The yeast species causing fungemia at a university hospital in Riyadh, Saudi Arabia, during a 10-year period

The Prevalence and Risk Factors of Trichosporonosis at King Abdulaziz University Hospital

Background

Fungal infections, especially those caused have emerged as a significant medical concern over the past three decades, particularly among immunocompromised patients. However, recent studies have highlighted the increasing prevalence of fungal infections resembling yeast other than Candida, such as trichosporonosis, especially among immunosuppressed individuals worldwide. Trichosporon has been identified as a significant contributor to superficial and invasive infections. Invasive trichosporonosis, primarily affecting immunocompromised patients, poses a significant threat with high mortality rates.

Purpose

The current study aimed to explore the clinical epidemiology of Trichosporon spp at King Abdulaziz University Hospital (KAUH) in Saudi Arabia.

Methods

This retrospective study aimed to assess the clinical epidemiology of Trichosporon spp. infections in microbiology cultures obtained from KAUH in Saudi Arabia. The study analyzed data from patients over a five-year period, focusing on demographic, clinical, and microbiological characteristics.

Results

This study encompassed 21 participants, categorized into four distinct age groups. Moreover, this study indicated T. asahii as the predominant species isolated, accounting for 90.5% of infections, followed by T. mucoides (9.5%). ICU hospitalization, diabetes mellitus, taking immunosuppressive drugs, and antifungal drugs, and the use of invasive medical equipment were identified as prominent risk factors for trichosporonosis. Urinary tract infections were the most common clinical presentation, particularly among male and elderly patients. Mortality rates were high, especially among older individuals.

Conclusion

This study contributes valuable epidemiological insights into trichosporonosis, highlighting the need for enhanced surveillance and preventive strategies in healthcare settings. Further research is warranted to optimize treatment approaches and infection control measures, ultimately reducing the burden of Trichosporon infections on patient outcomes.

Clinical and Microbiological Characteristics of Candidemia Cases in Saudi Arabia

Purpose

Candidemia and antifungal resistance are major healthcare challenges. The aim of this study is to describe the frequency of candidemia cases, distribution of Candida spp., and the associated risk factors for mortality in an academic institution in Saudi Arabia over an 18-month period. We also evaluated the susceptibility patterns of Candida blood isolates.

Methods

Candidemia cases were collected from King Fahad Hospital of the University over the period between July 1st, 2020 through December 31st, 2021. They were prospectively reviewed for the preceding risk factors and antifungal (AF) susceptibility, testing results to fluconazole (FL), voriconazole (VO), itraconazole (IT), posaconazole (PO), caspofungin (CASP), anidulafungin (AND), micafungin (MYC), flucytosine (FLC) and amphotericin B (AMPB) using a broth microdilution kit (Sensititre™ YeastOne).

Results

A total of 48 candidemia isolates were included that were isolated from 43 patients. The median age of cases was 62 ± 23.3 years (60.4% males and 83% ICU patients). Independent risk factors for mortality at 30 days in candidemia patients were age, COVID-19 co-infection, and use of tocilizumab. The most commonly isolated species were C. glabrata and C. parapsilosis (22.9% each) followed by C. albicans (18.75%). AF resistance for ≥1 antifungal was detected in 39.3% of 33 cases tested, with no cross-resistance identified. Resistance rates for each AF were as follows: FL (18%), VO (6%), IT (6%), PO (9%) and AMPB (3%). No resistance was seen for echinocandins apart from one C. krusei strain showing an intermediate result for CASP.

Conclusion

The study showed an overall high rate of non-albicans Candida, with the predominance of C. parapsilosis and C. glabrata, representing a therapeutic challenge. AF resistance rate was high which emphasizes the importance of continuing surveillance and providing accurate and reliable tools in the laboratories for rapid speciation and susceptibility testing.

Increased prevalence of fungemia in Medina, Saudi Arabia

Background

The prevalence of fungal infection is increasing globally due to an increase in the immunocompromised and aging population. We investigated epidemiological changes in fungemia in one of the major centers in Medina over seven years period with 87,447 admissions.

Methods

Retrospective search of records for causative agents of fungemia in inpatients at King Fahad Hospital (KFH) in 2013-2019. Fungal-positive blood cultures, demographic, and treatment data were extracted.

