Candida bloodstream infection: data from a teaching hospital in Mato Grosso do Sul, Brazil

Epidemiology, Antifungal Susceptibility, and Risk Factors of Invasive Candidiasis in a Tertiary Hospital During a Four-Year Period

Background: Candida infections are a significant cause of morbidity and mortality in hospitalized patients. Acquired resistance to antifungal agents and strains with intrinsic resistance makes it hard to manage the infection. Objectives: We aimed to examine the risk factors of candidemia associated with patient mortality, the species causing candidemia, and their antifungal susceptibility. Methods: Patient data were collected from medical records retrospectively. MALDI-TOF MS was used to identify Candida species. Antifungal susceptibility testing was conducted by the colorimetric broth microdilution method. Results: A total of 155 patients were included in the study. The incidences of candidemia were 0.92, 0.72, 0.99, 0.97, and 2.28 per 1,000 cases in 2016, 2017, 2018, 2019, and 2020, respectively. Candida albicans accounted for 45% of all cases, followed by C. parapsilosis complex (28%), C. tropicalis (10%), and C. glabrata (8%). The 30-day crude mortality was 45%. There was no significant difference in mortality between C. albicans and non-albicans yeast species. The susceptibility rates for anidulafungin, micafungin, caspofungin, voriconazole, and fluconazole were as follows: 97%, 97%, 97%, 97%, and 90% in C. albicans, 95%, 95%, 98%, 72%, and 67% in C. parapsilosis complex, and 100%, 100%, 100%, 38%, and 63% in C. tropicalis. The susceptibility rates for anidulafungin, micafungin, and caspofungin in C. glabrata were 100%, 100%, and 92%, respectively. All 12 C. glabrata strains were susceptible-dose-dependent against fluconazole and uninterpretable for voriconazole. Conclusions: Incidences of candidemia and susceptibility patterns of strains may vary over time and amongst the regions. Candida albicans was the predominant strain, and echinocandins demonstrated the highest susceptibility rates against the most common species isolated in this study. Antifungal susceptibility tests are crucial in guiding patient treatment.

Clinical efficacy and safety of antifungal drugs for the treatment of Candida parapsilosis infections: a systematic review and network meta-analysis

Antifungal drugs have already been established as an effective treatment option for Candida parapsilosis infections, but there is no universal consensus on the ideal target for clinical efficacy and safety of antifungal drugs for the treatment of C. parapsilosis infections. Few studies have directly compared the efficacies of antifungal drugs for the treatment of C. parapsilosis infections. We hypothesize that different antifungal drugs offer differing clinical efficacy and safety for the treatment of C. parapsilosis infections. We performed a comprehensive network meta-analysis on different strategies for C. parapsilosis infection treatment and compared the clinical efficacy and safety of antifungal drugs as interventions for C. parapsilosis infections. The Cochrane Database of Systematic Reviews, Medline, Embase, PubMed, Web of Science, China National Knowledge Infrastructure (CNKI), Technology of Chongqing VIP database, Wan Fang Data, and SinoMed databases were searched to identify appropriate randomized trials. Among the extracted C. parapsilosis cases, the survival and death rates with treatment of C. parapsilosis infection were compared among groups treated with different antifungal drugs. According to the evidence-network analysis, echinocandins were a better choice than other drugs for treating C. parapsilosis infections, and more importantly, caspofungin showed a more preferable effect for decreasing the risk of 30 day mortality. In conclusion, this study systematically evaluated the effectiveness and safety of antifungal drugs for the purpose of helping clinicians choose the most appropriate antifungal drugs. Future studies with larger samples are needed to evaluate the effects of patient factors on the clinical efficacy and safety of antifungal drugs for C. parapsilosis infections.

Time to Detection of Yeast Isolates in Pediatric and Adult Patients with Fungemia and its Relevance to Clinical Profile and Outcome

Context

Time to detection (TTD) given by continuous monitoring automated blood culture systems (CMABS) have been found to be a predictor of clinical outcome, drug resistance and type of microorganism in cases of bacteremia but the studies evaluating TTD with respect to fungemia are scarce especially from India.

Aims

To evaluate TTD for yeast isolates in fungal bloodstream infections with respect to the type of yeast isolates, risk factors and outcome and to study yeast susceptibility and distribution of yeast isolates with respect to patient population.

