REVIEW ARTICLE

Candida glabrata, Candida parapsilosis and Candida tropicalis:

biology, epidemiology, pathogenicity and antifungal resistance
Sónia Silva1, Melyssa Negri1, Mariana Henriques1, Rosário Oliveira1, David W. Williams2 &
Joana Azeredo1
1
Institute for Biotechnology and Bioengineering, Universidade do Minho, Campus de Gualtar, Braga, Portugal; and 2Tissue Engineering & Reparative
Dentistry, School of Dentistry, Heath Park, Cardiff, UK

Correspondence: Mariana Henriques, Abstract

Institute for Biotechnology and
Bioengineering, Universidade do Minho,
Campus de Gualtar 4710-057, Braga,
Portugal. Tel.: 1351 253 604 408; fax: 1351
253 604 429; e-mail: mcrh@deb.uminho.pt
Received 29 December 2010; revised 31 March
2011; accepted 6 May 2011.
Final version published online 6 June 2011.
DOI:10.1111/j.1574-6976.2011.00278.x
Editor: Martin Kupiec
Keywords
Candida species; candidosis; epidemiology;
virulence factors; antifungal resistance.
MICROBIOLOGY REVIEWS
The incidence of infections caused by Candida species (candidosis) has increased
considerably over the past three decades, mainly due to the rise of the AIDS
epidemic, an increasingly aged population, higher numbers of immunocompro-
mised patients and the more widespread use of indwelling medical devices.
Candida albicans is the main cause of candidosis; however, non-C. albicans
Candida (NCAC) species such as Candida glabrata, Candida tropicalis and
Candida parapsilosis are now frequently identified as human pathogens. The
apparent increased emergence of these species as human pathogens can be
attributed to improved identification methods and also associated with the degree
of diseases of the patients, the interventions that they were subjected and the drugs
used. Candida pathogenicity is facilitated by a number of virulence factors, most
importantly adherence to host surfaces including medical devices, biofilm forma-
tion and secretion of hydrolytic enzymes (e.g. proteases, phospholipases and
haemolysins). Furthermore, despite extensive research to identify pathogenic
factors in fungi, particularly in C. albicans, relatively little is known about NCAC

species. This review provides information on the current state of knowledge on the
biology, identification, epidemiology, pathogenicity and antifungal resistance of
C. glabrata, C. parapsilosis and C. tropicalis.

minority have been implicated in human candidosis. Addi-

Introduction
In last 30 years there has been a significant increase in the
incidence of fungal infections in humans (Lass-Flörl, 2009).
Such infections may either be superficial, affecting the skin,
hair, nails and mucosal membranes, or systemic, involving
major body organs (Ruping et al., 2008). A number of
factors have been implicated in this increased occurrence of
fungal disease, but it is generally accepted that the increased
and widespread use of certain medical practices, such as
immunosuppressive therapies, invasive surgical procedures
and use of broad-spectrum antibiotics are significant (Sa-
maranayake et al., 2002; Hagerty et al., 2003; Kojic &
Darouiche, 2004).
Of the fungi regarded as human pathogens, the members
of the genus Candida are the most frequently recovered from
human fungal infection. The Candida genus contains over
150 heterogeneous species (Calderone, 2002), but only a
tionally, it is known that approximately 65% of Candida
species are unable to grow at a temperature of 37 1C, which
precludes these species from being successful pathogens or
indeed commensals of humans (Calderone, 2002).
Of the Candida species isolated from humans, Candida
albicans is the most prevalent under both healthy and
disease (Calderone, 2002; Samaranayake et al., 2002) condi-
tions. However, while mycological studies have shown that
C. albicans represents over 80% of isolates from all forms of
human candidosis (Calderone, 2002) in the last two decades,
the number of infections due to non-C. albicans Candida
(NCAC) species has increased significantly (Kauffman et al.,
2000; Manzano-Gayosso et al., 2008; Ruan & Hsueh, 2009).
The apparent increased involvement of NCAC species in
human candidosis may partly be related to improvements in
diagnostic methods, such as the use of chromogenic media
with the ability to differentiate Candida species, as well as

FEMS Microbiol Rev 36 (2012) 288–305

c2011 Federation of European Microbiological Societies
Published by Blackwell Publishing Ltd. All rights reserved
Non-Candida albicans Candida species pathogenicity
the introduction of molecular techniques in the routine
diagnosis of fungemia (Liguori et al., 2009). However, the
high prevalence of NCAC species in disease could also be a
reflection of their inherently higher level of resistance to
certain antifungal drugs (Gonzalez et al., 2008) compared
with C. albicans, as this would promote their persistence,
possibly to the detriment of C. albicans, in mixed species
infections treated with traditional antifungal agents.
Unfortunately, compared with C. albicans there are
relatively few studies examining the virulence factors of
NCAC species. This review therefore provides information
on the current state of knowledge on the biology, identifica-
tion, epidemiology, pathogenicity and antifungal resistance
of Candida glabrata, Candida parapsilosis and Candida
tropicalis, three of the most frequent causes of candidosis
after C. albicans.
Biology of NCAC species
Candida comprises an extremely heterogeneous group of
fungal organisms that can all grow as yeast morphology.
Macroscopically, colonies of Candida, on the routinely used
Sabouraud dextrose agar (SDA), are cream to yellow in
colour. Depending on the species, colony texture may be
smooth, glistening or dry, or wrinkled and dull. Under
standard conditions with optimal nutrients, yeast grow in
log phase as budding cells (blastoconidia), which are sphe-
rical to oval in shape and are approximately 2–5  3–7 mm in
size (Fig. 1) (Larone, 2002). Moreover, certain species, such
as C. albicans and Candida dubliniensis, can produce a
Fig. 1. Epifluorescence photocomposition of the different morphological growth forms of Candida albicans stained with calcofluor white: (A)
blastoconidia; (B1) reproduction by budding; (B2) germ tube formation; (C1) pseudohyphae formation; (C2) yeast form; (C3) hyphae formation.
Internal cross walls (septa).
FEMS Microbiol Rev 36 (2012) 288–305
289
filamentous type of growth, such as true hyphae (Fig. 1) or
more frequently, pseudohyphae (Fig. 1).
The distinction between hyphae and pseudohyphae is
related to the way in which they are formed. Pseudohyphae
are formed from yeast cells or hyphae by budding (Fig. 1),
but the new growth remains attached to the parent cell and
elongates, resulting in filaments with constrictions at the
cell–cell junctions. There are no internal cross walls (septa)
associated with pseudohyphae (Fig. 1). In comparison, true
hyphae are formed from yeast cells or even as branches of
existing hyphae. The development of true hyphae is initiated
by a ‘germ tube’ projection (Fig. 1), which elongates and
then branches with defined septa that divide the hyphae into
separate fungal units (Fig. 1).
Candida albicans and C. dubliniensis are truly poly-
morphic, due to their ability to form hyphae and/or
pseudohyphae, and these species are also referred to germ
tube positive, a diagnostic feature (Table 1) (Calderone,
2002). In contrast, C. glabrata is not polymorphic, growing
only as blastoconidia (yeast) (Table 1; Fig. 2). Historically,
this species was originally classified in the genus Torulopsis
due to its lack of pseudohyphal formation. However, in
1978, it was determined that the ability to form pseudohy-
phae was not a reliable distinguishing factor for members of
the genus Candida and it was proposed that Torulopsis
glabrata could be classified in the genus Candida, due to its
association with human infection (Fidel et al., 1999). With
regard to C. parapsilosis, this species does not produce true
hyphae, but can generate pseudohyphae that are character-
istically large and curved, and often referred to as ‘giant cells’
ª 2011 Federation of European Microbiological Societies
Published by Blackwell Publishing Ltd. All rights reserved
290 S. Silva et al.

