Species distribution and antifungal susceptibility of blood Candida isolates at a tertiary hospital in southern Taiwan, 1999–2006

The aim of this study was to evaluate the incidence of candidaemia, consumption of fluconazole and susceptibility of blood Candida isolates at a tertiary hospital. From January 1999 to September 2006, all candidaemic episodes were identified and available strains were evaluated for the susceptibilities of antifungal agents. Annual defined daily doses of antifungal agents were collected. There had been 909 Candida isolates detected from the bloodstream of 843 patients during the study period. Among them, 740 isolates were available for the susceptibilities of antifungal agents. The incidence density of candidaemia was 28 episodes per 10 000 patient‐days. Species distribution of 909 isolates did not vary annually, but varied greatly in the units of the hospital. Candida parapsilosis was the more prominent (30.1%) isolate in the paediatric units, where C. tropicalis and C. glabrata were less common (12.3% and 1.4% respectively). Resistance rates for itraconazole, fluconazole and voriconazole were 6.9%, 3.8% and 3.8% respectively. There were 25 (3.4%) isolates resistant to amphotericin‐B. Although fluconazole usage increased over time (r² = 0.45; P = 0.07), fluconazole resistance did not increase accordingly (P = 0.33). In our institution in which the incidence of candidaemia was high, fluconazole resistance among blood Candida isolates remained rare.     

Neonatal invasive candidiasis in Tunisian hospital: incidence, risk factors, distribution of species and antifungal susceptibility

The aim of our study was to assess epidemiological features of neonatal invasive candidiasis in Farhat Hached hospital of Sousse, Tunisia, including incidence, risk factors, mortality, species distribution and antifungal susceptibility. Laboratory data from 1995 to 2010 and medical records of 127 invasive candidiasis cases were reviewed. We tested the susceptibility of 100 Candida sp isolates by using ATB fungus^®3 and to fluconazole by using E‐test^® strips. A total of 252 cases of neonatal invasive candidiasis occurred over the study period. The incidence increased 1.8‐fold from 1995 to 2006 and decreased fourfold from 2007 to 2010. Candida albicans was the predominant species up to 2006 and a shift in the species spectrum was observed with increase of the non‐albicans species mainly C. parapsilosis. The agreement between the ATB Fungus^® and the E‐test^® for determining fluconazole susceptibility was high. All tested isolates were susceptible to fluconazole, flucytosine, amphotéricine B and voriconazole and the itraconazole resistance rate was 5%. The mortality rate was 63%. The invasive candidiasis incidence increased from 1995 to 2006 and decreased from 2007 to 2010. The spectrum of Candida species and the lack of fluconazole‐resistant strains argue for the usefulness of fluconazole as an empiric treatment.     

The increased role of non‐albicans species in candidaemia: results from a 3‐year surveillance study

Various studies have documented a shift in species distribution in Candida bloodstream infections (BSI), but there are little data from Southeast Asia. This study was performed to determine the species epidemiology and antifungal susceptibilities of Candida species BSI in Singapore. Candida spp. from BSI were collected from a tertiary and secondary referral hospital, and an obstetrics/paediatric hospital over a 3‐year period. The most common isolates were Candida albicans (36%), Candida tropicalis (27%), Candida glabrata (16%) and Candida parapsilosis (16%). Candida parapsilosis and C. albicans were predominant in the paediatric hospital, and C. albicans and C. tropicalis predominant in the other two institutions. Candida tropicalis temporarily replaced C. albicans as the predominant strain from BSI in 2006. Overall, 87.3% of Candida isolates were susceptible to fluconazole, and 10.4% classified as susceptible‐dose‐dependent. Fluconazole resistance was detected in C. tropicalis (3.6%), C. parapsilosis (2.1%) and C. glabrata (4.0%). Candida albicans is the predominant species isolated from BSI in Singapore. However, non‐albicans species accounted for nearly two‐thirds of all cases of candidaemia and the relative increase in C. tropicalis infections deserves further investigation. Resistance to fluconazole was uncommon.     

Differences in patient risk factors and source of candidaemia caused by Candida albicans and Candida glabrata

There is an increasing frequency of candidaemia caused by Candida glabrata which has decreased in vitro susceptibility to fluconazole. Differences in risk factors for candidaemia caused by C. glabrata and C. albicans have not been formally evaluated in a diverse patient group. We performed a retrospective study of adult inpatients from January 1, 2003 to April 30, 2008 with C. glabrata and C. albicans candidaemia at a single tertiary care centre in Detroit, Michigan to evaluate for differences in risk factors and presumed source of infection in these groups. Patients’ underlying conditions, risk factors and source of infection (probable or definite) were compared. Among 119 patients, 80 (67.2%) were C. albicans and 39 (32.8%) C. glabrata. Using logistic regression analysis, patients with C. glabrata infection were more likely to have diabetes mellitus (OR 2.43; 95% CI, 1.06–5.54) and abdominal source of infection (OR 4.53, 95% CI, 1.72–11.92). Mortality rates in the two groups were similar. Patients with C. glabrata candidaemia are more likely to be diabetic and have an abdominal source of infection compared with patients with C. albicans.     

