|Year : 2014 | Volume
| Issue : 1 | Page : 44-48
Species distribution and drug susceptibility of candida in clinical isolates from a tertiary care centre at Indore
N Pahwa1, R Kumar2, S Nirkhiwale3, A Bandi4
1 Department of Nephrology, Department of laboratory medicine, greater Kailash Hospital, Indore, India
2 Central Research Laboratory, Sri Aurobindo Institute of Medical Sciences, Indore, India
3 Department of Laboratory Medicine, Greater Kailash Hospital, Indore, Madhya Pradesh, India
4 Department of Urology, Greater Kailash Hospital, Indore, Madhya Pradesh, India
|Date of Submission||24-May-2013|
|Date of Acceptance||02-Sep-2013|
|Date of Web Publication||4-Jan-2014|
Department of Laboratory Medicine, Greater Kailash Hospital, Indore, Madhya Pradesh
Source of Support: None, Conflict of Interest: None
Background: The incidence of fungal infections has increased significantly, contributing to morbidity and mortality. This is caused by an alarming increase in infections with multi-drug resistant bacteria leading to overuse of broad-spectrum antimicrobials, which lead to overgrowth of Candida, thus enhancing its opportunity to cause disease. Candida are major human fungal pathogens that cause both mucosal and deep tissue infections. Objective : The aim of our study was to identify the distribution of Candida species among clinical isolates and their sensitivity pattern for common antifungal drugs. Materials and Methods : Two hundred and thirty-seven different clinical isolates of Candida were collected from patients visiting to a tertiary care centre of Indore from 2010 to 2012. Identification of Candida species as well as antifungal sensitivity testing was performed with Vitek2 Compact (Biomerieux France) using vitek 2 cards for identification of yeast and yeast like organisms (ID-YST cards). Antifungal susceptibility testing was performed with Vitek2 "Fungal Susceptibility Card (AST YS01) kits respectively. Results : We found that the non-albicans Candida were more prevalent than Candida albicans in paediatric (<3 year) and older (>60 year) patients than other age group (4-18, 19-60 years) patients and also in intensive care unit (ICU) patients as compared to out patient department (OPD) patients. Resistance rates for amphotericin B, fluconazole, flucytosine, itraconazole, and voriconazole were 2.9%, 5.9%, 0.0%, 4.2% and 2.5%%, respectively. All the strains of C. krusei were found resistant to fluconazole with intermediate sensitivity to flucytosine. Conclusion: Species-level identification of Candida and their antifungal sensitivity testing should be performed to achieve better clinical results.
Keywords: Antifungal susceptibility, Candida, infection
|How to cite this article:|
Pahwa N, Kumar R, Nirkhiwale S, Bandi A. Species distribution and drug susceptibility of candida in clinical isolates from a tertiary care centre at Indore. Indian J Med Microbiol 2014;32:44-8
|How to cite this URL:|
Pahwa N, Kumar R, Nirkhiwale S, Bandi A. Species distribution and drug susceptibility of candida in clinical isolates from a tertiary care centre at Indore. Indian J Med Microbiol [serial online] 2014 [cited 2020 May 25];32:44-8. Available from: http://www.ijmm.org/text.asp?2014/32/1/44/124300
| ~ Introduction|| |
Fungal infections are a major cause of morbidity and mortality in immune compromised individuals and Candida are among the most common pathogens in these patients. The incidence of Candidaemia of 6.9 per 1,000 intensive care unit (ICU) patients was reported in a recent study, and 7.5% of ICU patients received antifungal therapy. , Candidaemia increases mortality rates in the range of 20-49%, , but still there are many open management questions.
The unmet medical needs surrounding Candidaemia, and invasive candidiasis are defined in general from diagnosis to prophylaxis, empiric and pre-emptive strategies to treatment. So far, the scientific community has not been able to accurately predict invasive candidiasis, and thus, to define populations that benefit from prophylaxis or early treatment.  Although, it is well known that treatment is being initiated too late in the majority of patients, identification of the optimal time point to commence antifungal therapy remains challenging. , Intertwined with this problem is insufficient support of reliable mycological assays preventing timely and diagnosis-driven early treatment initiation. 
