Germination-associated antifungal resistance in Candida albicans isolates from Menoufia University Hospitals

Background: Candida albicans (C. albicans) is an opportunistic pathogen, particularly affecting immunocompromised patients. Germ tube formation is a key virulence factor that promotes tissue invasion, immune evasion, and may contribute to antifungal resistance, highlighting the need for effective clinical management. This study aimed to isolate C. albicans from clinical specimens, evaluate antifungal susceptibility profiles, and assess the correlation between germ tube formation and antifungal resistance, including the expression of specific resistance genes. Methods: Fifty C. albicans isolates were collected from 298 patients admitted to various hospital departments and intensive care units. Antifungal susceptibility testing was performed using the disc diffusion method, both before and after germ tube induction. Conventional PCR was performed to detect HWP1and multiplex PCR was conducted to detect MDR1, CDR1, and CDR2 genes. Results: C. albicans was isolated in 16.7% of cases, predominantly from urine specimens (52%) and ICU patients (32%). Clotrimazole showed the highest resistance rate (48%) among azoles, while all isolates remained susceptible to voriconazole. Resistance to flucytosine and echinocandins was low (2% and 8%, respectively). Germination was significantly associated with reduced susceptibility to fluconazole, ketoconazole, and miconazole (p < 0.05). Gene detection revealed HWP1 in 46% of isolates, MDR1 and CDR1 in 2% and 6%, respectively, and co-occurrence of all four genes in 22%. No resistance genes were detected in 24% of isolates. Conclusion: Germination in C. albicans correlates with increased resistance to azole antifungals. Routine evaluation of germ tube formation alongside antifungal susceptibility testing may enhance clinical decision-making and infection control strategies.