Factors associated with candiduria and related mortality

Non-Candida albicans Candida species: virulence factors and species identification in India

BACKGROUND AND PURPOSE

The predominant cause of candidiasis was Candida albicans which has recently changed to non-Candida albicans Candida (NCAC) (i.e., Candida spp. other than the C. albicans). The NCAC spp., earlier considered non-pathogenic or minimally virulent, are now considered a primary cause of morbidity and mortality in immunocompromised individuals. Given the NCAC spp.has become more common in clinical cases, this study aimed to determine the prevalence of NCAC spp. in different clinical specimens and assess a few of their virulence factors.

MATERIALS AND METHODS

Routine samples for bacterial culture and sensitivity that showed colony characteristics, like Candida on Blood Agar and microscopic features resembling Candida spp., were processed further. Candida isolates underwent tests for chlamydospore formation and biochemical tests, including sugar fermentation and sugar assimilation tests. These were grown at 42oC, and their colony color was identified using HiCromeTM Candida Differential Agar (HiMedia Laboratories Pvt. Ltd., Mumbai, India), HiCandida TM Identification Kit (HiMedia Laboratories Pvt. Ltd., Mumbai, India), and VITEK-2® Compact (Biomérieux, France). Virulence factors, such as adherence to buccal epithelial cells (ABEC), biofilm formation, hemolytic activity, and production of coagulase enzyme were also tested.

RESULTS

Mean age of the patients was 38.46 years with a male-female ratio of 1.36:1. In total, 137 Candida isolates were recovered; 45.3%, 19.7%, and 13.9% of the isolates were isolated from urine, vaginal swabs, and oropharyngeal swabs, respectively. Moreover, 55 (40.1%) isolates were those of C. albicans and 82 (59.9%) isolates belonged to NCAC spp., with C. tropicalis (23.4%) contributing highest among NCAC species. Furthermore, C. albicans (3; 50%) was the most common spp. in cases of candidemia. Haemolysin production (85.5%) and ABEC (78.2%) were the major virulence factors in C. albicans. C. tropicalis (59.4%) and C. dubliniensis (50%) showed maximum ABEC. Biofilm forming capacity was higher in C. tropicalis (78.1%) than C. albicans (67%).

CONCLUSION

Results of this study suggest varied prevalence and virulence based on geographical locations, even within a subcontinent. It clearly indicates the emergence of the NCAC spp. and their predominance in different body fluids. Identification of Candida to the spp. level should become a routine in all laboratories.

A New Gold Rush: A Review of Current and Developing Diagnostic Tools for Urinary Tract Infections

Urinary tract infections (UTIs) are one of the most common infections in the United States and consequently are responsible for significant healthcare expenditure. The standard urine culture is the current gold standard for diagnosing urinary tract infections, however there are limitations of the test that directly contribute to increased healthcare costs. As a result, new and innovative techniques have been developed to address the inefficiencies of the current standard-it remains to be seen whether these tests should be performed adjunctly to, or perhaps even replace the urine culture. This review aims to analyze the advantages and disadvantages of the newer and emerging diagnostic techniques such as PCR, expanded quantitative urine culture (EQUC), and next generation sequencing (NGS).

Clinical and microbiological features of candiduria in critically ill adult patients in Shiraz, Iran (2016-2018): deviations from international guidelines and fluconazole therapeutic failure

Candiduria is common among patients admitted to intensive care units (ICUs); however, clinical and microbiological data are limited, which accounts for non-compliance with international guidelines, including over treatment of asymptomatic candiduria that promotes antifungal resistance. This prospective study included adult patients admitted to ICUs of five referral hospitals in Shiraz, Iran, during 2016-2018. Species were identified by MALDI-TOF MS, and antifungal susceptibility was assessed according to CLSI M27-A3/S4. Among 2086 patients, 162 and 293 developed candiduria and bacteriuria, respectively. In total, 174 yeast isolates were collected; 88.5% were Candida albicans (91/174; 52.2%), C. glabrata (38/174; 21.8%), and C. tropicalis (25/174; 14.3%). Antifungal resistance was rare; only two isolates (one C. tropicalis and one C. krusei) were fluconazole resistant. Symptomatic candiduria was noted in 31.4% of patients (51/162); only 37% (19/51) of them were treated and 36.82% (7/19) showed fluconazole therapeutic failure. Two symptomatic patients developed candidemia shortly after candiduria. Among asymptomatic patients, 31.5% (35/111) were overtreated with fluconazole. The mortality rate was 25.3% (41/162); it did not differ between symptomatic and asymptomatic patients. Our results indicate that deviation from standard-of-care treatment for candiduria is a matter of concern given the high rate of fluconazole therapeutic failure among patients with symptomatic candiduria.

LAY SUMMARY

Candiduria is an underestimated clinical presentation among critically ill patients and detailed data are scarce in this regard. Given the high rate of fluconazole therapeutic failure and development of candidemia in some cases, the mistreatment of candiduria should not be overlooked by clinicians.

