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Year : 2007  |  Volume : 25  |  Issue : 4  |  Page : 405-407

Candida spp. other than Candida albicans: A major cause of fungaemia in a tertiary care centre

Department of Microbiology, Amrita Institute of Medical Sciences and Research Centre, Kochi - 682 026, Kerala, India

Date of Submission22-Feb-2006
Date of Acceptance04-Mar-2007

Correspondence Address:
S Shivaprakasha
Department of Microbiology, Amrita Institute of Medical Sciences and Research Centre, Kochi - 682 026, Kerala
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0255-0857.37350

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 ~ Abstract 

This study was conducted to determine the frequency of different Candida spp. isolated from different parts of the hospital, associated risk factors and mortality rate. A total of 59 cases were selected for prospective analysis over a period of one and half years. Blood samples collected were processed by BACTEC (9240) method. Candidaemia was diagnosed by positive blood culture at least from two blood culture samples or from a clinically significant single blood culture sample. Candida spp. were identified by standard techniques. Most frequent isolates were C. tropicalis (35.6%), C. parapsilosis (28.8%), C. glabrata (11.9%) and C. pelliculosa (11.9%). Candida albicans was isolated only in 3.4% cases. Neonatology department accounted for highest number of isolates (27.1%), followed by gastrointestinal surgery (15.3%) and cardiac surgery (13.6%). Mortality was noted in 16.9%. Probable risk factors determined were intensive care unit stay (74.6%), antibiotic therapy (50.8%), central line (42.4%), urinary catheter (32.2%), ventilator (23.7%), malignancy (20.3%) and abdominal surgery (15.3%).

Keywords: Candidaemia, Candida tropicalis, Candida spp

How to cite this article:
Shivaprakasha S, Radhakrishnan K, Karim P. Candida spp. other than Candida albicans: A major cause of fungaemia in a tertiary care centre. Indian J Med Microbiol 2007;25:405-7

How to cite this URL:
Shivaprakasha S, Radhakrishnan K, Karim P. Candida spp. other than Candida albicans: A major cause of fungaemia in a tertiary care centre. Indian J Med Microbiol [serial online] 2007 [cited 2020 May 31];25:405-7. Available from:

Blood stream infections (BSI) due to Candida spp. are becoming an increasingly important cause of morbidity and mortality in hospitalized patients. Candida spp. have been shown to be the fourth most common cause of nosocomial BSI in the United States. Candida albicans has historically been the most frequent cause of candidaemia. However, over the last two decades, both the incidence of nosocomial candidaemia and the proportion of BSI due to Candida spp. other than C. albicans have increased. [1],[2] Limited Indian studies have also shown shift to Candida spp. other than C. albicans . [3],[4] Candida spp., which have been implicated are C. tropicalis , C. glabrata and C. parapsilosis . Previous studies have suggested that possible risk factors for candidaemia are antibiotic therapy, chemotherapy, presence of intravascular catheters, malignancy, surgery, parenteral nutrition, intensive care unit stay and prior fungal colonization. [1],[5],[6],[7] This study was conducted to determine the frequency of different Candida spp. isolated from different specialties, to predict the associated risk factors and mortality rate among hospitalized candidaemic patients in our hospital.

 ~ Materials and Methods Top

Candidaemia was diagnosed by isolation of Candida spp. from at least two blood culture samples or from a clinically significant single blood culture sample among hospitalized patients. Prospective study was conducted over one and half years, and 59 cases of candidaemia were selected. Patient's demographic features such as age, sex, department, patient location, date of admission, dates on which results of blood culture were positive, underlying illness, associated risk factors such as central line insertion, presence of urinary catheter, respiratory ventilation, duration of antibiotic therapy and antifungal prophylaxis if any, were considered. All the cases were followed up for one month and mortality was noted. Death attributed to candidaemia was defined as death which occurred ≤48 h after a blood culture positive for Candida spp., persistent candidiasis at clinical sites, and indication by clinician that candidiasis significantly contributed to death.

Blood samples collected were processed by BACTEC (9240). Samples that flagged positive for yeast species were cultured on Sabouraud dextrose agar. Speciation was done by germ tube test, sugar assimilation test, morphology on corn meal agar and urease reaction. Isolates which could not be identified by conventional techniques were identified by 32 ID (bioMιrieux). Sensitivity test was done on yeast nitrogen base glucose agar by disc diffusion method.

Statistical analysis was done using SPSS (Statistical Package for Social Sciences) version 11. Categorical variables were reported by using frequencies. To test the statistical significance of the association of mortality with different factors, Fisher's exact test was done and the exact P -values were obtained ( P < 0.05 was considered significant).

 ~ Results Top

A total of 59 cases of candidaemia were selected for analysis. Apart from Candida spp., other yeast species isolated during this period were three Trichosporon spp. and Cryptococcus neoformans from an HIV positive patient.