Candida species belong to the normal microbiota of an individual's mucosal oral cavity, gastrointestinal tract and vagina,  and are responsible for various clinical manifestations from mucocutaneous overgrowth to bloodstream infections  . These yeasts are commensal in healthy humans and may cause systemic infection in immune compromised situations due to their great adaptability to different host niches. The genus is composed of a heterogeneous group of organisms, and more than 17 different Candida species are known to be the aetiological agents of human infection; however, more than 90% of invasive infections are caused by C. albicans, C. glabrata, C. parapsilosis, C. tropicalis and C.krusei.
The potential clinical importance of species-level identification has been recognised as Candida species differ in the expression of putative virulence factors and antifungal susceptibility. , Rapid identification of yeast species also guides early appropriate antifungal therapy.
The aim of the present study is to identify the spectrum of Candida species in clinical infections and to identify their sensitivity pattern to available antifungal agents.
| ~ Materials and Methods|| |
All the isolates of Candida obtained during the year 2010-2012 from different clinical specimens submitted to the Department of Laboratory Medicine of a tertiary care centre at Indore were recruited for the study. Blood culture samples collected in blood culture bottles were incubated in BacTAlert3D (Biomerieux, France) automated blood culture system and up on getting a positive alarm, were sub-cultured onto Sabouraud dextrose agar (HiMedia, India) and blood agar plates after getting gram positive budding yeasts on gram stain of Blood culture broth. All other specimens were inoculated onto Sabouraud dextrose agar plates in addition to blood agar, chocolate agar and MacConkey agar (HiMedia, India). Suspected colonies of Candida were confirmed on Gram stain and then identified with Vitek2 Compact (Biomerieux, France) using vitek 2 cards for identification of yeast and yeast like organisms (ID-YST cards) Kits. Antifungal susceptibility testing was performed with AST YS01 Kits on Vitek2 Compact. Standard operative procedures as described by the manufacturer were followed. The study was done with prior approval from institutional research committee.
Data collected were analysed using the Statistical Package for Social Sciences (SPSS) 20.0 Software (IBM Corp, New York, USA). Chi-square test was used to see the association between two categorical variables. P < 0.05 was considered to be significant.
| ~ Results|| |
A total of 237 isolates of Candida species were obtained from different clinical specimens of patients visiting the Outpatient department (OPD) (106), and admitted to In-Patient Department (IPD) (52) and ICU (79) during the years 2010-2012. Of these, 58 (24.5%) were from Blood, 45 (19.0%) from voided urine, 33 (13.9%) from urine of patients with in dwelling urinary catheter, 25 (10.5%) from vaginal discharge, 32 (13.5%) from sputum, 17 (7.2%) from Endotracheal Secretion, 9 (3.8%) from pus, 4 (1.7%) from central venous catheter, 3 (1.3%) from Broncho-alveolar lavage, 3 (1.3%) from stool, 3 (1.3%) from throat swab, and 5 from other sources.
The distribution and percentage of different Candida species in these 237 isolates are given in [Table 1]. Accordingly, the species isolated were C. albicans [100 (42.2%)], C. tropicalis [53 (22.4%)], C. parapsilosis [15 (6.3%)], C. glabrata [nine (3.8%)], C. krusei [eight (3.4%)], C. lusitaniae [five (2.1%)], C. lipolytica [four (1.7%)], C. pelliculosa [three (1.3%)], C. sphaerica [three (1.3%)], C. guilliermondii [two (0.8%)], C. famata [two (0.8%)], C. utilis [two (0.8%)] and C. rugosa [one (0.4%)]. Thirty (12.7%) Candida isolates could not be definitively identified up to species level and were labelled as Candida. We observed that invasive candidiasis was more frequently caused by non-albicans Candida species as compared to albicans [Table 1].
There was significant difference in Candida species in different age group. In paediatric (<3 year) and older (<60 years) group Candida infection was mainly caused by non-albicans Candida as compared to other age groups (P = 0.006). No difference was observed in distribution of Candida species between male and female patients [Table 2].
