. All the strains of C. neoformans and Candida guilliermondii were susceptible to the new azoles derivatives and also Candida parapsilosis and Candida albicans had a great susceptibility to this antifungals. A greater level of resistance was found for Candida krusei, Candida tropicalis and Candida glabrata to fluconazole, itraconazole and ketoconazole, but resistance to fluconazole and itraconazole is not always linked because ten resistant strains for fluconazole were susceptible to itraconazole, and two other resistant to itraconazole were susceptible to fluconazole.