Epidemiology of candidemia: 3-year results from the emerging infections and the epidemiology of Iowa organisms study

Time to positivity of blood cultures causing candidemia and its relation to mortality

Background and Objectives

Early diagnosis of candidemia is of vital importance in reducing mortality and morbidity. The main objective of the study was to determine the TTP (Time to Positivity) of different species of Candida causing bloodstream infection and to see whether TTP can help differentiate Candida glabrata which is frequently fluconazole resistant from Fluconazole sensitive Candida.

Materials and Methods

TTP (Time to positivity) and AAT (Appropriate Antifungal therapy) were noted for Blood cultures becoming positive for Candida. Presence of Risk factors for candidemia like prolonged ICU stay, neutropenia, Total Parenteral Nutrition (TPN), use of steroids , broad spectrum antibiotics, use of Central Venous Catheter, Foleys catheter were also analyzed.

Results

The most frequent isolates were Candida parapsilosis, Candida tropicalis and Candida albicans. The median TTP for all Candida isolates in our study was 34 hours. The diagnostic sensitivity of TTP for detecting C. glabrata and C. tropicalis in patients with candidemia was 88% and 85% respectively. TTP showed that there was no difference in survival between TTP <24 hrs. and > 24hrs. Initiation of antifungal therapy <24 hours and > 24hrs after onset of candidemia had no association with survival.

Conclusion

Longer TTP maybe predictive of C. glabrata while shorter TTP may be predictive of C. tropicalis. In our study we found that fluconazole resistant Candida causing blood stream infection is quite unlikely if the TTP of the isolate is <48hrs.

Chemical composition, antifungal activity, antifungal mechanism and interaction manner of the fatty acid of Prunus mahaleb L. with fluconazole

The interaction manner of Prunus mahaleb L. (P. mahaleb) seed oil (MSO) and fluconazole (FLC: antimycotic) combinations (MSO*FLC) against C. albicans and C. parapsilosis were evaluated using the microdilution technique. The most representative compounds of mahaleb oil were found to be conjugated linolenic acid (34.39%), oleic acid (31.76%), and linoleic acid (25.54%) by GC-MS. In antimicrobial activity study, P. mahaleb had an inhibition zone (IZ) of C. albicans and C. parapsilosis with 6.89 mm and 11.39 mm and a minimum inhibitory concentration (MIC) with 35.3 µgmL^-1 and 23.9 µgmL^-1, respectively. The strongest indifferent effect was observed as 57.14% for C. albicans and 100% for C. parapsilosis in fluconazole-mahaleb oil combinations. An increase in DNA and protein leakage was observed when yeast was exposed to the FA. The destruction on the cell surface was visualized using Scanning Electron Microscopy (SEM) analysis.

Early Empirical Anidulafungin Reduces the Prevalence of Invasive Candidiasis in Critically Ill Patients: A Case-control Study

Introduction

Invasive candidiasis (IC) in critically ill patients is a serious infection with high rate of mortality. As an empirical therapy, like antibiotics, the use of antifungals is not common in intensive care units (ICUs) worldwide. The empirical use of echinocandins including anidulafungin is a recent trend.

Aim of the study

The objective of this study was to assess the impact of empirical anidulafungin in the development of invasive candidiasis in critically ill patients in ICU.

Methods

This retrospective case-control study was conducted on 149 patients with sepsis with/without septic shock and bacterial pneumonia. All the patients were divided into two groups. The ‘control group’ termed as ‘NEAT group’ received no empirical anidulafungin therapy and the ‘treated group’ termed as ‘EAT group’ received empirical anidulafungin therapy in early hospitalization hours.

Results

Seventy-two and 77 patients were divided into the control and the treated group, respectively. Patients in EAT group showed less incidences of IC (5.19%) than that of the NEAT group (29.17%) (p = 0.001). Here, the relative risk (RR) was 0.175 (95% CI, 0.064-0.493) and the risk difference (RD) rate was 24% (95% CI, 12.36%-35.58%). The 30-day all-cause mortality rate in NEAT group was higher (19.44%) than that of in EAT group (10.39%) (p = 0.04). Within the first 10-ICU-day, patients in the EAT group left ICU in higher rate (62.34%) than that in the NEAT group (54.17%).

Conclusion

Early empirical anidulafungin within 6 h of ICU admission reduced the risk of invasive candidiasis, 30-day all-cause mortality rate and increased ICU leaving rate within 10-day of ICU admission in critically ill patients.

