Candida Albicans Free Forever

Yeast Infection No More

Linda Allen is a professional health expert who has worked as a health consultant and medical researcher for more than 17 years. Linda has worked with many experts to create the special online guide called Yeast Infection No More. The program had helped many yeast infection sufferers to cure their yeast infection permanently. Linda Allen provides a clear and simple explanation of how to deal with all the factors that help yeast cells to flourish. For example, if you are not eating food that contains the 40 essential vitamins and minerals necessary for good health, you are creating an environment in your body in which Candida can grow. The methods described by Linda Allen are effective not only for women but also for men. There is no need to combine any sprays or creams with the Yeast Infection No More program which can save you a lot of money. Continue reading...

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Antifungal resistance in Candida species

These are very reasonable questions, and some authors have already published alarming accounts that have engendered concerns without necessarily delivering accurate detail and evidence to support their claims. For example, the now almost universal use of the ugly term non-albicans Candida species in publications has created a widespread illusion that only C. albicans is susceptible to fluconazole and other azoles. The detailed reality is quite different. The only clinically important Candida species regarded as resistant to fluconazole per se is C. krusei, and this species remains susceptible to most other triazole antifungals, albeit with lower susceptibility than C. albicans. C. glabrata is less susceptible to triazoles than C. albicans, but to characterize this species as azole-resistant is a gross oversimplification of the data in vitro, most isolates of C. glabrata fall within the susceptible range of triazole minimal inhibitory concentrations (MIC) (Pfaller et al., 2000) and...

Host Defense Against Candida

Clinical and experimental data have demonstrated that innate immunity based on intact antifungal activity of phagocytes is critical in the outcome of invasive candidiasis. Quantitative and qualitative modulation of anticandidal host defense using cytokines as adjuncts to antifungal drug therapy has been supported by extensive in vitro and in vivo preclinical data, as well as some limited clinical results (3). Host innate immune response to Candida spp. is predominantly based on the antifungal efficacy of cytokine-activated tissue macrophages (e.g., peritoneal macrophages, Kupffer liver cells, splenic macrophages) and circulating neutrophils (polymorphonuclear leukocytes PMNs ), as well as monocytes (mononuclear cells MNCs ). Macrophages have lost the capacity to produce significant amounts of oxygen-dependent metabolites. In contrast, they possess potent phagocytic activity and nonoxidative antifungal mechanisms such as cationic proteins and antifungal enzymes. These cells ingest...

Box 103 Vaginal Yeast Infections

The female genitourinary tract is colonized with yeasts, in particular Candida albicans. These fungi are normally balanced by bacterial flora. The use of antibiotics or changes in the local environment due to hormones or other physiological conditions can result in proliferation of yeasts. As a society, we encourage individuals to self-diagnose and self-treat by making available over-the-counter antifungal agents that are applied topically to the surface of mucosal membranes. Although individuals with such infections are advised to seek medical care and follow instructions carefully, compliance is a major problem. In 2001, nearly 2 of yeast samples cultured from the vaginal tracts of women using over-the-counter products were drug resistant.194 Although this overall resistance prevalence seems low, the total number of women colonized with drug-resistant yeasts is high. Yeast infections are generally not life threatening, but during serious illness, these colonizing strains may become...

Invasive Candida Infections

Invasive candidiasis is one of the leading causes of morbidity and mortality in hospitalized and immunocompromised patients nowadays (1). Although Candida albicans has been historically the most frequent cause of invasive candidiasis, non-albicans Candida spp. are becoming increasingly important being more resistant to mainstream antifungal agents than C. albicans (2). Hence, the intrinsic host response against Candida spp. and the effects of the immunomodulatory cytokine network on it need to be re-evaluated, especially in conjunction with the newer antifungal agents. Candida spp. replicate by cell-budding and grow as blastoconidia, the infectious form of the organism. When C. albicans and most other Candida spp. are

Vulvovaginal Candidiasis

The most common cause of vulvo-vaginal candidiasis is Candida albicans. Other non-albicans species, such as C. glabrata, account for less then 10 per cent of cases but it is this group that may be more resistant to treatment (Kinghorn and Priestly, 1998). Around 75 per cent of women will experience candidiasis at some time. It is usually related to pregnancy or follows antibiotic therapy. However, while sexual acquisition plays a small role in the aetiology of vulvo-vaginal candidi-asis, the infection may be passed on by male partners, who can then act as asymptomatic reservoirs of re-infection. Male partners can also develop symptomatic balanitis (Kinghorn and Priestly, 1998). Ten to twenty per cent of women of reproductive age may harbour Candida species and remain asymptomatic, and, for these women, treatment is not required. Candida albicans and the non-albicans species share common symptoms. Table 10 Clinical features (Candida albicans and non-albicans species share common Table...

Candida infections

The decrease in invasive Candida infections began during the 1990s and has been evidenced from US mortality records (McNeil et al., 2001), incidence data from US intensive care units (Trick et al., 2002) and neutropenic patients (Wisplinghoff et al., 2003), and from Japanese autopsy data (Yamazaki et al., 1999). Most of the decrease is attributable to a marked decline in infections caused by C. albicans, so it is not surprising that the proportion of other Candida species incriminated in disseminated disease has risen. However, evidence for a rising incidence of Candida infections due to species other than C. albicans is less impressive than data illustrating their increased prevalence. Only Candida glabrata infections may have increased in incidence in some areas in a manner and extent consistent with a general trend infections caused by Candida krusei, Candida parapsilosis, and Candida tropicalis have occurred at fairly consistent rates through the 1990s (Trick et al., 2002). In a...

Candida Species

The pathogenesis of Candida infections is extremely complex and probably varies with each spedes. Adhesion of Candida to the epithelium of the gastrointestinal or urinary tract is critically important. Candida spp. commonly colonize the mucosal surfaces, and their ability to invade and cause infection is first dependent on binding.60 Fibronectin, a component of the host extracellular matrix, may play a role in the initiation and dissemination of Candida albicans infections.157 Three distinct aspartyl proteases have been described in C. albicans, and strains with high levels of proteases have been shown to have an increased ability to cause disease in experimental animal models.94 Hydrophobic molecules present on the surface of Candida spp. also appear to be important in pathogenesis, and there is a strong correlation between adhesion and surface hydropho-bidty.37 Also, high levels of phospholipase, found in strains of C. albicans, has been correlated with a higher mortality rate for...


Candida spp. can also invade the oral mucosa. Immunosuppressed patients, including very young infants, may develop oral candidiasis, called thrush. Oral thrush can extend to produce pharyngitis and or esophagitis, a common finding in patients with acquired immunodeficiency syndrome and in other immunosuppressed patients. Thrush is suspected if whitish patches of exudate on an area of inflammation are observed on the buccal (cheek) mucosa, tongue, or oropharynx. Oral mucositis or pharyngitis in the granulocytopenic patient may be caused by Enterobacteriaceae, S. aureus, or Candida spp. and is manifested by erythema, sore throat and possibly exudate or ulceration.

Preface To Candida

This volume of the Methods in Molecular Medicine series, Antifungal Agents Methods and Protocols, is divided into three major sections covering molecular methods applied to antifungal resistance, the discovery and evaluation of new and existing antifungal agents, and host response and immunotherapy. We have avoided including methods that have been standardized, such as minimum inhibitory concentration testing, since these methods are readily available elsewhere. Many of the protocols were developed in authors' laboratories and are provided in sufficient detail to facilitate their application and reproduction in other laboratories. For some chapters, more extensive introductory material is provided prior to the methods. In cases in which the methods are not easily applied to other organisms, alternate methods are presented separately. For example, protocols may often be applicable for yeast only where dimorphic fungi must be studied using markedly different techniques, as in animal...

Joachim Morschhuser Peter Staib and Gerwald Khler

The emergence of resistance to antifungal drugs in medically important fungi has become a significant problem in recent years. Probably the best-studied example is the development of resistance to the widely used antifungal agent fluconazole in the yeast Candida albicans. The availability of matched series of clinical isolates representing the same strain in which drug resistance developed over time has provided opportunities to detect cellular alterations that are correlated with drug resistance. We describe a method for DNA fingerprinting of C. albicans isolates based on Southern hybridization of genomic DNA with the C. albicans-specific repetitive DNA element CARE-2. Molecular typing with CARE-2 permits highly reliable discrimination of unrelated strains to ascertain that serial isolates recovered from individual patients indeed represent the same C. albicans strain. Key Words Candida albicans DNA fingerprinting drug resistance fluconazole repetitive element strain typing.

Protein Identification by Mass Spectrometry

Two-dimensional polyacrylamide gel electrophoresis separation of total protein extract from Candida albicans matched isolates 2-79 and 12-99. The numbered spots represent up- or down-regulated proteins between these two isolates identified by peptide mass fingerprinting (see Table 4). Fig. 1. Two-dimensional polyacrylamide gel electrophoresis separation of total protein extract from Candida albicans matched isolates 2-79 and 12-99. The numbered spots represent up- or down-regulated proteins between these two isolates identified by peptide mass fingerprinting (see Table 4).

Evaluation of Antifungal Function

The interaction of Candida spp. with phagocytes activates antifungal functional responses, of which the most widely studied are the following The methods to evaluate these functions of phagocytes during immuno-therapy against invasive Candida infections are briefly described in this chapter.