Results

A total of 331 fungemia episodes proven by blood culture were identified in 46 patients. The annual prevalence of fungemia increased from 0.072 in 2013 to 1.546 patients per 1,000 in 2019. The mean age of fungemia episodes was 56 years, and 62% of episodes occurred in females. Samples from central blood incubated aerobically yielded the highest fungemia rate, accounting for 55% (n = 182). Among yeast species, Candida parapsilosis was responsible for the highest number of episodes 37% (n = 122), followed by Candida glabrata (32%; n = 107), Candid albicans (29%; n = 94), and Cryptococcus neoformans (1%; n = 4). Among molds, Lichtheimia (Absidia) species was the most common (1%; n = 3). Yeast-like fungi Trichosporion mucoides accounted for (0.003% n = 1). The use of antifungal treatment has increased (96%) over the years (2013-2019). An increase in resistance rate of 2% was found in C. albicans and C. glabrata. The most prevalent comorbidity was renal disease (24.2%).

Conclusions

C. parapsilosis was the leading cause of fungemia. The association of renal disease with increased candidemia was alarming. This study is a fundamental resource to establish management policies for fungal infection in the region.

A case of central nervous system infection by Candida famata in an immunosuppressed patient with HIV-1 infection

Invasive fungal infections caused by Candida species are increasingly observed in immunosuppressed patients. Candida albicans is the more often identified species and neurocandidiasis is associated with high mortality rates. Diagnosis and treatment of these infections are frequently challenging.

We report a case of central nervous system infection caused by Candida famata in an HIV-1 infected patient.

To our best knowledge this is just the second published case of neural infection by this agent.

Susceptibility of Fluconazole-Resistant Candida albicans to Thyme Essential Oil

Candida spp. is the most common microbial pathogen in fungal infections. There has been a tremendous increase in cases of candidiasis, especially among critically ill non-neutropenic patients. Candida albicans’ isolates were procured from the Prince Sultan Military Hospital, Riyadh, KSA. The isolates were characterized for their identification using CHROMagar, carbohydrate metabolism, germ tube formation, and RAPD-PCR techniques. The essential oil of Thymus vulgaris was obtained by hydro-distillation and characterized to decipher the major bioactive phytoconstituents. The antifungal activity of the thyme essential oil (TEO) was evaluated against fluconazole-resistant C. albicans isolates. The major phytocomponents identified by GC/MS were thymol (68.1%) followed by γ-terpinene (8.9%), cymol (7.7%), caryophyllene (1.1%), linalool (1.4%). The TEO successfully reduced the growth of C. albicans isolates. At very low doses, the TEO proved to be fungi static and fungicidal. TEO also effectively inhibited the germ tube formation and budging of fungal pathogens. The time kill assays have shown that TEO was more effective against drug resistant clinical isolates than fluconazole. This study provides an array of experimental evidence regarding the therapeutic efficacy of TEO against the drug-resistant clinical isolates of C. albicans. The findings may be used in the development of a new antifungal agent accordingly.

A seven-year surveillance of Candida bloodstream infection at a university hospital in KSA

Objectives

Candidemia incidence has increased in the past few years, with high mortality. Previous studies have reported a variable distribution of Candida spp. among different regions. This study aimed to identify the species found in Candida bloodstream infections, routine antifungal susceptibility testing, and mortality outcomes in an academic medical centre.

Methods

Between January 2012 and December 2018, the positive blood cultures for candidemia infection were retrieved and statistically analysed for species prevalence, susceptibility pattern, and crude mortality at 14, 30, 60 and 90 days.

Results

Of 156 candidemia cases, a majority (69.2%) was caused by non-albicans Candida spp. After Candida albicans (30.8%), Candida tropicalis and Candida parapsilosis were the second and third most frequeunt isolates spp, each counting for 23.7%. Acquired resistance was detected in 14.8% of candidemia strains. No other antifungal resistance was detected. The overall crude mortality rates of all species were 29.3%, 47.9%, 56.4%, and 58.0% at 14, 30, 60, and 90 days, respectively. A higher mortality rate was noted in cases of Candida krusei infection (crude mortality 71.4–100%, p = 0.002).