Nosocomial candidaemia in children: results of a 9-year study

The aim of this study was to determine changes in the incidence of nosocomial candidaemia and to evaluate the risk factors, demographic features, treatment and clinical outcome associated with candidaemia in a Turkish tertiary care paediatric unit within a 9-year period. The data of children who were diagnosed as nosocomial candidaemia, were examined in this study. Between January 1997 and December 2005, a total of 102 nosocomial candidaemia episodes were identified in 102 patients. The rate of nosocomial candidaemia in our clinic increased from 3.2 cases per 1000 admissions in 1997–1999, to 5.5 per 1000 admissions in 2000–2002 and to 6.9 per 1000 admissions in 2003–2005 ( P  = 0.003). The species most frequently causing candidaemia were Candida albicans (39.2%), Candida parapsilosis (21.6%) and Candida tropicalis (15.7%). The mortality of C. albicans (37.5%), was significantly higher than the mortality of non- albicans species (17.7%) ( P  = 0.04). Independent risk factors associated with candidaemia-related deaths by logistic regression analysis were disseminated candidiasis (odds ratio, 5.7; P  = 0.01), paediatric intensive care unit stay (odds ratio, 8.1; P  = 0.001), prolonged antibiotics therapy (odds ratio, 5.2; P  = 0.014), use of total parenteral nutrition (odds ratio, 4.4; P  = 0.038) and mechanical ventilation (odds ratio, 4.9; P  = 0.01). The rate of nosocomial candidaemia in our clinic increased >2-fold during the study period.     

Epidemiology and antifungal susceptibility patterns of Candida isolates from Greek women with vulvovaginal candidiasis

Vulvovaginal candidiasis (VVC) is a common infection of the genital tract affecting millions of women worldwide. Data on epidemiological trends of VVC in Greece are scarce. This study was undertaken to evaluate the prevalence of VVC among symptomatic women in Crete, Greece, identify the Candida species involved and determine their susceptibility to antifungals. Over a 6‐year period (2012‐2017), 10 256 symptomatic women with vaginitis were evaluated. Isolation of yeasts was performed on Sabouraud dextrose agar with chloramphenicol, and the isolates were identified using the API 20 C AUX and/or the Vitek 2 YST card. Susceptibility of the isolates to amphotericin, fluconazole, voriconazole and flucytosine was determined by the Vitek 2 automated system. The results were interpreted according to Clinical and Laboratory Standards criteria. Vaginal swab cultures of 1217 (11.9%) women yielded Candida species. Recurrent VVC was documented in 62 (5.1%) of them. Candida albicans was the most frequently isolated species (75.6%), followed by Candida glabrata (13.6%). Overall, resistance rates to amphotericin B, fluconazole, voriconazole and flucytosine were 0.2%, 6.6%, 1.4% and 2.1%, respectively. Fluconazole resistance of C. albicans significantly increased in the second period of the study (2015‐2017) (P = 0.031). This study demonstrated that VVC is a common infection among women in our region, with C. albicans being the predominant species involved. Although resistance to antifungals was infrequent, resistance to fluconazole among C. albicans isolates was found to significantly increase with time. Continued surveillance of changes in species distribution and susceptibility to antifungals are necessary to guide treatment.     

Prevalence,virulence factors and antifungal susceptibility of Candida spp. isolated from bloodstream infections in a tertiary care hospital in Brazil

Candida spp. are responsible for 80% of all systemic fungal infections and are associated with high mortality rates. This study characterised 79 bloodstream isolates of C. albicans, C. glabrata, C. orthopsilosis, C. parapsilosis and C. tropicalis from patients in a Brazilian hospital. The susceptibility to amphotericin B, caspofungin, fluconazole and voriconazole was determined; virulence factor production was assessed based on haemolysin, phospholipase and proteinase activities, and the patients’ clinical characteristics were analysed. C. albicans was the predominant species (44%), followed by C. glabrata (19%), C. tropicalis (19%), C. parapsilosis (14%) and C. orthopsilosis (4%). The candidemia incidence was 1.52 per 1000 admissions, and the crude mortality rate was 52%. One C. albicans isolate was resistant to fluconazole and voriconazole. Moreover, 20.2%, 2.5% and 3.8% of the isolates exhibited dose‐dependent susceptibility to fluconazole, voriconazole and caspofungin, respectively. In conclusion, although the C. glabrata incidence was higher than that usually described in Brazil, its increase was previously observed in studies conducted worldwide. Furthermore, the azole resistance of the C. albicans isolate could be due to previous exposure to these antifungals. These results highlight the importance of epidemiological studies and will facilitate an improved understanding of candidemia in the studied hospital.     