Epidemiological profile of patients hospitalized with candiduria in the Central-Western region of Brazil

BACKGROUND

Candida yeasts are considered the main agents of nosocomial fungal infections.

AIMS

This study aimed to establish the epidemiological profile of patients with candiduria hospitalized in the capital of the State of Mato Grosso, in the Central-Western region of Brazil.

METHODS

Patients from three private hospitals and a public hospital participated in the study. This was an observational and cross-sectional study including analysis of patients mortality. It was carried out from March to August 2015.

RESULTS

A total of 93 patients with candiduria were evaluated. Candida tropicalis was found most commonly (37.6%; n=35), followed by Candida albicans (36.6%; n=34), Candida glabrata (19.3%; n=18), psilosis complex (4.3%; n=4), Candida lusitaniae (1.1%; n=1) and Candida krusei (1.1%; n=1). Antibiotic therapy (100%) and the use of an indwelling urinary catheter (89.2%; n=83) were the most frequent predisposing factors. Antifungal treatment was given to 65.6% of the patients, and anidulafungin was the most used antifungal. Mortality rates were 48% higher among patients with candiduria who had renal failure. Micafungin was the antifungal most prescribed among the patients who died. Candidemia concomitant with candiduria occurred in eight (8.6%; n=8) cases. Considering the species recovered in the blood and urine, only one patient had genetically distinct clinical isolates.

CONCLUSIONS

Non-C. albicans Candida species were predominant, with C. tropicalis being the most responsible for most cases of candiduria.

Candiduria in hospitalized patients: an investigation with the Sysmex UF-1000i urine analyzer

Background

Candiduria is common in hospitalized patients. Its management is limited because of inadequate understanding. Previous epidemiological studies based on culture assay have been limited to small study populations. Therefore, data collected by automated systems from a large target population are necessary for more comprehensive understanding of candiduria in hospitalized patients.

Methods

To determine the performance of the Sysmex UF-1000i in detecting candiduria, a cross-sectional study was designed and conducted. A total of 203 yeast-like cell (YLC)-positive and 127 negative samples were randomly chosen and subjected to microbiologic analysis. The receiver operating characteristic curve (ROC) was used to evaluate the ability of YLC counts as measured by the Sysmex UF1000i to predict candiduria. Urinalysis data from 31,648 hospitalized patients were retrospectively investigated, and statistical analysis was applied to the data collected.

Results

Using a cutoff value of 84.6 YLCs/µL, the sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of the yeast like cell (YLC) counts to predict candiduria were 61.7%, 84.1%, 88.6% and 66.3%, respectively. C. glabrata (33.6%) and C. tropicalis (31.4%) were more prevalent than C. albicans (24.3%) in the present study. Of the investigated hospitalized patients, 509 (1.61%) were considered candiduria-positive. Age, gender and basic condition were associated with candiduria in hospitalized patients. In the ICU setting, urinary catheterization appeared to be the only independent risk factor contributing to candiduria according to our investigation. Although antibiotic therapy has been reported to be a very important risk factor, we could not confirm its significance in ICU candiduria patients because of excessive antibiotic usage in our hospital.

Conclusions

The YLC measured by Sysmex UF-1000i is a practical and convenient tool for clinical candiduria screening prior to microbiologic culture. Candiduria is common in hospitalized patients, and its incidence varies according to age, gender and the wards where it is isolated. Candiduria had no direct connection with mortality but might be considered a marker of seriously ill patients who need particular attention in the clinic.

Candidemia Following Ureteric Stent Placement in a Patient With Type 2 Diabetes Treated With Canagliflozin

A 38-year-old female patient with well-controlled type 2 diabetes mellitus treated with canagliflozin underwent ureteral stent placement for obstructive renal calculi. Ten days following ureteroscopy and ureteral stenting, she developed fevers and blood cultures grew Candida glabrata (C. glabrata). The patient was successfully treated with an extended course of broad-spectrum antibiotics and antifungal agents. The clinical presentation of candidemia is indistinguishable from bacteremia resulting in delay in diagnosis and treatment. Candiduria is commonly seen in patients with type 2 diabetes, however it rarely leads to candidemia in an otherwise healthy person following a relatively simple urologic procedure. Sodium-glucose co-transporter 2 (SGLT-2) inhibitors act by its glycosuric effect and further increases the risk of genitourinary candida infection. Urologic procedures may lead to bloodstream entry of the genitourinary fungal organisms and result in life-threatening fungemia. Our case emphasizes the importance of awareness of the increased risk of potentially life threatening fungemia in patients using SGLT-2 inhibitors to avoid delay in diagnosis and treatment.

