A study conducted by Seneviratne et al. [109] showed that Candida spp. isolates resistant to azoles and caspofungin showed a higher Sap activity than the susceptible isolates. The results obtained by Schulz et al. [110] evaluated, among other virulence-related Ibrutinib nmr factors, the secretion of proteinases in isolates of Candida spp. susceptible and resistant to fluconazole. No significant differences were observed among them. According to the study, the absence of a drug selective pressure may have hindered the emergence of differences in virulence,

but it is known that the qualitative method of determination of Sap proteolytic activity hardly detects small differences in the level of activity. Barelle et al. [111] observed that azole

antifungal agents stimulated up-regulation of SAP4 and SAP6 genes in filamentous C. Deforolimus in vivo albicans cells in vitro, possibly influencing virulence as well as growth of the fungus. However, these effects appear to be transient in vivo. In a study by Ripeau et al. [112], the expression of SAP1–SAP3 and SAP7–SAP9 in C. albicans, determined by RT-PCR, was unaltered after exposure to fungicidal concentrations of caspofungin, while expression of SAP5 increased progressively. They also reported that suppression of SAP gene expression by caspofungin did not occur at concentrations found in plasma in the clinical treatment of candidiasis. Copping et al. [113] tested the influence of azoles, amphotericin BCKDHB B, caspofungin and flucytosine on Sap activity in isolates of C. albicans. These antifungal agents, with different mechanisms of action, produced a rise in SAP2 expression and in secreted Sap2 gene product activity in most isolates. The differences in Sap activity in isolates susceptible to azoles when exposed to these drugs suggest that there are other factors that interfere in this response.[107] Candida spp. acquire azole resistance through the overexpression of efflux pumps, predominantly ABC transporters. Overexpression of a putative pump (Cdr l) in C. albicans may result in increased resistance to several antifungals. However, there is no evidence that these putative drug pumps

are directly involved in drug translocation and the substrate specificity for transport is not known,[114] Therefore, the increased activity of Sap in strains of Candida spp. resistant to fluconazole might be associated with the action of the efflux pumps in Kex2-like proteinase in the Golgi compartment that processes and activates Sap preproenzymes.[56] According to Kumar et al. [108] increased activity of Sap in isolates resistant to amphotericin B must also occur by similar mechanisms. Most researchers work with methodologies that assess the secretion of Saps by planktonic cells, but it is very important to remember that yeast do not live singly in the host, but are always grouped into biofilms.[104] Schulz et al.