Editorial
C. parapsilosis: The importance of an emerging pathogen
C. parapsilosis: la importancia de un patógeno emergente
a Microbiology Department, Hospital Universitari Vall d’Hebron, Barcelona, Spain
b Department of Infectious Diseases, Hospital Universitari de Bellvitge, Institute for Biomedical Research (IDIBELL), l’Hospitalet de Llobregat, Barcelona, Spain
c Center for Biomedical Research in Infectious Diseases Network (CIBERINFEC; CB21/13/00009), Instituto de Salud Carlos III, Madrid, Spain
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"paginaInicial" => "67" "paginaFinal" => "69" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "María Teresa Martín-Gómez, Mireia Puig-Asensio" "autores" => array:2 [ 0 => array:4 [ "nombre" => "María Teresa" "apellidos" => "Martín-Gómez" "email" => array:1 [ 0 => "mariateresa.martin@vallhebron.cat" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:4 [ "nombre" => "Mireia" "apellidos" => "Puig-Asensio" "email" => array:1 [ 0 => "mpuiga@bellvitgehospital.cat" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Microbiology Department, Hospital Universitari Vall d’Hebron, Barcelona, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Department of Infectious Diseases, Hospital Universitari de Bellvitge, Institute for Biomedical Research (IDIBELL), l’Hospitalet de Llobregat, Barcelona, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Center for Biomedical Research in Infectious Diseases Network (CIBERINFEC; CB21/13/00009), Instituto de Salud Carlos III, Madrid, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "<span class="elsevierStyleItalic">C. parapsilosis</span>: la importancia de un patógeno emergente" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Woolhouse defined an emerging pathogen as ‘<span class="elsevierStyleItalic">an infectious agent whose incidence is increasing following its first introduction into a new host population</span>’.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">1</span></a> Emergence mainly applies to two particular situations: (a) the description of an entirely new species as a result of taxonomic changes; (b) the description of a previously unknown/rarely documented association between a known species and a host pathological state. A re-emerging pathogen, in contrast, is ‘<span class="elsevierStyleItalic">one whose incidence is increasing in an existing host population as a result of long-term changes in its underlying</span><span class="elsevierStyleItalic">epidemiology</span>’. That evident increase in the number of cases caused by a particular species is usually linked to an evolutionary advantage newly developed by a known pathogen and/or to the expansion of the range of susceptible hosts.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Contemporary Medical Mycology has witnessed a bloom of emergent and re-emergent fungal pathogens, with <span class="elsevierStyleItalic">Candida auris</span>, triazole-resistant <span class="elsevierStyleItalic">Aspergillus fumigatus</span>, or COVID-19 associated mucormycosis being only a few recent notorious examples all of us are familiar with. But, can we apply the adjective emergent/re-emergent to species within the <span class="elsevierStyleItalic">Candida parapsilosis</span> complex? To answer this question, let's take a few minutes for reflection.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Cryptic species of the <span class="elsevierStyleItalic">C. parapsilosis</span> complex</span><p id="par0015" class="elsevierStylePara elsevierViewall">The first description of what we know today as <span class="elsevierStyleItalic">Candida parapsilosis</span> dates back to 1928. Seventy years would have to pass to recognize the existence of three separate species within the complex, namely <span class="elsevierStyleItalic">C. parapsilosis</span> sensu stricto, <span class="elsevierStyleItalic">C. metapsilosis</span>, and <span class="elsevierStyleItalic">C. orthopsilosis</span>.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Despite the interaction of <span class="elsevierStyleItalic">C. metapsilosis</span> and <span class="elsevierStyleItalic">C. orthopsilosis</span> with humans is thought to be mainly restricted to superficial colonization, they are able to cause invasive disease and candidemia. The rate of clinical infections, however, is considerably lower than <span class="elsevierStyleItalic">C. parapsilosis</span> sensu stricto and, according to published surveillance reports, these species may account for less than 9% of the <span class="elsevierStyleItalic">C. parapsilosis</span> complex infections.<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">2,3</span></a> Thus, by the time <span class="elsevierStyleItalic">C. metapsilosis</span> and <span class="elsevierStyleItalic">C. orthopsilosis</span> were described as separate entities, they merited to be considered emergent pathogens, but as no epidemiological changes have been noted since then, this may not hold true. Does this mean that they are no longer able to raise the interest of mycologists? The answer is no.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Until recently, microbiological methods commonly used in routine labs have not allowed the differentiation of the three species within the complex. This has hampered the precise identification of their epidemiology or the differences and similarities in their biology. However, as illustrated in the work Ruiz de Alegría and cols in this number of <span class="elsevierStyleItalic">Enfermedades Infecciosas y Microbiología Clínica</span>,<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">4</span></a> growing evidence points towards specific traits that justify the limited presence of <span class="elsevierStyleItalic">C. metapsilosis</span> and <span class="elsevierStyleItalic">C. orthopsilosis</span> in human pathology. As compared to <span class="elsevierStyleItalic">C. parapsilosis</span> sensu stricto, <span class="elsevierStyleItalic">C. metapsilosis</span> seems to present decreased virulence<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">5</span></a> and both <span class="elsevierStyleItalic">C. metapsilosis</span> and <span class="elsevierStyleItalic">C. orthospilosis</span> have reduced ability to produce biofilms. This reduced adherence may be one of the reasons why no nosocomial outbreaks have been related to the complex cryptic species.