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ORIGINAL RESEARCH ARTICLE
Year : 2018  |  Volume : 15  |  Issue : 4  |  Page : 219-222

Antifungal susceptibility of Candida species isolated from urine from patients in a neurosciences intensive care unit


1 Directorate of Medical Research, IMS and SUM Hospital, Siksha “O” Anusandhan Deemed to be University, Bhubaneswar, Odisha, India
2 Department of Community Medicine, IMS and SUM Hospital, Siksha “O” Anusandhan Deemed to be University, Bhubaneswar, Odisha, India

Date of Web Publication5-Dec-2018

Correspondence Address:
Mahesh Chandra Sahu
Directorate of Medical Research, IMS and SUM Hospital, Bhubaneswar, Odisha
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/am.am_43_18

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  Abstract 


Background and Objectives: The incidence of fungal infections in immunocompromised patients, especially by Candida species, has increased in recent years. This study was designed to identify Candida species and determine antifungal susceptibility patterns isolated strains from urine samples of intensive care unit (ICU) patients. Materials and Methods: All the urine samples of neuroscience ICU patients were cultured on Blood agar, Cystine–Lactose–Electrolyte-deficient agar, and Sabouraud Dextrose Agar. The grown colony was identified with color pigmentation on Candida Differential Agar. The antifungal susceptibilities of all Candida species were carried out with fluconazole, amphotericin B, ketoconazole, itraconazole, clotrimazole, nystatin, and miconazole. The generated results were analyzed with SPSS software (Version 20, IBM Corp., Armonk, NY, USA). Results: Candida Species were found in both genders of ICU patients with respect to all age groups. Among 100 urinary tract infection patients, 14 individuals were affected with diabetes and cerebrovascular accident. Whereas other disease comorbidity renal tubular acidosis, subarachnoid hemorrhage, head injury, acute respiratory distress syndrome, hypertension, and others were 9, 8, 8, 5, 11, and 31, respectively. Candida albicans (38.09%) was the most frequently isolated species, followed by Candida glabrata (23.8%), Candida krusei (23.8%), and Candida tropicalis (2.85%). Resistance varies depending on the species and the respective antifungal agents. From among 7 antifungal agents, itraconazole showed highest percentage of sensitivity (81.8%). Conclusions: Species definition and determination of antifungal susceptibility patterns are advised for the proper management and treatment of patients at risk for systemic candidiasis. Resistance to antifungal agents is an alarming sign for the emerging common nosocomial fungal infections.

Keywords: Amphotericin B, antifungal susceptibility, Candida, itraconazole, neuroscience intensive care unit


How to cite this article:
Rath S, Behera IC, Sahu MC. Antifungal susceptibility of Candida species isolated from urine from patients in a neurosciences intensive care unit. Apollo Med 2018;15:219-22

How to cite this URL:
Rath S, Behera IC, Sahu MC. Antifungal susceptibility of Candida species isolated from urine from patients in a neurosciences intensive care unit. Apollo Med [serial online] 2018 [cited 2018 Dec 15];15:219-22. Available from: http://www.apollomedicine.org/text.asp?2018/15/4/219/246888




  Introduction Top


Systemic candidiasis (SC) is the most common invasive fungal infection as the nosocomial infection in patients undergoing major surgeries during prolonged neutropenia, transplantation and extended hospital stay of days to weeks.[1] This infection is potentially a life-threatening complication in immunocompromised patients. The introduction of novel antineoplastic agents, antifungals, antibacterial, and antivirals over the past 10 years has led to a shift in fungal epidemiology[2],[3] and fever without specific signs and symptoms of localized fungal infection is the most common clinical presentation. Intensive and long-term use of antifungals leads to a decline in sensitivity and resistance development of Candida strains.[4] Antifungal resistance surveillance serves as a major strategy for prophylaxis, empirical therapy, and treatment of SC. For the management of patients suffering from SC, determination of the changes in the distribution of Candida species and respective sensitivity pattern to antifungal agents are important.