Resistance rates for amphotericin B (AMB), fluconazole (FLU), flucytosine (FCy), itraconazole (ITR), voriconazole (VOR) were 2.9%, 5.9%, 0.0%, 4.2% and 2.5%, respectively. Interestingly, Vitek 2 Compact system was not able to identify the correct species of Candida in five out of seven strains that were AMB resistant. We observed that C. albicans was less resistant to all the drugs as compared to non-albicans Candida species [Table 3]. All the strains of C. krusei were found resistant to FLU and also have intermediate sensitivity to FCy.
We analysed the year wise sensitivity pattern for all the antifungal agents and found that there was no change in sensitivity pattern from 2010 to 2012 [Figure 1].
|Figure 1: Year wise Sensitivity pattern of Candida Species with different anti-fungal drugs|
Click here to view
| ~ Discussion|| |
Infection represents a frequent complication among patients admitted to tertiary care hospitals. In particular, the incidence of candidiasis has been increasing during the past years. Infections with these yeasts also have a direct impact on the choice of empiric antifungal therapy and clinical outcome. Prior knowledge of species distribution in clinical isolates and drug sensitivity pattern among species help the clinician to choose early empirical therapy.
In this study, we observed that non-albicans Candida species had predominance over C. albicans, which is consistent with the published report from different parts of the world. [14-16] C. tropicalis was most common isolate in all samples, followed by C. albicans. A relatively greater proportion of C. tropicalis isolates in our study is concordant with other studies from India. , Furthermore, invasive Candida infection was mostly caused by non-albicans Candida, whereas the C. albicans was found mostly in skin and mucosal surfaces. Non-albicans Candida was also more prevalent paediatric and older patient groups than in patients with young age group.
Candida species differ in their susceptibility to antifungal agents. For instance, all Candida isolates tested were susceptible to FCy. Furthermore, all C. parapsilosis, C. lipolytica and C. famata isolates were also susceptible to azoles. However, C. tropicalis and C. glabrata isolates showed reduced susceptibility to VOR and some of these isolates were also resistant to ITR and FLU. All C. krusei isolates were found resistant to FLU.
Khotari et al.,  from North India reported the susceptibility profile of Candida isolates as 92% were sensitive to AMB, 36% to FLU, 24% to ITR, 56% to VOR and 96% to FCy whereas in another study from South India  showed 100% sensitivity to VOR, 92% to AMB, 90% to FCy and 75% to FLU. Our study differs from the previous studies in the fact that all the previous studies were restricted to small sample size. In this study, we have examined the sensitivity pattern in large number of various clinical isolates.
Reduced susceptibility as well as frank resistance to drugs such as azoles, as observed in our study, is an issue of crucial importance in treatment of immune compromised patients with serious infections. Hence, antifungal susceptibility testing is a promising tool for predicting the efficacy of a given agent.
| ~ Acknowledgment|| |
We sincerely acknowledge and appreciate Mrs. Amrita Jasani, Mr. Deepak Rathore and Mr. Mayank Bannatwala-Jr. Microbiologists, Department of Laboratory Medicine, Greater Kailash Hospital, Indore, for their dedication to microbiological processing of all specimens and data collection. We also thank Dr. Vinod Bhandari, Chairman, Sri Aurobindo Institute of Medical Sciences for his kind support for this study.
