Candida glabrata Esophagitis: Are We Seeing the Emergence of a New Azole-Resistant Pathogen?

Hindawi Publishing Corporation International Journal of Microbiology Volume 2014, Article ID 371631, 4 pages http://dx.doi.org/10.1155/2014/371631 Research Article Candida glabrata Esophagitis: Are We Seeing the Emergence of a New Azole-Resistant Pathogen? Aze Wilson,1 Johan Delport,2 and Terry Ponich3 1 Division of Clinical Pharmacology and Division of Gastroenterology, Department of Medicine, London Health Sciences Centre, Western University, University Campus, 339 Windermere Road, Room C9-101, London, ON, Canada N6A 5W9 2 Department of Medical Microbiology, London Health Sciences Centre, Western University, Victoria Campus, 800 Commissioners Road E., Room B10-105, London, ON, Canada N6A 5W9 3 Division of Gastroenterology, Department of Medicine, London Health Sciences Centre, Western University, Victoria Campus, 800 Commissioners Road E., Room E1-317, London, ON, Canada N6A 5W9 Correspondence should be addressed to Aze Wilson; Received 7 November 2014; Revised 19 November 2014; Accepted 19 November 2014; Published 3 December 2014 Academic Editor: Joseph Falkinham Copyright © 2014 Aze Wilson et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Background. Candida glabrata (C. glabrata) has become a recognized pathogen in fungal esophagitis. A proportion of these isolates are azole-resistant which may have treatment implications. Variability in the prevalence of this organism exists in the limited data available. Objective. To determine the incidence of C. glabrata esophagitis in a North American hospital setting and to highlight factors that may predispose patients to this condition. Methods. Patient charts were collected from January 1, 2009 to July 30, 2011. Any charts of patients identified as having esophagitis with a positive fungal culture were reviewed for the species of Candida and the presence of factors that would predispose them to esophageal candidiasis. Results. The prevalence of Candida esophagitis based on culture was 2.2% (37 subjects). C. glabrata was the 2nd most prevalent pathogen identified (24.3% or 9 subjects). Of the C. glabrata cohort, all patients had at least one factor predisposing them to candidiasis. Conclusion. C. glabrata esophagitis makes up a large portion of the candidal esophagitis seen in hospital. C. glabrata infections were associated with at least one risk factor for candidal infection. Given its resistance to azole-based therapy, this may have treatment implications for how candidal esophagitis is approached by the clinician. 1. Introduction Infections of the esophagus occur most commonly in immunocompromised patients such as those infected with human immunodeficiency virus and those receiving chemotherapy or immunosuppressive medications [1]. There are, however, esophageal infections that can occur in both the immunocompromised and the at-risk immunocompetent host (recent antibiotics, debilitated, aged, in-dwelling catheters). Candida species are one of the most commonly detected organisms in the setting of an esophageal infection [2]. Although Candida albicans (C. albicans) remains the most common cause of fungal esophagitis at many institutions, non-albicans species are increasingly associated with esophageal candidiasis [3]. Specifically, there have been an increasing number of reports identifying Candida glabrata (C. glabrata) as the causative agent in candidal mucosal and systemic infections [1, 4–10]. Despite this, publications on C. glabrata make up only a small proportion of publications on medically important fungal infections of the esophagus [11]. C. glabrata is yeast that belongs to the family Saccharomycetaceae and the genus Candida. Historically, it was thought to be primarily nonpathogenic; however, more recently, it has been shown to be highly opportunistic, achieving colonization through a series of adhesion proteins [11]. Unfortunately, very little is known about the pathogenesis and epidemiology of C. glabrata. What have emerged are reports of C. glabrata’s intermediate, dose-dependent susceptibility and 20% resistance rate against the azoles [12, 13]. With reports of resistance, an increasing prevalence of this organism could have an impact on the treatment of candidal esophagitis and how it is approached by the clinician. 2 International Journal of Microbiology The aim of this study was to determine the incidence of Candida glabrata esophagitis at a North American tertiary care centre and to highlight risk factors that may predispose patients to this condition. 1.7% 97% 2. Materials and Methods 3. Results 1701 charts were identified as meeting the inclusion criteria. Fifty-five subjects (3.2%) were recognized as having endoscopic findings consistent with Candida esophagitis (any species). However, the true prevalence of Candida esophagitis (any species) based on microbiologic culture was 2.2% (37 subjects) (Figure 1). C. albicans was implicated in the vast majority of infections (27 subjects or 73%) while C. glabrata was the next most prevalent (9 subjects or 24.3%), followed by C. tropicalis (1 subject or 2.7%) (Figure 2). Sixteen men (53%) and 14 women (47%) were affected. There were 6 cases where the subject had a mixed infection (5 mixed C. glabrata/albicans and 1 mixed C. tropicalis/albicans). With respect to the glabrata-infected subjects, ages ranged from 29 to 87, with a slightly younger mean age of 63 compared to the albicans-infected subjects, whose ages ranged from 23 to 99, with a mean age of 67 (𝑃 = 0.63). In the C. glabrata population, the majority of individuals were inpatients, while the C. albicans population were relatively equally distributed between in- and outpatients (Table 1). 0.5% 0.1% No esophagitis C. albicans C. glabrata C. tropicalis Figure 1: Prevalence of Candida esophagitis in an adult gastroenterology endoscopy cohort (2009–2011). C.: Candida. 100 80 Prevalence (%) This single centre, retrospective chart review was carried out in London, Ontario, Canada. Adult gastroenterology patient charts were included based on billing codes for esophageal biopsies and brushings taken from January 1, 2009, to July 30, 2011. All patients were at least 18 years of age. Outpatient and inpatient charts were included. Esophageal candidiasis was defined as the recovery of a Candida species from an esophageal biopsy or brushing. Candida esophagitis was confirmed endoscopically by the presence of typical sparse or coalescent white plaques. Neither the reason for performing the gastroscopy nor the patient’s clinical symptoms were evaluated for the purposes of this study. The microbiologic results of each chart were reviewed. Any charts identified as having a positive fungal culture were further reviewed for the presence or absence of any risk factors that would predispose that patient to esophageal candidiasis as w (...truncated)