Candiduria; a review article with specific data from Iran

Although, several categories of nosocomial infections are presented during the recent years, urinary tract infections (UTIs) considered as one of the most important systemic infections. The presence of Candida species in the urinary tract system (Candiduria) is seen in only 10-15% of the cases with UTI, however candiduria has been considered as more problematic infection for patients, laboratory workers and physicians. Due to increasing numbers of several predisposing factors, such as antibacterial agents, urinary tract instrumentation, diabetes mellitus, invasive therapies, and prolonged hospital stay, candiduria develops among the hospitalized patients, especially hospitalized in intensive care units (ICUs) and neonatal intensive care units (NICUs). According to the epidemiological studies, Candida albicans is the most common isolated species from candiduric patients. However, during the recent years, due to increasing resistance to antifungal drugs, non-albicans Candida species including, C. glabrata, C. krusei, C. parapsilosis and C. tropicalis have been also implicated. We found that the mean prevalence of candiduria among Iranian patients was lower (16.5%) than worldwide ratio and also males were more frequently affected than females (M:F, 1.2:1). Similar to other countries, C. albicans was most common infectious agent followed by non-albicans Candida species including, C. glabrata, C. tropicalis and C. krusei.

Editorial: The Risky Business of Fungal Infections in Patients with Cirrhosis

Hospitalized patients with cirrhosis have a high rate of mortality. In the report by Bajaj et al., the negative impact of fungal infections (FI) on outcomes in a large US cohort of hospitalized cirrhotics is highlighted. Risk factors for FI are identified. Increasing awareness of FI along with the application of new diagnostic tools in species identification will provide the opportunity to improve patient outcomes.

Candiduria in kidney transplant recipients: Is antifungal therapy useful?

A French single-centre retrospective study between 2010 and 2014 was undertaken to assess candiduria's incidence in kidney transplant recipients (KTR), and the use and impact of antifungal treatment on outcome. Candiduria was defined as a urine culture with ≥10³  cfu/mL of Candida species. Candiduria clearance, severe complications and death rates were estimated by Kaplan-Meier methods and the effect of treatment by Cox models. 52/1223 (4.3%) KTR had ≥1 episode of candiduria, 42 (81%) were females, 18 (35%) had diabetes, with an incidence of 2.3/100 person-year of follow-up. Candiduria was asymptomatic in 51 (98%) patients. Candida glabrata was the most frequent pathogen identified. Overall fungal clearance rate was 89%. Antifungal therapy was initiated in only 14 episodes (12%), according to guidelines. Three patients (6%) developed severe complications in the first 2 weeks after transplantation, and 8 (15%) died. Antifungal treatment had no impact on candiduria clearance (HR, 0.6; 95% CI, 0.3-1.1; P = .10), on recurrence rate (HR, 0.5; 95% CI, 0.1-2.3; P = .41) and on the risk of severe complications or death (HR, 1.1; 95% CI, 0.3-4.8; P = .89). Candiduria is rare and usually asymptomatic among KTR. Candiduria management in the immediate post-transplant period deserves careful attention.

Nosocomial Candiduria in the Elderly: Microbiological Diagnosis

Candiduria is associated with high morbidity, mortality, and long hospitalization, involving high costs for the healthcare system. The use of increasingly aggressive treatments has prolonged the lives of patients susceptible to candiduria, namely the immunosuppressed, the premature, and the elderly. Our objective was to evaluate the incidence of nosocomial candiduria and the implicated species in hospitalized patients aged over 80 years old from three Spanish centers during 2012 and 2013. Urine samples received from these patients were cultured and analyzed by flow cytometry in search of leukocyturia, hematuria, proteinuria, and microbial nitrate reductase activity. The isolated yeast species were identified microscopically, by germ tube formation in serum, colony morphology after subculture onto CHROMagar Candida (Becton-Dickinson, UK), assimilation of carbon compounds ID32C (bioMérieux, France), matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDITOF) (Bruker Daltonics, Germany) and, in case of inconsistency, by sequencing of the ITS regions of ribosomal DNA (ITS1-5, 8S-ITS2). Susceptibility tests were also performed. The incidence of candiduria in the elderly population was 10.3%. A total of 155 strains of yeasts were isolated. The predominant species was Candida albicans, followed by Candida glabrata and then Candida tropicalis. Several infrequent species were found; among them, the first isolate of candiduria-producing Candida pulcherrima described in the literature. Our finding should raise concerns about the elderly population, which is probably the most important risk group for candiduria in the present moment, and the emergence of unusual yeast species producing candiduria, which are resistant against the commonly used antifungal agents.

High prevalence of candiduria due to non-albicans Candida species among diabetic patients: A matter of concern?

BACKGROUND

Among the fungal pathogens, Candida species are the most common cause of urinary tract infection (UTI). Some predisposing factors such as diabetes mellitus, urinary retention, urinary stasis, renal transplantation, and hospitalization can increase the risk of candiduria. The aim of this cross-sectional study was to evaluate candiduria among type 2 diabetic patients and identification of the Candida isolates.