Antifungal prophylaxis is warranted in patients with developing risk of SC. As definitive early diagnosis is difficult, empiric therapy of antifungal agents has become a standard of practice in immune-suppressed patients like neutropenic patients who had received broad-spectrum antibacterial therapy but remain persistently febrile. The antifungal susceptibility testing of pathogenic fungi can manage the selection of adequate therapy and also provide an estimate of antifungal efficacy. Monitoring of drug resistance development can predict therapeutic outcome and therapeutic potential of untested compounds.[5],[6],[7]

The purpose of this study was to determine the distribution of Candida species and in vitro susceptibilities of antifungal agents against the Candida isolated from the patients referred to a mycology center in southern Iran using E-test for the best management and treatment of those at risk for SC.


  Materials and Methods Top


A total of 100 urine samples were collected from patients admitted to Neuroscience intensive care unit (ICU) department of IMS and SUM hospital, Bhubaneswar, Odisha, India, during the period December 18, 2017–April 27, 2018. All the samples were cultured both on blood, Sabouraud Dextrose Agar (SDA) and Cystine–Lactose–Electrolyte-deficient agar plates and incubated at 37°C for 24–48 h. The colonies so obtained were stained with Gram's staining chemicals. The budding yeast cells were observed under the microscope. Then, after colonies were grown on Candida Differential Agar (CDA) and incubated at room temperature for 24–48 h. Basing on the color pigmentation, all the fungi were identified with previous methods.[8]

Antifungal screening was done by disk-diffusion method. Colonies were cultured in test tubes containing 2 ml of Sabouraud dextrose broth and incubated for 24 h. Then, the cultures were poured on SDA plate and spreaded using sterile cotton swab. After 5 min, 7 antifungal disks were placed on the plates, maintaining a distance of 30 mm each. The 7 antifungal disks were used such as amphotericin B, clotrimazole, fluconazole, itraconazole, ketoconazole, miconazole, and nystatin.


  Results Top


The sample was collected from different age groups of patients admitted to ICU. Maximum numbers of the patient were ranged between 41 and 60 age groups [Table 1]. From among all 100 patients, 14 individuals were affected with diabetes and cerebrovascular accident. Whereas other disease comorbidity renal tubular acidosis, subarachnoid hemorrhage, head injury, acute respiratory distress syndrome, hypertension, and others were 9, 8, 8, 5, 11, and 31, respectively [Table 2]. A total number of 21 colonies of Candida spp. were obtained. Out of which 8 colonies were Candida albicans [green color on CDA, [Figure 1]a, 5 colonies were Candida glabrata [white color on CDA, [Figure 1]b, 5 colonies were Candida krusei [purple color on CDA, [Figure 1]c, and 3 colonies were Candida tropicalis [blue-purple color on CDA, [Figure 1]d and [Table 3].
Table 1: Total population participated in this study

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Table 2: Disease comorbidity of the participated study population

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Figure 1: Pure culture of Candida species with strick plate methods; (a) Candida albicans, (b) Candida glabrata, (c) Candida krusei, (d) Candida tropicalis

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Table 3: Number of Candida species among patients with respect to gender

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Antifungal screening showed variable results for all four species of Candida [Figure 2]a and [Figure 2]b. C. albicans, C. glabrata, and C. krusei showed 100% resistance to fluconazole. Again C. albicans and C. glabrata were 100% resistance to ketoconazole. C. glabrata also showed 100% resistance to nystatin. Itraconazole showed a high percentage of susceptible for C. albicans (87.5%), C. krusei (80%), C. tropicalis (100%), and C. glabrata (60%). Amphotericin-B showed variable results in all the 4 species, that is, C. albicans 62.5% susceptible, C. glabrata 60% resistance, C. krusei 80% susceptible, and C. tropicalis 66.6% resistance. Miconazole (MIC) showed resistance for C. albicans and C. glabrata by 75% and 80%, respectively. However, C. tropicalis and C. krusei were 100% and 80% susceptible, respectively. Similarly, clotrimazole showed 50%, 80%, and 60% resistance for C. albicans, C. glabrata, and C. krusei, respectively. However, it was 100% susceptible for C. tropicalis [Table 4].
Figure 2: Antifungal sensitivity of Candida species; (a) Candida albicans, (b) Candida glabrata

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Table 4: Antifungal screening test