Plasmid-Based CRISPR-Cas9 Editing in Multiple Candida Species

CRISPR-Cas9 technology radically changed the approach to genetic manipulation of both medically and industrially relevant Candida species, as attested by the ever-increasing number of applications to the study of pathogenesis, drug resistance, gene expression, and host pathogen interaction and drug discovery. Here, we describe the use of plasmid-based systems for high efficiency CRISPR-Cas9 gene editing into any strain of four non-albicans Candida species, namely, Candida parapsilosis, Candida orthopsilosis, Candida metapsilosis, and Candida tropicalis. The plasmids pCP-tRNA and pCT-tRNA contain all the elements necessary for expressing the CRISPR-Cas9 machinery, and they can be used in combination with a repair template for disrupting gene function by insertion of a premature stop codon or by gene deletion. The plasmids are easily lost in the absence of selection, allowing scarless gene editing and minimizing detrimental effects of prolonged Cas9 expression.

Antimycotic Drugs and their Mechanisms of Resistance to Candida Species

Fungal infections have shown an upsurge in recent decades, which is mainly because of the increasing number of immunocompromised patients and the occurrence of invasive candidiasis has been found to be 7-15 fold greater than that of invasive aspergillosis. The genus Candida comprises more than 150 distinct species, however, only a few of them are found to be pathogenic to humans. Mortality rates of Candida species are found to be around 45% and the reasons for this intensified mortality are inefficient diagnostic techniques and unfitting initial treatment strategies. There are only a few antifungal drug classes that are employed for the remedy of invasive fungal infections. which include azoles, polyenes, echinocandins, and pyrimidine analogs. During the last 2-3 decades, the usage of antifungal drugs has increased several folds due to which the reports of escalating antifungal drug resistance have also been recorded. The resistance is mostly to the triazole- based compounds. Due to the occurrence of antifungal drug resistance, the success rates of treatment have been reduced as well as major changes have been observed in the frequency of fungal infections. In this review, we have summarized the major molecular mechanisms for the development of antifungal drug resistance.

Deciphering the epidemiology of invasive candidiasis in the intensive care unit: is it possible?

Invasive candidiasis (IC) has emerged in the last decades as an important cause of morbidity, mortality, and economic load in the intensive care unit (ICU). The epidemiology of IC is still a difficult and unsolved enigma for the literature. Accurate estimation of the true burden of IC is difficult due to variation in definitions and limitations inherent to available case-finding methodologies. Candidemia and intra-abdominal candidiasis (IAC) are the two predominant types of IC in ICU. During the last two decades, an increase in the incidence of candidemia has been constantly reported particularly in the expanding populations of elderly or immunosuppressed patents, with a parallel change in Candida species (spp.) distribution worldwide. Epidemiological shift in non-albicans spp. has reached worrisome trends. Recently, a novel, multidrug-resistant Candida spp., Candida auris, has globally emerged as a nosocomial pathogen causing a broad range of healthcare-associated invasive infections. Epidemiological profile of IAC remains imprecise. Though antifungal drugs are available for Candida infections, mortality rates continue to be high, estimated to be up to 50%. Increased use of fluconazole and echinocandins has been associated with the emergence of resistance to these drugs, which affects particularly C. albicans and C. glabrata. Crucial priorities for clinicians are to recognize the epidemiological trends of IC as well as the emergence of resistance to antifungal agents to improve diagnostic techniques and strategies, develop international surveillance networks and antifungal stewardship programmes for a better epidemiological control of IC.

Effects of Propolis on Infectious Diseases of Medical Relevance

Infectious diseases are a significant problem affecting the public health and economic stability of societies all over the world. Treatment is available for most of these diseases; however, many pathogens have developed resistance to drugs, necessitating the development of new therapies with chemical agents, which can have serious side effects and high toxicity. In addition, the severity and aggressiveness of emerging and re-emerging diseases, such as pandemics caused by viral agents, have led to the priority of investigating new therapies to complement the treatment of different infectious diseases. Alternative and complementary medicine is widely used throughout the world due to its low cost and easy access and has been shown to provide a wide repertoire of options for the treatment of various conditions. In this work, we address the relevance of the effects of propolis on the causal pathogens of the main infectious diseases with medical relevance; the existing compiled information shows that propolis has effects on Gram-positive and Gram-negative bacteria, fungi, protozoan parasites and helminths, and viruses; however, challenges remain, such as the assessment of their effects in clinical studies for adequate and safe use.