Table 1. Morphological characteristics of Candida albicans, Candida tropicalis, Candida parapsilosis and Candida glabrata species
Species Germ tube production Hyphae/pseudohyphae Yeasts size (mm) CHROM-agar colony colour
C. albicans 1 1/1 4–6  6–10 Blue-green
C. tropicalis  /1 4–8  5–11 Dark blue
C. parapsilosis /1 2.5–4  2.5–9 White
C. glabrata / 1–4 White, Pink-purple

Fig. 2. Candida species macroscopic colonies on cornmeal Tween 80 and microscopy structure on SDA. Microscopic structures: (a) Candida glabrata;
(b) Candida parapsilosis; (c) Candida tropicalis; macroscopic colonies: (d) C. glabrata; (e) C. parapsilosis; (f) C. tropicalis.

(Fig. 2) (Larone, 2002; Trofa et al., 2008). In contrast, on
corn meal Tween 80 agar and at 25 1C after 72 h, C. tropicalis
produces oval blastospores, pseudohyphae depending on
some reports, true hyphae (Fig. 2) (Calderone, 2002; Larone,
2002; Yoshio & Kouji, 2006).
It should also be highlighted that C. glabrata cells
(1–4 mm) are noticeably smaller than the blastoconidia of
C. albicans (4–6 mm), C. tropicalis (4–8 mm) and C. para-
psilosis (2.5–4 mm) (Larone, 2002) (Table 1). On SDA (Fig.
2) C. glabrata forms glistening, smooth, and cream-co-
loured colonies, which are largely indistinguishable from
those of other Candida species except for their relative size,
which can be quite small (Fig. 2). Furthermore, C. para-
psilosis, when grown on SDA, yields white, creamy, shiny and
smooth/wrinkled colonies (Fig. 2). On the same medium, C.
tropicalis forms colonies that are cream-coloured with a
slightly mycelial border (Fig. 2) (Calderone, 2002).
Concerning the biochemistry of Candida species, C.
glabrata ferments and assimilates only glucose and trehalose,
which contrasts with C. albicans, which ferments and/or
assimilates a number of sugars with the notable exception of
sucrose (Odds, 1988). Additionally, C. tropicalis has the
ability to ferment and assimilate sucrose and maltose
(Martin, 1979). Interestingly, C. parapsilosis was firstly
classified as a species of Monilia, due to its inability to
ferment maltose (Odds, 1988; Trofa et al., 2008).
A main distinguishing genetic characteristic of C. glabrata
is that it has a haploid genome, in contrast to the diploid
genome of C. albicans and several other NCAC species (Fidel
et al., 1999). Genetically, C. tropicalis has the highest
similarity to C. albicans, and C. glabrata the least (Butler
et al., 2009). It is through the advent of molecular genetics
that new identification methods for Candida have been
developed, leading to the identification of new species
together with their increased recognition in human infec-
tion. Before 2005, C. parapsilosis was separated into three
groups (I–III), but further studies revealing genomic differ-
ences that have led to the separation of these groups into
closely related, but distinct species, namely, C. parapsilosis,
Candida orthopsilosis and Candida metapsilosis (Tavanti
et al., 2005; Gácser et al., 2007a, b).
Laboratory identification of NCAC species
The laboratory diagnosis of candidoses continues to be
problematic. Microbiological confirmation can be difficult

ª 2011 Federation of European Microbiological Societies FEMS Microbiol Rev 36 (2012) 288–305
Published by Blackwell Publishing Ltd. All rights reserved
Non-Candida albicans Candida species pathogenicity
as blood cultures can be negative in up to 50% of autopsy-
proven cases of deep-seated candidoses, or may only become
positive late in the infection (Ellepola & Morrison, 2005).
Positive cultures from urine or mucosal surfaces do not
necessarily indicate invasive disease although may occur
during systemic infection (Ellepola & Morrison, 2005).
Furthermore, differences in virulence between Candida
species as well as in their susceptibility to antifungal drugs
make identification important for clinical management.
Laboratory diagnosis has improved with the advent of
new methods for Candida isolation and identification.
Technologies such as species-specific FISH (Alexander
et al., 2006), antibody and antigen detection (Pfaller, 1992;
Ellepola & Morrison, 2005) and molecular approaches for
typing and detection of fungal pathogens (Ellepola &
Morrison, 2005) have all been used successfully. However,
many of these approaches have not yet been standardized or
validated in large clinical trials and therefore are not widely
used in clinical laboratory settings (Ellepola & Morrison,
2005). Laboratory surveillance of ‘at-risk’ patients could
result in earlier initiation of antifungal therapy if sensitive
and specific diagnostic tests, which are also cost effective,
become widely available.
The clinical symptoms of fungemia are not indicative of
particular Candida species and may be induced by other
microorganisms. The laboratory identification of Candida is
therefore essential for establishing a definitive diagnosis. A
standard approach to the laboratory diagnosis generally
involves nonmolecular methods, although PCR is increas-
ingly being used.
Non-PCR based methods of Candida
identification
CHROMagars Candida (CHROMagars, Paris, France), is a
relatively new differential agar medium for Candida species
identification and has been particularly useful in the pre-
sumptive identification of C. albicans, C. tropicalis and
Candida krusei upon primary culture of clinical specimens.
On CHROMagars Candida, C. glabrata colonies appear
white, pink or purple in contrast to C. albicans colonies,
which are blue-green, while C. parapsilosis colonies are white
and C. tropicalis dark blue (Table 1). Moreover, it is possible
to detect coinfection with different Candida species on
primary culture plates and this can have importance in
infection management strategies (Ellepola & Morrison,
2005; Furlaneto-Maia et al., 2007).
After Candida isolation, species can also be identified by
carbohydrate assimilation and fermentation tests as well as
morphological characteristics such as germ tube and chla-
mydospore development (Fig. 2). In addition, more rapid
and less laborious phenotypic identification methods have
become available. Perhaps the most widely used methods for
FEMS Microbiol Rev 36 (2012) 288–305
291
Candida species identification are those based on the format
of carbohydrate assimilation and/or enzyme detection with-
in plastic wells of commercially available kits. Examples of
such biochemical tests include the API 20C AUX (API
Candida) Auxacolor (Bio-Rad) and the Uni-Yeast-Tek kit
(Ellepola & Morrison, 2005). These tests generate reliable
identification for the most common species of Candida,
while identification of other Candida species may not be so
accurate. For example, the differentiation of C. dubliniensis
from C. albicans often requires the use of supplemental
biochemical or morphological tests for definitive identifica-
tion (Verweij et al., 1999; Ellepola & Morrison, 2005).
Additional methods for Candida species identification
include tests that allow the detection of an isolate in 1 day,
such as the RapID Yeast Plus System (Innovative Diagnostic
Systems, Norcross), the Fongiscreen test (Sanofi Diagnostics
Pasteur, France) and the automated Rapid Yeast Identifica-
tion Panel (Dade Microscan). However, as mentioned
above, most of these tests tend to be most accurate for the
identification of the more frequently encountered yeast
pathogens (Ellepola & Morrison, 2005).
The diagnosis of invasive candidosis should include a
collection of adequate volumes of blood and an agar-based
blood culture method for optimal detection of candidemia
(Pfaller, 1992). Several advances in blood culturing techni-
ques have been developed, which appear to have improved
the sensitivity and/or reduced the time required to obtain a
positive blood culture. Two automated methods for mon-
itoring of blood culture bottles, based on colour (BacT/
ALERT 3D, Organon Teknika Corp., Durham, NC) and
fluorescence (BACTEC 9240, Becton Dickinson), have been
developed recently (Ellepola & Morrison, 2005).
The identification of typical blastospores and pseudohy-
phae of Candida species on microscopic examination of
tissue remains the unequivocal standard for the diagnosis of
invasive or disseminated candidoses. Unfortunately, the
usefulness of this approach is frequently limited by sampling
problems (isolation source and sample size) (Pfaller, 1992).
The use of fluorescent antibody, acridine orange or calco-
fluor-white staining (Pfaller, 1992; Ellepola & Morrison,
2005) may enhance the sensitivity of microscopic examina-
tion. However, the production of fluorescent antibodies
specific for the identification of individual Candida species
has proved to be extremely difficult.
A relatively recent laboratory method based on PNA FISH
targeting the 26S rRNA gene allows the reliable detection of C.
albicans from NCAC species, within 2.5 h of yeast growth
detection in blood culture, with a sensitivity of 99% and
specificity of 100% (Rigby et al., 2002). According to recent
studies PNA FISH also results in substantial cost savings for
hospitals, making the method both an effective and affordable
one for the laboratory diagnosis of candidoses (Rigby et al.,
2002; Ellepola & Morrison, 2005; Alexander et al., 2006).
ª 2011 Federation of European Microbiological Societies
Published by Blackwell Publishing Ltd. All rights reserved
292 S. Silva et al.