Massoumeh Z Hooshdaran George M Hilliard and P David Rogers

The sequencing of the Candida albicans genome and recent refinements in protein resolution and identification techniques have greatly enhanced the application of proteomics for the study of this fungal pathogen. Proteome analysis includes the separation and isolation of proteins by two-dimensional polyacrylamide gel electrophoresis and subsequent protein identification by peptide mass fingerprinting using matrix-assisted laser desorption ionization time-of-flight mass spectrometry. This technique has been used for the study of the proteomes of Candida species in the context of virulence, drug response, and resistance. We describe here the application of this approach to the study of azole antifungal resistance in C. albicans. Key Words Candida albicans protein proteomics 2D-PAGE azole antifungal resistance.

General Microplate Based Whole Cell Screening

Mcfarland Candida Albicans

Comparison of inoculum counting methods using Candida albicans ATCC 90028. Optical density and colony-forming unit mL estimation using the 0.5 McFarland relationship is compared with resulting colony counts obtained on agar (viability counting). OD, optical density CFU, colony-forming unit. Fig. 3. Comparison of inoculum counting methods using Candida albicans ATCC 90028. Optical density and colony-forming unit mL estimation using the 0.5 McFarland relationship is compared with resulting colony counts obtained on agar (viability counting). OD, optical density CFU, colony-forming unit. CFUs mL of yeast (Candida and Cryptococcus) and Aspergillus conidia. The 0.5 McFarland also assumes consistent viability of the cells. 4. Incubate at 35 C for 48 h for Candida, 35 C for 72 h for Cryptococcus, or 30 C for 72 h for Aspergillus.

Animal Infection Model

A profound state of granulocytopenia (< 100 mm3) is produced in animals to maximize the growth of Candida in mice (see Note 4). This immuno-compromised state can be achieved by administration of cyclophosphamide prior to infection. Cyclophosphamide is administered via intraperitoneal injection 4 d (150 mg kg) and 1 d (100 mg kg) before the day of infection. This regimen will produce a neutropenic state for 5 d in this animal species. The degree and duration of neutropenia is confirmed by monitoring neutrophil counts of peripheral blood smears with a hemocytometer daily throughout the duration of study. 3. Using a (1 mL) tuberculin syringe with either a 26- or 27-gage needle the inoculum (0.1 mL of a suspension of 105-7 CFU mL Candida blastospores) is injected via the lateral tail vein (see Note 1).

Gordon Ramage and Jos Luis Lopez Ribot Summary

Candida albicans is capable of forming biofilms on a variety of inert and biological surfaces. Cells in biofilms display phenotypic properties that are radically different from their free-floating planktonic counterparts, including their recalcitrance to antimicrobial agents. Consequently, Candida biofilm-associated infections are difficult to treat and to fully eradicate with standard antifungal therapy. Here, we describe a simple, fast, inexpensive and highly reproducible microtiter plate-based assay for the antifungal susceptibility testing of C. albicans biofilms. Because of its simplicity, compatibility with widely available 96-well microplate platform, high throughput, and automation potential, this assay represents an important tool towards the standardization of in vitro antifungal susceptibility testing of fungal biofilms. Key Words Candida albicans fungal infections biofilms resistance sessile cells antifungal drugs susceptibility testing standardization microtiter plate...

Katherine S Barker and P David Rogers Summary

The near completion of sequencing the Candida albicans genome has made it possible to employ genomic technologies, such as microarray analysis, to aid in identifying key genes involved in such clinical problems as the acquisition of high-level resistance to azole antifun-gal agents. Here, we outline in detail the methodologies utilized in our laboratory to culture clinical isolates of C. albicans, isolate ribonucleic acid from such cultures, synthesize labeled complimentary deoxyribonucleic acid probes from the ribonucleic acid samples, hybridize the probes to microarray chips, analyze the data from such hybridizations, and validate results using reverse transcriptase-polymerase chain reactions. Microarray analysis gives researchers the ability to identify genes involved in processes such as acquisition of azole resistance and to use the data in a way that may lead to clinical approaches to inactivate these genes and improve patient outcomes. Key Words Candida albicans DNA microarray...

Construction of the Disruption Cassette

Fig. 1. (opposite page) Construction of homozygous Candida albicans mutants by targeted gene disruption using the MPAR-flipping strategy. The structure of the MPAR flipper cassette is shown on top. The C. albicans-adaptedFLP gene (caFLP, light grey arrow) is placed under the control of the inducible SAP2 promoter (SAP2p, indicated by the angled arrow) and fused to the transcription termination sequence of the ACT1 gene (ACT1t, indicated by the black circle). The MPAR marker is shown as a dark grey arrow, and the FLP recombination target sites by the short black arrows. The unique flanking restriction sites are A, ApaI N, NotI ScI, SacI ScII, SacII and Xh, XhoI. In the example shown, upstream and downstream sequences of the target gene (white boxes, labeled 5' and 3') are cloned as ApaI-XhoI and SacII-SacI fragments, respectively, on both sides of the MPAR flipper cassette to obtain the disruption construct. After the first round of transformation of the wild-type parental strain,...

Antifungal Susceptibility Testing Methods

Broth dilution methods for antifungals can be performed by macrodilution or micordilution methods (2). The macrodilution method is prepared in test tubes in 1-mL volumes. This method has been established as the basis for comparing all other methods of susceptibility testing for yeast. The macrodilution method has largely been replaced by the microdilution method that is performed in a 96-well microdilution plate in volumes of 200 L per well. Both methods use a starting inoculum on 0.5-2.5 x 103 colony-forming units (CFU) mL for Candida spp. and 1 x 104 CFU mL for Candida neoformans. The plates are incubated at 35 C for 48 or 72 h for Candida and C. neoformans, respec tively. The minimum inhibitory concentration (MIC) end point differs among the antifungal agents currently approved. The end point for amphotericin B is defined as the lowest concentration resulting in no visible growth, whereas the end point for the azole antifungals is when either 80 or 50 reduction in fungal growth...

Antifungal Activity and Cytokine Expression Assays Maria Simitsopoulou and Emmanuel Roilides

Candida albicans and non-albicans Candida spp. can cause serious infections in hospitalized and immunocompromised patients. A large number of antifungal agents and immunomodulators have been developed and may interact with both polymorphonuclear and mononuclear phagocytes against blastoconidia and pseudohyphae of Candida spp. Blastoconidia are predominantly destroyed by phagocytosis, whereas pseudohyphal killing is initiated after the attachment of phagocytes to the cell wall of the organism and subsequent extracellular release of oxidative and nonoxidative metabolites. An array of methods to evaluate phagocytosis of blastoconidia, oxidative burst, expression of cytokines and chemokines in response to Candida spp., as well as candidacidal activity are described in this chapter. Key Words Candida spp. phagocytes antifungal function phagocytosis cytokine expression.

Spot Identification Through Custom Database Searching

Proteins can be identified by searching in appropriate databases with pep-tide mass fragmentation data. Mass fingerprints for unknown proteins are generated using MALDI-TOF MS. PROWL software (formerly Proteometrics, Inc.) is used to search protein databases with mass spectrometry data. A custom database for PROWL has been constructed in our laboratory from a database of Candida albicans open reading frames (ORFs) DNA sequence (http CandidaDB ), and is used to match unknown C. albicans proteins to the specific ORFs in the organism. A probability score for the match is attained in PROWL, with an accompanying Z score that represents a goodness of fit of the probability score for the search result. A Z score of 1.65 ranks the search result in the 95th percentile of nonrandom matches of the mass dataset to the specific ORF. 2. Marichal, P., Vanden Bossche, H., Odds, F. C., et al. (1997) Molecular biological characterization of an azole-resistant Candida glabrata...

Assessment of Cytokine and Chemokine Production by MNCs Using RTPCR

Phagocytosis Notes Flow Chart

Immunomodulators expressed in phagocytes in response to Candida infection can be detected and quantified either at the ribonucleic acid (RNA) level by RT-PCR or at the protein level by the quantitative sandwich enzyme immunosorbent assay (Fig. 2). The method of RT-PCR described in Subheading 3.4.2. combines both complimentary deoxyribonucleic acid (cDNA) synthesis and PCR in a single tube using gene-specific primers and the polymerase mixture Superscript II HRT and Platinum Taq polymerase. PCR products are quantitated including a second set of internal control primers, which amplify a housekeeping gene in the RT-PCR (7-9). The amount of immunomodulatory mRNAs are expressed as a ratio between the sample mRNA and the internal control mRNA (10). Fig. 2. Flow chart for detection of cytokines chemokines expressed in phagocytes in response to Candida infection. RNA, ribonucleic acid RT-PCR, reverse transcriptase-polymerase chain reaction ELISA, enzyme-linked immunosorbent assay. Fig. 2....

Antifungal Susceptibility Testing

Antimicrobial susceptibility testing methods for fungi recently have been standardized by the Clinical and Laboratory Standards Institutes (CLSI) (formerly known as the National Committee for Clinical Laboratory Standards 1,2 ). The CLSI first published methods for antifungal susceptibility testing of Candida spp. and Cryptococcus neoformans in 1997, whereas the methods for filamentous fungi were approved in 2002. A macrodilution method for susceptibility testing was approved first, quickly followed by a microdilution method that is simpler and equally effective. It is important to note that only nonproprietary methods are standardized by the CLSI. Thus, some methods including colorimetric or E-test methods, although shown in studies to compare with the microdilution methods will not be standardized by the CLSI. Although in some instances proprietary tests may be more costly, they are often simpler and more easily implemented in laboratories with little experience working with fungi....