Temporal Trends of Candidemia Incidence Rates and Potential Contributions of Infection Control Initiatives over 18 Years within the US Veteran Health Administration System: A Joinpoint Time-Series Analysis

BACKGROUND

Candidemia is one of the most common causes of nosocomial bloodstream infections, but the impacts of factors affecting its incidence have not been evaluated.

METHODS

We analyzed a retrospective cohort of all candidemia patients at 130 acute care hospitals in the Veterans Health Administration (VHA) system from January 2000 through December 2017. Cases were classified as hospital-onset (HO) and non-hospital-onset (NHO). We used Joinpoint regression analysis to assess temporal associations between significant changes in candidemia incidence rates and guidelines or horizontal infection control (IC) interventions.

RESULTS

Over 18 years, 17,661 candidemia episodes were identified. Incidence rates of HO cases were increasing until the mid-2000s, followed by a sustained decline, while NHO cases showed a steady decline. The first change in HO candidemia incidence rates (8/2004 [95% CI: 2/2003-4/2005]) was preceded by the publication of catheter-related bloodstream infection (CRBSI) prevention guidelines and the CRBSI surveillance initiation. The second (9/2007 [95% CI: 9/2006-6/2009]) had close temporal proximity to the expansion of IC resources within the VHA system. Collectively, these trend changes resulted in a 77.1% reduction in HO candidemia incidence rates since its peak in 2004.

CONCLUSIONS

A substantial and sustained systemwide reduction in candidemia incidence rates was observed after the publication of guidelines, VHA initiatives about CRBSI reporting and education on CRBSI prevention, and the systemwide expansion of IC resources.

Risk factors predicting Candida infective endocarditis in patients with candidemia

Candida infective endocarditis (CIE) is a rare but serious complication of candidemia. Incidence and risk factors associated with CIE among candidemic patients are poorly defined from small cohorts. Identification of clinical predictors associated with this entity may guide more judicious use of cardiac imaging. We conducted a retrospective analysis of all inpatients aged ≥18 years diagnosed with candidemia at our institution. CIE was diagnosed by fulfilling two of the major Duke criteria: specifically a vegetation(s) on echocardiogram and positive blood cultures for Candida spp. We used univariable and multivariable regression analyses to identify risk factors associated with CIE. Of 1,873 patients with candidemia, 47 (2.5%) were identified to have CIE. In our multivariable logistic model, existing valvular heart disease was associated with a higher risk for CIE (adjusted odds ratio [aOR], 7.66; 95% confidence interval [CI], 2.95-19.84). Predictors that demonstrated a decreased risk of CIE included infection with C. glabrata (aOR, 0.17; 95% CI, 0.04-0.69), hematologic malignancy (aOR, 0.09; 95% CI, 0.01-0.68), and receipt of total parenteral nutrition (aOR, 0.38; 95% CI, 0.16-0.91). The 90-day crude mortality for CIE was 48.9%, similar to the overall non-CIE mortality of 41.9% (P = .338). We identified a set of clinical factors that can predict the presence of CIE among patient with candidemia. These findings may reduce the need for unnecessary expensive and invasive imaging studies in a subset of patients with a lower risk profile for endocarditis and alternative infection source.

A predictive nomogram for mortality of cancer patients with invasive candidiasis: a 10-year study in a cancer center of North China

Background

Invasive candidiasis is the most common fungal disease among hospitalized patients and continues to be a major cause of mortality. Risk factors for mortality have been studied previously but rarely developed into a predictive nomogram, especially for cancer patients. We constructed a nomogram for mortality prediction based on a retrospective review of 10 years of data for cancer patients with invasive candidiasis.

Methods

Clinical data for cancer patients with invasive candidiasis during the period of 2010–2019 were studied; the cases were randomly divided into training and validation cohorts. Variables in the training cohort were subjected to a predictive nomogram based on multivariate logistic regression analysis and a stepwise algorithm. We assessed the performance of the nomogram through the area under the receiver operating characteristic (ROC) curve (AUC) and decision curve analysis (DCA) in both the training and validation cohorts.