Materials and methods

All blood culture specimens were processed in CMABS. The TTD for yeast isolates were recorded. The identification of yeast and susceptibility testing was done by automated methods. A correlation of TTD was done with respect to prior/concurrent yeast isolates, use of antifungal, risk factors and clinical outcome.

Results

Out of 80 yeast isolates, the maximum was C. parapsilosis (26.25%) followed by C. albicans (16.25%) and C. tropicalis (13.75%). A statistically significant difference in the occurrence of yeasts with early TTD (TTD < = 48 hours) and late TTD (TTD > 48 hours) was found. TTD of C. glabrata was significantly longer (p = 0.002) while TTD of C. tropicalis was significantly shorter (p = 0.013). There was an observable favorable outcome in shorter TTD (< = 48 hours). C. albicans and C. tropicalis depicted 100% susceptibility for Azoles, Amphotericin B and Echinocandins.

Conclusion

TTD may be used as both diagnostic and prognostic adjunct in fungal bloodstream infections. This study is a step towards this novel approach. We also emphasize on the importance of speciation of yeast isolates and susceptibility testing.

How to cite this article

Butta H, Sardana R, Mendiratta L, Sibal A, Gupta V, Chawla R, Jafri AA. Time to Detection of Yeast Isolates in Pediatric and Adult Patients with Fungemia and its Relevance to Clinical Profile and Outcome. Indian Journal of Critical Care Medicine, January 2019;23(1):27-30.

Identification and antifungal susceptibility of Candida species isolated from the urine of patients in a university hospital in Brazil

The aim of this study was to identify Candida spp. isolated from candiduria episodes at a tertiary hospital in the Midwest region of Brazil, and to determine their susceptibility profiles to antifungal compounds. From May 2011 to April 2012, Candida spp. isolated from 106 adult patients with candiduria admitted to the University Hospital of the Federal University of Mato Grosso do Sul were evaluated. Both, species identification and susceptibility testing with fluconazole-FLC, voriconazole-VRC, and amphotericin B-AmB were carried out using the Vitek 2. To discriminate species of the C. parapsilosis complex, a RAPD-PCR technique using the RPO2 primer was performed. From the total of 106 isolates, 42 (39.6%) C. albicans and 64 (60.4%) Candida non-albicans (CNA) - 33 C. tropicalis, 18 C. glabrata, 5 C. krusei, 4 C. parapsilosis sensu stricto, 2 C. kefyr, 1 C. lusitaniae, and 1 C. guilliermondii were identified. All isolates were susceptible to AmB and VRC, whereas all C. glabrata isolates presented either resistance (5.6%) or dose-dependent susceptibility (94.4%) to FLC. The study of Candida spp. and their resistance profiles may help in tailoring more efficient therapeutic strategies for candiduria.

Candidaemia due to Candida parapsilosis species complex at a hospital in Brazil: Clinical characteristics and antifungal susceptibility profile

BACKGROUND

Recent decades have seen a global emergence of candidaemia caused by non-Candida albicans Candida species, particularly the Candida parapsilosis complex.

AIMS

To evaluate the clinical features and antifungal susceptibility profiles of isolates belonging to the C. parapsilosis species complex in patients with candidaemia in a midwestern Brazilian tertiary-care teaching hospital.

METHODS

Yeast identification was performed using an automated Vitek 2 Compact system. PCR-RFLP was employed for species differentiation.

RESULTS

Five cases of infection by C. parapsilosis sensu stricto and two by Candida orthopsilosis were found. Of the seven cases, five were adult patients undergoing haemodialysis. The only isolate of C. parapsilosis sensu stricto resistant to fluconazole (MIC=8μg/ml) was obtained from a patient on a long-term regimen with this drug. This was the only patient who evolved to death.

CONCLUSIONS

Resistance to antifungal agents poses a therapeutic challenge, especially for non-C. albicans Candida species, and requires continuous monitoring using susceptibility tests because resistance in vitro can be predictive of treatment failure. In the present study, in vitro antifungal susceptibility proved consistent with clinical outcome.

