Journal of Laboratory Physicians
Home About us Ahead of print Current issue Back issues Subscribe Instructions Contact Login 
Wide layoutNarrow layoutPrint this page  Email this page Bookmark this page Small font size Default font size Increase font size 
 


 
ORIGINAL ARTICLE
Year : 2009  |  Volume : 1  |  Issue : 2  |  Page : 53-55 Table of Contents   

Emergence of Nonalbicans Candida in neonatal septicemia and antifungal susceptibility: Experience from a tertiary care center


1 Department of Microbiology, Pt. B.D.S. PGIMS, Rohtak, India
2 Department of Pediatrics, Pt. B.D.S. PGIMS, Rohtak, India

Date of Web Publication5-Feb-2010

Correspondence Address:
Nidhi Goel
Department of Microbiology, Pt. B.D.S. PGIMS, Rohtak
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0974-2727.59699

Rights and Permissions
   Abstract 

Aims: To know the distribution and antifungal susceptibility pattern of Candida species in neonatal septicemia cases.
Materials and Methods: In a prospective analysis blood samples from 825 clinically suspected cases of neonatal septicemia, collected aseptically, were cultured to look for the role of Candida spp. in septicemia. Candida isolates were speciated by germ tube test, Hi-CHROME agar, sugar fermentation, and sugar assimilation tests using standard protocol. All the Candida isolates were tested for antifungal susceptibility to fluconazole by the Disk Diffusion (DD) method and broth micro dilution-minimum inhibitory concentration (BMD-MIC) method using NCCLS guidelines.
Results: Isolation rate of Candida from neonatal septicemia cases was 8.1%. Most common isolate was C. tropicalis (61.19%), followed by C. albicans (19.40%), C. glabrata (11.94%), C. parapsilosis (5.97%) and C. guillermondii (1.49%). Low birth weight and previous antibiotic prophylaxis was found in 100% cases. Crude mortality rate was 50.1%. By DD method, 95.53% of the Candida isolates were sensitive to fluconazole. A discrepancy between DD method and BMD-MIC method was noted in 4.47% strains. One isolates each of C. tropicalis, C. albicans, and C. glabrata showed discrepancy.
Conclusion: Nonalbicans Candida has emerged as an important cause of neonatal septicemia. Routine susceptibility testing of Candida isolates by DD method should be confirmed by BMD-MIC method. Fluconazole can be used as empirical therapy for neonatal candidemia at our center.

Keywords: Antifungal sensitivity, nonalbicans Candida, neonatal septicemia


How to cite this article:
Goel N, Ranjan PK, Aggarwal R, Chaudhary U, Sanjeev N. Emergence of Nonalbicans Candida in neonatal septicemia and antifungal susceptibility: Experience from a tertiary care center. J Lab Physicians 2009;1:53-5

How to cite this URL:
Goel N, Ranjan PK, Aggarwal R, Chaudhary U, Sanjeev N. Emergence of Nonalbicans Candida in neonatal septicemia and antifungal susceptibility: Experience from a tertiary care center. J Lab Physicians [serial online] 2009 [cited 2018 Dec 11];1:53-5. Available from: http://www.jlponline.org/text.asp?2009/1/2/53/59699


   Introduction Top


Importance of Candida species in nursery and intensive care units (ICUs) is increasingly being recognized. Candida species account for 9-13% of all blood isolates in neonatal intensive care units (NICUs). [1] Although C. albicans has historically been the most frequently isolated species, infections caused by the nonalbicans Candida have been diagnosed with increasing frequency in recent years, notably C. tropicalis, C. glabrata, and C. parapsilosis. Common use of broad-spectrum antibiotics, low birth weight (LBW), prematurity, and intravenous catheter, etc., makes neonates prone to candidemia. [2] The incidence and associated mortality due to candidemia can be influenced by several factors including characteristic of the population at risk, standard of the health care facilities available, distribution of Candida species, and prevalence of antifungal resistance. [3] These factors may vary from one geographical region to other. The increased isolation rates of nonalbicans Candida species and a gradual shift in the antifungal susceptibility profile have underlined the need to monitor laboratory data for possible emergence of resistance and to select most appropriate antifungal agent for therapy. We have noticed an increased isolation rate of nonalbicans Candida from neonatal septicemia cases over last few months. So we are presenting our findings that were observed while investigating the causes of candidemia in a neonatal ICU.