PCR-based methods of Candida identification mately 31–55% of healthy individuals. Historically, C.

albicans has accounted for 70–80% of clinical isolates, with
The molecular-based technology that has undoubtedly had
other NCAC species only rarely encountered (Odds, 1988;
the greatest impact in the clinical diagnosis of Candida
Calderone, 2002; Samaranayake et al., 2002). Nevertheless,
infections is PCR. This technique can detect highly limited
over the last 10–30 years NCAC species have emerged as
quantities of microbial nucleic acid from blood, tissue
important opportunistic pathogens of humans and the
specimens as well as cultured microorganisms. Over the last
reasons for this might be related to improved diagnostic
decade, numerous studies have been performed to investi-
methods or altered medical practices, as mentioned above.
gate the effectiveness of PCR in diagnosis of systemic
Regardless of the basis of this change, recent epidemiological
infection caused by Candida (Williams et al., 1995, 2001;
data reveal a mycological shift, and while C. albicans remains
Chen et al., 2000; Carvalho et al., 2007; Orazio et al., 2009).
the most common causative agent, its relative incidence in
In PCR, a pair of synthetic oligonucleotides homologous
infection is declining with the increasing prevalence of other
to specific sequences serves to prime the amplification of
species such as C. glabrata, C. tropicalis and C. parapsilosis
target DNA. The most important feature of any PCR
(Chandra et al., 2001; Colombo et al., 2003; Bassetti et al.,
primers used directly on clinical samples is that they are
2006).
specific and do not amplify host DNA or that of other
In a study on the epidemiology of invasive candidosis,
microorganisms.
Pfaller & Diekema (2007) observed that C. albicans, C.
To improve the sensitivity of PCR, many investigators
glabrata, C. tropicalis and C. parapsilosis collectively ac-
have designed primers that amplify regions of DNA that are
counted for about 95% of identifiable Candida infections.
repeated in the fungal genome. The most commonly used
Moreover, in the 1980s, according to Kiehn et al. (1980), C.
target for yeast diagnostic PCR primers is the rRNA gene
albicans constituted 68% of Candida isolates from sites
operon, encoding the 18S, 5.8S, and 28S rRNA gene
other than blood in cancer patients, while C. tropicalis, C.
subunits, namely internal transcribed spacer 1 (ITS1), ITS2
parapsilosis and C. glabrata accounted only for 12%, 10%
and ITS4 (Fell et al., 1992; Sullivan et al., 1995; Williams
and 3.0% of the isolates, respectively. Table 2 presents
et al., 1995, 2001; Haynes & Westerneng, 1996; Chen et al.,
epidemiologic studies published between 2000 and 2010,
2000). More recently, multiplex targets, coupled to real-time
concerning oral candidosis, candiduria and candidemia. In
PCR, have been used successfully (Sampaio et al., 2005;
more recent studies, most cases of fungemia have been
Carvalho et al., 2007; Orazio et al., 2009) for Candida species
significantly associated with NCAC species (Bassetti et al.,
identification.
2006; Colombo et al., 2007; Chakrabarti et al., 2009; Pfaller
Despite the increased development of new molecular
et al., 2010). However, it is important to emphasize that
approaches, the great majority of clinical diagnosis of
there are significant variations in Candida species isolation
candidosis are based on nonmolecular methodologies due
depending on the geographical region and patient group,
the reduced amount of PCR equipment in hospital labora-
with some NCAC species being more prevalent, even
tories, the problems with sample preparation and environ-
compared with C. albicans, in certain countries (Colombo
mental contamination and the lack of standardized
et al., 2007).
protocols for PCR methodologies.
The incidence of C. glabrata is higher in adults than in
children, and lower in neonates (Krcmery & Barnes, 2002).
Epidemiology and risk factors in NCAC
In contrast, C. parapsilosis appears to be a significant
species infection problem in neonates, transplant recipients and patients
The mortality rates associated with different microorgan- receiving parenteral nutrition (Trofa et al., 2008). Further-
isms have declined with the early administration of empiri- more, C. tropicalis is commonly associated with patients
cal antibiotics and antifungal agents. However, despite this, with neutropenia and malignancy (Colombo et al., 2007).
systemic fungal infections are increasingly recognized as For many years C. glabrata was considered a relatively
important causes of morbidity and mortality. Candida nonpathogenic saprophyte of the normal flora of healthy
species are among the most frequently recovered fungi from individuals and certainly not readily associated with serious
blood cultures of hospitalized patients (Pfaller et al., 1998, infection in humans. However, following the widespread
2010). In fact, an increasing incidence of fungal infections and the increased use of immunosuppressive therapies
with Candida species has been noted in immunocompro- together with broad-spectrum antibiotic treatment, the
mised patients, including those in intensive care, postsurgi- frequency of mucosal and systemic infections caused by
cal units and suffering from cancer (Kiehn et al., 1980; C. glabrata has increased significantly (Hajjeh et al., 2004).
Samaranayake et al., 2002; Hagerty et al., 2003). Candida Although the mortality rate associated with Candida infec-
species are most frequently isolated from the oral cavity, and tions varies with the type of patient and with the causative
vulvovaginal and urinary tracts and are detected in approxi- agent, the incidence rates of candidosis infections attributed