Epidemiology and antifungal susceptibility of Candida species in a tertiary care hospital, Kolkata, India

Background and Purpose:

The incidence of fungal infection as well as candidemia has increased significantly, contributing to morbidity and mortality in the developed countries. The alarming increase in infections with multidrug resistant bacteria is due to overuse of a broad spectrum antimicrobials, which leads to over growth of Candida spp.; thus, enhancing its opportunity to cause the disease. A shift has been observed in the relative frequency of each Candida spp. Antifungal agents available for the treatment of systemic and invasive candidiasis are restricted to polyenes, allylamines, azoles, and the recent echinocandin class of molecules. In the past few decades, the incidence of resistance to antifungal treatment of Candida spp. has increased rapidly, which is of serious concern for healthcare professionals. Studies on prevalence of infections and antifungal susceptibility testing can help with deciding on clinical strategies to manage this problem. Herein, we aimed to identify the epidemiology of Candida spp. among blood culture isolates and to investigate the susceptibility pattern of these species to antifungal agents.

Materials and Methods:

Candida spp. were isolated from blood cultures from 70 patients in a tertiary care hospital, Kolkata, India. The growth of Candida spp. on sabouraud dextrose agar was confirmed by Gram staining, where gram-positive budding fungal cells were observed. The species identification as well as antifungal susceptibility testing were performed with VITEK 2 compact automated system using VITEK-2 cards for identification of yeast and yeast-like organisms) ID-YST card). Antifungal susceptibility testing was carried out with VITEK 2 fungal susceptibility card (AST-YS07 kit).

Results:

Out of 70 samples, Candidaalbicans were isolated from 34 (%48.57) samples. The remaining 36 (%51.43) were non-albicans Candida ) NAC). Out of 34 C. Albicans, antifungal susceptiblity was detected in 28 isolates, all of which were sensitive to fluconazole (FLC .( Resistance to amphotericine B) AMP), flucytosine (5FC), voriconazole (VRC), and itraconazole (ITC) was observed in, %44.12 , %52.94 , %8.82 and %17.65 of the cases, respectively. For other Candida spp. (other than C. Albicans ,( antifungal susceptibility was evaluated for 36 isolates, among which resistance to AMP, FLC , 5FC, VRC , and ITC was found in, %30.56 , %61.11 , %33.33 , %19.44 and %38.89 cases, respectively.

Conclusion:

Species-level identification of Candida and their antifungal sensitivity testing should to be performed to achieve better clinical result and to select an appropriate and effective antifungal therapy. High resistance to antifungal agents is an alarming sign to the healthcare professionals.

FREQUENCY OF Candida SPECIES IN A TERTIARY CARE HOSPITAL IN TRIANGULO MINEIRO, MINAS GERAIS STATE, BRAZIL

Infections by Candida species are a high-impact problem in public health due to their wide incidence in hospitalized patients. The goal of this study was to evaluate frequency, susceptibility to antifungals, and genetic polymorphism of Candida species isolated from clinical specimens of hospitalized patients. The Candida isolates included in this study were obtained from blood cultures, abdominal fluids, and central venous catheters (CVC) of hospitalized patients at the Clinical Hospital of the Federal University of Uberlândia during the period of July 2010 - June 2011. Susceptibility tests were conducted by the broth microdilution method. The RAPD-PCR tests used employed initiator oligonucleotides OPA09, OPB11, and OPE06. Of the 63 Candida isolates, 18 (28.5%) were C. albicans, 20 (31.7%) were C. parapsilosis complex species, 14 (22.2%) C. tropicalis, four (6.4%) C. glabrata, four (6.4%) C. krusei, two (3.3%) C. kefyr, and one (1.6%) C. lusitaniae. In vitro resistance to amphotericin B was observed in 12.7% of isolates. In vitroresistance to azoles was not detected, except for C. krusei. The two primers, OPA09 and OPB11, were able to distinguish different species. Isolates of C. albicans and C. parapsilosis complex species presented six and five clusters, respectively, with the OPA09 marker by RAPD-PCR, showing the genetic variability of the isolates of those species. It was concluded that members of the C. parapsilosis complex were the most frequent species found, and most isolates were susceptible to the antifungals amphotericin B, flucozanole, and itraconazole. High genetic polymorphisms were observed for isolates of C. albicans and C. parapsilosis complex species, mainly with the OPA09 marker.