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Another interesting point is that the in vitro susceptibility behaviour of <span class="elsevierStyleItalic">C. metapsilosis</span> does not match that of <span class="elsevierStyleItalic">C. parapsilosis</span>, with fluconazole MICs moving in a slightly superior range. <span class="elsevierStyleItalic">C. orthopsilosis</span>, in turn, seems to be naturally susceptible to fluconazole. It should not be overlooked, however, that the Y132F mutation in the ERG11 gene (associated with fluconazole resistance), has been sporadically described in the latter.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">6</span></a> To date, it is unknown whether the breakpoints defined for <span class="elsevierStyleItalic">C. parapsilosis</span> also apply to their two siblings in the complex or if the treatment recommendations given in clinical guidelines result in similar success rates for the three species.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010"><span class="elsevierStyleItalic">Candida parapsilosis</span> sensu stricto: what's up, old chap?</span><p id="par0035" class="elsevierStylePara elsevierViewall">Initially considered to be non-pathogenic, decades of clinical experience have proven that, besides a common colonizer of the human skin, <span class="elsevierStyleItalic">Candida parapsilosis</span> sensu stricto is one of the major medically relevant fungal pathogens. It is of particular importance in warm-temperate areas, ranking as the second leading cause of bloodstream fungal infections in European countries of the Mediterranean Basin, Latin America, and Asia.<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">7</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">One of the key features of this species is its ability to attach and persist on inert surfaces thanks to its capacity to develop biofilms. This trait is the basis for the increased risk of catheter-related infections in fragile patients, but also for the long-standing persistence of this yeast in the nosocomial environment. Persistence, coupled with easy cross-transmission via the skin of healthcare workers’ hands or contaminated material, sets the scenario for a terrifying perfect storm: a long-standing hospital outbreak. In 1975, Plouffe et al. described a significant accumulation of <span class="elsevierStyleItalic">C. parapsilosis</span> candidemia cases linked to the use of contaminated hyperalimentation and albumin solutions in Michigan,<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">8</span></a> earning on its own merit the title of “emerging pathogen” and heralding the increasing number of genotypically related nosocomial cases that we can trace back in the literature nowadays. Outbreaks have mainly occurred in neonatal and adult intensive care units,<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">9</span></a> but have also been associated with surgical procedures after exposure to contaminated environmental reservoirs.<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">10</span></a> Of interest, cross-transmission has been documented to occur not only among patients admitted to a particular hospital ward, but also between hospitals.<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">11</span></a> Under the light of the currently existing body of evidence, why put back the focus on <span class="elsevierStyleItalic">C. parapsilosis</span>? Because many recent reports of <span class="elsevierStyleItalic">C. parapsilosis</span> nosocomial outbreaks have been caused by fluconazole non-susceptible clones.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Wildtype <span class="elsevierStyleItalic">C. parapsilosis</span> sensu stricto strains are characterized by an exquisite susceptibility to triazoles whereas, as compared to other important <span class="elsevierStyleItalic">Candida</span> species, it displays a reduced in vitro susceptibility to echinocandins. In Spain, as in other worldwide surveillance reports, the prevalence of fluconazole-resistant strains has been traditionally lower than 5%.<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">12</span></a> In Europe, however, this panorama has started to change with the sudden rise of fluconazole non-susceptible strains noted in 2015 at the expense of outbreaks involving centres from northern Italy.<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">13</span></a> Since then, outbreaks have been reported in France, Greece, Turkey, Brazil, Mexico, South Korea, and now, also in Spain.<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">11,14</span></a> Spanish isolates were first detected in Palma de Mallorca in 2015.<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">14</span></a> Since then, more than 10 hospitals in different geographical areas (Barcelona, Madrid, Burgos, Santander) have identified this new threat so far.<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">15</span></a> Such epidemiological global shift makes <span class="elsevierStyleItalic">C. parapsilosis</span> meet the definition of a re-emergent pathogen meriting the consideration of a priority species to keep under surveillance.</p><p id="par0050" class="elsevierStylePara elsevierViewall">The emergence of fluconazole non-susceptible <span class="elsevierStyleItalic">C. parapsilosis</span> sensu stricto resembles <span class="elsevierStyleItalic">Candida auris</span> in different aspects. First, it has the potential for silent dissemination. In centres without well-implemented screening policies, the spreading of non-susceptible strains goes undetected until the first cases of invasive infection develop. Second, once it is established in the environment, it is very difficult to eradicate, leading to long-lasting endemic situations. Data regarding the efficacy of common disinfectants are scarce and evidence on the most effective cleaning and disinfection procedures is lacking,<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">16</span></a> which hampers the design and implementation of appropriate policies aimed at the eradication of this species from the environment. And third, in case of infection, the antifungal treatment of choice is under debate. Guidelines recommend fluconazole as the preferred treatment for <span class="elsevierStyleItalic">C. parapsilosis</span> infections when the isolate is reported as susceptible. However, they fail to offer advice in cases of non-susceptible isolates due to the absence of solid scientific evidence to guide the proper management of these cases. At present, both liposomal amphotericin B and echinocandins might be options of treatment.