Male predominance was noted in ( n = 42/59) 71.2%. Candidaemia was associated more frequently with infants ( n = 26/59) 44% and ≥40-year age group ( n = 14/59) 23.7%. Neonatology department (27.1%) accounted for highest number of isolates followed by gastrointestinal surgery (15.3%) and cardiac surgery 13.6% [Table - 1]. Most frequent isolates were C. tropicalis 35.6%, C. parapsilosis 28.8%, C. glabrata 11.9% and C. pelliculosa 11.9% [Table - 2].

Common isolates from neonatal intensive care unit were C. pelliculosa ( n = 5/16, 31.3%) and C. glabrata ( n = 5/16, 31.3%). From gastrointestinal surgery, C. parapsilosis ( n = 4/9, 44.4%) and C. tropicalis ( n = 4/9 44.4%) were common. From cardiac surgery, C. tropicalis ( n = 4/8, 50%) were common. Maximum number of isolates were from intensive care unit ( n = 44/59, 74.6%). All isolates of C. glabrata (100%), C. tropicalis (76.1%) and C. pelliculosa (85.7%) were from intensive care units. There was not much difference in isolation rate, between ward and intensive care unit for C. parapsilosis .

Probable risk factors determined were intensive care unit stay ( n = 44/59, 74.6%), antibiotic therapy ( n = 30/59, 50.8%), central line ( n = 25/59, 42.4%), urinary catheter ( n = 19/59, 32.2%), ventilator ( n = 14/59, 23.7%), malignancy ( n = 12/59, 20.3%) and abdominal surgery ( n = 9/59, 15.3%). Overall mortality was noted in ( n = 10/59, 16.9%). Three patients died before instituting antifungal therapy and seven patients (11.8%) died after institution of antifungal therapy ( P = 0.004). Eight patients were in the age group of ≥40 years ( P = 0.013).

 ~ Discussion Top

Our study shows that there is emergence of Candida spp. other than C. albicans as a major cause of candidaemia. Other Indian studies also have documented shift to these species, C. tropicalis being the most commonly isolated. [3],[4] Emergence of Candida spp. other than C. albicans is due to selection of less susceptible species by the pressure of antifungal agent such as fluconazole apart from associated risk factors and underlying disorders. [8]

In our study, we observed that intensive care unit stay, antibiotics and central line played a major role in development of candidaemia. Univariate analysis of these probable risk factors against the species was statistically not significant. This is probably due to smaller number of cases studied.

Candida tropicalis was the most frequent isolate in our study. Recent data have shown that C. tropicalis is the second or third leading cause of candidaemia in adults, especially in patients with lymphoma, leukaemia and diabetes mellitus. [9] Candida parapsilosis has been isolated from HCW's hands, particularly of those working in neonatal ICUs. [10] Candida parapsilosis has been associated with endemic and epidemic nosocomial infections traced to total parenteral nutrition or intravascular devices. [11]

Candida glabrata and C. pelliculosa are the common species responsible for neonatal septicaemia in our study. Common underlying illness among neonates was septicaemia and respiratory distress syndrome. Low birth weight was noted in n = 4/16 (25%) and preterm in n = 5/16 (31.25%). Candida glabrata shows increased innate resistance to antifungal agents, specifically the azoles. According to several investigators, the increase in the frequency of C. glabrata infections has paralleled the increased use of fluconazole in some hospitals. In a more recent study, however, investigators described the association between C. glabrata infection and amphotericin B use rather than fluconazole. [12] In our study, only four patients who developed candidaemia were on fluconazole prophylaxis and none of these infections were due to C. glabrata .

Candida pelliculosa , a rare clinical isolate, has been implicated in an outbreak of nosocomial fungaemia in paediatric patients and from neonatal intensive care units. [13],[14] Further studies are required on these aspects at our centre.

Mortality attributable to candidaemia reported from other studies is 12-38%. [15],[16],[17] In our study, we noted 16.9% mortality. Age group ≥ 40 years (32% vs. 5.9%) was significantly associated with mortality compared to age group < 40 years. It is well-established fact that C. albicans is more virulent than other Candida spp. [18] In our study, there was no significant association of mortality with different species. This could be due to smaller number of cases studied.

From our study we are of the opinion that, of the fungal pathogens, Candida spp. other than C. albicans are a major cause of morbidity in hospitalized patients. Early antifungal therapy improves the outcome.

