Emergence of multiple resistance profiles involving azoles, echinocandins and amphotericin B in Candida glabrata isolates from a neutropenia patient with prolonged fungaemia

Sir, Candida glabrata fungaemia has gradually increased worldwide over the last decade, probably due to more frequently acquired resistance to azoles and echinocandins in Candida species.1 Here, we report the emergence of multidrug resistance involving azoles, echinocandins and amphotericin B in 10 serial bloodstream isolates of C. glabrata from a paediatric transplant patient. The patient showed persistent fungaemia despite 80 days of antifungal therapy. This report highlights the diversity and possible coexistence of multiple resistance profiles in the clonal isolates of C. glabrata from a patient with prolonged fungaemia. This case study was granted exemption from Institutional Review Board review (IRB no. 2014-1109). In 2012, a male patient who had undergone HLA-haploidentical stem cell transplantation due to AML was admitted for neutropenic fever that had developed 2 days earlier. The bone marrow revealed relapsed leukaemia and neutropenia was never recovered. C. glabrata was isolated repeatedly from blood and urine cultures between hospital day (HD) 80 and HD 160. The Hickman catheter indwelled for 242 days was removed on HD 97 and the tip culture was negative. The patient was treated with micafungin for 23 days from HD 82 to 104, amphotericin B for 16 days from HD 105 to 120 and 40 days from HD 124 to 163, and caspofungin for 6 days from HD 121 to 126 and 16 days from HD 147 to 162. The chest CT suggested fungal pneumonia on HD 128. Transoesophageal echocardiography was performed three times, but all were normal. The patient died on HD 164 (Figure 1).