METHOD

Four hundred clean-catch midstream urine specimens were obtained from patients with type 2 diabetes mellitus. The specimens were centrifuged and the sediments were examined by direct examination and cultured on Sabouraud dextrose agar. The plates were incubated for 2-3 days at 35°C. The Candida colonies were counted and purified using CHROMagar Candida. The isolates were identified by matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS) system.

RESULTS

Of the 400 urine specimens, 40 (10%) had positive cultures for Candida species with a colony count of ≥1 × 10³ colony forming units (CFU)/mL. The frequencies of the Candida species were as follows: C. albicans (n = 19, 47.5%), C. glabrata (n = 15, 37.5%), C. kefyer (n = 4, 10%) and C. krusei (n = 2, 5%). Seventy-three (88%) of the patients with candiduria had hemoglobin A1c (HbA1c) levels above 7%.

CONCLUSION

The rate of candiduria was relatively high in type 2 diabetic patients and they were also suffering from a lack of proper blood glucose control. Although the frequency of non-albicans Candida species had not significantly higher than C. albicans, however, they obtained more from those with symptomatic candiduria.

Characterization and identification of candiduria due to Candida species in diabetic patients

BACKGROUND AND PURPOSE

The presence of Candida yeasts in urine, known as candiduria, is an indicator of infection or colonization of the urinary tract by Candida species. This condition in diabetic patients can be hazardous due to diminished immune system response. The objective of this study was to investigate the incidence of candiduria in diabetic patients and to identify its causative agents. Furthermore, the demographic and laboratory (HbA_1c, urine glucose and pH, urine culture colony count, and fasting blood sugar) data and their possible associations with candiduria were investigated.

MATERIALS AND METHODS

This cross-sectional, descriptive study was performed on 305 diabetic patients referred to the diabetes research center, Hamedan, Iran, during April 2015 to September 2015. Urine and blood specimens were collected and urine analysis, urine culture, FBS, and HbA_1c tests were performed. Positive cases were subjected to colony count and the causative agents were subsequently identified through the routine identification tests, as well as colony color in CHROMagar Candida medium, and the assimilation patterns in API 20 C auxanographic method.

RESULTS

Among the 305 cases, 38 (%12.5) were positive for candiduria. Causative agents were identified as Candidaglabrata (n=19, 50%), C. albicans (n=12, 31.6%), C. krusei (n=4, 10.5%), C. tropicalis (n=2, 5.3%), andC. kefyr (n=1, 2.6%). According to the results of the statistical analyses, there were significant association between candiduria and female gender, high FBS and urine glucose, uncontrolled diabetes (HbA1c ≥8), and acidic urine pH (P<0.05).

CONCLUSION

Considering the high incidence rate of candiduria in diabetic patients, control of diabetes, predisposing factors, and causal relationships between diabetes and candiduria should be highlighted.

Clinical Practice Guideline for the Management of Candidiasis: 2016 Update by the Infectious Diseases Society of America

It is important to realize that guidelines cannot always account for individual variation among patients. They are not intended to supplant physician judgment with respect to particular patients or special clinical situations. IDSA considers adherence to these guidelines to be voluntary, with the ultimate determination regarding their application to be made by the physician in the light of each patient's individual circumstances.

Mannose-Binding Lectin Serum Levels in Patients With Candiduria

Background:

Candida species are normal mycoflora of human body which are capable to cause urinary tract infection (UTI). Mannose-binding lectin (MBL) is a kind of innate immune system and decreasing plasma levels of MBL may disrupt the natural immune response and increase susceptibility to infections.

Objectives:

The aim of the present study was to assess MBL in the serum of patients with candiduria and compare them with control.

Patients and Methods:

The blood and urine samples were collected from 335 patients (hospitalized in Golestan hospital, Ahvaz) using standard methods and the growing colonies on CHROMagar were identified using routine diagnostic tests. MBL activity in the serum of 45 patients with candiduria and 45 controls was measured using Eastbiopharm enzyme-linked immunosorbent assay (ELISA) kit.

Results:

In this study, 45 (13.4 %) urine samples were positive for Candida species (17 males and 28 females). The most common isolated yeast was Candida albicans (34%), followed by C. glabrata (32.1%), C. tropicalis (9.4%), other Candida species (22.6%), and Rhodotorula species (1.9%). The mean serum levels of MBL were 0.85 ± 0.01 ng/mL and 1.02 ± 0.03 ng/mL among candiduric patients and controls, respectively, and there was no significant difference between the two groups (P = 0.6).

Conclusions:

Our results showed that there was no significant relationship between MBL serum levels and candiduria.