Conclusion

In this study, a considerable shift to non-albicans Candida causing most bloodstream infections was observed. As such infections pose a serious threat to hospitalised patients, microbiology laboratories are urged to adopt rapid diagnostic and minimal inhibitory concentration-based testing for the detection of susceptible dose-dependent phenotypes. Prospective studies are essential to consider the prognosis of bloodstream infections by various Candida species in a multivariate model.

Candida Bloodstream Infection: Changing Pattern of Occurrence and Antifungal Susceptibility over 10 Years in a Tertiary Care Saudi Hospital

Background

Candida has emerged as one of the most important pathogens that cause bloodstream infection (BSI).Understanding the current Candida BSI trends, the dominant species causing disease and the mortality associated with this infection are crucial to optimize therapeutic and prophylaxis measures.

Objectives

To study the epidemiology and to evaluate the risk factors, prognostic factors, and mortality associated with candidemia and to compare these findings with previously published studies from Saudi Arabia.

Design

A retrospective medical record review.

Setting

Tertiary hospital in Riyadh.

Patients and Methods

The analysis included all cases of Candida blood stream infection who are >18 years old over the period from 2013 to 2018. Continuous variables were compared using the parametric T-test while categorical variables were compared using the Chi-squared test.

Main Outcome Measure

Incidence, resistance, and hospital outcomes in Candida blood stream infection.

Sample Size

324 patients.

Results

Three hundred and twenty-four episodes of Candida blood stream infections were identified. Median age of patients was 49.7 SD ± 28.1 years, and 53% of patients were males. More than half of the patients had an underlying disease involving the abdomen or laparotomy, 78% had an indwelling intravenous catheter, and 62% had suffered a bacterial infection within 2 weeks prior to candidemia. Candida albicans represents 33% of all isolates with decreasing trend overtime. There was an increase in the number of nonalbicans Candida overtime with Candida tropicalis in the lead (20%). Use of broad spectrum antibiotics (82%), prior ICU admission (60%) and use of central venous catheters (58%) were the most prevalent predisposing factors of candidemia. Azole resistance was variable overtime. Resistance to caspofungin remained very low (1.9%). Fourteen days crude mortality was 37% for ICU patients and 26.7% in non-ICU patients, while hospital crude mortality was 64.4% and 46.7%, respectively.

Conclusion

There is an increasing trend of nonalbicans Candida blood stream infection. Fluconazole resistance remained low to C. albicans. Most isolates remain susceptible to caspofungin, voriconazole, and amphotericin B. Candida bloodstream infection is associated with high 14-day hospital mortality.

The epidemiology of Candida species in the Middle East and North Africa

In recent decades, the epidemiology of invasive candidiasis (IC) has progressively changed worldwide. This notably includes emergence of several Candida species. Although some surveillance programs provided global trends in IC epidemiology, data from countries from the Middle East and North Africa (MENA) remain scarce. In this manuscript, we reviewed the existing available data on the epidemiology of Candida species associated with IC, particularly candidemia, in MENA region regarding species distribution. As witnessed worldwide, an evident shift of Candidaalbicans towards non-albicansCandida (NAC) has been observed in the MENA region. The worrying emergence of multi-drug resistant Candida species in MENA calls for a better understanding of their epidemiology. This represents an essential prerequisite for the implementation of effective infection control strategies and surveillance systems to prevent IC among high-risk patients.

Epidemiology and burden of invasive fungal infections in the countries of the Arab League

The burden of invasive fungal infections is alarming worldwide. The aim of this paper is to review the published literature and evaluate the knowledge gap pertaining to studies on invasive fungal infections in the countries of the Arab League. Few countries from this region have published reports. The most commonly studied invasive fungal infections is invasive candidiasis. Candida albicans remains overall the most common causative pathogen (33.8-60%), however, non-albicans Candida species are increasing. Antifungal susceptibility testing is non-standardized across the published studies. Data on aspergillosis and other fungal infections is scarce. This sheds light on the need for standardized surveillance in the region encompassing more countries of the Arab League to guide diagnostic approach and empiric therapy.

