title: Changes in susceptibility to posaconazole in clinical isolates of Candida albicans.
abstract: OBJECTIVE
  To characterize the molecular mechanisms responsible for reduced susceptibility to azoles in Candida albicans clinical isolates.
  
  
  METHODS
  Seven sequential C. albicans isolates were cultured from an AIDS patient treated with posaconazole for refractory oropharyngeal candidiasis. Expression levels of the CDR1, CDR2 and MDR1 genes, encoding efflux pumps previously implicated in azole resistance, and ERG11, encoding the azole target site, were monitored using northern blot and real-time PCR. The ERG11 genes from all seven isolates were sequenced.
  
  
  RESULTS
  The seven closely related isolates exhibited significant decreases in susceptibility to fluconazole (MIC >or= 32 mg/L) and voriconazole (MIC >or= 2 mg/L) and progressive decreases in susceptibility to both posaconazole (isolates 1-4 MIC 0.25 mg/L, isolates 5-7 MIC 2 mg/L) and itraconazole (isolates 1-4 MIC 1 mg/L, isolates 5-7 MIC > 8 mg/L). None of the isolates exhibited any significant changes in the expression levels of ERG11 or the efflux pump genes. All seven isolates had multiple mutations in ERG11; isolates one through four each had five missense mutations; four of the resultant amino acid changes were previously associated with azole resistance. The fifth isolate had an additional novel mutation in one copy of ERG11, resulting in a Pro-230 to Leu substitution. This mutation was present in both ERG11 genes in the last two isolates. Select ERG11 genes were expressed in Saccharomyces cerevisiae, the ERG11 allele with all six mutations conferred the highest level of posaconazole resistance.
  
  
  CONCLUSIONS
  Multiple mutations in ERG11 are required to confer decreased susceptibility to posaconazole.
authors.affiliation: Schering-Plough Research Institute, 2015 Galloping Hill Road, 4700 Kenilworth, NJ 07033, USA.
authors.forename: Xin
authors.initials: X
authors.lastname: Li
authors.forename: Nathaniel
authors.initials: N
authors.lastname: Brown
authors.forename: Andrew S
authors.initials: AS
authors.lastname: Chau
authors.forename: José L
authors.initials: JL
authors.lastname: López-Ribot
authors.forename: Maria T
authors.initials: MT
authors.lastname: Ruesga
authors.forename: Guillermo
authors.initials: G
authors.lastname: Quindos
authors.forename: Cara A
authors.initials: CA
authors.lastname: Mendrick
authors.forename: Roberta S
authors.initials: RS
authors.lastname: Hare
authors.forename: David
authors.initials: D
authors.lastname: Loebenberg
authors.forename: Beth
authors.initials: B
authors.lastname: DiDomenico
authors.forename: Paul M
authors.initials: PM
authors.lastname: McNicholas
mesh_terms: D017088:AIDS-Related Opportunistic Infections / Q000188:drug therapy / Q000382:microbiology; D000935:Antifungal Agents / Q000627:therapeutic use*; D002176:Candida albicans / Q000187:drug effects* / Q000235:genetics / Q000302:isolation & purification; D002180:Candidiasis, Oral / Q000188:drug therapy* / Q000382:microbiology; D025141:Drug Resistance, Fungal / Q000235:genetics*; D005814:Genes, Viral / Q000235:genetics; D015658:HIV Infections / Q000382:microbiology; D006801:Humans; D008826:Microbial Sensitivity Tests; D009154:Mutation; D014230:Triazoles / Q000627:therapeutic use*
chemical_list: D000935:Antifungal Agents; D014230:Triazoles; C101425:posaconazole