[Isolated yeast species in urine samples in a Spanish regional hospital]

Candiduria detection in hospitalized or immunocompromised patients is of great clinical significance. The aim of our study was to describe the isolation frequency of significant species of yeasts in urine samples processed in our hospital during the period 2010- 2013, and to analyze their susceptibility to commonly used antifungal agents. Species identification was performed by seeding on a chromogenic medium, the filamentation test and automated systems (ASM Vitek and MALDI Biotyper), while susceptibility was determined using the ASM Vitek system. Of the 632 yeast isolates in urine, 371 were Candida albicans species and 261 non-C. albicans Candida spp. The species with the highest number of resistant isolates were Candida glabrata and Candida krusei. Based on the results obtained, we believe that species identification and the susceptibility study should be current practice in the laboratories when species other than C. albicans are isolated.

Colonization and antifungals susceptibility patterns of Candida species isolated from hospitalized patients in ICUs and NICUs

BACKGROUND

Several studies have shown that there are an increasing in invasive candidiasis during 2-3 last decades. Although, Candida albicans is considered as the most common candidiasis agents, other non-albicans such as C. glabrata, C. krusei, C. parapsilosis, and C. tropicalis were raised as infectious agents. Resistance to fluconazole among non-albicans species is an important problem for clinicians during therapy and prophylaxis.

OBJECTIVES

The aim of current study was to detect the Candida species from hospitalized neonatal and children in intensive care units (ICUs) and neonatal intensive care units (NICUs). In addition, the susceptibility of isolated agents were also evaluated against three antifungals.

MATERIALS AND METHODS

In the present study 298 samples including 98 blood samples, 100 urines and 100 swabs from oral cavity were inoculated on CHROMagar Candida. Initial detection was done according to the coloration colonies on CHROMagar Candida . Morphology on cornmeal agar, germ tube formation and growth at 45°C were confirmed isolates. Amphotericin B, fluconazole and terbinafine (Lamisil) were used for the susceptibility tests using microdilution method.

RESULTS

In the present study 21% and 34% of urines and swabs from oral cavity were positive for Candida species, respectively. The most common species was C. albicans (62.5%) followed by C. tropicalis (15.6%), C. glabrata (6.3%) and Candida species (15.6%). Our study indicated that the most tested species of Candida, 70.3% were sensitive to fluconazole at the concentration of ≤8 μg/mL. Whereas 9 (14.1%) of isolates were resistant to amphotericine B at ≥8 μg/mL.

CONCLUSIONS

This study demonstrates the importance of species identification and antifungals susceptibility testing for hospitalized patients in ICUs and NICUs wards.

Phenotypic Detection of Genitourinary Candidiasis among Sexually Transmitted Disease Clinic Attendees in Ladoke Akintola University Teaching Hospital, Osogbo, Nigeria

The management of genitourinary candidiasis (GC) is fraught with challenges, especially, in an era of increasing antifungal resistance. This descriptive cross-sectional study conducted between May 2013 and January 2014 determined the prevalence and characteristics of GC and the species of Candida among 369 attendees of a Sexually Transmitted Disease (STD) clinic of Ladoke Akintola University Teaching Hospital, Osogbo, Nigeria. Appropriate urogenital specimen collected from each attendee was examined by microscopy and culture for Candida, with preliminary species identification by CHROMAgar Candida and confirmation by Analytical Profile Index (API) 20C AUX. The age range of attendees was 1-80 years, mean age was 36.32 ± 11.34 years, and male to female ratio was 1 to 3. The prevalence of genitourinary candidiasis was 47.4%, with 4.9% in males and 42.5% in females (p < 0.0001). The age groups 31-45 and 16-30 have the highest prevalence of 23.3% and 16.8%, respectively. The species of Candida recovered include Candida glabrata 46.9%, Candida albicans 33.7%, Candida dubliniensis 9.7%, Candida tropicalis 5.7%, Candida krusei 1.7%, Candida lusitaniae 1.7%, and Candida utilis 0.6%. This study reported non-C. albicans Candida, especially C. glabrata, as the most frequently isolated species in GC, contrary to previous studies in this environment and elsewhere.

Clinical significance of the isolation of Candida species from hospitalized patients

In this study, we isolated and phenotypically identified 108 yeast strains from various clinical specimens collected from 100 hospitalized patients at three tertiary hospitals in São Luís-Maranhão, Brazil, from July to December 2010. The isolates were analyzed for their susceptibility to four of the most widely used antifungal agents in the surveyed hospitals, amphotericin B, fluconazole, 5-flucytosine and voriconazole. The species identified were Candida albicans (41.4%), Candida tropicalis (30.1%), C. glabrata (7.4%), Candida parapsilosis (5.5%), Candida krusei (4.6%), Cryptococcus neoformans (4.6%), Trichosporon spp . (3.7%), Candida norvegensis (0.9%), Rhodotorula glutinis (0.9%) and Pichia farinosa (0.9%). A higher isolation rate was observed in the following clinical specimens: urine (54 isolates; 50%), respiratory tract samples (21 isolates; 19.4%) and blood (20 isolates; 18.6%). Candida albicans isolates were 100% sensitive to all antifungal agents tested, whereas Candida krusei and Crytococcus neoformans displayed intermediate resistance to 5-flucytosine, with Minimal Inhibitory Concentration (MIC) values of 8 mg/mL and 16 mg/mL, respectively. Both strains were also S-DD to fluconazole with an MIC of 16 mg/mL. C. tropicalis was resistant to 5-flucytosine with an MIC of 32 μg/mL. This study demonstrates the importance of identifying the yeast species involved in community and nosocomial infections.