Assessment of Fungal Cell Damage

MTT is reduced to a blue-colored formazan deriva 2. Incubate the plate at 37 C for 4 h (C. albicans) or appropriate times depending on Candida spp. to allow germination of blastoconidia into hyphae (see Notes 3 and 4). 2. Add 200 L of blastoconidial suspension per well in a 96-well flat-bottomed plate and incubate at 37 C for 4 h (C. albicans) or appropriate times depending on the Candida spp. to allow germination of blastoconidia into hyphae (see Notes 3 and 4). 1. Incubate 108 Candida blastoconidia in 50 pooled HS at 37 C for 30 min in a 15-mL glass tube (2-mL final volume) for opsonization. 5. Add 106 opsonized blastoconidia milliliter in CM to each cover slip and incubate at 37 C for 15, 30, or 60 min depending on the Candida spp. and the goal of the study. 3.3.7. Candidacidal Growth Inhibition Of Blastoconidia by PMNs or MNCs 8. Count the colonies and calculate the candidacidal activity using the formula

Animal Models

Of the drug-development process to be able to combine susceptibility results with a clinical end point, such as the sterilization of a target tissue. These types of studies allow for the characterization of the pharmacodynamic properties of the antifungals under evaluation and may aid in the selection of dosage regimens to improve activity and decrease toxicity. Although Candida and Aspergillus animal models exist and have been used to evaluate the pharmacodynamic properties, including fungicidal activity of available and investigational drugs, appropriate models for other fungal pathogens have yet to be developed. Once useful animal models have been established, alternative and comparable in vitro models may be implemented to decrease the cost of evaluating the pharmaocodynamic properties of candidate antifungal agents.

In Vitro Methods

A proposed method for time-kill testing of Candida and nonmucoid strains of Cryptococcus has been published (28,29). This method, similar to those for bacteria and standard susceptibility tests, takes into consideration factors such as starting inoculum, medium, volume transferred, antifungal carryover, and agitation of the culture to ensure optimal growth. MFC determinations for filamentous fungi are also hindered by lack of standardization, although progress is being made in this are as well. Most of the studies in this area are with Aspergillus spp. and are based on microdilution methods. In this case the recommended starting inoculum for susceptibility testing of Aspergillus spp. is 1-5 x 104 CFU mL. Although it is higher than for Candida, reaching the 3 log unit decrease in CFU mL is still troublesome. Most studies are able to determine at least a > 99 reduction in colony forming units. A recent report demonstrates very good reproducibility among three laboratories employing...

RFLP With a Probe

Grow a 2-mL culture of Candida spp. in YPD broth to stationary phase (10s cells mL). Harvest the cells by centrifugation at 15,000g in a Microfuge for 3 min and wash the pellet one time with 1 mL of sterile water (see Note 2). 1. Digest 3 g of the Candida genomic DNA with EcoRI or another appropriate restriction enzyme in a 30- L final volume following the manufacturers instructions. Use a threefold excess of enzyme and allow the reactions to take place for at least 4 h. Add 3 L of DNA loading dye to each reaction. where E is the number of bands in patterns A and B, which are the same size, a is the number of bands in pattern A with no correlate in pattern B, and b is the number of bands in pattern B with no correlates in pattern A. Again, this value will vary according to the complexity of the patterns that are compared. In the case of Candida albicans fingerprinted with the moderately repetitive probe Ca3, the average SAB for unrelated isolates is 0.69 0.11 (3). This average will...

Data Analysis

This is a representative microarray from a competitive hybridization of labeled probes from a matched pair of susceptible and resistant Candida albicans isolates. Each dot is C. albicans DNA spotted onto the glass slide and hybridized with the mixture of both labeled probes. Fig. 1. This is a representative microarray from a competitive hybridization of labeled probes from a matched pair of susceptible and resistant Candida albicans isolates. Each dot is C. albicans DNA spotted onto the glass slide and hybridized with the mixture of both labeled probes. formed using the results of BLASTn searches from the Stanford University (Palo Alto, Calif.) Candida sequencing database (http group candida), and the CandidaDB database

Biofilm Formation

Seeding the plates and growth of Candida biofilms. 3.1.1. Storage and Growth of Candida Isolates Candida isolates are typically stored either as glycerol stocks or on Sabouraud dextrose slopes (BBL, Cockeysville, MD) at -70 C. Some laboratories keep their yeast collections as suspensions in water at room temperature. For propagation of Candida organisms, a loopful of cells from the stocks (or a fresh culture from a clinical sample) is streaked onto YPD agar, which is incubated overnight at 37 C. Flasks containing YPD liquid medium (typically 20 mL of medium in a 150-mL flask) are then inoculated with a loopful of cells from the YPD agar plates containing freshly grown isolates, and incubated overnight in an orbital shaker (150-180 rpm) at 30 C. Typically, all C. albicans isolates grow in the budding-yeast phase under these conditions. 3.1.2. Standardizing the Candida Inoculum

David Andes

Animal models have been helpful in assessing a drug's potential application to treatment of humans. These controlled experiments allow description of the impact of a wide range of important treatment variables, including drug dose or concentration, dosing interval, pathogen, and host immune state. Animal models of mycoses are designed to address particular therapeutic questions. Some models are designed to screen multiple compounds in a rapid manner. Other models are selected to more closely mimic clinical infections. The following chapter will be limited to the description of a murine model of disseminated candidiasis in which in vitro results, pharmacokinetic properties, and a microbiological in vivo end point is used in the assessment of a wide variety of antifungal compounds. Key Words Candida antifungals animal model pharmacokinetics pharmacodynamics drug development in vitro susceptibility drug resistance.


Tion) is usually needed to characterize the mechanism of potential drug candidates. Several methods are available for probing fungal drug targets (23-27) however screening crude plant extracts in isolated enzyme assays is generally not advisable because of false positives owing to the presence of tannins and other nonspecific inhibitors (see Note 1 Table 1, Fig. 1 28-30 ). Subcellular enzymatic assays are usually therefore reserved for pure compounds as adjuncts to whole cell assays. It should be mentioned that it is possible, with some targets, to develop cellular assays that are more mechanistically specific. For example, yeast cells may be engineered with reporter genes linked to a specific promoter relevant for particular mechanistic pathways in fungi and mammals (31,32). Examples of cellular, yet mechanism-based assays, include sterol synthesis inhibition (33), assessment of estrogenic activity (34), and other techniques presented in this chapter (see Subheadings 3.1.2. and...


The Candida inoculum (prepared using methods in Subheading 3.1.3. to afford 1 x 106 CFU mL) in SD broth is swabbed onto a 50-mL SD agar plate and allowed to dry for 15-30 min. Nonpathogenic fungi may be sprayed directly onto a TLC plate using a device such as a chromatographic sprayer provided that the organism will grow adequately on the TLC medium (silica gel is compatible). However, Candida, Cryptococcus, etc. should be applied using an autoclavable roller device (draped with sterile filter or chromatography paper) under a biological safety cabinet. Visualization of growth with tetrazolium salts (62) may be necessary depending upon the inherent color of the organism. A two-dimensional version of direct TLC bioautography allows improved resolution of the components of the extract (63). 2. The Candida inoculum (prepared using methods in Subheading 3.1.3. to afford 1 x 106 CFU mL) is rolled directly onto the TLC plate.

Acquired immunodeficiency syndrome

(AIDS) A disease of humans caused by Human immunodeficiency viruses (HIV) 1 and 2. Globally, more than 36 million people were infected by the year 2000. The incubation time from infection to development of AIDS appears to range from 6 to 13 years (median 10 years). AIDS is primarily a disease of the immune system so the infection usually results in a wide range of adverse immunological and clinical conditions. The extent of the disease is generally measured by the CD4+ lymphocyte count, and as the count declines to below 200 per microliter there is serious risk of AIDS-related complex (ARC), a syndrome involving opportunistic infections, such as recurrent bacterial infections, candidiasis, pulmonary tuberculosis, Pneumocystis carinii pneumonia, EBV-associated lymphoma, and Kaposi's sarcoma. The opportunistic infections (i.e. those caused by microorganisms that seldom cause disease in persons with normal defense mechanisms) and cancers resulting from immune deficiency are

Interpretation of Significance

Several common blood isolates are almost always significant Staphylococcus aureus, Escherichia coli, and other members of the family Enterobacteriaceae, Pseudomonas aeruginosa, and Candida albicans. In contrast, common skin organisms, such as coagulase-negative staphylococci (CoNS), Coryneform bacilli, alpha-hemolytic streptococci, and Propionibacterium acne, are frequent contaminants. However, with many patients carrying an intravascular device that is prone to colonization and infection, each positive culture entails clinical correlation with other findings and sound judgment to make final assessment (Mirrett et al., 2001 Weinstein, 2003).

Humans Live with Many Pathogens

Many microbes and viruses are found in and on our bodies (see Box 1-1). Some are beneficial others are harmful. Some pathogens only occasionally cause infectious symptoms. For example, Mycobacterium tuberculosis enters a dormant state in most persons it infects, with a minority of infected persons exhibiting symptoms. However, immune deficiency enables M. tuberculosis to exit dormancy and cause disease. Other serious diseases arise from microbes, such as the yeast Candida albicans, that ordinarily live harmlessly in or on humans. This organism causes vaginitis with healthy women and more serious disease with immune-compromised patients.

Aspects of Virulence Quorum Sensing

There is evidence for quorum-sensing systems in many other pathogens, including Escherichia coli, Enterococcus faecalis, Helicobacter pylori, Candida albicans, Vibrio spp., and Salmonella typhimurium (Donabedian 2003). Some utilize similar systems others actively metabolize signaling molecules from other species in order to disrupt the quorum-sensing process belonging to potential competitors. Inappropriate or insufficient antimicrobial chemotherapy, by removing susceptible commensals, encourages the growth of a pathogen and thereby accelerates the quorum-sensing process, turning a relatively benign visitor into a virulent invader. The system does, however, offer an additional target for potential therapy in the future, in that natural and artificial peptide inhibitors of the quorum sensing response have already been evaluated in vitro (Gorske and Blackwell 2006). Biostable peptide blockers might not eradicate the targeted pathogen but would allow more time for conventional...