</p><p id="par0055" class="elsevierStylePara elsevierViewall">In vivo studies with the <span class="elsevierStyleItalic">Galleria melonella</span> model suggest that fluconazole-non susceptible <span class="elsevierStyleItalic">C. parapsilosis</span> isolates carrying the Y132F mutation (the most frequently found in outbreaks) are not necessarily more virulent and that amphotericin B might be an effective treatment,<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">17</span></a> albeit its potential risk for toxicity. As an alternative, echinocandins might be considered a safer option. Some clinicians might be concerned by the reduced in vitro activity of <span class="elsevierStyleItalic">C. parapsilosis</span> complex isolates against echinocandins and its theoretically decreased response to therapy. A limited number of randomized controlled trials have shown that echinocandin use is more frequently associated with persistent candidemia and microbiological failure when compared to fluconazole or amphotericin B in the subgroup of susceptible <span class="elsevierStyleItalic">C. parapsilosis</span> isolates.<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">18,19</span></a> However, observational studies have failed to link the use of echinocandins with increased clinical failure or 30-day mortality.<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">20</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Setting aside the in vitro susceptibility profile, other major factors must be carefully balanced before deciding on the treatment: potential and severe side-effects should be considered when administering amphotericin B and the risk of clinical failure should be monitored when administering echinocandins, especially if the source of infection cannot be controlled. As for today, we lack scientific evidence to recommend which antifungal treatment is the best therapeutic option for fluconazole-non susceptible isolates.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Relevance of the <span class="elsevierStyleItalic">C. parapsilosis</span> complex from a Public Health perspective</span><p id="par0065" class="elsevierStylePara elsevierViewall">In light of previously presented data, <span class="elsevierStyleItalic">C. parapsilosis</span> has re-emerged as a pathogen of public health importance that has captured the attention of the scientific community. Similar to <span class="elsevierStyleItalic">C. auris</span>, it is of nosocomial relevance and infection prevention strategies are essential to control the worldwide spread of fluconazole non-susceptible <span class="elsevierStyleItalic">C. parapsilosis</span> strains. Not surprisingly, the World Health Organization has listed azole-resistant <span class="elsevierStyleItalic">Candida</span> species as a priority fungal pathogen to keep under surveillance and in need of more research. Gaps in knowledge remain for optimal treatment options and critical infection control interventions.</p><p id="par0070" class="elsevierStylePara elsevierViewall">In Spain, the National Centre for Microbiology from the Instituto de Salud Carlos III acts as a national reference centre for clinically isolated fungi. However, it is not mandatory to surveil all <span class="elsevierStyleItalic">Candida</span> isolates and detecting real-time epidemiological changes at a national level is challenging. These limitations hamper our capacity of response to fungal outbreaks and our ability to detect and prevent cross-transmission between hospitals. However, local initiatives are also important and offer a front-line surveillance response to <span class="elsevierStyleItalic">Candida</span> infections/outbreaks. At a hospital level, laboratories can track a new resistant pattern in yeasts or an unexpected cluster of candidemia cases in a specific unit. In this line, every effort to strengthen the lab capacity to correctly identify <span class="elsevierStyleItalic">Candida</span> species should be encouraged, as this is the first step to improving our health system.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">4</span></a> Finally, we should not forget that stewardship strategies aimed at optimizing antifungal use are of special relevance to address the growing concern of antifungal resistance.</p><p id="par0075" class="elsevierStylePara elsevierViewall">In conclusion, is <span class="elsevierStyleItalic">C. parapsilosis</span> an emergent/re-emergent pathogen? The answer is yes. Spain is experiencing a worrying rise of fluconazole non-susceptible <span class="elsevierStyleItalic">C. parapsilosis</span> strains capable of causing long-lasting outbreaks. Global awareness of this new threat is key to surveil this re-emerging pathogen we cannot let go under-recognized.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Funding</span><p id="par0080" class="elsevierStylePara elsevierViewall">None.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conflict of interest</span><p id="par0085" class="elsevierStylePara elsevierViewall">M. Martín-Gómez and M. Puig-Asensio have received honoraria on behalf of Gilead and Pfizer.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:6 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Cryptic species of the C. parapsilosis complex" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Candida parapsilosis sensu stricto: what's up, old chap?" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Relevance of the C. parapsilosis complex from a Public Health perspective" ] 3 => array:2 [ "identificador" => "sec0020" "titulo" => "Funding" ] 4 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflict of interest" ] 5 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:20 [ 0 => array:3 [ "identificador" => "bib0105" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Population biology of emerging and re-emerging pathogens" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "M.E. 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