Nosocomial bloodstream Candida infections in a tertiary-care hospital in South Brazil: a 4-year survey

The aims of this study were to evaluate the epidemiology of nosocomial candidemia in a tertiary hospital in South Brazil and the in vitro antifungal susceptibility of isolates. Blood strains from 108 patients were identified by PCR-based method. Some 30.5 % of candidemia were caused by Candida tropicalis, 28.7 % were due to Candida albicans, 24.1 % with Candida parapsilosis sensu stricto, 8.3 % with Candida glabrata sensu lato, 1.8 % involved Candida krusei and 6.6 % with other species. Candidemia was more common in intensive care unit settings (66 %). In vitro susceptibility to antifungal drugs was determined by a microdilution method; and new species-specific clinical breakpoints for fluconazole and voriconazole were applied. Overall susceptibility rates were 100 % for itraconazole, 91 % for fluconazole, 98 % for voriconazole and 99 % for amphotericin B. Fluconazole resistance was mostly among C. parapsilosis sensu stricto isolates (26.9 %). Most of the findings reported here agreed with epidemiological features common to other tertiary hospitals in Brazil; but also revealed some peculiarities, such as a high frequency of C. tropicalis associated with candidemia. Besides, high rate of fluconazole resistance among C. parapsilosis stricto sensu isolates was obtained when applying the new species-specific clinical breakpoints.

Molecular typing of Candida albicans isolates from hospitalized patients

SUMMARY

Introduction: The majority of nosocomial fungal infections are caused by Candida spp. where C. albicans is the species most commonly identified. Molecular methods are important tools for assessing the origin of the yeasts isolated in hospitals.

Methods: This is a study on the genetic profifiles of 39 nosocomial clinical isolates of C. albicans using two typing methods: random amplifified polymorphic DNA (RAPD) and microsatellite, two different primers for each technique were used.

Results: RAPD provided 10 and 11 different profiles with values for S_AB of 0.84 ± 0.126 and 0.88 ± 0.08 for primers M2 and P4, respectively. Microsatellite using two markers, CDC3 and HIS3, allowed the observation of six and seven different alleles, respectively, with combined discriminatory power of 0.91.

Conclusions: Although genetic variability is clear, it was possible to identify high similarity, suggesting a common origin for at least a part of isolates. It is important to emphasize that common origin was proven from yeasts isolated from colonization (urine, catheter or endotracheal secretions) and blood culture from the same patient, indicating that the candidemia must have started from a site of colonization. The combination of RAPD and microsatellite provides a quick and efficient analysis for investigation of similarity among nosocomial isolates of C. albicans.

Bloodstream infection in patients with end-stage renal disease in a teaching hospital in central-western Brazil

INTRODUCTION

Vascular access in patients undergoing hemodialysis is considered a critical determinant of bloodstream infection (BSI) and is associated with high morbidity and mortality. The purpose of this study was to investigate the occurrence of BSI in patients with end-stage renal disease using central venous catheters for hemodialysis.

METHODS

A cohort study was conducted in a public teaching hospital in central-western Brazil from April 2010 to December 2011. For every patient, we noted the presence of hyperemia/exudation upon catheter insertion, as well as fever, shivering, and chills during hemodialysis.

RESULTS

Fifty-nine patients were evaluated. Thirty-fi ve (59.3%) patients started dialysis due to urgency, 37 (62.7%) had BSI, and 12 (20%) died. Hyperemia at the catheter insertion site (64.9%) was a significant clinical manifestation in patients with BSI. Statistical analysis revealed 1.7 times more cases of BSI in patients with hypoalbuminemia compared with patients with normal albumin levels. The principal infective agents identified in blood cultures and catheter-tip cultures were Staphylococcus species (24 cases), non-fermentative Gram-negative bacilli (7 cases of Stenotrophomonas maltophilia and 5 cases of Chryseobacterium indologenes), and Candida species (6). Among the Staphylococci identified, 77.7% were methicillin-resistant, coagulase-negative Staphylococci. Of the bacteria isolated, the most resistant were Chryseobacterium indologenes and Acinetobacter baumannii.