ª 2011 Federation of European Microbiological Societies FEMS Microbiol Rev 36 (2012) 288–305
Published by Blackwell Publishing Ltd. All rights reserved
Non-Candida albicans Candida species pathogenicity 293

Table 2. Selected epidemiological studies published from 2000 to 2010, concerning the distribution of Candida species isolates among various types of
candidosis
Period of Region/ Number C. albicans C. tropicalis C. parapsilosis C. glabrata
Candidosis References observation country of strains (%) (%) (%) (%)
Oral candidosis Gonzalez Gravina et al. February–May Venezuela 43 42.3 12.8 14.9 2.1
(2007) 2003
Martins et al. (2010a, b) May 2005–2006 Portugal 53 79 4.8 6.5 4.8
Luque et al. (2009) - Argentine - 60.7 4.5 - 5.6
Candiduria Kauffman et al. (2000) - USA 530 51.8 7.9 4.1 15.6
Kobayashi et al. (2004) - Brazil 45 35.5 22.3 11.1 8.8
Passos et al. (2005) - Brazil 43 70 4.6 4.6 7
Binelli et al. (2006) 1999–2001 Brazil 23 52 43.5 - 17.3
Chen et al. (2008) June–August 2006 Australia 65 85.2 - 4.4 27.8
Álvarez-Lerma et al. 1998–1999 Spain 389 68.4 36 0.5 8.2
(2003)
Dorko et al. (2002) - Slovakia 94 61.7 6.3 24.5 -
Candidemia Hazen et al. (1986) - USA 126 21 38 12 3
Chakrabarti et al. (2009) - India - 26.3 - 10.5
Colombo et al. (2007) - Brazil 282 38 48 23 9
Costa-de-Oliveira et al. During 2004 Portugal - 35 - 26.5 -
(2008)
Bassetti et al. (2006) 1999–2003 Italy 182 40 9 23 15
Miranda et al. (2009) 2004–2005 Brazil - 42 33 16 2
Tortorano et al. (2006) 1997–1999 Europe 473 53 7 14 14
Trick et al. (2002) During 1999 USA - 59 10 11 12
Pfaller et al. (2010) 2008–2009 Europe/ 1239 50 9.8 17.4 17.4
Asia/
American

-, Not mentioned.

to NCAC species were 14% for C. glabrata and C. parapsilosis
and 7% for C. tropicalis according to a European Confedera-
tion of Medical Mycology survey (Tortorano et al., 2006).
Recently, Chen et al. (2008) reported that C. glabrata was a
causative agent of candiduria in Australia. This is extremely
important, because, compared with other NCAC species
infection, the mortality rate associated with C. glabrata is
the highest (Abi-Said et al., 1997; Krcmery, 1999b).
Until recently, few studies had evaluated independent risk
factors associated with nosocomial C. glabrata acquisition
and subsequent disease. Although C. glabrata is known to be
present in patient’s flora, relatively little is known about the
hospital reservoirs of C. glabrata, with likely sources of
infection involving a complex interaction of both environ-
mental and human reservoirs. Two studies (Isenberg et al.,
1989; Vazquez et al., 1993) have indicated hand carriage on
hospital personnel as possible sources of infection. Thus,
similar to other nosocomial pathogens, C. glabrata may also
be acquired, directly or indirectly, from contaminated
environmental surfaces. However, the role of carriage by
personnel in dissemination of C. glabrata remains to be
clarified. Lately, the most frequent combination of mixed
species infection by Candida species is C. glabrata and
C. albicans, which has been found in approximately 70% of
the patients with oral candidosis (Redding et al., 2002).
Candida parapsilosis, despite being initially considered a
nonpathogenic species, was initially identified as the causa-
tive agent of a fatal case of endocarditis in an intravenous
drug user in 1940 (Joachim & Polayes, 1940). Furthermore,
over the past decade, the incidence of C. parapsilosis in
infections has increased drastically. In fact, reports indicate
that C. parapsilosis is often the second most frequently
isolated Candida species from blood cultures (Almirante
et al., 2006; Colombo et al., 2007; Costa-de-Oliveira et al.,
2008). Furthermore, C. parapsilosis is one of the fungi most
frequently isolated from human hands (Bonassoli et al.,
2005) and the second most commonly isolated Candida
species from normally sterile body sites of hospitalized
patients. This species accounts for 15.5% of Candida isolates
in North America, 16.3% in Europe, and 23.4% in Latin
America, outranked only by C. albicans (51.5%, 47.8% and
36.5%, respectively) and C. glabrata (21.3%) in North
America (Messer et al., 2006). However, C. parapsilosis
fungemia has a lower mortality rate (4%) compared with
that caused by C. albicans and C. glabrata (Kossoff et al.,
1998).
The increased incidence of C. parapsilosis infections has
been attributed to a variety of risk factors, similar to other
Candida species, including the organism’s selective growth
capabilities in hyperalimentation solutions and its high