Epidemiologic characteristics of adult candidemic patients in a secondary hospital in Kuwait: A retrospective study

Candida blood steam infection is a life-threatening disease that seems to be under estimated. Understanding epidemiology of such disease is crucial for improved diagnosis, optimized treatment, and better outcome. Through this retrospective study, we aimed to determine the incidence of candidemia in a secondary care hospital, and to describe the epidemiology and outcome of candidemia among adult patients. The incidence of candidemia for all age groups was 0.24, 0.16 and 0.15 cases/1000 patient-days in 2014, 2015 and 2016 respectively. Among adult patients, 82 cases were identified. The patients had the following clinical characteristics with varying proportions: old age, diabetes, antibiotic exposure, use of vascular catheter, abdominal surgery, ICU hospitalization, haemodialysis, and total parenteral nutrition. All-cause 30-day mortality was 54% and ICU hospitalization was a recognized risk factor for death. The leading causative agents were Candida albicans (32%), and Candida parapsilosis (32%), followed by Candida tropicalis (20%), Candida glabrata (13%) and one each by Candida dubliniensis, Candida famata, and Candida auris. Almost all tested isolates were susceptible to caspofungin and amphotericin B. With regard to fluconazole, C. glabrata showed variable susceptibility. Other species were susceptible except one isolate, each of C. parapsilosis and C. auris. The study highlights the growing importance of non-C. albicans Candida species in the etiology of candidemia. Emergence of C. auris is a warning sign and needs to be closely monitored.

Invasive Candidiasis in Critically Ill Patients: A Prospective Cohort Study in Two Tertiary Care Centers

Background:

Invasive candidiasis is not uncommon in critically ill patients but has variable epidemiology and outcomes between intensive care units (ICUs). This study evaluated the epidemiology, characteristics, management, and outcomes of patients with invasive candidiasis at 6 ICUs of 2 tertiary care centers.

Methods:

This was a prospective observational study of all adults admitted to 6 ICUs in 2 different hospitals between August 2012 and May 2016 and diagnosed to have invasive candidiasis by 2 intensivists according to predefined criteria. The epidemiology of isolated Candida and the characteristics, management, and outcomes of affected patients were studied. Multivariable logistic regression analyses were performed to identify the predictors of non-albicans versus albicans infection and hospital mortality.

Results:

Invasive candidiasis was diagnosed in 162 (age 58.4 ± 18.9 years, 52.2% males, 82.1% medical admissions, and admission Acute Physiology and Chronic Health Evaluation II score 24.1 ± 8.4) patients at a rate of 2.6 cases per 100 ICU admissions. On the diagnosis day, the Candida score was 2.4 ± 0.9 in invasive candidiasis compared with 1.6 ± 0.9 in Candida colonization (P < .01). The most frequent species were albicans (38.3%), tropicalis (16.7%), glabrata (16%), and parapsilosis (13.6%). In patients with candidemia, antifungal therapy was started on average 1 hour before knowing the culture result (59.6% of therapy initiated after). Resistance to fluconazole, caspofungin, and amphotericin B occurred in 27.9%, 2.9%, and 3.1%, respectively. The hospital mortality was 58.6% with no difference between albicans and non-albicans infections (61.3% and 54.9%, respectively; P = .44). The independent predictors of mortality were renal replacement therapy after invasive candidiasis diagnosis (odds ratio: 5.42; 95% confidence interval: 2.16-13.56) and invasive candidiasis leading/contributing to ICU admission versus occurring during critical illness (odds ratio: 2.87; 95% confidence interval: 1.22-6.74).

Conclusions:

In critically ill patients with invasive candidiasis, non-albicans was responsible for most cases, and mortality was high (58.6%). Antifungal therapy was initiated after culture results in 60% suggesting low preclinical suspicion. Study registration: NCT01490684; registered in ClinicalTrials.gov on February 11, 2012.

Predictors and outcomes of Candida bloodstream infection: eight-year surveillance, western Saudi Arabia

OBJECTIVES

To assess the epidemiological pattern of Candida bloodstream infection (BSI) over an 8-year period (2002-2009) in King Abdulaziz Medical City, western Saudi Arabia.

METHOD

A retrospective chart review was performed.

