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 Table of Contents  
Year : 2016  |  Volume : 3  |  Issue : 1  |  Page : 33-36

Species distribution and antifungal susceptibility of candidemia at a multispecialty center in North India

Department of Microbiology, Christian Medical College and Hospital, Ludhiana, Punjab, India

Date of Web Publication22-Dec-2015

Correspondence Address:
Maria Thomas
Department of Microbiology, Christian Medical College and Hospital, Ludhiana - 141 008, Punjab
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2348-3334.172395

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Introduction: Fungi have emerged as major opportunistic pathogens. Candida species account for nearly 96% of all opportunistic mycoses and is an important cause of bloodstream infections. There has been a progressive shift from the predominance of Candida albicans to nonalbicans Candida species as the major cause of candidemia all over the world. Resistance to antifungal drugs is more in nonalbicans Candida species. Hence, speciation and antifungal susceptibility testing is the need of the hour. Materials and Methods: This retrospective study was conducted in a multispecialty center in North India from January 1, 2014 to March 31, 2015. The blood culture samples that were positive for Candida species were processed further. Species identification was done by standard microbiological techniques. Antifungal drug susceptibility was done by disk diffusion method (Clinical and Laboratory Standards Institute M44-A2). Results: A total of 10893 samples were processed, 1440 (13.2%) blood cultures were positive. Candida species was isolated from 105 (7.3%) samples, of which 15 (14.3%) were C. albicans and 90 (85.7%) were nonalbicans Candida. Nonalbicans Candida included Candida tropicalis (50.5%), Candida glabrata (19.0%), Candida parapsilosis (14.3%) and one isolate each of Candida guillermondi and Candida krusei. Majority of the Candida spp. isolates were resistant to clotrimazole (55.5%) fluconazole (42%) and itraconazole (69%) and and ketoconazole (38%). All isolates were uniformly sensitive to amphotericin B. Conclusion: There is predominance of nonalbicans Candida species in hospital setting. A high index of suspicion, early diagnosis, and a prompt and appropriate therapy remains the cornerstone of treatment.

Keywords: Antifungal resistance, blood culture, candidemia, nonalbicans Candida

How to cite this article:
Thomas M, Oberoi A, Dewan E. Species distribution and antifungal susceptibility of candidemia at a multispecialty center in North India. CHRISMED J Health Res 2016;3:33-6

How to cite this URL:
Thomas M, Oberoi A, Dewan E. Species distribution and antifungal susceptibility of candidemia at a multispecialty center in North India. CHRISMED J Health Res [serial online] 2016 [cited 2022 May 20];3:33-6. Available from: https://www.cjhr.org/text.asp?2016/3/1/33/172395

  Introduction Top

Candida species are the leading cause of invasive fungal infections in hospitalized patients and are the fourth most common cause of bloodstream infections.[1] The reported crude mortality rates due to candidemia range from 30% to 81%.[2] Risk factors include exposure to broad-spectrum antibacterial agents, diabetes, increased complexity of surgical procedures, prolonged use of central venous catheters, renal failure, dialysis, total parenteral nutrition, underlying malignancy, corticosteroids, and cytotoxic chemotherapy.[3],[4],[5]

Candida albicans, Candida tropicalis, Candida glabrata, Candida parapsilosis, and Candida krusei are the five most common species causing candidemia, in combination accounting for more than 95% of the cases.[6] The treatment of choice for systemic fungal infections include azoles, echinocandins, and polyenes.[4],[6] The widespread prophylactic use of azoles especially in immunocompromised and critically ill patients have led to a notable shift from infections with C. albicans to infections with nonalbicans Candida species.[7]

  Materials and Methods Top

A retrospective study was conducted in a Tertiary Care Center in North India from January 1, 2014 to March 31, 2015. Candidemia was defined as the isolation of Candida species from one or more blood culture samples of a patient.[2] Blood culture was performed using the semi-automated BACTEC system. Candida species isolated from patient's blood culture were identified up to the species level, using standard microbiological techniques, which included germ tube test, corn meal agar morphology, CHROMagar, sugar fermentation test, and sugar assimilation test [Figure 1].[8] Antifungal drug susceptibility was done by disk diffusion method according to the Clinical and Laboratory Standards Institute guidelines.[9] The disks tested were clotrimazole (10 mcg), fluconazole (10 mcg), ketoconazole (10 mcg), itraconazole (10 mcg), and amphotericin B (100 units).
Figure 1: Sugar assimilation test