Bacteremia and Mortality with Urinary Catheter–Associated Bacteriuria

Objective.

Although catheter-associated urinary tract infection (CAUTI) and catheter-associated asymptomatic bacteriuria (CAABU) are clinically distinct conditions, most literature describing the risks of bacteriuria does not distinguish between them. We studied the relationship between catheter-associated bacteriuria and bacteremia from a urinary source in CAUTI relative to that in CAABU. Second, we investigated whether the presence or absence of urinary symptoms in catheterized patients with bacteriuria was associated with bacteremia from any source or mortality. Finally, we explored the effect of antimicrobial treatment of bacteriuria on subsequent bacteremia from any source and mortality.

Design.

We performed a retrospective cohort study with 30 days of follow-up after an initial positive urine culture. CAUTI and CAABU were defined by Infectious Diseases Society of America guidelines.

Setting.

A large tertiary care facility.

Patients.

All inpatients with a urinary catheter (external or indwelling) and a positive urine culture between October 2010 and June 2011.

Results.

We captured 444 episodes of catheter-associated bacteriuria in 308 patients; 128 (41.6%) patients had CAUTI, and 180 (58.4%) had CAABU. Three episodes of bacteriuria were followed by bacteremia from a urinary source (0.7%). CAUTI, rather than CAABU, was associated with bacteremia from any source, but neither CAUTI nor CAABU predicted subsequent mortality. Use of antimicrobial agents to treat bacteriuria was not associated with either bacteremia from any source or mortality.

Conclusions.

Bacteremia from a urinary source was infrequent, and there was no evidence of an association of mortality with symptomatic versus asymptomatic bacteriuria in this population. Antibiotic treatment of bacteriuria did not affect outcomes.

Genotypic variability and antifungal susceptibility of Candida tropicalis isolated from patients with candiduria

BACKGROUND

Candida tropicalis is an emerging major human pathogen in nosocomial infections, and it is considered the second or third species of Candida most isolated from urine cultures.

AIMS

The study aimed at characterizing genotypically C. tropicalis strains from patients with candiduria in a university hospital, and assessed the antifungal susceptibility profile.

METHODS

The study was conducted with hospitalized patients who developed urinary tract infection from C. tropicalis from June 2010 to June 2011 at the Grande Dourados University Hospital of the Federal University, Dourados, MS, Brazil. Susceptibility to the antifungal agents amphotericin B and fluconazole was determined by broth microdilution. The genotypic variability of isolates of C. tropicalis was analyzed by microsatellite markers and RAPD-PCR.

RESULTS

Only one isolate was resistant to amphotericin B (MIC→16μg/ml); the others were susceptible to fluconazole and amphotericin B. The genotypic variability by RAPD-PCR resulted in distinct profiles for RAPD markers. A total of 10 alleles were observed for the microsatellite loci, URA3 and CT14, which were grouped differently, and four associations were observed for locus URA3 and eight for locus CT14.

CONCLUSIONS

C. tropicalis isolates from urine were susceptible to the antifungal agents tested. The genotyping techniques make possible proving the similarity and genetic diversity among isolates of C. tropicalis involved in nosocomial infections. This knowledge is important for the control and prevention of nosocomial infections caused by this yeast species.

Biofilm Formation and Susceptibility to Amphotericin B and Fluconazole in Candida albicans

Background:

The ability of Candida albicans to form biofilms and adhere to host tissues and biomaterial surfaces is an important factor in its pathogenesis. One of the main characteristics of biofilms is their resistance to broad-spectrum anti-microbial drugs.

Objectives:

In the present study the formation of biofilm by C. albicans from different sources was evaluated. In addition, the minimum biofilm inhibitory concentration (MBIC) for two antifungals was evaluated.

Materials and Methods:

In total, 120 isolates of C. albicans from different sources (patients with vaginitis, patients with candiduria, bucal cavity and environmental surfaces) were collected. Biofilm formation was determined by the 96-well micro-titeration plate method. MBIC testing was also performed, using the calorimetric indicator resazurin for amphotericin B and fluconazole.

Results:

The results indicated that 100% of C. albicans isolates from different sources had the ability to form biofilms in vitro. Amongst these isolates, 83.3% of isolates had the maximum potential (4+) to form biofilms, while only one (0.9%) of isolates had the minimum ability (1+) to form biofilms. Our results showed that 65.0% of the tested isolates are sensitive to amphotericin B at amounts lower than 10 µg/mL, while only 26.7% are sensitive to fluconazole (had MBIC < 10 µg/mL).

