Reduction of susceptibility to azoles and 5-fluorocytosine and growth acceleration in Candida albicans by glucose in urine

Abstract

ABSTRACTCandida species are causal pathogens for urinary tract infections, vulvovaginitis, and balanitis. Diabetes mellitus is a risk factor for Candida infection. To investigate the potential effects of glucosuria on Candida spp. (C. albicans, C. krusei, and C. glabrata), we investigated the influence of their growth and antifungal susceptibilities by glucose in urine.Candida spp. exhibited greater growth in urine with glucose (300 and 3,000 mg/dL) than in plain urine taken from healthy volunteers. After 24 h incubation, the viable cell number was more than 10-fold higher in the urine added 3,000 mg/dL glucose than in plain urine.In antifungal susceptibility, more than 80% of C. albicans clinical isolates increased minimum inhibitory concentrations of azoles (fluconazole, itraconazole, voriconazole, and miconazole) and 5-fluorocytosine with the addition of glucose exceeding their breakpoints. This phenomenon was not observed in clinical isolates of C. krusei and C. glabrata. We observed the growth in the urine to which 3,000 mg/dL glucose was added even in the presence of a 128-fold higher minimum inhibitory concentration of fluconazole. In most of the C. albicans clinical isolates, the mRNA expression of the azole resistance genes ERG11, CDR1, CDR2, and MDR1 increased in glucose-added urine compared with plain urine.In conclusion, the growth of C. albicans is accelerated and azoles and 5-fluorocytosine become ineffective as a result of a high concentration of glucose in urine. These observations provide valuable information about the clinical course and therapeutic effects of azoles against C. albicans infections in patients with diabetes mellitus and hyperglucosuria.IMPORTANCEDiabetes mellitus is a chronic metabolic disease characterized by hyperglycemia and glucosuria, with a high risk of Candida infection. The current study demonstrated the acceleration of Candida growth and ineffectiveness of azoles and 5-fluorocytosine against C. albicans in urine in the presence of glucose. These observations provide novel and valuable information about the clinical course and antifungal treatment of Candida spp. in urinary tract and genital infections of diabetes mellitus patients. For the treatment of urinary tract infections caused by Candida spp., the guidelines do not mention glucosuria. Thus, this study suggests the necessity to conduct clinical evaluations for glucosuria in patients with diabetes mellitus who have urinary tract and genital infections with Candida spp.