Results

A total of 207 cases of invasive candidiasis were examined, and the crude 30-day mortality was 28.0%. Candida albicans (48.3%) was the predominant species responsible for infection, followed by the Candida glabrata complex (24.2%) and Candida tropicalis (10.1%). The training and validation cohorts contained 147 and 60 cases, respectively. The predictive nomogram consisted of bloodstream infections, intensive care unit (ICU) admitted > 3 days, no prior surgery, metastasis and no source control. The AUCs of the training and validation cohorts were 0.895 (95% confidence interval [CI], 0.846–0.945) and 0.862 (95% CI, 0.770–0.955), respectively. The net benefit of the model performed better than “treatment for all” in DCA and was also better for opting low-risk patients out of treatment than “treatment for none” in opt-out DCA.

Conclusion

Cancer patients with invasive candidiasis exhibit high crude mortality. The predictive nomogram established in this study can provide a probability of mortality for a given patient, which will be beneficial for therapeutic strategies and outcome improvement.

In vitro biological properties of Streptomyces cangkringensis isolated from the floral rhizosphere regions

This context was investigated to determine in vitro antimicrobial, antioxidative, and anticancer traits of crude ethyl acetate extract of Streptomyces cangkringensis strain TSAS 04 isolated from soil sample of rhizosphere regions. The antimicrobial activity of ethyl acetate extract of strain TSAS 04 was determined against indicator pathogens using disc diffusion assay which exhibited maximum zones of inhibition of 20.6 ± 0.3 and 16.3 ± 0.6 mm against Bacillus subtilis and Trichoderma viride, respectively. In vitro antioxidant properties of the crude ethyl acetate extract were performed using standard methodologies. The extract revealed maximum DPPḢ and ABTS^•+ radical scavenging activities of 51.1 ± 0.39 and 81.25 ± 0.33%, respectively. Likewise, maximum phosphomolybdenum reduction and Fe³⁺ reduction of the crude ethyl acetate extract of strain TSAS 04 were estimated 76.18 ± 0.10 and 89.01 ± 0.44%, respectively. In vitro anticancer trait of the extract was determined against HeLa cell line using 3-(4,5-Dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) assay which showed anticancer activities in a dose dependent manner with an IC₅₀ value of 410.5 µg/mL. Fourier transform infrared spectroscopy (FT-IR) and Gas chromatography–mass spectrometry (GC-MS) analyses indicated the presence of distinct functional groups and bioactive components in the extract, respectively. In conclusion, S. cangkringensis strain TSAS 04 showed its effectiveness as ideal bioactive agent by exhibiting substantial antimicrobial, antioxidant, and anticancer properties.

Risk factors for candidaemia: A prospective multi-centre case-control study

OBJECTIVES

Candidaemia carries a mortality of up to 40% and may be related to increasing complexity of medical care. Here, we determined risk factors for the development of candidaemia.

METHODS

We conducted a prospective, multi-centre, case-control study over 12 months. Cases were aged ≥18 years with at least one blood culture positive for Candida spp. Each case was matched with two controls, by age within 10 years, admission within 6 months, admitting unit, and admission duration at least as long as the time between admission and onset of candidaemia.

RESULTS

A total of 118 incident cases and 236 matched controls were compared. By multivariate analysis, risk factors for candidaemia included neutropenia, solid organ transplant, significant liver, respiratory or cardiovascular disease, recent gastrointestinal, biliary or urological surgery, central venous access device, intravenous drug use, urinary catheter and carbapenem receipt.

CONCLUSIONS

Risk factors for candidaemia derive from the infection source, carbapenem use, host immune function and organ-based co-morbidities. Preventive strategies should target iatrogenic disruption of mucocutaneous barriers and intravenous drug use.

Survival Strategies of Pathogenic Candida Species in Human Blood Show Independent and Specific Adaptations

To ensure their survival, pathogens have to adapt immediately to new environments in their hosts, for example, during the transition from the gut to the bloodstream. Here, we investigated the basis of this adaptation in a group of fungal species which are among the most common causes of hospital-acquired infections, the Candida species. On the basis of a human whole-blood infection model, we studied which genes and processes are active over the course of an infection in both the host and four different Candida pathogens. Remarkably, we found that, while the human host response during the early phase of infection is predominantly uniform, the pathogens pursue largely individual strategies and each one regulates genes involved in largely disparate processes in the blood. Our results reveal that C. albicans, C. glabrata, C. parapsilosis, and C. tropicalis all have developed individual strategies for survival in the host. This indicates that their pathogenicity in humans has evolved several times independently and that genes which are central for survival in the host for one species may be irrelevant in another.

