Antifungal susceptibility.

MICs were determined for all isolates for 3 antifungal agents: fluconazole, provided by Pfizer, Inc., (New York, USA), Sigma-Aldrich (Merck KGaA, Darmstadt, Germany), and Alsachim (Shimadzu Group Company, France); voriconazole, provided by Pfizer and Alsachim; and posaconazole provided by SheringPlough (Merck & Co., Inc., USA) and Alsachim. The MICs were determined by the standardized broth microdilution method of EUCAST following the procedure E.DEF 7.3.2 (https://www.eucast.org/fileadmin/src/media/PDFs/EUCAST_files/AFST/Files/EUCAST_E_Def_7.3.2_Yeast_testing_definitive_revised_2020.pdf) in 96-well, flat bottom, clear polystyrene, sterile tissue culture plates (product no. 92096; TPP Techno Plastic Products AG, Switzerland). The concentrations tested ranged between 0.0015 and 8 mg/liter for posaconazole and voriconazole and between 0.125 and 64 mg/liter for fluconazole. QC strains (ATCC 22019 and ATCC 6258) were included in each set. The concentrations corresponding to the MIC that inhibited 50% (MIC₅₀) and 90% (MIC₉₀) of the isolates were determined for species with 10 or more isolates.

Our data set (MIC distribution) was compared with that available on the EUCAST website (https://mic.eucast.org/Eucast2/SearchController/search.jsp?action=init; June 2020).

The BP or ECOFF values determined by EUCAST for some species and some antifungal agents (https://www.eucast.org/fileadmin/src/media/PDFs/EUCAST_files/AFST/Clinical_breakpoints/AFST_BP_v10.0_200204.pdf) were used to calculate the percentages of resistant (R) and non-wild-type (NWT) isolates, respectively. Non-species-related BPs for fluconazole, defined by EUCAST (MIC > 16 mg/liter) for Candida, were also used to calculate percentages of resistant isolates for C. orthopsilosis, C. metapsilosis, C. nivariensis, C. haemulonii, C. duobushaemulonii, and C. palmioleophila. Since not all isolates were collected through unbiased epidemiological survey (7,358/9,319 [78.8%]), we did not determine the local ECOFF and reported only the percentage of resistant or non-wild-type isolates in our collection.