Risk factors and outcome for breakthrough candidaemia in patients with cancer

While candidaemia that develops during systemic antifungal prophylaxis or therapy [breakthrough (BT) candidaemia] has been reported increasingly, the risk factors and outcome of BT candidaemia are not yet known definitely. We evaluated a consecutive series of cancer patients with candidaemia at Asan Medical Center during 6 years to identify risk factors and outcome in BT candidaemia comparing with non-BT candidaemia. Fifty-four episodes of candidaemia in cancer patients diagnosed during this period were reviewed retrospectively. There were 10 episodes (18.5%) of BT candidaemia in which the species distribution and frequency of catheter-related infection in the BT and non-BT groups were similar. BT candidaemia had a tendency to occur more frequently in patients with haematological than non-haematological diseases. Profound neutropenia and disseminated candidiasis were more common in the BT group; however, these differences were not statistically significant (P = 0.17 and 0.07 respectively). The duration of prior antibiotic therapy and duration of profound neutropenia (<100 mm(-3)) were identified as risk factors for BT candidaemia (P < 0.01 and 0.02 respectively) in univariate analysis and the latter was the only risk factor in multivariate analysis. The death rates due to candidaemia were 85.7% in the BT group and 42.9% in the non-BT group (P = 0.08); however, BT candidaemia alone did not increase mortality rate.     

Epidemiology,risk factor,species distribution,antifungal resistance and outcome of Candidemia at a single French hospital: a 7‐year study

Candidemia remains a major cause of disease worldwide and is associated with a high mortality rate. We conducted a retrospective study of candidemia at Nantes Hospital, France, between 2004 and 2010. A total of 191 episodes (n = 188 patients) were reviewed. Incidence, demographics, risk factors, antifungal management, species identification, in vitro susceptibility and 12 weeks survival were analysed. Global incidence of candidemia was 0.37‰ admissions. Higher incidences were observed in haematology (6.65‰) and intensive care units (2‰). Central venous catheter and antibiotic exposure were the most frequent risk factors (77% and 76% respectively). Candida albicans was the predominant species (51.8%) followed by C. parapsilosis (14.5%), C. glabrata (9.8%), C. tropicalis (9.8%) and C. krusei (4.1%). However, species distribution differed significantly between medical units with frequency of C. tropicalis being higher in haematology compared to other medical units. Fluconazole and caspofungin were the main antifungals given as first‐line therapy. Although not significant, 12 weeks mortality rate was 30.9%, being higher for C. tropicalis (44.4%) than for C. parapsilosis (16%). Acquired azole or echinocandin resistance was noted in some isolates, underlining the need for systematic antifungal susceptibility testing in patients with candidemia. These epidemiological findings will be of interest for antifungal stewardship at our hospital.     

Antifungal susceptibility of clinical Candida parapsilosis isolates in Kuwait

This study presents data on antifungal susceptibility of 114 Candida parapsilosis isolates recovered from clinical specimens in Kuwait. Candida parapsilosis isolates originating from blood ( n  = 66) and other clinical specimens ( n  = 48) were tested by Etest against amphotericin B (AP), caspofungin (CS), 5-flucytosine (FC), fluconazole (FL) and voriconazole (VO). The plates were incubated at 35 °C and readings for minimum inhibitory concentrations (MIC) were recorded after 24 and 48 h of incubation. The MIC ranges and MIC₉₀ read after 48 h were as follows: 0.064–1 and 0.5 μg ml⁻¹ for AP; 0.125–4 and 1.5 μg ml⁻¹ for CS; 0.047 to >256 and 1 μg ml⁻¹ for FL; 0.023 to >32 and 0.125 μg ml⁻¹ for FC and <0.002–1 and 0.047 μg ml⁻¹ for VO respectively. According to Clinical Laboratory Standards Institute criteria, all the isolates were susceptible to VO, and resistance against FC and FL was <2%. Eight (7%) isolates exhibited reduced susceptibility (MIC >1 μg ml⁻¹) to CS including six isolates with MIC of ≥2 μg ml⁻¹ at 48 h reading. The antifungal resistance among bloodstream isolates of C. parapsilosis against AP, FL, FC and VO in Kuwait is rare. This is the first report on CS susceptibility of C. parapsilosis isolates from Arabian Gulf region.     