Goitrin toxic to thyroid

We have examined antiyeast saponins, and disclosed that a saponin fraction from stems of Mohave yucca which is mainly composed of spirostanol monodesmosides, exhibited potent antiyeast activity against brewing yeast (Saccharomyces cerevisiae), food-detriorating yeasts (Candida famata, Hansenula anomala, Cryptpcoccus sp., and Pichia carsonii) and film-forming yeasts (damaging of soy sauce) (Pichia nakazawae, Debaryomyces hansenii and Zygosaccharomyces rouxii) (Table 1). This fraction was also exhibited growth inhibition of some dematophytic yeasts and fungi.

Pathogens Are a Diverse Group of Life Forms

Until they land on a suitable nutrient surface. There, they germinate, forming filamentous hyphae. The opportunistic pathogenic yeast Candida albicans also generates hyphae upon infection. Protozoa are a third type of single-celled organism. Parasitic protozoa often have complex life cycles in which some forms grow in insect vectors, whereas quite different forms live in our bodies. Helminths are multicellular worms that invade our bodies pinworm and hookworm are examples. Viruses lack the molecular machinery for independent life, but when they penetrate our cells, they can force the cells to make viral components. Those components assemble to form progeny virus particles that are then released to infect other host cells. A common feature of these diverse life forms is their ability to multiply inside our bodies and form large populations.

Submandibular and Sublingual Spaces

A variety of microorganisms has been isolated from cases of Ludwig's angina. In recent years, anaerobic bacteria have predominated, including Fusobacterium spp., AGNB, and Peptostreptococcus spp. Often, one or more of the following also have been found staphylococci, streptococci, pneumococci, E. coli, Vincent's spirochetes, Haemophilus influenzae, and Candida albicans (4). Management includes high doses of parenteral antibiotics, airway monitoring, early intubation or tracheostomy, soft tissue decompression, and surgical drainage (55).

Family Medical History

'In your family - that is, your parents, brothers and sisters - are there any health problems that seem to run through the family ' You may prompt with suggestion such as diabetes, hypertension, and skin problems. This gives you information about predisposition, especially with diabetes and skin problems, and helps with differential diagnosis and may be a contributing factor in the reason for the visit, as for example with impotence or recurrent vaginal candidiasis.

Box 45 Immigrant Self Medication

Examples of self-medication are not limited to developing countries or immigrants. One of the most striking situations involves yeast vaginitis. Over-the-counter antifungal agents are widely available in many countries for self-treatment. Millions of women self-treat each year with these products, and if used properly, the agents are safe and effective. However, the possibility of poor compliance and consequent development of resistance looms large. The consequences may not be seen until many years later when the patient experiences immunocompromise and a life-threatening yeast infection. Persistent or recurrent infections call for consultation with a physician.

Non QuorumSensing Inhibitors

Additional antibiofilm molecules have been discovered that appear to affect bacterial mechanisms other than quorum sensing. Another molecule that interferes with S. aureus biofilm formation is farnesol, produced by Candida albicans (Jabra-Rizk et al. 2006). Farnesol compromised membrane integrity of Staphylococcus aureus biofilm bacteria and acted synergistically in reducing the minimum inhibitory concentration of gentamicin for both methicillin-sensitive and methicillin-resistant S. aureus. In a separate study, Ren et al. screened thousands of natural plant extracts and discovered that ursolic acid disrupts biofilms formed by E. coli, P. aeruginosa, and V. harvey (Ren et al. 2005). It was demonstrated that quorum sensing was not involved in this effect. While the exact mechanism of inhibition remained elusive, microarray profiling implicated motility, heat shock, cysteine synthesis, and sulfur

Resistance Arises from Several Molecular Mechanisms

Many microbes also contain proteins that pump out noxious substances, including antibiotics. The bacterium Pseudomonas aeruginosa is particularly well protected by efflux pumps (see Box 5-2), as are some species of the yeast Candida. Increased pumping and the associated loss of antibiotic susceptibility can arise through mutations that raise the synthesis of pump components. Some pumps remove drugs of several types (multidrug pumps). With these pumps a single mutation reduces susceptibility to several classes of agent simultaneously. Such pumps are a major reason why we worry about excessive use of disinfectants and antiseptics. These agents permit efflux mutants to selectively amplify and lower susceptibility to several antibiotics at once.

Antifungal Drug Resistance in Developing Countries

Abstract Opportunistic fungal infections are a major cause of morbidity and mortality in immunosuppressed patients and in HIV-positive individuals, infections due to Candida, Cryptococcus, and Pneumocystis are AIDS-defining illnesses. The widespread use of antifungal drugs, particularly triazole drugs, has led to the emergence of primary resistance, which largely reflects infection with inherently less susceptible strains. Secondary resistance in normally susceptible strains also occurs and involves a variety of mechanisms including target site modification and drug efflux transporters. Resistance is a clinical management issue, but it has remained relatively constant in most developed countries. In developing countries, resistance is minimal due to limited antifungal therapy. However, as access to these drugs increases, it is particularly important to evaluate trends that reflect evolving resistance issues observed elsewhere, especially among individuals with HIV AIDS.

Mechanisms of Resistance

The development of azole resistance in C. albicans is most problematic in patients who receive extended or repeated courses of azole drugs for therapy or prevention of oral candidiasis (Marr et al. 2001 Brion et al. 2007). The molecular mechanisms responsible for triazole resistance in C. albicans are common to other Candida spp., as well as to less related fungi (Vanden Bossche et al. 1998 Perea et al. 2001 Sanglard 2002 Sanglard and Odds 2002 White et al. 2002). Three major mechanisms have been elucidated in recent years. First, mutations in the drug target, cytochrome P450 14a-demethylase, encoded by Erg11 (yeasts) and Cyp51A (molds), alter the apparent drug-binding domain. Second, overexpression of drug efflux transporters reduces the steady-state intracellular level of drug (Fig. 9.1). As in other eukaryotic systems, the two principal families of efflux pumps are the ATP-binding cassette (ABC) (e.g., CDR1 and CDR2) and the major facilitator superfamily (MFS) (e.g., MDR1) (Perea...

Antifungal Resistance

The widespread use of antifungal agents in the past 15 years has led to the development of antifungal resistance. Like resistance to other antimicrobial agents, the development of antifungal resistance is complex and relies on multiple host and microbial risk factors (White et al. 2002). Antifungal resistance is a clinical management challenge for patients with serious mycoses. It typically involves either primary resistance, observed as a shift toward colonization with inherently less susceptible organisms, or secondary resistance in susceptible strains involving the emergence of cell-specific resistance mechanisms (target site mutations, drug pumps, etc.). Primary resistance comprises the majority of antifungal resistance, while secondary resistance occurs less frequently, but it is observed in patients with recurrent episodes of fungal infections requiring therapy, such as patients with HIV AIDS. As Candida spp. represent the most abundant source of fungal mycoses, resistance to...

Genital Ulcer Diseases

Herpes simplex virus typically presents as multiple painful vesicles or pustules, which break down to form erosive ulcers. These are generally painful and may coalesce to form larger areas of painful ulceration. True primary episodes are generally more severe than subsequent episodes, and are often associated with systemic symptoms. Many people, however, are unaware they are infected, as they do not experience symptoms. Asymptomatic shedding of Herpes simplex virus has been shown to occur and is probably an important means of trans-mission.An understanding of asymptomatic shedding can facilitate acceptance of what may become a chronic recurring condition. Differential diagnoses include primary syphilis, candidiasis, contact dermatitis and fixed drug reaction.

Epidemiology Of Invasive Fungal Infections

Expressed concerns about a rising incidence of invasive Candida infection can be traced back at least to the 1950s (Keye and Magee, 1956). There is little doubt, however, that the greatest rise in invasive infections caused by Candida spp. and many other types of fungi began in the early 1980s, in parallel with rapidly increasing medical and surgical use of immunosuppressive procedures. The AIDS epidemic also began at this same time and AIDS became recognized as a factor predisposing not only to superficial fungal infections, but also commonly to potentially fatal deep-tissue mycoses such as cryptococcal meningitis and Pneumocystis jiroveci pneumonia worldwide, and disseminated histoplasmosis and Penicillium marneffei infection in geographical areas where these mycoses are endemic. By 1990, the major emphasis of clinical mycology had switched from infections of the skin and mucous membranes to the study of disseminated, invasive, and all too commonly lethal fungal diseases. While...

Antifungal resistance cannot be transmitted by extrachromosomal DNA

Current experimental studies with C. albicans show that, contrary to longheld opinions, the fungus probably can undergo mating, but does so naturally at a remarkably low frequency (Soll et al., 2003). The same seems likely to apply to A. fumigatus (Poggeler, 2002). This inability to transmit antifungal resistance implies that development of clinically relevant resistance, at least to amphotericin B and triazoles where experience with their usage now extends to 20-30 years, is likely to be encountered almost exclusively among patients undergoing active treatment with these agents. How else can it be explained that the fluconazole resistance that developed so readily with oropharyngeal Candida infections in HIV-positive patients during the 1990s is now so much reduced in the most recent surveys (Barchiesi et al., 2002 Martins et al., 1998 Tacconelli et al., 2002) The low prevalence or absence of resistance among patients who have received no prior azole treatment is demonstrated clearly...

