title: Clinically significant azole cross-resistance in Candida isolates from HIV-positive patients with oral candidosis.
abstract: OBJECTIVE
  To determine the proportion of fluconazole-resistant Candida albicans isolates that have clinically significant cross-resistance to itraconazole or ketoconazole, that is sufficient to result in failure of these agents at their standard doses (200 and 400 mg daily for 7 days, respectively).
  
  
  METHODS
  Seven hundred C. albicans isolates from HIV-positive patients with oral candidosis underwent susceptibility testing using a relative growth method, for which cut-off values corresponding to clinical drug failure have been established.
  
  
  RESULTS
  A total of 431 isolates were fully azole-susceptible and three main resistance patterns were detected: isolates resistant to fluconazole alone (n = 100); isolates resistant to fluconazole and ketoconazole but susceptible to itraconazole (n = 94); and isolates resistant to all three drugs (n = 50). No isolates were consistently resistant to ketoconazole without being fluconazole-resistant, and no itraconazole resistance was detected without ketoconazole resistance. Resistance to fluconazole alone was more common in specimens obtained soon after first clinical fluconazole failure, whereas specimens from patients with a longer history of fluconazole-unresponsive candidosis were more likely to be infected with cross-resistant isolates. Median days of prior azole exposure and cumulative fluconazole dose were significantly less for those with isolates resistant to fluconazole alone than for those with ketoconazole cross-resistant isolates, who had received less azole therapy and smaller cumulative fluconazole doses than those with isolates cross-resistant to all three drugs (although not statistically significant). After the diagnosis of fluconazole-unresponsive candidosis, increasing cumulative doses of itraconazole solution were associated with increasing likelihood of cross-resistance.
  
  
  CONCLUSIONS
  Clinically significant cross-resistance to other azoles may occur in fluconazole-resistant isolates of C. albicans, although initially most isolates are not cross-resistant and the detection of cross-resistant isolates is associated with a history of greater prior azole exposure. Patients who have been treated for fluconazole-resistant candidosis for longer and with greater cumulative doses of itraconazole solution tend to become infected with increasingly cross-resistant isolates of C. albicans.
authors.affiliation: Department of HIV/GU Medicine, St Stephen's Centre, Chelsea and Westminster Hospital, London, UK.
authors.forename: J D
authors.initials: JD
authors.lastname: Cartledge
authors.forename: J
authors.initials: J
authors.lastname: Midgley
authors.forename: B G
authors.initials: BG
authors.lastname: Gazzard
mesh_terms: D017088:AIDS-Related Opportunistic Infections / Q000382:microbiology*; D000935:Antifungal Agents / Q000494:pharmacology*; D002176:Candida albicans / Q000187:drug effects* / Q000302:isolation & purification; D002180:Candidiasis, Oral / Q000150:complications / Q000382:microbiology*; D004352:Drug Resistance, Microbial; D018432:Drug Resistance, Multiple; D015725:Fluconazole / Q000494:pharmacology*; D006801:Humans; D017964:Itraconazole / Q000494:pharmacology*; D007654:Ketoconazole / Q000494:pharmacology*
chemical_list: D000935:Antifungal Agents; D017964:Itraconazole; D015725:Fluconazole; D007654:Ketoconazole