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The percentage of sensitive 7 antifungal agents against 4 Candida species was analyzed with ANOVA test, and it was revealed that there were significant difference among the antifungal agents with respect to 4 Candida species at P = 0.04. As highest mean of the sensitivity of Itraconazole10 were 81.88%. Hence, it is the most sensitive drug against 4 Candida species [Table 5].
Table 5: Percentage of sensitivity

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  Discussion Top


In the present study, the agar-based E-test was used and performed well for the testing of antifungal agents as there are reports about the usefulness of this method and agreement between the E-test and the broth microdilution MIC for Candida species and different types of antifungal agents.[9],[10]

In this study, we isolated 21 strains from 100 clinical samples with higher rate of C. albicans (38.09%), followed by C. krusei (23.8%), C. glabrata (23.8%), and C. tropicalis (14.28%). The distributions of the species are different in various regions and studies such as 50% C. albicans, 24.7% C. glabrata, and 1% C. parapsilosis in other studies.[11],[12] These observations establish the great importance of non-albicans Candida as a pathogen in clinical samples. It is important that increase in non-albicans species in SC with intensive and long-term use of antifungals leads to higher level of resistance of Candida strains to the antifungal drugs.[13],[14],[15] A remarkable point in our study is that the most commonly isolated species was C. albicans in the clinical samples followed by C. krusei, C. glabrata, and C. tropicalis which can pose a serious threat due to resistance to the routine antifungal agents.

Amphotericin B deoxycholate was the first systemic antifungal agent for the treatment of invasive fungal infections and has been the drug of choice,[16],[17] however, due to nephrotoxicity in up to 80% of the patients, use of amphotericin B has been limited.[18] Specific breakpoint for amphotericin B has not been proposed because it can positively affect the immune system and stimulate the body defenses against fungal infections;[19],[20] therefore, the correlation between in vitro susceptibility pattern and in vivo responses in patients is not predictable. Resistance to amphotericin B as a routine antifungal agent and valid in our hospital for SC varies in different studies. All Candida isolates in Tseng et al., 2005, were susceptible to amphotericin,[10] but in our study, it was 37.5% resistance to C. albicans, 20% to C. krusei, 60% to C. glabrata, and 66.6% resistance to C. tropicalis.

Development of the triazoles in the 1990s provided alternative options for treating SC. Long-term fluconazole and itraconazole prophylaxis were associated with reduction in susceptibility to these agents. Susceptibility of C. albicans to fluconazole in this study was 0 comparable with the susceptibility rates reported in other studies (80.9%, 87%, 79%, and 87.5%).[9],[21],[22],[23] The resistant rate of C. albicans to itraconazole in this study was 12.5%. Different rates of resistance to fluconazole and itraconazole were detected in Candida strains especially non-albicans strain.[10],[24] From the standpoint of antifungal resistance, C. albicans, C. glabrata, and C. krusei are clearly the Candida species with the greatest potential to acquire resistance to fluconazole and other azoles.[24],[25] Of the 5 C. krusei strains, 1 (20%) were resistant to itraconazole, 5 (100%) to fluconazole, and 1 (20%) to amphotericin B.

There are many viewpoints on the use of new antifungal agents. Such agents are very effective, but in many countries, especially in the developing ones, they are very expensive or not available to the respective patients. Therefore, we need to know the antifungal susceptibility rates in each region for the available agents to better manage the patients.

The successful treatment of SC depends on the early identification of the species and sensitivity patterns to antifungal agents. The high growing rate of non-albicans Candida resistant to azole confirms the importance of monitoring changes in the distribution of pathogenic Candida species. The sensitivity pattern of Candida species as revealed in this study shows that itraconazole seems to be suitable drug for empirical therapy and fluconazole and amphotericin B are not suitable because of their high resistance to Candida species.


  Conclusions Top


In ICU as compared to bacteria, Candida spp. is also found vigorously with this current study. However, empirically, clinicians prescribe antibiotics only. Hence, before prescribe drugs, the culture sensitivity is highly required. With this study, it was revealed that Candida spp. is more susceptibility to itraconazole.

Acknowledgment

Authors are grateful to Prof. S Nayak, HOD, Center for Biotechnology and Dean, IMS and SUM Hospital, Siksha “O” Anusandhan Deemed to be University for extended facility in research work.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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