Only four species, Candida albicans, C. glabrata, C. parapsilosis, and C. tropicalis, together account for about 90% of all Candida bloodstream infections and are among the most common causes of invasive fungal infections of humans. However, virulence potential varies among these species, and the phylogenetic tree reveals that their pathogenicity may have emerged several times independently during evolution. We therefore tested these four species in a human whole-blood infection model to determine, via comprehensive dual-species RNA-sequencing analyses, which fungal infection strategies are conserved and which are recent evolutionary developments. The ex vivo infection progressed from initial immune cell interactions to nearly complete killing of all fungal cells. During the course of infection, we characterized important parameters of pathogen-host interactions, such as fungal survival, types of interacting immune cells, and cytokine release. On the transcriptional level, we obtained a predominantly uniform and species-independent human response governed by a strong upregulation of proinflammatory processes, which was downregulated at later time points after most of the fungal cells were killed. In stark contrast, we observed that the different fungal species pursued predominantly individual strategies and showed significantly different global transcriptome patterns. Among other findings, our functional analyses revealed that the fungal species relied on different metabolic pathways and virulence factors to survive the host-imposed stress. These data show that adaptation of Candida species as a response to the host is not a phylogenetic trait, but rather has likely evolved independently as a prerequisite to cause human infections.

Molecular Methods for the Diagnosis of Invasive Candidiasis

Invasive infections caused by members of the genus Candida are on the rise. Especially patients in intensive care units, immunocompromised patients, and those recovering from abdominal surgery are at risk for the development of candidemia or deep-seated candidiasis. Rapid initiation of appropriate antifungal therapy can increase survival rates significantly. In the past, most of these infections were caused by C. albicans, a species that typically is very susceptible to antifungals. However, in recent years a shift towards infections caused by non-albicans species displaying various susceptibly patterns has been observed and the prompt diagnosis of the underlying species has become an essential factor determining the therapeutic outcome. The gold standard for diagnosing invasive candidiasis is blood culture, even though its sensitivity is low and the time required for species identification usually exceeds 48 h. To overcome these issues, blood culture can be combined with other methods, and a large number of tests have been developed for this purpose. The aim of this review was to give an overview on strengths and limitations of currently available molecular methods for the diagnosis of invasive candidiasis.

The prevalence and clinical significance of microcolonies when tested according to contemporary interpretive breakpoints for fluconazole against Candida species using E-test

Changes in the interpretive-breakpoints for antifungals against various Candida species have raised the need to examine the significance of the phenomenon of the growth of microcolonies in agar diffusion inhibition zones, which has generally been considered negligible. The objective was to determine the incidence of cases in which microcolonies demonstrate fluconazole resistance according to current interpretive-breakpoints and whether their growth is associated with therapeutic failure. The fluconazole minimum inhibitory concentrations (MICs) of 100 blood culture isolates of Candida were performed by E-test on Roswell Park Memorial Institute (RPMI) agar and examined for the appearance of microcolonies. Fluconazole MICs of microcolonies were then determined over three generations. The significance of the phenomenon of microcolonies was determined according to clinical data retrieved from electronic files. Microcolonies were a common phenomenon among Candida isolates following incubation on RPMI agar, with a higher frequency among C. albicans isolates as compared to non-albicans Candida across generations (57-93% vs 31-93%, respectively) and a similar fluconazole susceptibility rate over three generations. The rate of microcolonies was similar in both patients with successful and unsuccessful outcome (41% vs 42%, respectively). Microcolonies are a common phenomenon. No increase in MIC was demonstrated throughout three generations of microcolony inoculation on RPMI, and no difference in clinical outcome was observed.

Efficacy of Chelerythrine Against Mono- and Dual-Species Biofilms of Candida albicans and Staphylococcus aureus and Its Properties of Inducing Hypha-to-Yeast Transition of C. albicans