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  Results Top

During the 15 months of the study, a total of 10893 blood cultures samples were processed of which 1440 (13.2%) were detected positive. Among the positive samples Candida species were isolated from 105 (7.3%) cases. Of these, 15 (14.3%) were C. albicans and 90 (85.7%) were nonalbicans Candida. Nonalbicans Candida included C. tropicalis −53 (50.5%), C. glabrata −20 (19.0%), C. parapsilosis −15 (14.3%), and one isolate each of Candida guillermondi and C. krusei [Figure 2].
Figure 2: Incidence of candidemia

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The majority of the C. albicans were resistant to commonly used antifungal drugs such as fluconazole (47%), itraconazole (60%), clotrimazole (47%), and ketoconazole (33%). Among the nonalbicans Candida spp., C. tropicalis showed 49% resistance to fluconazole, 42% resistance to ketoconazole, 60% resistance to clotrimazole, and 64% resistance to itraconazole. C. glabrata showed 55% resistance to clotrimazole, 45% resistance to fluconazole, 50% resistance to ketoconazole, and 65% to itraconazole. C. parapsilosis showed 60% resistance to clotrimazole, 27% to fluconazole and ketoconazole and 87% to itraconazole. C. krusei and C. guillermondi were resistant to fluconazole, ketoconazole, itraconazole and clotrimazole. All the isolates were uniformly sensitive to amphotericin B [Figure 3].
Figure 3: Antifungal resistance pattern

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Chi-square test was applied to compare the sensitivity of various azoles among C. albicans and nonalbicans Candida. The P value was found to be P > 0.5 which was suggestive that there was no significant difference in the susceptibility pattern between C. albicans and other species of Candida.

  Discussion Top

Candidemia is an emerging problem in healthcare settings. Recent studies have shown an increase in the incidence of candidemia due to nonalbicans Candida species with the isolation rate ranging from 50% to 96% from tertiary care centers in India. C. tropicalis and C. parapsilosis are an emerging cause of candidemia in India.[2]

In our study, C. tropicalis caused 50.5% cases of candidemia. Previous studies by Chakrabarti et al,[10] Singh et al.[11] and Chander et al.[1] are in agreement with our study, and it appears that C. tropicalis is the predominant species causing candidemia in North India. Studies done by Adhikary et al.[12] and Giri et al.[13] in South India also showed a predominance of C. tropicalis that is consistent with our study.

However, studies done by Al-Rawahi and Roscoe [3] in Canada and Oliveira et al.[14] in Brazil showed predominance of C. albicans although the incidence of nonalbicans Candida species was on the rise. Recent study done in Shangai by Yang et al.[4] showed a predominance of nonalbicans Candida which was consistent with our study.

Our study showed an increase in the antifungal drug resistance, especially for the azole group of drugs, both in C. albicans and nonalbicans Candida species. The study by Chander et al.[1] and Kothari and Sagar.[15] also showed high resistance to fluconazole. But the study done by Zhang et al.[16] over a period of 10 years in China showed a very low resistance to fluconazole. We observed no resistance to amphotericin B in any of the strains, which is in concordance with the findings of previous studies from India.[13]

Our study has a number of limitations. It was a retrospective study conducted at a single institution. More number of studies should be done in a larger population. Antifungal susceptibility test was done by disk diffusion method, but minimum inhibitory concentration

should also have been determined. Susceptibility to echinocandins and flucytosine were not tested. Furthermore, no follow-up was done on the patients on the treatment and outcome, which is a major limitation.