Identification of Candida species isolated from patients in intensive care unit and in vitro susceptibility to fluconazole for a 3-year period

Species level identification of Candida and antifungal susceptibility testing is not generally performed in routine laboratory practice. There is limited information about the distribution of Candida species and antifungal susceptibility in Turkey. In this study, we aimed at identifying Candida isolates to species level from various samples obtained from patients treated in an intensive care unit between 2002 and 2005 and to evaluate fluconazole susceptibilities of the isolates. A total of 320 Candida isolates obtained from 270 patients were identified by conventional methods and using API (Candida and/or 20C AUX) system. Antifungal susceptibility testing was performed by broth microdilution method. Candida albicans was isolated with the highest frequency (65.6%) followed by C. parapsilosis (11.3%), C. glabrata (8.8%) and C. tropicalis (7.8%). Of all the isolates, 92.9% revealed susceptibility to fluconazole. Susceptibility to fluconazole was highest for C. albicans followed by C. parapsilosis and C. glabrata. The MIC(90) values for C. albicans, C. parapsilosis, C. glabrata and C. tropicalis were 1, 2, 8 and 4 mug ml(-1) respectively. Fluconazole remains effective against both C. albicans and the majority of non-albicans Candida species. In this study, we determine the distribution of Candida species and evaluate the susceptibilities of the isolates, particularly for the azoles.     

An investigation of Candida species isolated from blood cultures during 17 years in a university hospital

Candidemia is the most frequent manifestation observed with invasive candidiasis. The aim of this study was to analyse the trends of candidemia in a large tertiary‐care hospital to determine the overall incidence during January 1996 – December 2012, as well as to determine the susceptibility of 453 isolates according to the revised Clinical and Laboratory Standards Institute (CLSI) breakpoints. Candidemia episodes in adult and paediatric patients were retrospectively analysed from the laboratory data of Uluda? University Healthcare and Research Hospital. The 17‐year period studied was divided into three periods (1996–2001, 2002–2007 and 2008–2012) for better comparison, and candidemia incidence was determined by the ratio of total number of patients with candidemia per 1000 patients admitted to the hospital and per 10 000 patient days in these three periods. Redefined CLSI M27‐A3 breakpoints were used for interpretation of antifungal susceptibility results. Candidemia incidence was determined as 2.2, 1.7 and 1.5 per 1000 admitted patients during 1996–2001, 2002–2007 and 2008–2012 respectively. A significantly decreased candidemia incidence was obtained in the third period. C. albicans (43.8%) was the most common candidemia agent, followed by C.parapsilosis (26.5%) in all three periods. According to the revised CLSI breakpoints, there was fluconazole resistance in C. albicans, C.parapsilosis, C.tropicalis and C.glabrata species (1.4%, 18.2%, 2.6% and 14.3% respectively). Almost all Candida species were found susceptible to voriconazole except one C.glabrata (7.1%) isolate. Candidemia is an important health problem. Local epidemiological data are determinative in the choice of appropriate antifungal treatment agents.     

Molecular identification and antifungal susceptibility of clinical fungal isolates from onychomycosis (uncommon and emerging species)

Onychomycosis is a common nail problem, accounting for up to 50% of all nail diseases. The aim of the present study was to determine the species distribution based on the restriction fragment length polymorphism and susceptibility patterns of the causative agents of onychomycosis. This cross‐sectional study was conducted on nail samples collected from 257 patients suspected of onychomycosis during 14 months. Fungal isolates were identified by polymerase chain reaction‐restriction fragment length polymorphisms (PCR‐RFLP) with the enzymes Msp I, Mva I, Alw I and sequencing. According to the results, out of the 257 patients participating in the study, onychomycosis was diagnosed in 180 (70.03%) cases, among which 51.1% were caused by non‐dermatophyte moulds (NDMs), 35% by yeast and 10.6% by dermatophytes. Numerous cryptic species recovered from onychomycosis for the first time. In the majority of cases, novel triazoles and imidazoles (ie, efinaconazole, luliconazole and lanoconazole) showed potent activity in comparison with other antifungal agents. The minimum inhibitory concentration (MIC) of luliconazole and lanoconazole ranged within 0.001 to >1 μg/mL and their geometric mean MICs were 0.0154 and 0.0309 μg/mL against all isolates, respectively. It seems that obtained data will be useful to improve the knowledge of researchers, clinicians and dermatologists about onychomycosis distribution, species diversity and adoption of appropriate treatment.     