RESULTS

A total of 258 BSI were identified in 134 males (53.2%) and 118 females (46.8%). There were 86 (34.1%) cases of Candida albicans and 166 (65.9%) non-albicans Candida species. Malignancy was independently associated with the development of candidemia by non-albicans Candida species (odds ratio 3.24, 95% confidence interval 1.25-8.41). Fluconazole in vitro susceptibility was 38.5% for C. albicans and 52.5% for other Candida species. The overall, crude 12-month mortality rate was 50% for C. albicans and 57.8% for non-albicans Candida species.

CONCLUSIONS

The antifungal resistance coinciding with a change in the epidemiologic pattern of candidemia identified in this study is alarming and urges the need for a review of empiric antifungal therapy and potential contributing environmental factors.

Candida identification: a journey from conventional to molecular methods in medical mycology

The incidence of Candida infections have increased substantially in recent years due to aggressive use of immunosuppressants among patients. Use of broad-spectrum antibiotics and intravascular catheters in the intensive care unit have also attributed with high risks of candidiasis among immunocompromised patients. Among Candida species, C. albicans accounts for the majority of superficial and systemic infections, usually associated with high morbidity and mortality often caused due to increase in antimicrobial resistance and restricted number of antifungal drugs. Therefore, early detection of candidemia and correct identification of Candida species are indispensable pre-requisites for appropriate therapeutic intervention. Since blood culture based methods lack sensitivity, and species-specific identification by conventional method is time-consuming and often leads to misdiagnosis within closely related species, hence, molecular methods may provide alternative for accurate and rapid identification of Candida species. Although, several molecular approaches have been developed for accurate identification of Candida species but the internal transcribed spacer 1 and 2 (ITS1 and ITS2) regions of the rRNA gene are being used extensively in a variety of formats. Of note, ITS sequencing and PCR-RFLP analysis of ITS region seems to be promising as a rapid, easy, and cost-effective method for identification of Candida species. Here, we review a number of existing techniques ranging from conventional to molecular approaches currently in use for the identification of Candida species. Further, advantages and limitations of these methods are also discussed with respect to their discriminatory power, reproducibility, and ease of performance.

Clinical practice guidelines for the management of invasive Candida infections in adults in the Middle East region: Expert panel recommendations

Invasive Candida infections contribute to significant morbidity and mortality in patients with healthcare-associated infections. They represent a major burden on the public health system, and are challenging to diagnose and treat. A multidisciplinary expert panel critically reviewed available evidence to provide consensus recommendations for the management of invasive Candida infections in the Middle East. Based on diagnosis, recommendations were provided for the management of Candida infections in non-neutropenic and neutropenic patients. Polyenes (amphotericin B-deoxycholate [AmB-d] and lipid formulations amphotericin B [LFAmB]), triazoles (fluconazole, itraconazole and voriconazole), echinocandins (caspofungin, anidulafungin, and micafungin) and flucytosine are the recommended categories of antifungal agents for treatment of Candida infections. Echinocandins are preferred for treatment of proven and suspected Candida infections, especially in critically ill patients or those with previous exposure to azoles. Recommendations were also provided for infections caused by specific Candida species as well as management of different disease conditions. The experts highlighted that the guidelines should be used along with clinical judgment. Given the paucity of published data from the region, research in the form of randomized clinical trials should be given priority.

Candida dubliniensis: an appraisal of its clinical significance as a bloodstream pathogen

A nine-year prospective study (2002–2010) on the prevalence of Candida dubliniensis among Candida bloodstream isolates is presented. The germ tube positive isolates were provisionally identified as C. dubliniensis by presence of fringed and rough colonies on sunflower seed agar. Subsequently, their identity was confirmed by Vitek2 Yeast identification system and/or by amplification and sequencing of the ITS region of rDNA. In all, 368 isolates were identified as C. dubliniensis; 67.1% came from respiratory specimens, 11.7% from oral swabs, 9.2% from urine, 3.8% from blood, 2.7% from vaginal swabs and 5.4% from other sources. All C. dubliniensis isolates tested by Etest were susceptible to voriconazole and amphotericin B. Resistance to fluconazole (≥8 µg/ml) was observed in 2.5% of C. dubliniensis isolates, 7 of which occurred between 2008–2010. Of note was the diagnosis of C. dubliniensis candidemia in 14 patients, 11 of them occurring between 2008–2010. None of the bloodstream isolate was resistant to fluconazole, while a solitary isolate showed increased MIC to 5-flucytosine (>32 µg/ml) and belonged to genotype 4. A review of literature since 1999 revealed 28 additional cases of C. dubliniensis candidemia, and 167 isolates identified from blood cultures since 1982. In conclusion, this study highlights a greater role of C. dubliniensis in bloodstream infections than hitherto recognized.