FEMS Microbiol Rev 36 (2012) 288–305 ª 2011 Federation of European Microbiological Societies
Published by Blackwell Publishing Ltd. All rights reserved
294
ability to colonize intravascular devices and prosthetic
materials. Additionally, patients requiring prolonged used
of a central venous catheter or indwelling devices, such as
cancer patients, are at increased risk of infection with
C. parapsilosis. A recent Spanish study of 72 patients with
invasive C. parapsilosis identified vascular catheterization
(97%), prior antibiotic therapy (91%), parenteral nutrition
(54%), prior surgery (46%), prior immunosuppressive
therapy (38%), malignancy (27%), transplant receipt
(16%), neutropenia (12%) and prior colonization (11%),
as risk factors for infection (Almirante et al., 2006). In a
report of 64 episodes (between 2002 and 2003) of
C. parapsilosis candidemia in Brazilian hospitals, the pri-
mary risk factors were neutropenia, the use of central venous
catheters and cancer chemotherapy (Brito et al., 2006). The
population at greatest risk for nosocomial infection with
C. parapsilosis is that of extremely low-birth-weight neonates
(Solomon et al., 1984; Voss et al., 1994). In fact, colonization
of the skin or gastrointestinal tract is frequently the first step in
the pathogenesis of invasive candidosis, and neonates are
especially prone to such infections given their compromised
skin integrity, susceptibility to gastrointestinal tract infection,
long-term need for central venous or umbilical catheters and
prolonged endotracheal intubation (Benjamin et al., 2000).
Furthermore, C. parapsilosis has been isolated from approxi-
mately one-third of neonates with gastrointestinal coloniza-
tion by Candida species (Saiman et al., 2001) and from
oropharynges of 23% of healthy neonates (Contreras et al.,
1994). Furthermore, in contrast to other NCAC species, the
rates of mortality in low-birth-weight neonates caused by
C. parapsilosis are drastically higher and sometimes equivalent
to those associated with C. albicans (Trofa et al., 2008).
Candida tropicalis is one of the three most commonly
isolated NCAC species (Álvarez-Lerma et al., 2003; Binelli
et al., 2006; Colombo et al., 2007; Hasan et al., 2009).
Usually, C. tropicalis is considered the third most frequently
isolated NCAC species from blood and urine cultures (Table
2) (Kauffman et al., 2000; Álvarez-Lerma et al., 2003).
Moreover, in a recent epidemiology study conducted in 12
Brazilian medical centres, C. tropicalis was the second most
frequently recovered Candida species, accounting for
33–48% of all candidemia cases (Colombo et al., 2007;
Miranda et al., 2009). Additionally, C. tropicalis is often
found in patients admitted to intensive care units, especially
in patients requiring prolonged catheterization, receiving
broad-spectrum antibiotics or with cancer (Kauffman et al.,
2000; Rho et al., 2004; Colombo et al., 2007; Nucci &
Colombo, 2007). Furthermore, C. tropicalis appears to dis-
play a higher potential for dissemination in neutropenic
individuals compared with C. albicans and other NCAC
species (Colombo et al., 2007).
According to Kontoyiannis et al. (2001), there are distinct
differences in the presentation and risk factors of C. tropica-
ª 2011 Federation of European Microbiological Societies
Published by Blackwell Publishing Ltd. All rights reserved
S. Silva et al.
lis and C. albicans fungemia, with the former more persis-
tent and leading to longer intensive care unit stays during
the course of infection. This may imply a higher virulence
and greater resistance to commonly used antifungals by
C. tropicalis when compared with C. albicans. In fact, some
epidemiologic studies (Krcmery, 1999a; Kontoyiannis et al.,
2001; Eggimann et al., 2003; Colombo et al., 2007)
documented that C. tropicalis was associated with higher
mortality than other NCAC species and C. albicans.
This propensity of C. tropicalis for dissemination and the
associated high mortality may be related to the virulence
factors exhibited by this species such as biofilm formation,
proteinases secretion and dimorphism (Krcmery, 1999b;
Negri et al., 2010a).
Pathogenicity and virulence factors of
NCAC species
There remains a debate over what actually constitutes a
virulence factor. It can be argued that all the traits required
for establishing disease are virulence factors; however,
strictly speaking, virulence factors are those that interact
directly with host cells causing damage (Haynes, 2001). The
pathogenicity of Candida species is mediated by a number of
virulence factors, including adherence and biofilm forma-
tion on host tissue as well as medical devices, the ability to
evade host defences and the production of tissue-damaging
hydrolytic enzymes (e.g. proteases, phospholipases and
haemolysins).
Infection models of candidosis in animals suggest that
C. albicans is the most pathogenic species (Samaranayake &
Samaranayake, 2001), and in vitro investigations indicate
that it also expresses higher levels of putative virulence
factors compared with other species (Jayatilake et al.,
2006). Furthermore, it is important to emphasize that these
yeasts are not usual pathogens of these animals and therefore
such studies do not necessarily reflect the reality of patho-
genicity of Candida species. Moreover, Candida species can
colonize and cause disease at several anatomically distinct
sites including the skin, oral cavity, gastrointestinal tract,
vagina and vascular system. In order to establish infection,
opportunistic pathogens have to evade the immune system,
survive, reproduce in the host environment, and in the case
of systemic infection, disseminate to new tissues and organs.
Adhesion and biofilm formation
The primary event in Candida infection is adherence to host
surfaces, which is required for initial colonization. Adher-
ence contributes to persistence of the organism within the
host, and is considered essential in the establishment of
disease. Furthermore, Candida species can also adhere to the
surfaces of medical devices and form biofilms. Several
factors have been implicated in influencing adhesion,
FEMS Microbiol Rev 36 (2012) 288–305
Non-Candida albicans Candida species pathogenicity
including the profile of cell wall proteins (Chaffin, 2008) and
cell surface physicochemical properties (Anil et al., 2001;
Henriques et al., 2002).
Candida cell surface proteins that are involved in specific
adherence are described as adhesins. In C. glabrata, a major
group of adhesins is encoded for by the EPA (epithelial
adhesin) gene family (De las Penas et al., 2003). The overall
structure of Epa proteins is similar to that of the ALS
(agglutinin-like sequence) proteins of C. albicans. Although
there are few studies concerning C. glabrata Epa proteins, it
is known that EPA1p is a calcium-dependent lectin that
binds to N-acetyl lactosamine-containing glycol conjugates
(Cormack et al., 1999). Furthermore, despite the large
number of EPA genes, it has been shown that deletion of
merely Epa1p reduces adherence in vitro (De las Penas et al.,
2003). In addition, although EPA6 is not expressed in vitro,
its expression increases during in vivo urinary tract infec-
tion, suggesting that C. glabrata is capable of adapting to
different environmental conditions (Domergue et al., 2005).
Furthermore, a bioinformatic search of pathogen-specific
gene families of Candida species revealed a number of genes
for putative cell wall adhesins-like-proteins in C. parapsilo-
sis. This study included genes for five Als proteins and six for
Pga 30 (predicted glycosylphosphatidylinositol-anchored
protein 30) (Butler et al., 2009). Unfortunately, there has
been no further work in studying the role that these
proteins play in C. parapsilosis adhesion. Concerning,
proteins from the C. tropicalis cell wall, at least three Alsp
have been identified through Western blot analysis with
anti-Als antibodies (Hoyer et al., 2001); however, to the
authors’ knowledge, no further work has been undertaken in
this area.
The fungal cell surface is the site of physical–chemical
interactions with host tissues or medical devices leading to
its adherence (Cannon & Chaffin, 1999). Previous studies of
the cell wall of Candida have suggested a relationship
between cell surface hydrophobicity and adherence (Pana-
goda et al., 2001). In a study with a limited number of C.
glabrata isolates, this species was found to exhibit a degree of
hydrophobicity similar to C. albicans (Hazen et al., 1986).