Complications Infection

Fungal infections can also complicate the course of AD. Trichophyton rubra and M. furfur or orbiculare are the most commonly implicated organisms. Candida albicans have also been implicated in some reports, but strong evidence for those yeasts being a source of infection does not exist at present. Infection with M. furfur is typically seen in the adolescent or adult patient with AD in whom a typical head and neck distribution of lesions is noted. Topical and systemic antifungal agents may be necessary to control infection.

Antifungal resistance conclusion

The most considered response that can be given to questions about the danger of emergence of antifungal-resistant fungi is that the phenomenon definitely occurs and that it has been seen to occur rapidly in oral Candida isolates in HIV-infected patients. However, in other clinical settings, the emergence of resistant fungi seems not to be an inevitable corollary of antifungal usage, and recorded changes in incidence and or prevalence of causative fungal species have been associated with alterations in the type of patient at risk of mycosis and the methods of their management (Husain et al., 2003 Kovacicova et al., 2001 Krcmery and Barnes, 2002 Nucci and Colombo, 2002 Singh et al., 2002 Torres et al., 2003), and by no means exclusively with alterations in antifungal treatments. Prudence to avoid unnecessary use of antifungal agents is reasonable anxiety about the large-scale emergence of resistant strains is not.

Antifungal agents available for prophylaxis and treatment of invasive mycoses

Candida spp., Ciyptococcus neoformans Candida spp., Ciyptococcus neoformans, some filamentous fungi but not Aspergillus or Fusarium spp. Most Candida and Aspergillus spp., some other filamentous fungi not Cryptococcus neoformans Most Candida sad Aspergillus spp., some other filamentous fungi not Cryptococcus neoformans Most Candida sad Aspergillus spp., some other filamentous fungi not Cryptococcus neoformans Flucytosine inhibits growth of fungi that can actively import the compound and convert it to 5-fluorouracil, which restricts its use principally to Candida and Cryptococcus infections. The prevalence of yeast isolates resistant to flucytosine was probably overstated in the past, when susceptibility testing was not standardized (Sanglard and Odds, 2002). The current use of flucytosine is mainly as adjunct therapy in combination with other antifungal agents. Fluconazole is well established as a safe and effective drug that has now been used for many years for the prophylaxis and...

New Agents Under Development

Azoles - The publication of an excellent review of current and emerging azole antifungal agents in January 1999 (2) serves as a timely summary of progress up to early 1998, and the material herein covers important advances since then. The most advanced clinical candidates are conveniently compared in a recent edition of Current Opinion in Anti-Infective Investigational Drugs (6). Voriconazole (1), previously known as UK-109,496 (Pfizer), is in Phase III clinical trials. Unlike fluconazole, this derivative has potent activity against a wide variety of fungi, including all the clinically important pathogens. Several publications substantiating this have appeared with regard to newer or more rare pathogens (7-10), and comparison with other azoles (1114).' Voriconazole is clearly more potent than itraconazole against Aspergillus spp. (12) and is comparable to posaconazole (previously known as SCH 56592) and BMS-207,147 in its activity against C. albicans however, it appears slightly more...

Recommending uses of antifungal agents the limitations

Fluconazole represents a reasonable antifungal choice where the infection under treatment is known or likely to be caused by C. albicans or other fluconazole-susceptible Candida sp. For infections caused by C. krusei or fluconazole-resistant strains of a Candida species, a systemic antifungal agent with activity against the infecting yeast is the preferred choice.

Rational therapy of diagnosed invasive mycosis

Published guidelines for the management of proven candidaemia and other forms of Candida infection (Rex et al., 2000) and of proven invasive aspergillosis of all types (Stevens et al., 2000) indicate that the well-established systemi-cally active antifungal agents all have a role to play in appropriate circumstances. For candidaemia, amphotericin B, liposomal amphotericin B, fluconazole, and caspofungin (but not yet voriconazole or itraconazole) are all licensed therapies in the United States. Choice of agent should be determined according to the circumstances of the patient. For invasive aspergillosis, voriconazole and amphotericin B are now regarded as the agents of first choice, with caspo-fungin and itraconazole available should alternative therapies be required. From published case reports and small series, voriconazole is developing a reputation as a useful agent for treatment of Scedosporium infections (Girmenia et al., 1998 Munoz et al., 2000 Walsh et al., 2002) and the drug...

Laboratory Diagnosis

Diseases mimicking oral herpes infections are other vesicular or ulcerating lesions herpangina caused by coxsackie virus, mononucleosis by Epstein-Barr virus, Stevens-Johnson syndrome, aphthous stomatitis, bacterial infections or lesions caused by drug intolerance, irradiation or immunosuppressive therapy. The diagnosis of genital HSV infection should include chancroid, syphilis, genital lesions, Behcet syndrome, erythema multiforme, local candidiasis and simple erosions. The symptoms of neonatal herpes can be caused by other infections such as rubella, cytomegalovirus and toxoplasma, and sometimes by erythroblastosis.

Clinicallyimportant Mechanisms Of Antifungal Resistance

Target modification is clearly a common contributor to clinical resistance to azole therapy, and has been implicated directly for C. neoformans (97), C. albicans (98100), C. glabrata (101), and by inference for other Candida spp. (102). Different mutations have been documented, making the rational design of new agents less prone to this resistance mechanism difficult. Target modification has also been implicated as a mode of resistance to 5-fluorocytosine (103), the sordarins (84) and the aureobasidins (104) efflux has also been implicated for the latter (105). Functional compensation for the effects of an antifungal agent has been documented in two areas. Fungal resistance to the polyenes in vitro is associated with a marked decrease in ergosterol content however, clinical resistance to Amphotericin B (AmB) in common fungal pathogens remains rare. For example, all 193 Candida spp. isolates obtained over an 8-year period (1990-1997) at a hospital in Madrid, Spain were susceptible to...

Classical Antifungal Agents

Polyene macrolides - Amphotericin B, a fungicidal agent which causes disruption of the fungal membrane, remains the most useful of the systemic antifungal drugs despite its nephrotoxicity. Most of the current work in this field is devoted to the reduction of the toxicity of Amphotericin B by altering its pharmacokinetic properties, using either liposomal preparations or colloidal suspensions of the drug complexed with other constituents of cell membranes (11-14). Efforts to reduce the toxicity of Amphotericin B by chemical modification have not been successful thus far (15). Resistance to the drug has not been considered to be a major problem (16), but a recent survey suggests that resistance among species of Candida and Torulopsis is becoming significant, and may be due to changes in the fungal population (17). Cell Wall Synthesis Inhibitors - Agents currently under development include a semisynthetic polypeptide, cilofungin (7), which inhibits the enzyme R-1,3-D-glucan synthase...

In Vivo and In Vitro Studies Investigating Fungal Biofilms

An increasing proportion of device-related infections, in particular device-related bloodstream and urinary tract infections, are caused by Candida spp. Mortality rates due to Candida infections on vascular catheters may be as high as 26 -38 (Kojic and Darouiche 2004). Because removal of the catheter is normally required to resolve these infections (Kojic and Darouiche 2004), special consideration should be given to the effect of antifungal agents on Candida biofilms. Schinabeck et al. (2004) used a rabbit model to examine the effect of either a liposomal amphotericin B or fluconazole lock on biofilms of Candida albicans on implanted catheters. The concentration and dwell times for these locks were 10 mg ml- 1 and 8 h in both cases for 7 days. Results showed that the liposomal amphotericin B lock completely eradicated the biofilms (2-3 log reduction, p < 0.001). By comparison, there was no significant difference between the fluconazole-treated and untreated catheters. Results from a...

Antifungal Resistance In C Glabrata

Among Candida species, C. glabrata has become recognized as an emerging infection not only because of its increasing incidence, but also because it is often associated with antifungal resistance. Unlike C. albicans, which is almost universally fluconazole-susceptible, C. glabrata is often fluconazole dose-dependent susceptible or resistant as defined by the Clinical Laboratory Standards Institute (CLSI) (14). The increase in fluconazole dose-dependent susceptible and resistant isolates has had important treatment implications.

Antifungal Resistance In Nonc Albicans Nonc Glabrata Isolates

Other Candida species responsible for candidemia are also associated with anti-fungal resistance. C. krusei is inherently fluconazole-resistant due to differences in its 14-a-demethylase (21). It has been reported to have decreased susceptibilities to amphotericin B and flucytosine as well (10,22). Despite its fluconazole resistance, unlike C. glabrata, it is often voriconazole susceptible. C. parapsilosis and C. guilliermondii have been reported to have increased MICs to echinocandins compared to other Candida species (23,24). A study by Mora-Duarte and colleagues reported that caspofungin was as effective as amphotericin B in the treatment of invasive candidiasis (25). However, five of the nine treatment failures in the caspofungin arm had C. parapsilosis bloodstream infections. Therefore, there is concern that patients with invasive C. parapsilosis infections who are treated with caspofungin may develop resistance and experience clinical failures.