Spondylodiscitis due to an emergent fungal pathogen: Blastoschizomyces capitatus, a case report and review of the literature

The study includes a case report and a literature review. The main objective of this study is to present a case of spondylodiscitis due to a fungal pathogen, Blastoschizomyces capitatus and to review the published literature on this emergent fungus in etiology of spondylodiscitis, and osteomyelitis. Osteoarticular involvement due to B. capitatus has been reported in six cases, and vertebral involvement has been seen in five of them. All of these cases had underlying malignancy. Infection is usually advanced at presentation. Case notes and online databases were reviewed. Organism was isolated from bone material in all of the cases and antibiotic treatment by antifungal agents cured the infection. We present another case of infectious spondylodiscitis due to B. capitaus, which is reported first in Turkey and tried to attract attendance to this emergent fungal pathogen as an etiologic agent of spine infections in cancer patients.

Evolution of antibody response and fungal antigens in the serum of a patient infected with Candida famata

The presence of fungal antibodies and antigens in the serum of a patient diagnosed in 1996 with acute zonal occult outer retinopathy caused by Candida famata infection was examined. Antibodies against C. famata increased until 1999–2000 when antifungal treatment was initiated. The antibodies were detected by ELISA and immunofluorescence analysis using C. famata. These antibodies were not immunoreactive against several Candida species tested. Positive immunofluorescence was obtained with IgM, but not IgA, IgG or IgE. Moreover, the IgM response disappeared several months after treatment with antifungal compounds, despite the fact that C. famata antigens were present in the blood. Finally, a sensitive test was developed to assay for the presence of C. famata antigens in serum based on the immunodetection of fungal antigens transferred to a nitrocellulose membrane and incubated with rabbit antibodies raised against C. famata. According to this method, the infection diminished with antifungal treatment.

Candidaemia in patients with haematological disorders and stem cell transplant

The incidence of non-albicans species of Candida has recently increased, especially in patients with malignant haematological disorders receiving fluconazole prophylaxis. A retrospective study of patients who developed candidaemia at Riyadh Armed Forces Hospital between January 1992 and December 2002 was carried out. Thirty one episodes of candidaemia occurred in 27 patients with a variety of haematological disorders. Twenty-four episodes were caused by non-albicans species of Candida and only 7 episodes were caused by C.albicans. The most frequent underlying haematological disorders were acute myeloid leukaemia (AML) followed by acute lymphoblastic leukaemia (ALL). The main predisposing factors for the development of candidaemia were: broad spectrum antibiotics, central venous catheters, neutropenia, cytotoxic chemotherapy, coexisting bacterial infections, steroid therapy, relapsing or untreated primary disease and fluconazole prophylaxis.

Eight episodes were complicated by chronic disseminated candidiasis. Amphotericin-B and amBisome were used in the treatment of Candida infections. The treatment was successful in 86% of the episodes of C. albicans and 50% of the episodes due to nonalbicans species of Candida. The highest mortality rate was encountered with C.tropicalis infections.

Candidaemia is an important cause of mortality and morbidity in patients with malignant haematological disorders and stem cell transplant. The predominance of non-albicans species of Candida especially C.krusei and C.tropicalis is alarming. The early administration of appropriate antifungal therapy and the removal of infected intravascular catheters improve the outcome considerably.

Distribution and epidemiology of Candida species causing fungemia at a Saudi Arabian hospital, 1996-2004

OBJECTIVES

The objective of this study was to evaluate the Candida species and the change over time in the organisms causing candidemia at Saudi Aramco Medical Services Organization in Saudi Arabia. We also describe the risk factors associated with mortality.

METHODS

This was a retrospective study of candidemia over nine years (1996-2004).