 ~ References Top

1.Nguyen MH, Peacock JE Jr, Morris AJ, Tanner DC, Minh LN, Snydman DR, et al . The changing face of candidemia: Emergence of non- Candida albicans species and antifungal resistance. Am J Med 1996; 100 :617-23.  Back to cited text no. 1    
2.Pfaller MA, Jones RN, Doern GV, Sader HS, Messer SA, Houston A, et al . Bloodstream infections due to Candida species: SENTRY antimicrobial surveillance program in North America and Latin America, 1997-1998. Antimicrob Agents Chemother 2000; 44 :747-51.  Back to cited text no. 2  [PUBMED]  [FULLTEXT]
3.Agarwal J, Bansal S, Malik GK, Jain A. Trends in neonatal septicemia: Emergence of non- albicans Candida. Indian Pediatr 2004; 41 :712-5.  Back to cited text no. 3  [PUBMED]  [FULLTEXT]
4.Singhi SC, Reddy TC, Chakrabarti A. Candidaemia in a pediatric intensive care unit. Pediatr Crit Care Med 2004; 5 :369-74.  Back to cited text no. 4  [PUBMED]  [FULLTEXT]
5.Beck-Sague CM, Jarvis WR. The national nosocomial infection surveillance system: Secular trends in the epidemiology of nosocomial fungal infections in the United States. J Infect Dis 1993; 167 :1247-51.  Back to cited text no. 5    
6.Fridkin SK, Jarvis WR. Epidemiology of nosocomial fungal infections. Clin Microbiol Rev 1996; 9 :499-511.  Back to cited text no. 6  [PUBMED]  [FULLTEXT]
7.Blumberg HM, Jarvis WR, Soucie JM, Edwards JE, Patterson JE, Pfaller MA, et al . Risk factors for candidal bloodstream infections in surgical intensive care unit patients: The NEMIS prospective multicenter study. Clin Infect Dis 2001; 33 :177-86.  Back to cited text no. 7  [PUBMED]  [FULLTEXT]
8.Berrouane YF, Herwaldt LA, Pfaller MA. Trends in antifungal use and epidemiology of nosocomial yeast infections in a university hospital. J Clin Microbiol 1999; 37 :531-7.  Back to cited text no. 8  [PUBMED]  [FULLTEXT]
9.Kao AS, Brandt ME, Pruitt WR, Conn LA, Perkins BA, Stephens DS, et al . The Epidemiology of candidemia in two United States cities: Results of a population-based active surveillance. Clin Infect Dis 1999; 29 :1164-70.  Back to cited text no. 9  [PUBMED]  [FULLTEXT]
10.Strausbaugh LJ, Sewell DL, Ward TT, Pfaller MA, Heitzman T, Tjoelker R. High frequency of yeast carriage on hands of hospital personnel. J Clin Microbiol 1994; 32 :2299-300.  Back to cited text no. 10  [PUBMED]  [FULLTEXT]
11.Weems JJ Jr, Chamberland ME, Ward J, Willy M, Padhye AA, Solomon SL. Candida parapsilosis fungemia associated with parenteral nutrition and contaminated blood pressure transducers. J Clin Microbiol 1987; 25 :1029-32.  Back to cited text no. 11  [PUBMED]  [FULLTEXT]
12.Fidel PL Jr, Vazquez JA, Sobel JD. Candida glabrata : Review of epidemiology, pathogenesis, and clinical disease with comparison to C. albicans . Clin Microbiol Rev 1999; 12 :80-96.  Back to cited text no. 12    
13.Chakrabarti A, Singh K, Narang A, Singhi S, Batra R, Rao KL, et al . Outbreak of Pichia anomala infection in the pediatric service of a tertiary-care center in Northern India. J Clin Microbiol 2001; 39 :1702-6.  Back to cited text no. 13  [PUBMED]  [FULLTEXT]
14.Pasqualotto AC, Sukiennik TC, Severo LC, de Amorim CS, Colombo AL. An outbreak of Pichia anomala fungemia in a Brazilian pediatric intensive care unit. Infect Control Hosp Epidemiol 2005; 26 :553-8.  Back to cited text no. 14  [PUBMED]  [FULLTEXT]
15.Pappas PG, Rex JH, Lee J, Hamill RJ, Larsen RA, Powderly W, et al . A prospective observational study of candidemia: Epidemiology, therapy, and influences on mortality in hospitalized adult and pediatric patients. Clin Infect Dis 2003; 37 :634-43.  Back to cited text no. 15  [PUBMED]  [FULLTEXT]
16.Wey SB, Mori M, Pfaller MA, Woolson RF, Wenzel RP. Hospital acquired candidemia. Arch Intern Med 1988; 148 :2642-5.  Back to cited text no. 16  [PUBMED]  
17.Wenzel RP. Nosocomial candidemia: Risk factors and attributable mortality. Clin Infect Dis 1995; 20 :1531-4.  Back to cited text no. 17  [PUBMED]  
18.Andriole VT, Hasancleven IT. Factors influencing experimental candidiasis in mice. Yale J Biol Med 1962; 35 :96-112.  Back to cited text no. 18    


  [Table - 1], [Table - 2]

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