Diagnosis And Susceptibility Testing

Once yeast is cultured from blood, various methods are used to identify the specific Candida species. Many laboratories utilize the biochemical tests of the API-20C strip. Other methods that can assist in identifying the particular species include the germ tube tests, the ChromAGAR test, and the C. albicans peptide nucleic acid fluorescence in situ hybridization (PNA FISH) test. The germ tube test is performed by placing a pure culture of an unknown yeast in serum. If the test is positive, germ tube formation will become apparent within a few hours. The ChromAGAR test differentiates between C. albicans, C. krusei, and C. tropicalis using distinctive colors associated with these species. The newest FDA approved

Treatment Of Candidemia

Any blood culture positive for Candida species should be treated as a serious infection and appropriate treatment should be initiated in a timely manner, including instituting antifungal therapy and removing all indwelling percutaneous catheters (23). Empiric treatment of candidemia has often involved initiating the antifungal agent, fluconazole, given its comparable efficacy and improved toler-ability in comparison to amphotericin B (51). Fluconazole is also available both in an oral as well as an intravenous form. Once blood culture results, including identification of Candida species and susceptibility testing, are finalized, antifungal therapy can be appropriately modified. If there is no evidence for end-organ involvement, the patient should receive at least 2 weeks of appropriate antifungal therapy.

Empiric Antifungal Therapy

Several antifungal agents, including amphotericin B, fluconazole, itraco-nazole, and voriconazole, have been utilized in this setting. Antifungal agents that have activity against not only yeast, but also molds, are preferable. Fluconazole does not have activity against Aspergillus species. Therefore, according to the Infectious Diseases Society of America guidelines, fluconazole should be considered in a select group of patients who have not received prior azole prophylaxis and are at low risk for infection with aspergillosis and azole-resistant Candida species (23).

Box 83 Determining Antibiotic Resistance for M tuberculosis by Genotyping

An increasing prevalence of resistance will drive efforts to quickly determine both the cause of disease and antibiotic susceptibility profiles for many common diseases. The detailed pathogen information derived from these tests will permit narrow-spectrum antibiotics to be used more often, which will reduce damage to commensal populations and reduce emergence of resistance among commensals. DNA tests will also enable antibiotics to be used in geographic regions where the prevalence of resistance is high Only patients with susceptible isolates would receive particular antibiotics. Correlation of molecular changes with resistance is an active area of research that is producing promising results. For example, triazole resistance in Aspergillus and echinocandin resistance in Candida are now known to be limited to specific regions of the Cyp51A and FKS genes, respectively. Thus, genotype diagnostics may become available for these forms of resistance.

Antifungal Prophylaxis

There is evidence supporting the use of antifungal prophylaxis in certain patient populations, including neutropenic patients and liver transplant recipients. Patients with prolonged neutropenia, including those undergoing intensive chemotherapy or bone marrow transplantation, are at higher risk for invasive candidiasis and mold infections. Antifungal therapy should be considered in high risk patients and, if given, should extend at least through the neutropenic period (23). In solid organ transplantation, liver transplant recipients, particularly those with identified risk factors (renal insufficiency, retransplantation, fungal colonization, choledochojejunostomy, and numerous intraoperative blood transfusions), are at higher risk for invasive candidiasis (23,54). A randomized, double-blinded, placebo-controlled study demonstrated that liver transplant recipients who received fluconazole prophylaxis have significantly decreased rates of superficial (4 vs. 28 p< .001) as well as...

Kadipiro virus Java7075 KDVJa7075 A

Kaisodi virus (KSOV) An unassigned virus in the family Bunyaviridae, related to Lanjan virus and Silverwater virus. A member of the Kaisodi serogroup. Isolated from ticks and a ground thrush in the Shimoga district of Mysore, India. Not reported to cause disease in humans.

Drug Resistance in Fungi

Data from a 8.5-year global antifungal surveillance revealed no consistent trend toward increasing resistance to fluconazole and voriconazole among the common species (C. albicans, C. glabrata, or C. tropicalis) (Pfaller et al. 2007). The resistance rates to both fluconazole and voriconazole among isolates of C. glabrata were the lowest rates to both agents seen in the Asia-Pacific region and the highest in North America (Pfaller et al. 2007). A national surveillance of candidosis from Japan found fluconazole resistance in 1.8 of C. albicans, 0.8 of C. parapsilosis, 5.2 of C. glabrata and 3.2 of C. tropicalis isolates, respectively (Takakura et al. 2004). Thirty-five percent of isolates less susceptible (> 16 mg L) to fluconazole showed resistance to voriconazole (> 2 mg L). In Taiwan, Hsueh et al. (2005c) reported that all isolates of Candida species other than C. glabrata and C. krusei were susceptible to fluconazole, 27 of C. glabrata isolates were not susceptible to...

Microbiology and Pathogenesis

The bacteriology of paronychia is polymicrobial aerobic and anaerobic in three-fourth of the cases. The predominant aerobic organisms are S. aureus, Streptococcus spp., Eikenella corrodens, GABHS, Klebsiella pneumoniae, Proteus spp., Pseudomonas aeruginosa, and Candida albicans. The predominant anaerobes are gram-negative bacilli of oral origin (Prevotella and Porphyromonas), Fusobacterium, and Peptostreptococcus spp. BLPB are present in about half of the patients (8).

Emerging Antigungal Agents 31 Amino acids

B-Amino acids, 2-aminocyclohexenecarboxylic acid and cis-2-amino-cyclohexanecarboxylic acid (cispentacin) were recently identified as novel antifun-gal agents targeting protein biosynthesis through inhibition of isoleucyl tRNA synthetase. SAR studies of these lead compounds led to the discovery of acid, (PLD-118, icofungipen, 19). Icofungipen showed high antifungal activity against C. albicans in in vitro studies (IC50 0.13 mg ml). A successful outcome from a phase IIb study (started in November 2003) would indicate potential for salvage therapy in the oral treatment of azole-resistant oropharyngeal and esophageal candidiasis. Icofungipen was administrated for 10 days starting 24 h after intravenous inoculation of C. albicans blastoconidia in rabbits. Treatment with icofungipen at 25mg kg day in two divided dosages gave significant tissue clearance of C. albicans 72 .

Performance Schedule

T To aid in the management of patients who have invasive candidiasis when the use of the azoles is questioned in infections caused by non-C. albicans Isolates of the same spedes may exhibit differences in minimum inhibitory concentrations (MICs) because of previous exposure to antifungal agents and or the acquisition of a genetic mechanism of resistance. For example, some isolates of Candida glabrata exhibit susceptibility to fluconazole, whereas others do not. It is recommended that the interpretative guidelines of the CLSI are followed whenever possible, but anecdotal experience is useful, too.

The Sorbarod Filter System

As a system, the Sorbarod filter model is able to satisfy these criteria and its use is described here. The initial work defining the Sorbarod biofilm system showed that the system maintained both Staphylococcus aureus and Pseudomonas aeruginosa at concentrations of 108-109 cfu mL for up to 100 h (15). The system has been used for the growth of other bacteria. Budhani and Struthers (16) showed that the Sorbarod system maintained Streptococcus pneumoniae for at least 96 h, where the number of recoverable cfu filter was in excess of 1012from 24 h after inoculation of the filters. The titer of the planktonic bacteria in effluent was in the order of 108 cfu mL. Muli and Struthers (17,18) achieved similar titers in their studies of the growth of Gardnerella vaginalis and Lactobacillus acidophilus. Similar titers were obtained with Enterococcus faecalis, whereas Candida albicans achieved biofilm concentrations of 109 cfu filter (19).

Direct Visual Examination Or Detection

A Gram stain of material obtained from upper respiratory secretions or lesions can do very little to help with diagnosis. Yeastlike cells can be identified, helpful in identifying thrush, and the characteristic pattern of fusifoims and spirochetes of Vincent's angina may be visualized. Plain Gram's crystal violet (allowed to remain on the slide for 1 minute before rinsing with tap water) and the Gram stain can be used to identify the agents of Vincent's angina. However, if only crystal violet is used, the smear should be very thin because everything will be intensely Gram positive, making a thick smear difficult to read.

Corn Kernel Proteins Enzymes

The most extensively studied proteinase inhibitor is trypsin inhibitor (TI). Among these inhibitors, some have been found to have activity against both trypsin and a-amylase.109 So far, TIs have been isolated from many plants, and antifungal activities have been reported for TI proteins from barley,110 corn,111 cabbage,112 and pearl millet.113 Thus far, three proteinase inhibitors have been isolated from corn. One is the 7-kDa TI protein,114 for which no antifungal activity has been reported. Another is the 22-kDa TI a-amylase inhibitor,115 which shares over 97 homology with a 22-kDa antifungal protein99 and zeamatin.116 The latter has demonstrated in vitro antifungal properties at low concentrations against Candida albicans, Neurospora crassa, Trichoderma reesei,116 and Aspergillus flavus117 by causing a rapid release of cytoplasmic material from these fungi.116 The third one is the 14-kDa TI protein, which shares no homology to the 22-kDa TI and belongs to the cereal proteinase...

Consume Only with Sound Indications Choose Optimal Antibiotics

In some cases, as with treatments for vaginal yeast infection, patients often self-diagnose and self-treat with over-the-counter products. To restrict the emergence of resistance, such products must be used according to the manufacturer's recommendations. When used responsibly, these topical treatments are expected to generate high local concentrations, making it unlikely for resistance to be significant.292

The functional relevance of the lectinlike activities of cytokines TNF as an illustrative example

Certain cytokines, in particular IL-1, IL-2 and TNF, have also been shown to directly interact with various pathogens through TV, W-diacetylchitobiose and Man5 6GlcNAc2-R lectin-like interactions 14-19 (Table 1). IL-1 binds virulent Escherichia coli, acting as a growth factor for the bacteria. Similarly, IL-2 binds Candida albicans and acts as a growth factor for virulent E. coli and Leishmamia mexicana. In addition, TNF was shown to interact through lectin-like interactions with Gram-negative bacteria or fungal J-1,3 glucans. TNF also exhibits a direct lytic activity on bloodstream forms of the protozoan parasites Trypanosoma brucei by binding V.W-diacetylchitobiose moieties on parasite surface components.