   Materials and Methods Top


A total of 825 clinically suspected cases of neonatal septicemia were included in the study from June 2008-December 2008. Demographic and clinical data such as age, sex, birth weight, antibiotic prophylaxis, presence of CVC, and clinical outcome of the neonates were noted from clinical records. Approximately 1 to 2 ml of blood was collected under aseptic precautions and inoculated in biphasic brain heart infusion medium. Subculture was done on third, fifth, and seventh day. All the Candida isolates were subjected to germ tube test using normal human serum. Colonies were identified up to the species level on the basis of morphology on Corn meal agar, growth on Hi- CHROME Candida agar, carbohydrate fermentation, and assimilation patterns. [4] All the isolates were screened for antifungal susceptibility testing by the Disk Diffusion (DD) method using fluconazole (25 µg) (Hi- media, Mumbai) on Mueller-Hinton agar (MHA) supplemented with 2% glucose and methylene blue (GMB) 5 µg/ml. Zone diameters were interpreted as per the approved NCCLS (M44-A) guidelines. [5] The broth micro dilution-minimum inhibitory concentration (BMD-MIC) of the isolates was performed to the fluconazole using RPMI medium and MOPS buffer. MIC results were interpreted as per NCCLS (M27-A2) guidelines. [6] Isolates showing MIC # 8 µg/ml were regarded as susceptible, 16-32 µg/ ml as dose-dependent susceptible and $ 64 µg/ml as resistant. The quality control test was performed by using C. parapsilosis (ATCC 22019), C. krusei (ATCC 6258), and C. albicans (ATCC 90028).


   Results Top


A total of 67 (8.1%) Candida isolates were recovered from 825 specimens. Male to female ratio was 2:1. The mean age of neonates was 3.8 days (SD ± 5.9). All the neonates (100%) were low birth weight (between 1.0-1.5 kg), and had received prophylactic antibiotics. Other associated findings were presence of central venous line in 71%, prematurity 40%, perinatal asphyxia 31.2%, jaundice 27.8%, and meconium aspiration in 10.8% of neonates; crude mortality rate was 50.1%. One isolate was from HIV positive neonate. Majority of isolates were C. tropicalis (61.19%), followed by C. albicans (19.40%), C. glabrata (11.94%), C. parapsilosis (5.97%), and C. guillermondii (1.49%). The result of in vitro susceptibility testing of Candida isolates to fluconazole is shown in [Table 1]. By DD method, 89.55% of Candida isolates were sensitive to fluconazole. The results of antifungal susceptibility testing by DD and BMD-MIC were compared for fluconazole. The DD testing performed in accordance with NCCLS M 44-A guidelines was comparable in 95.53% strains. A discrepancy between DD method and BMD-MIC test result for susceptibility to fluconazole was noted in 4.47% strains.


   Discussion Top


In our study, isolation rate of Candida from neonatal septicemia cases was 8.1%, which was lower than several other reports showing frequency of isolation in 13.6-19.6% cases. [2] C. albicans was the predominant organism in the earliest population based study conducted during 1992-1993 by CDC USA. [7] But a notable feature of our study was the emergence of nonalbicans Candida (80.59%) as a major cause of neonatal candidemia. C. tropicalis (61.19%) was the most common species followed by C. albicans (19.40%), and C. glabrata (11.94%). Our findings are supported by other studies from the same geographical area that have documented predominance of nonalbicans Candida over the C. albicans in neonatal septicemia. [8],[9]

Antifungal susceptibility testing in our study revealed that all the Candida isolates except C. glabrata were 100% sensitive to fluconazole, though, three isolates of C. tropicalis were found to be in the Susceptible Dose Dependant (SDD) range with MIC 16 µg/ml, when tested by broth micro-dilution MIC method. In contrast to our study, several other Indian studies have reported a high (18.75-24%) fluconazole resistance against all the Candida spp. [10] The results of DD susceptibility testing to fluconazole were compared by BMD-MIC method. Overall, four strains of C. tropicalis were SDD by DD method that was reduced to three with BMD-MIC method. One strain of C. tropicalis that was resistant by DD method was found to be SDD with MIC 16 µg/ml. This result of our study emphasizes that DD method alone gives false resistance. Several risk factors have been cited as predisposing to candidemia in neonates including underlying illness, LBW, broad-spectrum antibiotic, asphyxia neonatorum, hyperalimentation, and total parentral nutrition. [2] In our study, LBW and broad spectrum antibiotic were the most common associated findings present in 100% neonates with candidemia.