Candida albicans and Staphylococcus aureus specifically often resulted in biofilm-associated diseases, ranging from superficial mucosal to life-threatening systemic infections. Recent studies reported that chelerythrine displayed antimicrobial activities against a few microorganisms, but its effects on mono- and dual-species biofilms of C. albicans and S. aureus have never been reported. The purpose of this study was to evaluate the efficacy of chelerythrine against mono- and dual-species biofilms, and explore its effect on the hyphal growth and the hypha-to-yeast transition of C. albicans. The results showed that minimum inhibitory concentrations (MICs) and minimum biofilm inhibitory concentration (MBIC_90S) of chelerythrine against planktonic cells of mono-species were 4 and 2 μg/mL, while the MIC and MBIC₉₀ were 6 and 3 μg/mL for dual-species. Meanwhile, the decrease in three matrix component levels and tolerance to antibiotics of biofilms formed by mono- and dual-species exposed to chelerythrine were confirmed by a confocal laser scanning microscope, in conjugation with five fluorescent dyes and a gatifloxacin diffusion assay. Moreover, C. albicans and S. aureus mono-species showed a 96.4, and 92.3% reduction, respectively, in 24-h preformed biofilm biomass in the presence of 128 µg/mL of chelerythrine. Similarly, preformed (24 h) dual-species biofilm biomass also displayed a significant reduction (90.7%) when treated with 192 μg/mL chelerythrine. Chelerythrine inhibited hyphae formation of C. albicans at 4 μg/mL, and C. albicans in hypha-form can be converted into yeast-form at 8 μg/mL of chelerythrine. Therefore, chelerythrine shows promise as a potential antimicrobial and antibiofilm agent for clinical effective treatments of mono- and mixed-species and/or biofilm-associated infections.

Health care-associated invasive Candida infections in children

The aims of the study were to examine the distribution of Candida spp. isolated from sterile body sites, the antifungal susceptibility of the isolates to amphotericin B, and fluconazole, risk factors and clinical outcomes associated with invasive health care-associated Candida infections in neonates and children. Between January 2007 and January 2012, the patients with invasive candidiasis were detected from microbiology laboratary records and medical records were examined retrospectively. Candida spp. were isolated from sterile body sites in 94 patients. The most common underlying diseases were prematurity in neonates and surgery in children. Parenteral nutrition, stay in intensive care unit (ICU), and mechanical ventilation (MV) were major risk factors in neonates. Hospitalization before infection and immunosuppressant therapy were significantly more frequent in children. Of Candida infection episodes, 29.8% was due to C. albicans and 70.2% was due to non-albicans Candida spp. The most common isolated species was C. parapsilosis. Of the Candida species, 90.8% were sensitive, and 9.2% were resistant to fluconazole. The rate of amphotericin B resistant was 1.3%; 23.4% of the patients died in the first 30 days. The main variables associated with mortality were neonates, prematurity, stay in the ICU, parenteral nutrition, MV, length of stay, amphotericin B susceptibility, and high levels of C-reactive protein.

To study the profile of Candida isolates and antifungal susceptibility pattern of neonatal sepsis in a tertiary care hospital of North India

AIMS AND OBJECTIVE

To study the profile of Candida infection and antifungal susceptibility (AFS) pattern in neonatal sepsis.

MATERIALS AND METHODS

In this prospective observational study, 850 blood samples were collected and processed from neonates who were suspected clinically to have sepsis. The blood culture that showed growth of Candida was further processed for species identification. Antifungal susceptibility was done as per the National Committee for Clinical Laboratory Standards (NCCLS)/Clinical Laboratory Standards Institute (CLSI) M44-A-2 guidelines by disc diffusion method and automated vitek-2 compact system. Candidemia was diagnosed by isolation of Candida species from at least one positive blood culture containing pure growth of Candida species with supportive clinical features.

RESULTS

Candida species were isolated in 32 specimens of the total 322 culture-positive cases. The most common isolate was Candida tropicalis (14/32; 43.75%) followed by Candida albicans (7/32; 21.87%) and Candida glabrata (6/32; 18.75%). The three most common neonatal risk factors for candidemia were low birth weight, prolonged use of intravenous antibiotics and presence of central venous line. Non-albicans Candida (NAC) showed good sensitivity to fluconazole as compared to Candida albicans. The fluconazole sensitivity of Candida tropicalis, Candida glabrata, and Candida parapsilosis was 93, 67, and 100%, respectively, whereas it was 57% in Candida albicans. The sensitivity to amphotericin B was 95% among all Candida isolates. All NAC were sensitive to amphotericin B, while only 72% Candida albicans were sensitive to amphotericin B.

CONCLUSIONS

The incidence of neonatal sepsis secondary to NAC is increasing and has replaced Candida albicans as a major cause of neonatal fungal sepsis. Low birth weight is the most important risk factor for Candida sepsis. The resistance of Candida albicans is increasing for both fluconazole and amphotericin B when compared to NAC. Increasing antifungal resistance warrants its judicious use both for prophylaxis and treatment.