RESULTS

A total of 98 distinct episodes of candidemia were identified over the study period. The annual incidence of candidemia ranged between 0.2 and 0.76 cases/1000 hospital discharges with an incidence per 10 000 patient-days per year of 0.45 to 1.6. The most frequent Candida species were Candida albicans (53%), Candida tropicalis (19%), Candida parapsilosis (16%), and Candida glabrata (7%). In relation to predisposing factors, 83% of candidemia occurred in patients with central venous catheters and 96% had received broad-spectrum antibiotics. Other predisposing factors included complicated abdominal surgeries (22%), total parenteral nutrition (52%), neutropenia (9%), acute renal failure (24%), malignancy (26%) and burns (15%). However, prior fluconazole use was low (8%). The overall crude mortality rate was 43% for all candidemia. Logistic regression analysis identified two independent determinants of death, C. albicans (OR 5.91, 95% CI 1.50, 23.24, p=0.01) and acute renal failure (OR 5.15, 95% CI 1.18, 22.55, p=0.03).

CONCLUSION

The study showed that the rate of candidemia was low in our hospital and that C. albicans was the major species followed by C. tropicalis and C. parapsilosis. Future studies are needed to evaluate the antifungal susceptibility pattern in our hospital.

Initial Candida dubliniensis isolate in Candida spp. positive haemocultures in Turkey between 2001 and 2004

Candida dubliniensis which was first recognized in 1995 can be easily misidentified because of its phenotypic similarities with Candida albicans. In this study blood samples of patients from various departments of Ankara University Medical Faculty between January 2001-June 2004 were investigated for the distribution of Candida spp. and the presence of C. dubliniensis. Culture positive 67 fungi were included to the study. Phenotypic tests such as chlamydospore formation, colony morphology on Staib agar, growth at 45 degrees C, carbohydrate assimilation profiles were investigated for identification and differentiation of C. dubliniensis from C. albicans. To confirm the results polymerase chain reaction were used for suspected C. albicans and C. dubliniensis isolates. Among 38 germ tube and chlamydospore forming isolates, 37 of them were found as C. albicans and one as C. dubliniensis. The incidence of C. dubliniensis in our hospital is still low, this is the first C. dubliniensis isolate as an agent of candidaemia reported from Turkey.

Cockroaches as carriers of fungi of medical importance

The fungal pathogenic flora of the external surface of 103 cockroaches (Periplaneta americana) collected from the intensive care unit of a hospital were investigated. In this study, a high percentage of test cockroaches (93.2%) were found to carry fungi of medical importance. The main fungi isolated were species of Candida, Aspergillus and Penicillium. Information about the carriage of pathogenic fungi by cockroaches in hospital environment is scanty. The results suggest that cockroaches can play a role in dissemination of fungi, which they can carry on their external surface.

Prevalence of Candida dubliniensis among germ tube-positive Candida isolates in a maternity hospital in Kuwait

In this study, 1644 germ tube-positive Candida isolates from a maternity hospital was prospectively examined for the prevalence of Candida dubliniensis. Candida species were isolated from different clinical specimens, but majority (>90%) of them came from high vaginal swabs and urine specimens. The phenotypic and molecular identification methods for C. dubliniensis included production of rough colonies and chlamydospores on simplified sunflower seed agar, determination of assimilation profile by Vitek 2 yeast identification system, specific amplification of rDNA of internally transcribed spacer (ITS)-2 region by semi-nested PCR and direct DNA sequencing of the ITS-1 and ITS-2 regions. Three germ tube-positive Candida isolates were identified as C. dubliniensis with an overall prevalence of 0.2%. Of these, two came from urine specimens and one from a vaginal swab. None of the C. dubliniensis isolates showed resistance against fluconazole, voriconazole and amphotericin B. The study reinforces the usefulness of sunflower seed agar in presumptive identification of C. dubliniensis and confirms the prevailing view that this species forms only a minor constituent of Candida species occurring in vagina or other anatomic sites of non-HIV/AIDS-infected individuals.