Interestingly, while the hydrophobicity of C. albicans was
extremely sensitive to specific growth conditions, numerous
isolates of C. glabrata were relatively insensitive to the same
growth conditions (Kikutani & Makino, 1992). In addition,
Camacho et al. (2007) did not find a correlation between the
hydrophobicity and adherence for Candida cells on silico-
nized latex catheters, demonstrating that cell hydrophobi-
city alone was not a predictor for adhesion levels. As
reported for C. glabrata, Panagoda et al. (2001) showed that
the initial adhesion of C. parapsilosis and C. tropicalis cells
was associated with surface hydrophobicity.
Initial attachment of Candida to host or/and medical
devices is followed by cell division, proliferation and sub-
FEMS Microbiol Rev 36 (2012) 288–305
295
sequent biofilm development (Ramage et al., 2006). Biofilms
are described as surface-associated communities of micro-
organisms embedded within an extracellular matrix. It is
now considered that biofilms represent the most prevalent
growth form of microorganisms (Al-Fattani & Douglas,
2006; Silva et al., 2009a). Biofilm formation is an important
virulence factor for a number of Candida species, as it
confers significant resistance to antifungal therapy by limit-
ing the penetration of substances through the matrix and
protecting cells from host immune responses (Donlan &
Costerton, 2002; Mukherjee & Chandra, 2004). Moreover,
biofilms formed by C. albicans, C. parapsilosis, C. tropicalis
and C. glabrata isolates have been associated with higher
morbidity and mortality rates compared with isolates un-
able to form biofilms (Kumamoto, 2002). It is assumed that
the formation of mature biofilms and subsequent produc-
tion of extracellular matrix is strongly dependent on species,
strain and environmental conditions (pH, medium compo-
sition, oxygen) (Ramage et al., 2006; Jain et al., 2007).
Recently, Silva et al. (2010b) showed that C. glabrata
produced a higher biofilm biomass on silicone surfaces in
the presence of urine, compared with C. parapsilosis and C.
tropicalis. The opposite was found for biofilms formed in
Sabouraud dextrose broth (Silva et al., 2009a). These results
are in accordance with Shin et al. (2002) who reported that
biofilm formation by C. glabrata was lower compared with
other NCAC species, when grown in rich culture media.
Candida tropicalis clinical isolates have been classified as
being extensive biofilm formers on silicone and latex
catheter (Fig. 3) (Redding et al., 2002; Silva et al., 2009a;
Negri et al., 2010b). Biofilms are readily formed by C.
parapsilosis cells grown in media containing high glucose
and lipid concentrations, and can be associated with the
increased prevalence of this organism in bloodstream infec-
tions of patients receiving parenteral nutrition (Nosek et al.,
2009). The selective preference of this species for plastic
medical devices is of particular interest, as biofilm formation
enhances the capacity of the organism to colonize catheters
and intravascular lines (Weems, 1992; Trofa et al., 2008). In
contrast to C. albicans, C. parapsilosis biofilms are thinner,
less structured and consist exclusively of aggregated blastos-
pores (Kuhn et al., 2002). These biofilm features are in
accordance with those recently reported by Silva et al.
(2009a). Lattif et al. (2009) demonstrated that, like C.
parapsilosis, the two newly identified Candida species (C.
orthopsilosis and C. metapsilosis) were also able to form
biofilms.
Little is known about the matrix composition of NCAC
species biofilms, but according to Baillie & Douglas (2000),
C. albicans biofilm matrix is mainly composed of carbohy-
drates, proteins, phosphorus and hexosamines. Silva et al.
(2009a) reported that the extracellular matrices of C. para-
psilosis biofilms contained large amounts of carbohydrates
ª 2011 Federation of European Microbiological Societies
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296
(a)
Fig. 3. Scanning electron microscopy images of
Candida tropicalis biofilms formed on (a) silicone
and (b) latex catheter in artificial urine at 24 h.
Scale bar = 20 mm.
with correspondingly low levels of proteins. In the same
study, C. glabrata biofilm matrices were found to have high
levels of both proteins and carbohydrates, while C. tropicalis
biofilm matrices had low levels of carbohydrates and pro-
teins compared with the other NCAC species. Interestingly,
the biofilm matrix composition is highly strain dependent, a
phenomenon that has not been observed in related yeasts
(Silva et al., 2009a). Furthermore, Al-Fattani & Douglas
(2006) showed that matrix material extracted from biofilms
of C. tropicalis and C. albicans contained carbohydrates,
proteins, hexosamine, phosphorus and uronic acid. How-
ever, the major component in C. tropicalis biofilm matrices
was hexosamine (27%). The same authors also reported that
these biofilms partially detached after treatment with lipase
type VII and chitinase, which is in contrast to biofilms
of C. albicans that detached only after treatment with
proteinase K, chitinase, DNase I or b-N-aceytyglucosami-
dase. DNA has been described as a component of the
extracellular matrix in bacteria biofilms (Allesen-Holm
et al., 2006; Vilain et al., 2009). In Candida species, there is
scarce knowledge concerning the contribution of extracel-
lular DNA to biofilm matrix and overall structure. Recently,
Martins et al. (2010a, b) highlighted the importance of DNA
in C. albicans biofilm formation, integrity and structure.
However, there is a lack of knowledge concerning NCAC
species and the role of extracellular DNA on biofilm
composition.
While extensive work has been performed on the
C. albicans genes involved in adhesion/colonization and
biofilm formation, little is known about equivalent control-
ling genes in C. glabrata, C. parapsilosis and C. tropicalis.
However, two recent studies involving the study of
C. parapsilosis lipase knockout mutants found that these
had a decreased ability to form biofilms. The C. parapsilosis
mutants produced significantly less biofilm than the wild-
type strain (Gácser et al., 2007a). Moreover, the BCR
(biofilm and cell wall regulator) gene was also deemed
necessary for proper biofilm formation (Gácser et al.,
2007b). Notably, the biofilm-deficient C. parapsilosis lipase
mutants were less virulent in tissue culture infection models
and in mice (Gácser et al., 2007b). As documented above,
the cell wall seems to play a crucial role in colonization and
infection, and therefore, elucidation of its structure and
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S. Silva et al.
(b)
composition may lead to a better understanding of NCAC
pathogenicity, and also aid in identifying therapeutic targets.
Hydrolytic enzymes
Destruction of host tissues by Candida species may be
facilitated by the release of hydrolytic enzymes into the local
environment. Secreted aspartyl proteinases (Saps), phospho-
lipases, lipases (LIPs) and haemolysins are the enzymes most
frequently implicated in Candida species pathogenicity.
Saps facilitate invasion and colonization of host tissues by
disruption of the host mucosal membranes (Rüchel, 1999)
and by degrading important immunological and structural
defence proteins (Pichová et al., 2001). In the case of
C. glabrata, only one study has shown that this species is
capable of proteinase production, but the type of proteinase
was not specified (Chakrabarti et al., 1991). For C. para-
psilosis, three SAP genes have been identified (SAPP1-3), two
of which remain largely uncharacterized (Merkerova et al.,
2006). The Sapp1p isoenzyme has, however, been biochemi-
cally characterized (Fusek et al., 1994; Pichová et al., 2001;
Dostal et al., 2005), and SAPP2 encodes a functional
proteinase that constitutes only 20% of the Saps isolated
from a culture supernatant (Fusek et al., 1994). It has been
reported (Silva et al., 2009b) that SAPP1-3 genes expression
varies with different clinical isolates of C. parapsilosis when
grown in contact with an oral epithelium and even in
planktonic growth forms. However, there is a trend relating
Sap production and site of strain isolation, because both
vaginal and skin isolates of C. parapsilosis exhibit higher
in vitro Sap activity than blood isolates (Cassone et al., 1995;
Dagdeviren et al., 2005). Candida parapsilosis has been
shown to be poorly invasive of an oral epithelium, but can
nevertheless induce significant damage, which was related to
specific SAP gene expression (Silva et al., 2009b). As with C.