   Conclusion Top


Our study shows that nonalbicans Candida has emerged as a major cause of neonatal candidemia. LBW and broad spectrum antibiotics are the most common predisposing factors. Routine susceptibility testing of Candida isolates by DD method should be confirmed by BMD-MIC method. Fluconazole can be used as empirical therapy for neonatal candidemia at our center.

 
   References Top

1.Baradkar VP, Mathur M, Kumar S, Rathi M. Candida glabrata emerging pathogen in neonatal sepsis. Ann Trop Med Public Health 2008;1:5-8.  Back to cited text no. 1    Medknow Journal  
2.Agarwal J, Bansal S, Mailk GK, Jain A. Trends in neonatal septicemia: Emergence of non-albican Candida. Indian Pediatr 2004;41:712-5.   Back to cited text no. 2      
3.Hobson RP The global epidemiology of invasive Candida infections: Is the tide turning? J Hosp Infect 2003;20:159-68.  Back to cited text no. 3      
4.Chander J. Candidiasis. A text book of medical mycology. 3 rd ed. New Delhi: Mehta Publishers; 2009. p. 266-90.  Back to cited text no. 4      
5.National Committee for Clinical Laboratory Standards. Methods for antifungal disk diffusion susceptibility testing yeast: Approved guideline M-44A. Wayne, PA: NCCLS; 2004.  Back to cited text no. 5      
6.National Committee for Clinical Laboratory Standards. Reference method for broth dilution testing of yeast approved standard. 2 nd ed. M27-A2.Wayne, PA: NCCLS; 2002.  Back to cited text no. 6      
7.Chakrabarti A, Shivaprakash MR. Microbiology of systemic fungal infection. J Postgrad Med 2005;51:16-20.  Back to cited text no. 7  [PUBMED]  Medknow Journal  
8.Xess I, Jain N, Hasan F, Mandal P, Banerjee U. Epidemiology of candidemia in a tertiary care centre of North India: 5-year study. Infection 2007;35:256-9.  Back to cited text no. 8      
9.Baradkar VP, Mathur M, Kumar S, Rathi M. Candida glabrata emerging pathogen in neonatal sepsis. Ann Trop Med Pub Health 2008;1:5-8.  Back to cited text no. 9      
10.Narain, Shastri JS, Mathur M, Mehta PR. Neonatal systemic candidiasis in a tertiary care hospital. Indian J Med Microbiol 2003;21:56-8.  Back to cited text no. 10      



 
 
    Tables

  [Table 1]

This article has been cited by
1 Virulence Factors Contributing to Pathogenicity of Candida tropicalis and Its Antifungal Susceptibility Profile
Sachin C. Deorukhkar,Santosh Saini,Stephen Mathew
International Journal of Microbiology. 2014; 2014: 1
[Pubmed] | [DOI]
2 Fungemia by Candida pelliculosa (Pichia anomala) in a Neonatal Intensive Care Unit: A Possible Clonal Origin
Carolina Maria da Silva,Ana Maria Rabelo Carvalho Parahym,Mariele Porto Carneiro Lećo,Neiva Tinti Oliveira,Rosemary Jesus Machado Amorim,Rejane Pereira Neves
Mycopathologia. 2013; 175(1-2): 175
[Pubmed] | [DOI]



 

Top
 
  Search
 
  
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this article
    Abstract
    Introduction
    Materials and Me...
    Results
    Discussion
    Conclusion
    References
    Article Tables

 Article Access Statistics
    Viewed3326    
    Printed272    
    Emailed1    
    PDF Downloaded400    
    Comments [Add]    
    Cited by others 2    

Recommend this journal