CONCLUSIONS

Blood culture was demonstrated to be an important diagnostic test and identified over 50% of positive BSI cases. The high frequency of BSI and the isolation of multiresistant bacteria were disturbing findings. Staphylococcus aureus was the most frequently isolated microorganism, although Gram-negative bacteria predominated overall. These results highlight the importance of infection prevention and control measures in dialysis units.

Antifungal susceptibility and distribution of Candida spp. isolates from the University Hospital in the municipality of Dourados, State of Mato Grosso do Sul, Brazil

INTRODUCTION

Hospital infections caused by Candida spp. are a leading cause of morbidity and mortality in hospitalized patients, particularly those that are critically ill or immunocompromised. In this study, the distribution of Candida species in isolates from the University Hospital of the Federal University at Grande Dourados and their in vitro susceptibility to antifungal drugs were analyzed.

METHODS

Yeasts were phenotypically identified using classical methodologies. Antifungal susceptibility tests to amphotericin B and fluconazole were performed using the broth microdilution technique.

RESULTS

A total of 50 Candida isolates were obtained from hospitalized patients during the study period. We analyzed yeast isolates from urine (n=31; 62%), blood (n=12; 24%), and tracheal secretions (n=7; 14%). The following Candida species were identified: C. tropicalis (n=21; 42%), C. albicans (n=18; 36%), C. glabrata (n=10; 20%), and C. krusei (n=1; 2%). Antifungal susceptibility tests demonstrated that C. albicans was susceptible to both antifungal agents. However, 31.2% of the non-C. albicans Candida isolates displayed dose-dependent susceptibility to fluconazole, and 3.1% were resistant to amphotericin B.

CONCLUSIONS

In contrast to previous reports, our results indicated that C. tropicalis was the most commonly isolated yeast species among the hospital patients. The predominance of non-C. albicans Candida infections confirms the importance of species-level identification for implementing appropriate antifungal therapies.

Six-year trend analysis of nosocomial candidemia and risk factors in two intensive care hospitals in Mato Grosso, midwest region of Brazil

We conducted this cross-sectional retrospective study using clinical and laboratory data from two tertiary hospitals in Cuiabá, Mato Grosso, Brazil, in order to explore the risk factors and estimate mortality, prevalence and lethality of candidemia between 2006 and 2011. A total of 130 episodes of candidemia were identified. The prevalence of candidemia was 1.8 per 1,000 admissions, the mortality rate was 0.9 per 1,000 admissions, and the lethality was 49.2 %. The main agent in this population was Candida parapsilosis (n = 50), followed by C. albicans (n = 45). Comparison between the numbers of episodes in the two triennia revealed that the non-albicans group grew by 48.2 %. The distribution of yeast species of Candida per hospital unit revealed that C. albicans was more prevalent than C. parapsilosis in the adult ICU and C. parapsilosis was more prevalent than C. albicans in the neonatal ICU. Patients remained hospitalized for an average of 53.5 days. Central venous catheters, parenteral nutrition and age were the variables that proved to be independent in the multivariate analysis and that maintained a statistically significant association with the incidence of death in patients with candidemia. The annual prevalence of candidemia showed a significant increase in the second triennium (2009-2011) compared with the first (2006-2008) probably due to increased exposure to risk factors: central venous catheter, H2 blockers, nutrition parenteral corticosteroids and mean hospital duration.

Aspartic proteinases of Candida spp.: role in pathogenicity and antifungal resistance

Fungal infections represent a serious health risk as they are particularly prevalent in immunocompromised individuals. Candida spp. pathogenicity depends on several factors and secreted aspartic proteinases (Sap) are considered one of the most critical factors as they are associated with adhesion, invasion and tissue damage. The production of proteinases is encoded by a family of 10 genes known as SAP, which are distributed differently among the species. The expression of these genes may be influenced by environmental conditions, which generally result in a higher fungal invasive potential. Non-pathogenic Candida spp. usually have fewer SAP genes, which are not necessarily expressed in the genome. Exposure to subinhibitory concentrations of antifungal agents promotes the development of resistant strains with an increased expression of SAP genes. In general, Candida spp. isolates that are resistant to antifungals show a higher secretion of Sap than the susceptible isolates. The relationship between Sap secretion and the susceptibility profile of the isolates is of great interest, although the role of SAPs in the development of resistance to antifungal agents remains still unclear. This review is the first one to address these issues.