albicans, in vitro studies reveal that C. tropicalis secretes high
levels of Saps in a medium containing bovine serum
albumin as the sole source of nitrogen (Zaugg et al., 2001;
Negri et al., 2010b). Furthermore, C. tropicalis possesses at
least four genes encoding Saps, designated as SAPT1 to
SAPT4 (Togni et al., 1991; Zaugg et al., 2001). To date,
Sapt1p is the only enzyme that has been purified from
culture supernatant, biochemically characterized and
FEMS Microbiol Rev 36 (2012) 288–305
Non-Candida albicans Candida species pathogenicity
crystallized (Togni et al., 1991; Symersky et al., 1997). The
presence of Saps secreted by C. tropicalis has also been
reported on the surface of fungal elements penetrating
tissues during disseminated infection and evading macro-
phages after phagocytosis of yeast cells (Borg & Ruchel,
1990; Rüchel et al., 1992). Recently, Silva et al. (2010b)
demonstrated that, like C. albicans (Lermann & Morsch-
hauser, 2008; Naglik et al., 2008), Sap expression during
C. tropicalis colonization of an oral epithelium was not
associated with invasion and tissue damage.
In addition to Saps, enzymes categorized as phospholi-
pases are often considered to be involved in Candida
pathogenicity. Phospholipases are enzymes that hydrolyze
phospholipids into fatty acids. The production of all classes
of phospholipases have been described for Candida species
and are suggested to contribute to host cell membrane
damage, which could also expose receptors to facilitate
adherence (Ghannoum, 2000; Kantarciǒlu & Yücel, 2002).
The most widely used diagnostic method for phospholipase
determination is based on yeast growth in an egg yolk agar
media. Several studies indicate that NCAC species produce
extracellular phospholipases (Furlaneto-Maia et al., 2007;
Cafarchia et al., 2008; Galan-Ladero et al., 2010), but at
significantly lower levels compared with C. albicans (Ghan-
noum, 2000). There have been contradictory findings, with
some investigators reporting phospholipase activity in 51%
of the strains assayed (Ghannoum, 2000) and others finding
no phospholipase activity in the examined strains (Kantar-
ciǒlu & Yücel, 2002). According to recent studies, while
C. tropicalis appears to have a reduced ability to produce
extracellular phospholipases, production is highly strain
dependent (Furlaneto-Maia et al., 2007; Cafarchia et al.,
2008; Galan-Ladero et al., 2010; Negri et al., 2010b). Further-
more, contrary to the few studies on C. tropicalis and
C. parapsilosis (Kumar et al., 2009), no studies have been
reported concerning C. glabrata phospholipase production.
Lipases are involved in the hydrolysis of triacylglycerols.
In C. albicans, 10 genes encoding for lipases have been
identified and it has been shown that C. albicans CaLIP8
mutants were significantly less virulent in a murine intrave-
nous infection model (Gácser et al., 2007b). For C. para-
psilosis, CpLIP1 and CpLIP2 have been reported, with the
latter known to encode for an active protein (Neugnot et al.,
2002). Recently, Gácser et al. (2007a) demonstrated that a
lipase inhibitor significantly reduced tissue damage during C.
parapsilosis infection of a reconstituted human tissue, and
that CpLIP1/CpLIP2 mutants formed thinner and less com-
plex biofilms. Sequences similar to C. albicans (LIP1-10) were
also detected in C. tropicalis, but not in C. glabrata. However,
no studies have been performed to investigate the role of these
genes in the virulence of C. tropicalis (Fu et al., 1997).
Pathogenic microorganisms can grow in the host using
haemin or haemoglobin as a source of iron. Haemolysins are
FEMS Microbiol Rev 36 (2012) 288–305
297
used by Candida species to degrade haemoglobin and
facilitate recovery of the elemental iron from host cells.
Thus, haemolysins are considered key virulence factors
enabling pathogen survival and persistence in the host
(Manns et al., 1994; Watanabe et al., 1999; Luo et al., 2004).
Furthermore, it is known that C. albicans has the ability to
utilize iron to produce a factor that can release haemoglobin
by lysing erythrocytes (Manns et al., 1994; Watanabe et al.,
1999). Production of this haemolytic factor may be regu-
lated by the presence of glucose in the growth medium.
Candida glabrata, C. parapsilosis and C. tropicalis are all able
to produce haemolysins in vitro, inducing partial or total
erythrocyte lyses, although the extent of this is both strain
and species dependent (Luo et al., 2004). Other authors
(Furlaneto-Maia et al., 2007; Kumar et al., 2009; Negri et al.,
2010b) only observed production of haemolysins by
C. albicans. Although haemolysins are known to be putative
virulence factors contributing to pathogenicity in Candida
species, the genetic expression of haemolytic activity of
Candida is poorly understood at present, but a study
conducted by Luo et al. (2004) showed that a haemolysin-
like protein (HLP) gene was associated with the haemolytic
activity of C. glabrata.
Filamentous growth
Hyphae are believed to play an important role in tissue
invasion, and in vitro research has shown that C. albicans
lacking hyphal formation exhibited lower ability to invade
tissue compared with wild-type C. albicans strains (Jayati-
lake et al., 2006). Furthermore, filamentous forms (hyphae
and/or pseudohyphae) of Candida species also demonstrate
increased resistance to phagocytosis compared with yeast
(Gow et al., 2002). The morphological forms exhibited by
C. tropicalis are similar to those shown by C. albicans, but
despite this few studies have explored the importance of
C. tropicalis morphology on virulence. However, Silva et al.
(2010a) demonstrated recently that only filamentous forms
of C. tropicalis were able to invade an oral epithelium. In the
case of C. parapsilosis, it has been found that hyphal
transition occurs in a strain-dependent manner (Enger
et al., 2001), and contrary to C. albicans and C. tropicalis,
the ability of C. parapsilosis to invade an oral epithelium did
not correlate with pseudohyphal production (Silva et al.,
2009b).
Antifungal therapies and mechanisms of
resistance of NCAC species
Compared with antibiotics, the development of antifungal
agents has been relatively limited. This can be attributed to
several factors including inherent problems in the identifi-
cation of an effective agent that acts on eukaryotic fungal
cell type without being toxic to host cells. Resistance to
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298
Table 3. Common antifungal agents used in the management of
candidosis, mode of action and susceptibilities of Candida species
Susceptibility of NCAC species
Antifungal C. albicans C. parapsilosis C. tropicalis C. glabrata
Polyenes Disruption of fungal cell membrane
Amphotericin B S S S S to I
Azoles Inhibition of ergosterol synthesis
Fluconazole S S S SDD to R
Itraconazole S S S SDD to R
Voriconazole S S S S
Posoconazole S S S S
Ravuconazole S S S S
5-Flucytosine Inhibition of DNA and protein synthesis
S S S S
Echinocandins Inhibition of b1,3-D-glucan synthesis
Caspofungin S S S S
Adapted from references Rex et al., 1995, 1997, 2000; Diekema et al.,
2002; Roling et al., 2002; Eggimann et al., 2003; S-DD, susceptible-dose
dependent; I, intermediate; R, resistant.
antifungal drugs is an increasingly recognized phenomenon
and can be defined clinically as the persistence of signs and
symptoms of the infection despite the presence of a tolerable
level of the drug. Depending on the drug and the Candida
species, the mechanism of antifungal resistance can either be
inherent (present without previous exposure to the anti-
fungal) or acquired, where resistance develops in a pre-
viously susceptible organism after a period of exposure to
the agent.
The classification of these drugs is currently based on
their target of activity (Table 3). Polyene antifungals, such as
amphotericin B, are fungicidal due to their ability to interact
with the ergosterol component within the cell membrane to
generate pores, causing cell membrane leakage leading to
loss of cytoplasmic content. Azoles are another class of
antifungal agents that inhibit the biosynthesis of ergosterol
by interfering with the fungal enzyme, lanosterol demethy-
lase. A key function of this enzyme is to convert lanosterol to
ergosterol and the inhibition of this leads to depletion of the
sterol in the fungal cell membrane. Azole antifungals have a
fungistatic or fungicidal activity against Candida species and
the most frequently used azole antifungals are fluconazole