Conclusions:

Although biofilm formation was detected in all tested isolates, there were differences in the ability to form biofilms between isolates from different sources. In addition, there were differences in the MBIC against the two examined antifungals, amphotericin B and fluconazole.

Yeasts isolated from nosocomial urinary infections: antifungal susceptibility and biofilm production

BACKGROUND

Urinary Candida infections in the hospital environment are frequent and need to be better understood.

AIMS

To compare the results of antifungal susceptibility profiles of yeasts isolated from patients with urinary infections obtained by broth microdilution method (BM) and by disk diffusion (DD), and also evaluate the capacity of these yeasts to form biofilms.

METHODS

Only yeasts obtained from pure urine cultures with counts higher than 10(5) colony-forming units per milliliter, without bacteria development, of symptomatic patients were included. The isolates were identified by classical methods and the antifungal susceptibility tests were performed with the following drugs: amphotericin B, ketoconazole, fluconazole, itraconazole, voriconazole and caspofungin. The biofilm studies were carried out in polystyrene microtitration plates.

RESULTS

Ninety-five yeasts isolates were analyzed, including 40 Candida albicans, 31 Candida glabrata, 24 Candida tropicalis. In general, the majority of the isolates were susceptible to the tested drugs but some resistance was observed, especially against fluconazole. Great variability in the antifungal susceptibility results was observed with the different tested drugs and a few discrepancies were observed between both methods. We suggest that in case of DD resistance this result should be confirmed by BM, the standard method. C. tropicalis isolates showed high biofilm production (91.7%) compared to C. albicans (82.5%) and C. glabrata (61.3%), with statistical significance (p=0.0129).

CONCLUSIONS

Candiduria in critical patients requires major attention and a better control. The different susceptibility results obtained in this study showed the need to identify yeasts up to the species level, especially in patients with urinary tract infection. The development of techniques of antifungal susceptibility tests can help the clinicians in the empiric treatment of candiduria.

Candiduria in haematologic malignancy patients without a urinary catheter: nothing more than a frailty marker?

There is scarcity of data regarding significance of candiduria in patients with haematologic malignancies and its association with invasive candidiasis. To that end, we retrospectively evaluated all hospitalised, non-intensive care unit patients with haematologic malignancies and candiduria during a 10-year period (2001-2011). To decrease the possibility of bladder colonisation and sample contamination, we excluded all patients with candiduria who had urinary catheters and those with concomitant bacteriuria. Twenty-four such patients (21 females) were identified, with median age at diagnosis 62 years (range, 20-82 years). Acute leukaemia was the most common underlying disease (54%); 62% of these cases were not in remission. Twenty-nine percent of the patients had diabetes mellitus and 25% were neutropenic. The most common isolated Candida species was Candida glabrata (37%), followed by C. albicans (29%). Only 8% of them had urinary tract infection symptoms. However, 88% received systemic antifungals. Candidemia and crude mortality rates at 4 weeks were low (4% and 12% respectively). Isolated candiduria in patients with haematologic malignancies has risk factors similar to those in other hospitalised patients, and it does not seem to be a strong predictor of subsequent invasive candidiasis.

Insights into Candida tropicalis nosocomial infections and virulence factors

Candida tropicalis is considered the first or the second non-Candida albicans Candida (NCAC) species most frequently isolated from candidosis, mainly in patients admitted in intensive care units (ICUs), especially with cancer, requiring prolonged catheterization, or receiving broad-spectrum antibiotics. The proportion of candiduria and candidemia caused by C. tropicalis varies widely with geographical area and patient group. Actually, in certain countries, C. tropicalis is more prevalent, even compared with C. albicans or other NCAC species. Although prophylactic treatments with fluconazole cause a decrease in the frequency of candidosis caused by C. tropicalis, it is increasingly showing a moderate level of fluconazole resistance. The propensity of C. tropicalis for dissemination and the high mortality associated with its infections might be strongly related to the potential of virulence factors exhibited by this species, such as adhesion to different host surfaces, biofilm formation, infection and dissemination, and enzymes secretion. Therefore, the aim of this review is to outline the present knowledge on all the above-mentioned C. tropicalis virulence traits.

Candiduria in renal transplant recipients: incidence, clinical repercussion, and treatment indication

INTRODUCTION

The incidence of candiduria in renal transplant recipients is unknown. In clinical practice, the indications for antifungal therapy are not well established. Furthermore, there is the problem of the choice of the antifungal drug since some of them may select resistant Candida species, or interact with immunosuppressive agents or only be used intravenously.

AIM

We sought to study the incidence, clinical repercussions and effectiveness of antifungal treatment to prevent recurrence of candiduria.

MATERIALS AND METHODS

We examined all episodes of Candida-positive urine cultures (>50,000 cfu/mL) in 996 recipients over 2 years. We considered the Candida species, administered treatment, presence of fever, requirement for hospital admission versus outpatient case, occurrence of simultaneous bacterial urinary tract infection (UTI), antibiotic use during the week before candiduria, and presence of an indwelling urinary catheter.

