Distribution and antifungal susceptibility pattern of Candida species from mainland China: A systematic analysis

Abstract

Antifungal resistance to Candida pathogens increases morbidity and mortality of immunosuppressive patients, an emerging crisis worldwide. Understanding the Candida prevalence and antifungal susceptibility pattern is necessary to control and treat candidiasis. We aimed to systematically analyse the susceptibility profiles of Candida species published in the last ten years (December 2011 to December 2021) from mainland China. The studies were collected from PubMed, Google Scholar, and Science Direct search engines. Out of 89 included studies, a total of 44,716 Candida isolates were collected, mainly comprising C. albicans (49.36%), C. tropicalis (21.89%), C. parapsilosis (13.92%), and C. glabrata (11.37%). The lowest susceptibility was detected for azole group; fluconazole susceptibilities against C. parapsilosis, C. albicans, C. glabrata, C. tropicalis, C. guilliermondii, C. pelliculosa, and C. auris were 93.25%, 91.6%, 79.4%, 77.95%, 76%, 50%, and 0% respectively. Amphotericin B and anidulafungin were the most susceptible drugs for all Candida species. Resistance to azole was mainly linked with mutations in ERG11, ERG3, ERG4, MRR1-2, MSH-2, and PDR-1 genes. Mutation in FKS-1 and FKS-2 in C. auris and C. glabrata causing resistance to echinocandins was stated in two studies. Gaps in the studies' characteristics were detected, such as 79.77%, 47.19 %, 26.97%, 7.86%, and 4.49% studies did not mention the mortality rates, age, gender, breakpoint reference guidelines, and fungal identification method, respectively. The current study demonstrates the overall antifungal susceptibility pattern of Candida species, gaps in surveillance studies and risk-reduction strategies that could be supportive in candidiasis therapy and for the researchers in their future studies.

Keywords: Candida; antifungal susceptibility pattern; candidiasis; china; systematic review.

Figure 1.

Studies identification and selection based on PRISMA guidelines.

Figure 2.

Prevalence of Candida species, (a) the total occurrence of Candida species, the numerical on the top of the bar is the number of specific Candida species, (b) the occurrence of Candida species in different regions of China, each region is represented by specific colour as shown in the box, Multiple locations mean the that studies mentioned more than one region of China, (c) Prevalence of Candida species in association with various infection type, OC; oral candidiasis, UTI; urinary tract infection, NM; not mentioned the infection type, MI; multiple infections, involved in more than one infections, VVC; vulvovaginal candidiasis, BSI; bloodstream infection, IC; invasive candidiasis.

Figure 3.

Antifungal susceptibility patterns of Candida albicans in the form of median susceptibility/wild type with 95% confidence interval.

Figure 4.

Antifungal susceptibility patterns of Candida tropicalis in the form of median susceptibility/wild type with 95% confidence interval.

Figure 5.

Antifungal susceptibility patterns of Candida parapsilosis in the form of median susceptibility/wild type with 95% confidence interval.

Figure 6.

Antifungal susceptibility patterns of Candida glabrata in the form of median susceptibility/wild type with 95% confidence interval.

Figure 7.

Antifungal susceptibility patterns of Candida krusei in the form of median susceptibility/wild type with 95% confidence interval.

Figure 8.

Antifungal susceptibility patterns of C. auris, C. pelliculosa, C. guilliermondii and C. lusitaniae in the form of median susceptibility/wild type with 95% confidence interval.