Contaminação por fungos antes e após limpeza e desinfecção de colchões hospitalares

OBJETIVO: Verificar se existe contaminação por fungos antes e após limpeza e desinfecção terminal de colchões hospitalares utilizados por portadores de candidemia. MÉTODOS: Estudo transversal que investigou 25 colchões de diferentes unidades hospitalares e utilizados por pacientes com candidemia, confirmados por hemocultura. Utilizou-se amostragem por conveniência. Após crescimento em Ágar Sabouraud Dextrose as leveduras isoladas foram identificadas pelas características macroscópicas, microscópicas e fisiológicas. RESULTADOS: Totalizou-se 15 (60%) colchões contaminados com Candida spp. Desse total, 10 (66,7%) e cinco (33,3%) corresponderam respectivamente à coleta antes e após a desinfecção dos colchões, sendo que a espécie mais frequentemente isolada foi Candida parapsilosis. CONCLUSÃO: Considerando que a metade dos colchões permaneceram contaminados após o processo de limpeza e desinfecção, pode-se inferir sobre o risco destes atuarem como reservatórios secundários na cadeia de infecção.

Epidemiology and predictors of a poor outcome in elderly patients with candidemia

BACKGROUND

Candidemia affects patient populations from neonates to the elderly. Despite this, little information is available about the epidemiology of candidemia in elderly patients.

METHODS

We performed a retrospective analysis of 987 episodes of candidemia in adults (>14 years of age) from the databases of three laboratory-based surveys of candidemia performed at 14 tertiary care hospitals. Patients aged ≥60 years were considered elderly (group 1, n=455, 46%) and were compared to younger patients (group 2, n=532, 54%) regarding demographics, underlying diseases, comorbidities, exposure to medical procedures, species, treatment, and outcome.

RESULTS

The median APACHE II score was significantly higher in the elderly patients (19 vs. 15, p=0.03). Variables that were observed significantly more frequently in elderly patients included admission to an intensive care unit, diabetes mellitus, renal failure, cardiac disease, lung disease, receipt of antibiotics or H2 blockers, insertion of a central venous catheter, mechanical ventilation, and candidemia due to Candida tropicalis. The 30-day mortality of elderly patients was significantly higher than that of younger patients (70% vs. 45%, p<0.001). Factors associated with higher mortality by multivariate analysis included APACHE II score and being in group 1 (elderly). Factors associated with mortality in elderly patients were lung disease and the receipt of mechanical ventilation.

CONCLUSIONS

Elderly patients account for a substantial proportion of patients with candidemia and have a higher mortality compared to younger patients.

Species distribution and in vitro fluconazole susceptibility of clinical Candida isolates in a Brazilian tertiary-care hospital over a 3-year period

INTRODUCTION

In this study, we aimed at identifying Candida isolates obtained from blood, urine, tracheal secretion, and nail/skin lesions from cases attended at the Hospital Universitário de Londrina over a 3-year period and at evaluating fluconazole susceptibilities of the isolates.

METHODS

Candida isolates were identified by polymerase chain reaction (PCR) using species-specific forward primers. The in vitro fluconazole susceptibility test was performed according to EUCAST-AFST reference procedure.

RESULTS

Isolates were obtained from urine (53.4%), blood cultures (19.2%), tracheal secretion (17.8%), and nail/skin lesions (9.6%). When urine samples were considered, prevalence was similar in women (45.5%) and in men (54.5%) and was high in the age group >61 years than that in younger ones. For blood samples, prevalence was high in neonates (35%) and advanced ages (22.5%). For nail and skin samples, prevalence was higher in women (71.4%) than in men (28.6%). Candida albicans was the most frequently isolated in the hospital, but Candida species other than C. albicans accounted for 64% of isolates, including predominantly Candida tropicalis (33.2%) and Candida parapsilosis (19.2%). The trend for non-albicans Candida as the predominant species was noted from all clinical specimens, except from urine samples. All Candida isolates were considered susceptible in vitro to fluconazole with the exception of isolates belonging to the intrinsically less-susceptible species C. glabrata.

CONCLUSIONS

Non-albicans Candida species were more frequently isolated in the hospital. Fluconazole resistance was a rare finding in our study.