RESULTS

Among 996 subjects, 34 displayed 83 episodes of candiduria, yielding an accumulated incidence of 3.4% after 2 years. The frequency was higher among women (6.3% vs 1.7%, P<.001). Of the 45 outpatient episodes (54.2%), 17 were treated and one required hospitalization (5.9%). Of the 28 nontreated outpatients, two were hospitalized (7.1%, P=.68 vs treated patients). All cases of hospital admission presented simultaneous bacterial UTI, none developed candidemia, and two patients did not receive any antifungal therapy. With respect to the first episodes of each patient (n=34), 5/11 treated (45.5%) and 4/23 untreated (17.4%) patients developed recurrences (P=.095). Selection of more resistant Candida species was not observed. Fifty cases (60%) were associated with antibiotic therapy and 34 (41%) the presence of a urinary catheter.

CONCLUSIONS

It does not seem necessary to treat candiduria in this setting. Antifungal therapy was not associated with either a reduction in recurrence or the appearance of more resistant species in this study. We observed no important clinical repercussions.

Candiduria in those over 85 years old: a retrospective study of 73 patients

OBJECTIVE

Candiduria is a common finding in the growing population of very old patients that has not been previously studied. The objective was to study candiduria in the population aged 85 and over, including an estimation of the incidence, factor of acquisition, and evaluation of treatment and mortality.

METHODS

Retrospective monocentric study. Materials medical charts of patients aged of 85 and over who have candiduria diagnosed at Nimes University Hospital.

RESULTS

The prevalence of candiduria in the hospitalized very old patients was 8.9%. More than half of strains isolated were C. albicans (59%). Mean age was 89.7 years old with 53 women and 20 men. Urinary catheter (55%) and prior antibiotic use (67%) were commonly found. Fifteen patients with candiduria were treated, consistently with fluconazole. Patients treated had higher Mini Mental Test score than the others. A high C-reactive protein level, Mac Cabe score or Charlson's score >7 were associated with 6 months mortality.

CONCLUSION

Episodes of candiduria in oldest old were associated with frailty and vulnerability of the patient. The medical decision for antifungal treatment is usually difficult to make but it did not seem to influence mortality.

Candida infections of the genitourinary tract

All humans are colonized with Candida species, mostly Candida albicans, yet some develop diseases due to Candida, among which genitourinary manifestations are extremely common. The forms of genitourinary candidiasis are distinct from each other and affect different populations. While vulvovaginal candidiasis affects mostly healthy women, candiduria occurs typically in elderly, hospitalized, or immunocompromised patients and in neonates. Despite its high incidence and clinical relevance, genitourinary candidiasis is understudied, and therefore, important questions about pathogenesis and treatment guidelines remain to be resolved. In this review, we summarize the current knowledge about genitourinary candidiasis.

Surveillance of catheter-associated urinary tract infection in 4 intensive care units at Alexandria university hospitals in Egypt

BACKGROUND

We sought to measure the incidence rate of catheter-associated urinary tract infections (CAUTIs), identify risk factors associated with acquiring the infections; and identify the etiologic and antibiotic resistant patterns associated with CAUTIs in the intensive care units (ICUs) of a large University Hospital in Alexandria, Egypt.

METHODS

Prospective active surveillance of CAUTIs was conducted in 4 ICUs during a 13-month period from January 1, 2007 through January 31, 2008 in Alexandria University Hospital using the standard Centers for Disease Control National Nosocomial Infection Surveillance (NNIS) case definitions. Rates were expressed as the number of infections per 1000 catheter days.

RESULTS

During the study period, 757 patients were monitored after ICU admission, with either existing indwelling urinary catheters (239), or got catheters inserted after ICU admission (518), for a total duration of 16301 patient days, and 10260 patient catheter days. A total of 161 episodes of infection were diagnosed, for an overall rate of 15.7 CAUTIs per 1000 catheter days. Important risk factors associated with acquiring CAUTI were female gender (Relative risk (RR), 1.7; 95% confidence interval (CI); 1.7-4.3), and previous catheterization within the same hospital admission (RR, 1.6; 95% CI; 1.3-1.96). Patients admitted to the chest unit, patients =40 years, patients with prolonged duration of catheterization, prolonged hospital and ICU stay had a significantly higher risk of acquiring CAUTIs. Out of 195 patients who had their urine cultured, 188 pathogens were identified for 161 infected patients; 96 (51%) were Candida, 63 (33.5%) gram negatives, 29 (15.4%) gram positives. The prevalence of ESBL producers among K. pneumoniae and E. coli isolates was 56% (14/25) and 78.6% (11/14), respectively.

CONCLUSION

Despite infection control policies and procedures, CAUTI rates remain a significant problem in Alexandria University hospital. Using the identified risk factors, tailored intervention strategies are now being implemented to reduce the rates of CAUTIs in these 4 ICUs.