Infections Caused by Community Acquired Organisms Colonization Recurrence or Reinfection

The etiology of infectious diseases includes the potential infection not only from community sources but also from colonization of patients or health care workers. Because MRSA can colonize healthy individuals, screening of employee strains may indicate routes of transmission. One study using PFGE found that of seven staff members, three carried the same strain as found in patients (Macfarlane et al., 1999). Using CARE-2 probe-based DNA fingerprinting, Candida infection isolates from burn patients, results indicated that strains collected from different patients were different. It is noteworthy that patients with disseminated candidiasis had a similar but unique strain isolated from all body locations, suggesting infection from patient colonization (Gupta et al., 2004).

Surgical Site Infections

Approximately 4 of surgical patients develop surgical site infections 50 of these infections develop after the patient has left the hospital so this number may be an underestimate. Gram-positive organisms S. aureus, coagulase-negative staphylococci and enterococci) cause the majority of these infections, followed by gram-negative rods and Candida spp. The risk factors that predispose patients to acquire a nosocomial wound infection include (X) advanced age, (2) obesity, (3) infection at a remote site (that spreads through the bloodstream), (4) malnutrition, (5) diabetes, (6) extended preoperative hospital stay, (7) greater than 12 hours between preoperative shaving of site and surgery, (8) extended time of surgery, and (9) inappropriate timing of prophylactic antibiotics (given to prevent common infections before they seed the surgical site). Surgical wounds are classified as either clean, clean' contaminated, contaminated, or dirty depending on the number of contaminating organisms...

Bloodstream Infections

The overall rate of nosocomial bloodstream infections increased in all NNIS hospitals between 1980 and 1989 when the inddence of infections with coagulase-negative staphylococci, enterococd, S. aureus, and Candida spp, increased. The risk factors that predispose patients to acquire a nosocomial bloodstream infection indude (1) age 1 year of age or younger or 60 years of age and older, (2) malnutrition, (3) immunosuppressive chemotherapy, (4) loss of skin integrity (e.g., bum or decubiti bedsore ), (5) severe underlying illness, (6) indwelling device (e.g catheter), (7) intensive care unit stay, and (8) prolonged hospital stay.

Characteristics of staff authorised to take responsibility for the supply or administration of medicines under Patient

Clinical condition, inclusion and exclusion criteria for the treatment of genital candidiasis Clinical condition - The PGD is applicable to any patient (male or female) who has been diagnosed with genital candidiasis. Genital candidiasis is a fungal infection and is commonly caused by the species Candida albicans. In women the sites of infection may include the vulva, vagina and the urethra, and in men the most common sites include the glans, prepuce and urethra. Signs and symptoms are variable. Women may complain of a thick white vaginal discharge, pruritus, soreness, erythema, dysuria and dyspareunia. Fissuring may be apparent on the vulva. Men may present with a visible rash on the glans and they may also complain of pruritus and dysuria. Diagnosis is confirmed either clinically, microscopically (by wet and dry slide) or by culture media. Inclusion criteria - symptomatic patients who have had Candida diagnosed clinically and or microscopically, and symptomatic patients who have had...

Emergence Of Antibioticresistant Microorganisms

Aerobic gram-negative rods, such as Klebsiella, Ente-Tobacter, Serratia, and Pseudomonas. During the late 1970s and early 1980s, the use of more potent cephalosporins played a role in the emergence of antibiotic-resistant, coagulase-negative staphylococci, enterococd, methidllin-resistant S. aureus (MRSA), and Candida spp. The 1990s witnessed the emergence of beta-lactamase-producing, high-level gentamicin-resistant, and vancomydn-resistant enterococd (VRE). The twenty-first century has seen the emergence of vancomydn-resistant Staphylococcus aureus preliminary work at the CDC suggests that, at least in one case, the plasmid coding for resistance to vancomycin was transferred from vancomydn-resistant Enterococcus) Patients' normal flora changes quickly after hospitalization from viridans streptococd, saprophytic Neisseria spp., and diphtheroids to potentially resistant microorganisms found in the hospital environment. Then, their colonized nares, skin, gastrointestinal tract, or...

Subject Index Vol 13 No 4 2007

Antibacterial peptides 220 Antimicrobial peptides 210, 226 Antiviral activity 255 Ascorbic acid 243 Bacteriocins 194, 210 -, food application 194 -, production 194 -, purification 194 Candida albicans 243 Carnobacterium divergens V41 259 Cytomegalovirus 255 Dendrimeric peptides 220 Divercin RV41 259 - -, antimicrobial activity 259 Escherichia coli 200

Vitek Biochemical Cards

Overall accuracy of identification near 100 compared with API-20C AUX. Less than one fourth of the yeasts required supplemental biochemical or morphologic features to confirm their identification. Of all correctly identified yeasts, more than half were reported after 24 hours of incubation.36 The accuracy of identification of common and uncommon species was satisfactory. It is not necessary to identify germ tube-positive yeasts using this system. For laboratories already using this system, accurate and reliable identification of most commonly encountered yeasts can be accomplished. Another evaluation by Dooley, Beckius, and Jeffrey31 showed that the Vitek YBC system correcdy identified 93 of common yeasts however only 55 of uncommon yeasts were correcdy identified. The latter included isolates such as Candida guilliermondii, Candida krusei, Candida lambica, Candida lusitaniae, Candida rugosa, species of Cryptococcus (non-neofonnans), Geotrichum candi-dum, Rhodoiorula, Saccharomyces,...

Antifungal Drugs in Clinical

Resistance to polyene antifungals is rare and studies have shown amphotericin B resistance, whether primary or secondary, to almost always be associated with a decrease or complete absence of ergosterol in fungal membranes 14-17 . The incidence of primary or intrinsic resistance to amphotericin B is relatively limited but such resistance can be demonstrated by yeasts such as Malassezia furfur, Trichosporon cutaneum, Candida lusitaniae, and C. guilliermondii, as well as filamentous fungi such as Aspergillus terreus, Scedosporium apiospermum, and Fusarium species. Secondary, or acquired, resistance to amphotericin B during or following amphotericin B therapy appears to be uncommon as 'breakthrough' candidemias in patients treated with amphotericin B are rarely noted 18, 19 . A recent study in 4 US children's hospitals suggested that amphotericin B resistance among C. parapsilosis isolates causing can-didemia in children may represent an emerging threat 9 . implications for prophylaxis...

Pharmacological Management

Local side effects of hoarseness and candidiasis sometimes occurs with ICS therapy but can be reduced by using spacer devices and rinsing the mouth after inhalation. These techniques can also help decrease absorption of ICSs from the gastrointestinal tract. To minimize side effects, the goal is to use the lowest effective dose that controls the child's asthma. For children with severe asthma, higher doses of ICS may be needed to taper the oral steroid dose. The benefits of ICSs consistently outweigh their side effects, and longitudinal studies offer reassurance that at conventional doses, ICSs do not have significant long-term adverse effects.

Antimicrobial Activity

The inhibitory action of sorbate against yeasts was first documented in the 1950s in fermented vegetable products. The effectiveness of sorbates against yeasts has been documented by numerous studies (Emard and Vaughn, 1952 Ferguson and Powrie, 1957 Geminder, 1959 Pederson et al., 1961 Huang and Armstrong, 1970 El Halouat et al., 1998 Bracey et al., 1998 Piper et al., 1998). Yeasts inhibited by sorbates include species of the genera Brettanomyces, Candida, Cryptococccus, Debaryomyces, Endomycopsis, Hansenula, Kloeckera, Pichia, Rhodotorula, Saccharomyces, Sporobolomyces, Torulaspora, Torulopsis, and Zygosaccharomyces (Sofos, 1989). In addition to their effectiveness in fermented vegetables, sorbates inhibit yeasts in fruit juices, wines, cottage cheese, dried fruits, and meat and fish products. Use of sorbates for inhibition of yeasts is especially important in low-pH and or intermediate water activity (aw) products, such as carbonated beverages, salad dressings, syrups, tomato...

Specific Infections Vulvovaginitis

In both specific and nonspecific VV, changes occur in the normal vulvovaginal flora that may induce inflammation. The specific organisms that cause infection in the prepubertal female are often respiratory, enteric, or sexually transmitted pathogens. The respiratory pathogens include Group A streptococcus, Streptococcus pneumoniae, Neisseria meningitidis, S. aureus, and Haemophilus influenzae. Other rare pathogens are Shigella (8), Yersinia (9), and Candida (6). The three most common types of VV include nonspecific VV, or VV caused by candida, or trichomonas. Sexually acquired infections include Neisseria gonorrhoeae, G. vaginalis, Trichomonas vaginalis, Chlamydia trachomatis, herpes simplex virus, and Condyloma accuminata.

Methods Of Antibody Detection

Widal Test Slide Method

Complete systems for the use of latex or other particle agglutination tests are available commercially for the accurate and sensitive detection of antibody to cytomegalovirus, rubella virus, varicella-zoster virus, the heterophile antibody of infectious mononucleosis, teidioic acid antibodies of staphylococci, antistrepto-coccal antibodies, mycoplasma antibodies, and others. Latex tests for antibodies to Coccidioides, Sporothrix, Echinococcus, and Trichinella are available, although they are not widely used because of the uncommon occurrence of the corresponding infection or its limited geographic distribution. Use of tests for Candida antibodies has not yet shown results reliable enough for accurate diagnosis of disease.