and itraconazole.
5-Flucytosine is an antifungal that enters the fungal cell
through a cytosine permease and is then converted by the
fungus into 5-fluorouracil. This nucleoside analogue gets
incorporated into RNA molecules and subsequently inter-
feres with the synthesis of proteins within the fungal cell.
Several antifungals have been developed that target cell
wall components, for example b-1,3-D-glucan, a key com-
ponent of the fungal cell wall is not present within mamma-
lian cells. Interference with the enzyme b-1,3-D-glucan
synthetase can inhibit the synthesis of b-1,3-D-glucan. A
ª 2011 Federation of European Microbiological Societies
Published by Blackwell Publishing Ltd. All rights reserved
S. Silva et al.
group of antifungals demonstrating this mode of action are
the echinocandins, and three drugs (caspofungin, micofun-
gin and anidulafungin) have shown antifungal activity
against Candida species.
Amphotericin B is generally regarded to have the broadest
spectrum of antifungal activity and is used in cases of serious
and invasive Candida infections, such as in the treatment of
systemic infection in hospitalized patients. Resistance to
amphotericin B remains uncommon during treatment, but
reports of isolates exhibiting elevated minimum inhibitory
concentration (MIC) have become more frequent (Pfaller &
Diekema, 2007). Resistance to polyenes is believed to result
from the alteration of sterol content or composition in the
cell membrane (Ghannoum & Rice, 1999). Lupetti et al.
(2002) described that among Candida species, polyene
resistance was usually due to defective ergosterol biosynth-
esis, and most likely resulted from mutation in the ERG3
gene that produces altered d5,6-sterol desaturase activity. In
addition to ERG3 gene, mutation in ERG11 (the gene that
produces lanosterol 14a-demethylase) and in ERG6 (a gene
that is required for normal membrane function, but is not
essential for sterol biosynthesis) may generate polyene
resistance. Importantly, C. glabrata isolates have been iden-
tified with mutations in the ERG6 gene (Vandeputte et al.,
2007).
The development of the azole antifungals enhanced the
treatment options for fungal infections and their reduced
host toxicity has led to their widespread use. Consequently,
with this extensive use, it is perhaps not surprising that
resistance to these agents, particularly fluconazole, has been
encountered (Rex et al., 1995; Pfaller & Diekema, 2007).
Resistance to the azoles can result from quantitative or
qualitative modifications of target enzymes, reduced access
of the drug to the target or a combination of these mechan-
isms. Qualitative modifications in target enzymes result
from point mutations in ERG11, the gene responsible for
production of 14a-demethylase, which is the principal
target of the azoles. The other primary mechanism by which
Candida species resist the effects of azole antifungals in-
volves the active efflux of the drug out of the cell via the
activation of two kinds of efflux transport proteins encoded
by either MDR or CDR genes (Lupetti et al., 2002; Ghan-
noum & Rice, 1999; Sanglard & Odds, 2002). Candida
glabrata may be intermediately resistant to all azoles and
about 20% of strains develop resistance during therapy and
prophylaxis with fluconazole (Pfaller & Diekema, 2007).
Susceptibility testing has shown that fluconazole is active
against several Candida species, including C. albicans, C.
parapsilosis and C. tropicalis (Pfaller & Diekema, 2007).
Itraconazole is moderately active against most medically
important fluconazole-susceptible and -resistant Candida
species, with the exception of C. glabrata (Pfaller et al.,
2005). Voriconazole exerts fungicidal activity against most
FEMS Microbiol Rev 36 (2012) 288–305
Non-Candida albicans Candida species pathogenicity
yeasts and certain opportunistic fungi, specifically against
some NCAC species (Groll et al., 2001). This agent is
generally active against Candida species including flucona-
zole-resistant C. albicans and C. glabrata (Pfaller & Dieke-
ma, 2007). With the exception of C. tropicalis, voriconazole
is more active than fluconazole against medically important
Candida species (Pfaller & Diekema, 2007). Posaconazole
exerts fungistatic activity against some NCAC species,
including C. glabrata, C. tropicalis and C. parapsilosis (Scozo
et al., 2007).
Flucytosine has a narrow spectrum of activity, and several
mechanisms of resistance are possible due to the multiple
intracellular enzymatic steps required for its action. These
include alterations in the target enzymes UMP pyropho-
sphorylase, cytosine permease and cytosine deaminase, or
increased production of pyrimidines (Atkinson & Israel,
1973). The antifungal spectrum of flucytosine is extremely
narrow: Candida species, Cryptococcus species and Aspergil-
lus species (Polak et al., 1982; Vermes et al., 2000). Further-
more, due to the multiple steps in its mode of action,
including transport into the cell and deamination of the
active compound, flucytosine is normally used only in
combination with other agents, including amphotericin B
and fluconazole (Vermes et al., 2000).
As a class, the echinocandins are the most recent addition
to the antifungal arsenal, and to date their use has been very
limited to assess whether significant resistance will develop
to these agents. Microorganisms that demonstrate inherent
resistance to echinocandins either generate insufficient
target enzyme b-1,3-D-glucan synthase or produce an alter-
nate form of the enzyme with reduced echinocandin bind-
ing. All echinocandins exert fungicidal activity against
Candida species. The echinocandins are highly active against
C. albicans, C. glabrata and C. tropicalis both in vitro and in
vivo (Pfaller et al., 2003, 2005; Bayegan et al., 2010;
Kucharı́nová et al., 2010). It is important is to emphasize
that the MIC values for echinocandins tend to be higher for
C. parapsilosis than for most other common Candida
species, particularly C. albicans (Walsh, 2002).
From the clinical perspective, the most important feature
of Candida biofilms is their role in increasing tolerance to
conventional antifungal therapy. The reduced susceptibility
of C. albicans biofilms to antifungal agents was first reported
in 1995 (Hawser et al., 1995). Furthermore, several groups
have demonstrated that biofilm cells drastically increase
their tolerance to the most commonly used antifungal
agents (fluconazole and amphotericin B) (Ramage et al.,
2001). Biofilms of NCAC species, such as C. tropicalis,
C. parapsilosis and C. glabrata, have also been shown to
exhibit reduced antifungal susceptibility (Hawser &
Douglas, 1994, 1995). Although the mechanisms of biofilm
drug resistance are not fully understood, the current con-
sensus is that biofilm tolerance is a complex multifactorial
FEMS Microbiol Rev 36 (2012) 288–305
299
phenomenon involving different molecular mechanisms,
restricted penetration of the drug through the matrix and
the presence of so-called ‘persister’ cells within the biofilm,
which survive exposure to the agent (Lewis, 2001; Donlan &
Costerton, 2002; Douglas, 2003).
Concluding remarks
Changes in the host are generally required for opportunistic
yeast to alter from harmless commensal microorganisms to
potentially life-threatening human pathogens. Management
of candidosis involves the identification and control of host
factors that may predispose one to infection. Furthermore,
Candida species can exhibit several virulence factors such as
adherence, biofilm formation and secretion of hydrolytic
enzymes that both increase their persistence within the host
as well as cause host cell damage. Therefore, the increase in
the incidence and antifungal resistance of NCAC species,
specifically C. glabrata, C. parapsilosis and C. tropicalis, and
the unacceptably high morbidity and mortality associated
with these species, make it essential to further enhance our
knowledge on the virulence and resistance mechanisms
associated with these species. Studies in this area will con-
tribute towards the identification of new targets for novel
therapeutics against these recently emerged pathogens.
Acknowledgements
The authors acknowledge FCT, Portugal, for supporting
S.S.’s work through grant SFRH/BD/28341/2006 and
CAPES, Brazil, for supporting M.N.’s work through grant
BEX-4642/06-6. We would like to thank Designer Fabio
Grassi for helping in the improvement of the images.
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