| ~ References|| |
|1.||Kett DH, Azoulay E, Echeverria PM, Vincent JL. Extended Prevalence of Infection in ICU Study (EPIC II) Group of Investigators. Candida bloodstream infections in intensive care units: Analysis of the extended prevalence of infection in intensive care unit study. Crit Care Med 2011;39:665-70. |
|2.||Azoulay E, Dupont H, Tabah A, Lortholary O, Stahl JP, Francais A, et al. Systemic antifungal therapy in critically ill patients without invasive fungal infection*. Crit Care Med 2012;40:813-22. |
|3.||Gudlaugsson O, Gillespie S, Lee K, Vande Berg J, Hu J, Messer S, et al. Attributable mortality of nosocomial candidemia, revisited. Clin Infect Dis 2003;37:1172-7. |
|4.||Arendrup MC, Sulim S, Holm A, Nielsen L, Nielsen SD, Knudsen JD, et al. Diagnostic issues, clinical characteristics, and outcomes for patients with fungemia. J Clin Microbiol 2011;49:3300-8. |
|5.||Ostrosky-Zeichner L, Shoham S, Vazquez J, Reboli A, Betts R, Barron M, et al. Msg-01: A multicenter, randomized, double-blind, placebo controlled trial of caspofungin (cas) prophylaxis vs placebo followed by pre-emptive therapy for invasive candidiasis (ic) in high-risk adults in the critical care setting. Preliminary results. SHEA Annual Scientific Meeting. Dallas, Texas, United States; 2011. |
|6.||Garey KW, Rege M, Pai MP, Mingo DE, Suda KJ, Turpin RS, et al. Time to initiation of fluconazole therapy impacts mortality in patients with candidemia: A multi-institutional study. Clin Infect Dis 2006;43:25-31. |
|7.||Kumar A, Ellis P, Arabi Y, Roberts D, Light B, Parrillo JE, et al. Cooperative Antimicrobial Therapy of Septic Shock Database Research Group. Initiation of inappropriate antimicrobial therapy results in a fivefold reduction of survival in human septic shock. Chest 2009;136:1237-48. |
|8.||Cuenca-Estrella M, Verweij PE, Arendrup MC, Arikan-Akdagli S, Bille J, Donnelly JP, et al. ESCMID Diagnostic and Management Guidelines of Candida Diseases 2012: Diagnostic Procedures. Clin Microbiol Infect 2012;18 Suppl 7:9-18. |
|9.||Shao LC, Sheng CQ, Zhang WN. Recent advances in the study of antifungal lead compounds with new chemical scaffolds. Yao Xue Xue Bao 2007;42:1129-36. |
|10.||Eggimann P, Garbino J, Pittet D. Epidemiology of Candida species infections in critically ill non-immunosuppressed patients. Lancet Infect Dis 2003;3:685-702. |
|11.||Pfaller MA, Diekema DJ, Procop GW, Rinaldi MG. Multicenter comparison of the VITEK 2 antifungal susceptibility test with the CLSI broth microdilution reference method for testing amphotericin B, flucytosine, and voriconazole against Candida spp. J Clin Microbiol 2007;45:3522-8. |
|12.||Murray MP, Zinchuk R, Larone DH. CHROMagar Candida as the sole primary medium for I solation of yeasts and as a source medium for the rapid-assimilation-of-trehalose test. J Clin Microbiol 2005;43:1210-2. |
|13.||Baillie GS, Douglas LJ. Iron-limited biofilms of Candida albicans and their susceptibility to amphotericin B. Antimicrob Agents Chemother 1998;42:2146-9. |
|14.||Méan M, Marchetti O, Calandra T. Bench-to-bedside review: Candida infections in the intensive care unit. Crit Care 2008;12:204. |
|15.||Mokaddas EM, Al-Sweih NA, Khan ZU. Species distribution and antifungal susceptibility of Candida bloodstream isolates in Kuwait: A 10-year study. J Med Microbiol 2007;56:255-9. |
|16.||Jain N, Mathur P, Misra MC, Behera B, Xess I, Sharma SP. Rapid identification of yeast isolates from clinical specimens in critically ill trauma ICU patients. J Lab Physicians 2012;4:30-4. |
|17.||Kothavade RJ, Kura MM, Valand AG, Panthaki MH. Candida tropicalis: Its prevalence, pathogenicity and increasing resistance to fluconazole. J Med Microbiol 2010;59:873-80. |
|18.||Mathews MS, Samuel PR, Suresh M. Emergence of Candida tropicalis as the major cause of fungaemia in India. Mycoses 2001;44:278-80. |
|19.||Kothari A, Sagar V. Epidemiology of candida bloodstream infections in a tertiary care institute in India. Indian J Med Microbiol 2008;27:171-2. |
|20.||Adhikary R, Joshi S. Species distribution and antifungal susceptibility of candidemia at a multi super specialty centre in Southern India. Indian J Med Microbiol 2011;29:309-11. |
[Table 1], [Table 2], [Table 3]
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