Isolation of Candida famata from a patient with acute zonal occult outer retinopathy

The etiology of a number of retinopathies, such as acute zonal occult outer retinopathy (AZOOR), remains undetermined. Candida famata was isolated from conjunctival exudates of a patient diagnosed with AZOOR. This yeast was very abundant, particularly in the more affected eye, while no other pathogens or fungal species were in evidence. Immunological tests revealed the presence of antigen-specific T lymphocytes by using C. famata as a challenge. Moreover, enzyme-linked immunosorbent assay analysis showed the presence of specific antibodies against this yeast in the patient's blood. Delayed hypersensitivity by use of a skin test was also positive. Finally, antifungal treatments led to improvements in several clinical symptoms, including funduscopic analysis. However, despite prolonged treatment with fluconazole and itraconazole, C. famata still appeared in the conjunctival exudates. The new antifungal voriconazole may represent a better choice for treatment.

Invasive infections caused by Trichosporon species and Geotrichum capitatum in patients with hematological malignancies: a retrospective multicenter study from Italy and review of the literature

Trichosporonosis is an uncommon but frequently fatal mycosis in immunocompromised patients. A multicenter retrospective study was conducted to characterize cases of proven or probable invasive trichosporonosis diagnosed over the past 20 years in Italian patients with hematological diseases. Of the 52 cases identified, 17 were classified as Trichosporon sp. infections and 35 were attributed to Geotrichum capitatum. Acute myeloid leukemia accounted for 65.4% of the cases. The incidence rates of Trichosporon sp. and G. capitatum infections in acute leukemia patients were 0.4 and 0.5%, respectively. Overall, 76.9% of cases had positive blood cultures. Pulmonary involvement was documented in 26.9% of cases. Death was reported for 57.1% of G. capitatum infections and for 64.7% of Trichosporon sp. infections. A literature review on trichosporonosis in patients with any underlying disease or condition reveals G. capitatum as a predominantly European pathogen, particularly in certain Mediterranean areas, while Trichosporon sp. infections are seen with similar frequencies on all continents. The majority of published Trichosporon sp. and G. capitatum infections occurred in patients with hematological diseases (62.8 and 91.7%, respectively). Well over half of these were suffering from acute leukemia (68 and 84% of patients with Trichosporon sp. and G. capitatum infections, respectively). Crude mortality rates were 77% for Trichosporon spp. and 55.7% for G. capitatum. The optimal therapy for trichosporonosis has yet to be identified; however, in vitro experiences are providing encouraging evidence of the potential role of the new triazoles, in particular, voriconazole.

Phenotypic and molecular characterization of Candida dubliniensis isolates from clinical specimens in Kuwait

OBJECTIVE

This study was carried out to characterize Candida dubliniensis using phenotypic and molecular methods and to determine the occurrence of C. dubliniensis in clinical specimens in Kuwait.

MATERIALS AND METHODS

A total of 880 clinical specimens for isolation of fungi were processed according to standard procedures. Of these, 390 germ-tube-positive clinical isolates of Candida species were examined for rough colonies with hyphal fringes and chlamydospore production on simplified sunflower seed agar for their presumptive phenotypicidentification as C. dubliniensis. The identification of C. dubliniensis isolates was further confirmed by the Vitek 2 yeast identification system, semi-nested (sn) PCR amplification of high-copy rDNA and direct DNA sequencing of the internally transcribed spacer 2 (ITS2) region.

RESULTS

Of the 390 isolates of Candida species investigated, 12 were identified as C. dubliniensis, giving an overall occurrence of 3%. All the C. dubliniensis isolates formed rough colonies with hyphal fringes and abundant chlamydospores on sunflower seed agar, did not assimilate trehalose, lactate and alpha-methyl-D-glucoside, and were isolated from human immunodeficiency virus (HIV)-negative patients. Four C. dubliniensis isolates utilized D-xylose. The species-specific primer derived from the ITS2 sequence of C. dubliniensis and used together with the panfungal reverse primer in the reamplification step of the snPCR specifically amplified rDNA from reference and clinical C. dubliniensis isolates and not from C. albicans or other Candida species. The identity of two representative isolates was confirmed by DNA sequencing of the ITS2 region.

CONCLUSIONS

The identity of 12 C. dubliniensis isolates was first established by phenotypic characteristics and then by snPCR using species-specific primers derived from ITS2 sequences. The recovery of C. dubliniensis from HIV-negative patients from Kuwait reinforces the existing view that this novel yeast species has a worldwide distribution and its occurrence is not restricted to any particular immunocompromised population.