Pathological Infective Skin Rashes That May Be Seen In Gum Clinics

FUNGAL INFECTIONS Candida infections Candida infections can cause marked skin irritation and oedema. Erythema is commonly present in women and fissuring may occur at the introitus. Though infection is less common in men, mild erythema and balanitis or balanoposthitis may occur, with fissuring of the prepuce.

Doripenem Antibiotic [2225

Eberconazole is a new member of the azole class of antifungal agents, and it is indicated for the topical treatment of cutaneous fungal infections, including tinea corporis (ringworm of the body), tinea cruris (ringworm of the groin) and tinea pedis (athlete's foot) infections. Its mode of action is similar to that of other azole antifungals, namely inhibition of fungal lanosterol 14a-demethylase. Eberconazole exhibits good in vitro activity against a wide range of Candida species, including Candida. tropicalis, dermatophytes and Malassezia spp. yeasts. It shows good activity against Candida. Parapsilosis (MIC90 0.125 mg mL), which is a relevant species in skin and nail disorders. In addition, eberconazole is effective against some of the highly triazole-resistant yeasts such as Candida. glabrata and Candida. krusei, as well as fluconazole-resistant Candida. albicans. However, eberconazole is less active than clotrimazole and ketoconazole against Candida. neoformans and a number of...

Topical Microbicides Under Development 51 Preclinical

Candida albicans Candida albicans, Candida tropicalis, Candida albicans, HIV-l trachomatis, Neisseria gonorrheae, Candida albicans, Streptococcus agalactiae, Escherichia coli, Pseudomonas aeruginosa HIV-1 Phase 3 Haemophilus ducreyi, HIV-1, Herpes simplex, human papillomavirus, Candida albicans HIV-1 Phase 1 trachomatis, Herpes simplex, Haemophilus ducreyi, Neisseria gonorrheae, Trichomonas vaginalis, Candida albicans, Garnerella vaginalis trachomatis, Neisseria gonorrheae, Trichomonas vaginalis, Candida albicans HIV-1 Phase 1 For more information on candidate microbicides and trials, consult the Alliance for Microbicide Development's Microbicide Research and Development Database (MRDD) at For more information on candidate microbicides and trials, consult the Alliance for Microbicide Development's Microbicide Research and Development Database (MRDD) at

Pathogenesis Routes of Infection

UTIs may also occur by the hematogenous, or blood-borne, route.9 Hematogenous spread usually occurs as a result of bacteremia. Any systemic infection can lead to seeding of the kidney, but certain organisms, such as Staphylococcus aureus or Salmonella spp., are particularly invasive, Although most infections involving the kidneys are acquired by the ascending route, yeast (usually Candida albicans), Mycobacterium tuberculosis, Salmonella spp., Leptospira spp., or Staphylococcus aureus in the urine often indicates pyelonephritis acquired via hematogenous spread, or the descending route. Hematogenous spread accounts for less than 5 of UTIs.

Persisters in Yeast Biofilms

The focus of yeast biofilm research has been on C. albicans, an important human pathogen that causes oral thrush, relapsing vaginosis, and is a leading cause of morbidity and mortality in immunocompromised individuals. The biofilm forms when single cells attach to a surface and grow into microcolonies, which then merge and produce a complex 3D structure that is held together by hyphae and an exopolymer matrix (Chandra et al. 2001). The biofilm contains a mixture of yeast, hyphae, and pseudohyphae. Similarly to bacteria, yeast biofilm exopolymer matrix restricts penetration of immune system components (Hoyle et al. 1990 von Eiff et al. 1999), but does not appreciably hinder diffusion of antifungal drugs (Baillie and Douglas 2000 Samaranayake et al. 2005). Genes encoding multidrug resistance (MDR) pumps MDR1, CDR1, and CDR2 are upregulated upon attachment of C. albicans cells to a surface, and this accounts for the resistance of young biofilms to azole antibiotics (Mukherjee et al....

Std Sex Colleges Girling

Sexually Transmitted Infections 80 244-6 BASHH (British Association for Sexual Health and HIV) (2001) National Guideline on the Management of Vulvovaginal Candidiasis. http guidelines 2002 candida BASHH (British Association for Sexual Health and HIV) (2002) National Guideline for the Management of Bacterial Vaginosis. http guidelines 2002 bv BASHH (British Association for Sexual Health and HIV) (2005) United Kingdom National Guideline for the Management of Pelvic Inflammatory Disease (author Jonathan Ross) Berger BJ, Kolton S, Zenilman JM, Cummins MC, Feldman J, McCormack WM (1995) Bacterial vaginosis in Lesbians a sexually transmitted disease. Clinical Infectious Diseases 21(6) 1402-5 Bevan CD, Johal BJ, Mumtaz G, Ridgway GL, Siddle NC (1995) Clinical, laparoscopic and microbiological findings in acute salpingitis report on a United Kingdom cohort. British Journal of Obstricians and Gynaecologists 102 407-14 DH (Department of...

Risk Factors For C Glabrata Bloodstream Infections

Despite the emergence of bloodstream infections due to C. glabrata, only a few studies have evaluated the risk factors for this infection. None of these studies performed susceptibility testing to differentiate between fluconazole-susceptible and fluconazole dose-dependent susceptible or resistant isolates. The possible association between fluconazole and the emergence C. glabrata has been mentioned in the literature. As previously mentioned, prior fluconazole use could result in resistance endogenously by upregulating drug efflux pumps, or exogenously by providing selective pressure, decreasing C. albicans colonization in the skin or gastrointestinal tract, and allowing colonization with more resistant Candida species. Studies of oncology patients seem to most strongly support this association. Abi-Said and colleagues performed a retrospective review of all cases of hemato-geneous candidiasis, defined as episodes of candidemia and acute disseminated candidiasis, which occurred at a...

Phagocytosis The Lesser Evil

In light of the ROS generated and the proteases that are active in the phago-some, phagocytosis would certainly seem to be a death sentence for many bacteria. Yet a number of bacteria manage to escape death by converting the phagosome from a death chamber into a refuge. These bacteria carry out covert operations that we are only beginning to understand that allow their survival within the phagosome (Allen 2003 Cosart and Samsonetti 2004 Rosen 2004). These include preventing fusion of the phagosome with endo-somes and lysosomes, thereby cutting off supplies of bactericidal proteases and microbicidal enzymes that reside in these compartments. Some bacteria opt to retreat out of the phagosome and set up camp in the cytosol rather than combat ROS or reroute trafficking of granules and lysosomes. Other bacteria can modulate neutrophil apoptotic responses (reviewed in DeLeo 2004). Apoptotic PMN do not respond to chemoattractants, phagocytose, or undergo a respiratory burst. Thus, by causing...

Unconventional Theories Of Allergy

Periodically over the past century, this clinical condition has also been ascribed to the effects of a specific microorganism, usually one that enjoys a normal symbiotic or commensal relationship with the human organism. Formerly called autointoxication, presumably from normal gastrointestinal microbial flora, this concept has reappeared as a presumptive chronic viral disease. In this case, according to one unproved theory, the persistence of a virus such as the Epstein-Barr virus or human herpesvirus 6 (HHV-6) was postulated to cause chronic activation of the immune system. There is no substantiated evidence or even a clear definition of what activation means in this context, and there is no proof currently that persistence of any virus can explain the pattern of symptomatology experienced by such patients. A variant of this theory is the so-called Candida hypersensitivity syndrome, attributed to the existence of Candida albicans on certain mucous membranes of many healthy...

Fungi Are Eukaryotes Having Cell Walls But Not Chloropasts

Yeasts are single-celled fungi that grow much like bacteria. Liquid cultures become cloudy when many yeast cells are present, and yeast form colonies on agar. Some yeast species reproduce by dividing (fission yeast), whereas others form buds that break off and grow into new cells. (A bud is a protrusion of the cell that gradually increases in size until it pinches off.) Bakers' yeast, commonly used to make bread, is one of the most thoroughly studied eukaryotic organisms. Its cousin, Candida albicans, kills immune-deficient persons. Yeasts and molds are everywhere in our environment. For most persons, they are not a problem because healthy immune systems remove fungal cells from our bodies. However, as our populations age and immunosuppression becomes increasingly common, fungal diseases also become increasingly common. Invasive fungal infections are now a major cause of death for cancer patients. In some types of patient, fungal infections account for nearly half the deaths. Newborns...

Collection And Transport Of Specimens

Cotton-, Dacron-, or calcium alginate-tipped swabs are suitable for collecting most upper respiratory tract microorganisms. If the swab remains moist, no further precautions need to be taken for specimens that are cultured within 4 hours of collection. After that period, some kind of transport medium to maintain viability and prevent overgrowth of contaminating organisms should be used. Swabs for detection of group A streptdr cocci (Streptococcus pyogenes) are the only exception. This organism is highly resistant to desiccation and remains viable on a dry swab for as long as 48 to 72 hou Throat swabs of this type can be placed in glassine paper envelopes for mailing or transport to a distant labora* tory. Throat swabs are also adequate for recovery of adenoviruses and herpesviruses, Corynebacterium diphthe-riae, Mycoplasma, Chlamydia, and Candida spp. Recovery ofj C. diphtheriae is enhanced by culturing both the throat and nasopharynx.

Specimens From Sterile Body Sites Fluids

Of the liver, called Fitz-Hugh-Curtis syndrome). Tuberculous peritonitis occurs infrequendy in the United States and is more likely to be found among persons recendy arrived from South America, Southeast Asia, or Africa. Fungal causes of peritonitis are not common, but Candida spp. may be recovered from immunosuppressed patients and padents receiving prolonged antibacterial therapy.

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