Epidemiology,risk factors for and outcome of candidaemia among non‐neutropenic patients in a Greek intensive care unit

To determine the epidemiology, risk factors for and outcome of candidaemia in critically ill patients, a matched case–control study was performed in a 25‐bed intensive care unit (ICU) from August 2004 to January 2006. Candidaemia occurred in 33 patients; each patient was matched to four controls according to admission illness severity, diagnostic category and length of ICU stay. Candida non‐albicans species predominated (67.7%). The presence of acute respiratory distress syndrome (ARDS) was the only independent risk factor for candidaemia development (OR, 2.93; 95% CI 1.09–7.81, P = 0.032). Mortality was 60.6% among patients with candidaemia and 22% among controls (P < 0.001). The presence of candidaemia (OR, 9.37; 95% CI 3.48–25.26, P < 0.001) and the illness severity on admission (acute physiologic and chronic health evaluation II score, OR, 1.17; 95% CI 1.12–1.24, P < 0.001) were independently associated with mortality. Among candidaemic patients, risk factors for mortality were the severity of organ dysfunction (sequential organ failure assessment score, OR, 1.57; 95% CI 1.00–2.46, P = 0.05) and a low serum albumin level (OR, 0.74; 95% CI 0.59–0.94, P = 0.012) both of them occurred on candidaemia onset. We conclude that in critically ill patients matched for illness severity and length of ICU stay, the only independent risk factor for candidaemia was the presence of ARDS. Mortality was independently associated with acquisition of candidaemia and with the illness severity at candidaemia onset.     

Epidemiology,species distribution,clinical characteristics and mortality of candidaemia in a tertiary care university hospital in Turkey, 2007‐2014

Candidaemia still continues to be a serious medical concern and the epidemiology of candidaemia varies according to geographical areas. We aim to determine the incidence, local epidemiology, Candida species distribution and crude mortality rates of candidaemia. We retrospectively evaluated candidaemia episodes in between January 2007 and August 2014. We compared demographic, clinical, microbiological findings and mortality rates of episodes caused by Candida albicans and non‐albicans Candida species. Overall the candidaemia incidences were 1.23 episodes/1000 admissions. A significant negative slope among candidaemia episodes and years was determined. Overall C. albicans (54.6%) was the most common species followed by Candida glabrata, Candida tropicalis and Candida parapsilosis respectively. Preinfection hospital stay and length of hospital stay were statistically longer in patients with non‐albicans Candida candidaemia than in patients with C. albicans candidaemia. The source of candidaemia was unknown in 52.5% of all episodes. Central venous catheters among non‐albicans Candida candidaemia episodes and urinary system among C. albicans candidaemia episodes were common source of candidaemia compared to each other. Previous antifungal therapy preceding candidaemia and concomitant bacteraemia were significantly associated with non‐albicans Candida candidaemia. Continuous local surveillance will preserve its pivotal importance in formulating empirical antifungal therapy and improving management of candidaemia.     

Species diversity,antifungal susceptibility and phenotypic and genotypic characterisation of Exophiala spp. infecting patients in different medical centres in Brazil

The Exophiala genus is responsible for many superficial and invasive infections resulting from black fungi. Identification of Exophiala at the species level is based on morphological observations complemented by molecular tests. The aim of this study was to identify 23 clinical isolates of Exophiala spp. and evaluate the antifungal susceptibility to seven different agents. Molecular identification was based on an analysis of ITS region of rDNA using genomic databases. The micromorphology was evaluated by microculture and scanning electron microscopy. The susceptibility tests were performed using the antifungal agents 5‐fluorocytosine (5‐FC), amphotericin B (AMB), itraconazole (ITC), voriconazole (VRC), posaconazole (PSC), caspofungin (CFG) and terbinafine (TRB). The ITS analysis identified 100% of the following isolates as: E. dermatitidis (8), E. xenobiotica (6), E. bergeri (4), E. oligosperma (3), E. spinifera (1) and E. mesophila (1). The antifungal susceptibility tests showed that the triazoles compounds were in vitro the most active agents against Exophiala. ITS sequencing enabled the accurate identification of the 23 tested isolates. The triazoles, particularly itraconazole and posaconazole, exhibited MIC values lower than AMB, CAS and 5‐FC. Although the guidelines do not indicate AMB for treatment against Exophiala spp., this study showed activity for all of the tested species, except E. mesophila.