  Conclusion Top

Candidemia in hospitalized patients is a significant problem worldwide. Nonalbicans Candida species, especially C. tropicalis is the most frequent pathogen isolated in our tertiary care center. Based on the present results, it is evident that routine identification of Candida isolates to the species level, and the detection of resistant strains by antifungal susceptibility test is essential. Furthermore, there is a continued need for surveillance of candidemia to monitor changes in the epidemiological features and antifungal susceptibility and also to develop and evaluate prevention strategies.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Chander J, Singla N, Sidhu SK, Gombar S. Epidemiology of Candida blood stream infections: Experience of a tertiary care centre in North India. J Infect Dev Ctries 2013;7:670-5.  Back to cited text no. 1
Tak V, Mathur P, Varghese P, Gunjiyal J, Xess I, Misra MC. The epidemiological profile of candidemia at an Indian trauma care center. J Lab Physicians 2014;6:96-101.  Back to cited text no. 2
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Al-Rawahi GN, Roscoe DL. Ten-year review of candidemia in a Canadian tertiary care centre: Predominance of non-albicans Candida species. Can J Infect Dis Med Microbiol 2013;24:e65-8.  Back to cited text no. 3
Yang ZT, Wu L, Liu XY, Zhou M, Li J, Wu JY, et al. Epidemiology, species distribution and outcome of nosocomial Candida spp. bloodstream infection in Shanghai. BMC Infect Dis 2014;14:241.  Back to cited text no. 4
Zaoutis TE, Argon J, Chu J, Berlin JA, Walsh TJ, Feudtner C. The epidemiology and attributable outcomes of candidemia in adults and children hospitalized in the United States: A propensity analysis. Clin Infect Dis 2005;41:1232-9.  Back to cited text no. 5
Chang TP, Ho MW, Yang YL, Lo PC, Lin PS, Wang AH, et al. Distribution and drug susceptibilities of Candida species causing candidemia from a medical center in central Taiwan. J Infect Chemother 2013;19:1065-71.  Back to cited text no. 6
Farmakiotis D, Tarrand JJ, Kontoyiannis DP. Drug-resistant Candida glabrata infection in cancer patients. Emerg Infect Dis 2014;20:1833-40.  Back to cited text no. 7
Winn WC Jr, Koneman EW, Allen SD, Procop GW, Schreckenberger PC, Janda WM, et al. Koneman's Colour Atlas and Textbook of Diagnostic Microbiology. 6th ed. Philadelphia: Lippincott Williams and Wilkins; 2006.  Back to cited text no. 8
Clinical and Laboratory Standards Institute. Method for Antifungal Disk Diffusion Susceptibility Testing of Yeasts; Approved Guideline. CLSI Document M44-A2. 2nd ed. Pennsylvania; 2009.  Back to cited text no. 9
Chakrabarti A, Chatterjee SS, Rao KL, Zameer MM, Shivaprakash MR, Singhi S, et al. Recent experience with fungaemia: Change in species distribution and azole resistance. Scand J Infect Dis 2009;41:275-84.  Back to cited text no. 10
Singh RI, Xess I, Mathur P, Behera B, Gupta B, Misra MC. Epidemiology of candidaemia in critically ill trauma patients: Experiences of a level I trauma centre in North India. J Med Microbiol 2011;60(Pt 3):342-8.  Back to cited text no. 11
Adhikary R, Joshi S. Species distribution and anti-fungal susceptibility of candidaemia at a multi super-specialty center in Southern India. Indian J Med Microbiol 2011;29:309-11.  Back to cited text no. 12
[PUBMED]  Medknow Journal  
Giri S, Kindo AJ, Kalyani J. Candidemia in intensive care unit patients: A one year study from a tertiary care center in South India. J Postgrad Med 2013;59:190-5.  Back to cited text no. 13
[PUBMED]  Medknow Journal  
Oliveira VK, Ruiz Lda S, Oliveira NA, Moreira D, Hahn RC, Melo AS, et al. Fungemia caused by Candida species in a children's public hospital in the city of São Paulo, Brazil: Study in the period 2007-2010. Rev Inst Med Trop Sao Paulo 2014;56:301-5.  Back to cited text no. 14
Kothari A, Sagar V. Epidemiology of Candida bloodstream infections in a tertiary care institute in India. Indian J Med Microbiol 2009;27:171-2.  Back to cited text no. 15
[PUBMED]  Medknow Journal  
Zhang XB, Yu SJ, Yu JX, Gong YL, Feng W, Sun FJ. Retrospective analysis of epidemiology and prognostic factors for candidemia at a hospital in China, 2000-2009. Jpn J Infect Dis 2012;65:510-5.  Back to cited text no. 16


  [Figure 1], [Figure 2], [Figure 3]

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