Mechanisms of resistance to cell wall and plasma membrane targeting antifungal drugs in Candida species isolated in Africa.

Introduction: There is a rise in the emergence of multidrug resistant fungal pathogens worldwide, including in Africa.

Method: This systematic review summarized the published data on the mechanisms and epidemiology of antifungal resistance in Candida species in Africa between 2000 and early 2024.

Result: Seventeen reports from seven African countries were analyzed but due to the paucity of data, the prevalence of antifungal resistant Candida isolates in Africa could not be estimated. However, a total of 1376 (out of 2812) resistant isolates were documented with South Africa reporting the most. Candida auris was the most reported species with multidrug and pandrug resistant strains documented in South Africa. Generally, azoles but not posaconazole or isavuconazole, resistance was reported. Fluconazole resistant isolates harbored Erg11 Y132F, VF125LA and K177A/R/N335S/E343D substitutions, MRR1 gain of function mutations or efflux pump protein over expression. Resistance to members of the echinocandin family was also reported and Fks1 S639P substitution was observed.

Conclusion: The data highlight that the increasing Candida species resistance to cell wall and cell membrane active antifungals is a cause for serious concern in Africa. There is need to increase antifungal research capacity and mount epidemiological surveillance to determine the true scale of the problem.

Prospero registration number: CRD42024550231.