Reduction of susceptibility to azoles and 5-fluorocytosine and growth acceleration in Candida albicans by glucose in urine

Candida albicans species are causal pathogens for urinary tract infections, vulvovaginitis, and balanitis. Diabetes mellitus is a risk factor for Candida infection. To investigate the potential effects of glucosuria on Candida spp. (C. albicans,C. krusei, and C. glabrata), we investigated the influence of their growth and antifungal susceptibilities by glucose in urine. C. albicans spp. exhibited greater growth in urine with glucose (300 and 3,000 mg/dL) than in plain urine taken from healthy volunteers. After 24 h incubation, the viable cell number was more than 10-fold higher in the urine added 3,000 mg/dL glucose than in plain urine. In antifungal susceptibility, more than 80% of C. albicans clinical isolates increased minimum inhibitory concentrations of azoles (fluconazole, itraconazole, voriconazole, and miconazole) and 5-fluorocytosine with the addition of glucose exceeding their breakpoints. This phenomenon was not observed in clinical isolates of C. krusei and C. glabrata. We observed the growth in the urine to which 3,000 mg/dL glucose was added even in the presence of a 128-fold higher minimum inhibitory concentration of fluconazole. In most of the C. albicans clinical isolates, the mRNA expression of the azole resistance genes ERG11, CDR1, CDR2 and MDR1 increased in glucose-added urine compared with plain urine. In conclusion, the growth ofC. albicans is accelerated and azoles and 5-fluorocytosine become ineffective as a result of a high concentration of glucose in urine. These observations provide valuable information about the clinical course and therapeutic effects of azoles against C. albicans infections in patients with diabetes mellitus and hyperglucosuria.