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Evaluation of Molecular Epidemiology, Clinical Characteristics, Antifungal Susceptibility Profiles, and Molecular Mechanisms of Antifungal Resistance of Iranian Candida parapsilosis Species Complex Blood Isolates

  • Arastehfar, Amir1
  • Daneshnia, Farnaz1
  • Najafzadeh, Mohammad Javad2
  • Hagen, Ferry1, 3, 4
  • Mahmoudi, Shahram5
  • Salehi, Mohammadreza6
  • Zarrinfar, Hossein7
  • Namvar, Zahra8
  • Zareshahrabadi, Zahra9
  • Khodavaisy, Sadegh10
  • Zomorodian, Kamiar9
  • Pan, Weihua11
  • Theelen, Bart1
  • Kostrzewa, Markus12
  • Boekhout, Teun1, 13
  • Lass-Flörl, Cornelia14
  • 1 Yeast Biodiversity Department, Westerdijk Fungal Biodiversity Institute, Utrecht , (Netherlands)
  • 2 Department of Parasitology and Mycology, School of Medicine, Mashhad University of Medical Sciences, Mashhad
  • 3 Department of Medical Microbiology, University Medical Center Utrecht, Utrecht , (Netherlands)
  • 4 Laboratory of Medical Mycology, Jining No. 1 People's Hospital, Jining , (China)
  • 5 Department of Medical Parasitology and Mycology, School of Medicine, Iran University of Medical Sciences, Tehran
  • 6 Department of Infectious Diseases and Tropical Medicine, Faculty of Medicine, Tehran University of Medical Sciences, Tehran
  • 7 Allergy Research Center, Mashhad University of Medical Sciences, Mashhad
  • 8 Department of Microbiology, School of Biological Sciences, Islamic Azad University, Tehran
  • 9 Basic Sciences in Infectious Diseases Research Center, Shiraz University of Medical Sciences, Shiraz
  • 10 Department of Medical Parasitology and Mycology, School of Public Health, Tehran University of Medical Sciences, Tehran
  • 11 Medical Mycology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai , (China)
  • 12 Bruker Daltonik GmbH, Bremen , (Germany)
  • 13 Institute of Biodiversity and Ecosystem Dynamics, University of Amsterdam, Amsterdam , (Netherlands)
  • 14 Division of Hygiene and Medical Microbiology, Medical University of Innsbruck, Innsbruck , (Austria)
Published Article
Frontiers in Cellular and Infection Microbiology
Frontiers Media SA
Publication Date
May 21, 2020
DOI: 10.3389/fcimb.2020.00206
PMID: 32509592
PMCID: PMC7253641
PubMed Central


Clonal expansion of fluconazole resistant (FLZ-R) Candida parapsilosis isolates is increasingly being identified in many countries, while there is no study exploring the antifungal susceptibility pattern, genetic diversity, and clinical information for Iranian C. parapsilosis blood isolates. Candida parapsilosis species complex blood isolates ( n = 98) were recovered from nine hospitals located in three major cities, identified by MALDI-TOF MS, and their genetic relatedness was examined by AFLP fingerprinting. Antifungal susceptibility testing followed CLSI-M27-A3 and ERG11, MRR1 and hotspots 1/2 (HS1/2) of FKS1 were sequenced to assess the azole and echinocandin resistance mechanisms, respectively. Ninety-four C. parapsilosis and four Candida orthopsilosis isolates were identified from 90 patients. Only 43 patients received systemic antifungal drugs with fluconazole as the main antifungal used. The overall mortality rate was 46.6% (42/90) and death mostly occurred for those receiving systemic antifungals (25/43) relative to those not treated (17/47). Although, antifungal-resistance was rare, one isolate was multidrug-resistant (FLZ = 16 μg/ml and micafungin = 8 μg/ml) and the infected patient showed therapeutic failure to FLZ prophylaxis. Mutations causing azole and echinocandin resistance were not found in the genes studied. AFLP revealed five genotypes (G) and G1 was the main one (59/94; 62.7%). Clinical outcome was significantly associated with city ( P = 0.02, α <0.05) and Mashhad was significantly associated with mortality ( P = 0.03, α <0.05). Overall, we found a low level of antifungal resistance for Iranian C. parapsilosis blood isolates, but the noted MDR strain can potentially become the source of future infections and challenge the antifungal therapy in antifungal-naïve patients. AFLP typing results warrants confirmation using other resolutive typing methods.

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