Twenty Years of the SENTRY Antifungal Surveillance Program: Results for Candida Species From 1997-2016

Background

The emergence of antifungal resistance threatens effective treatment of invasive fungal infection (IFI). Invasive candidiasis is the most common health care–associated IFI. We evaluated the activity of fluconazole (FLU) against 20 788 invasive isolates of Candida (37 species) collected from 135 medical centers in 39 countries (1997–2016). The activity of anidulafungin, caspofungin, and micafungin (MCF) was evaluated against 15 308 isolates worldwide (2006–2016).

Methods

Species identification was accomplished using phenotypic (1997–2001), genotypic, and proteomic methods (2006–2016). All isolates were tested using reference methods and clinical breakpoints published in the Clinical and Laboratory Standards Institute documents.

Results

A decrease in the isolation of Candida albicans and an increase in the isolation of Candida glabrata and Candida parapsilosis were observed over time. Candida glabrata was the most common non–C. albicans species detected in all geographic regions except for Latin America, where C. parapsilosis and Candida tropicalis were more common. Six Candida auris isolates were detected: 1 each in 2009, 2013, 2014, and 2015 and 2 in 2016; all were from nosocomial bloodstream infections and were FLU-resistant (R). The highest rates of FLU-R isolates were seen in C. glabrata from North America (NA; 10.6%) and in C. tropicalis from the Asia-Pacific region (9.2%). A steady increase in isolation of C. glabrata and resistance to FLU was detected over 20 years in the United States. Echinocandin-R (EC-R) ranged from 3.5% for C. glabrata to 0.1% for C. albicans and C. parapsilosis. Resistance to MCF was highest among C. glabrata (2.8%) and C. tropicalis (1.3%) from NA. Mutations on FKS hot spot (HS) regions were detected among 70 EC-R isolates (51/70 were C. glabrata). Most isolates harboring FKS HS mutations were resistant to 2 or more ECs.

Conclusions

EC-R and FLU-R remain uncommon among contemporary Candida isolates; however, a slow and steady emergence of resistance to both antifungal classes was observed in C. glabrata and C. tropicalis isolates.

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

Context

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

Aims

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

Materials and methods

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

Results

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

Conclusion

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

How to cite this article

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

First case reports of bloodstream infection by Candida magnoliae in two neonates with low birth weight

Invasive candidiasis is a serious neonatal sepsis with high morbidity and mortality despite the correct treatment. Candida albicans and Candida parapsilosis are the most common pathogens causing these events; however, a new emergent pathogen has evolved with time. Herein, we describe two cases of Candida magnoliae infection in neonates with a fatal outcome. This microorganism is commonly used in the food industry given its high capacity to produce erythritol and mannitol. This report is important to gain more information about this pathogen and manage it in a more effective way.

Invasive Candidiasis in the Elderly: Considerations for Drug Therapy

Candida infections in the elderly are an important and expanding clinical problem, with significantly higher mortality in this group than in younger patients. The increasing problem of invasive Candida infections may be related to higher prevalence of immunocompromised older people and the emergence of treatment resistance. Older people, especially the frail and critically ill, are at higher risk of medication-related harmful effects due to changes in pharmacokinetics and pharmacodynamics, which may be further complicated by organ dysfunction, diminished homeostatic control, co-morbidities and polypharmacy. Here, we review the available options for the treatment of Candida infections and provide insights into the challenges surrounding the optimal use of antifungal drugs in the elderly.

Prevalence of, and risk factors for, hematogenous fungal endophthalmitis in patients with Candida bloodstream infection

PURPOSE

Endogenous fungal endophthalmitis (EFE) is a severe consequence of candidemia. The prevalence of, and risk factors for, EFE is not well studied.

METHODS

We retrospectively collected cases of patients with candidemia who had undergone ophthalmological examination between April 2011 and March 2016 in five regional hospitals. We conducted bivariate and multivariate analyses using patients' age, gender, causative Candida species, diabetes status, corticosteroid use, cancer status, neutropenia, intensive care unit admission, presence of central venous catheter (CVC), presence of shock, prior antibiotic use, 30-day mortality, and highest Sequential Organ Failure Assessment (SOFA) score. Data on sustained positive blood culture, β-D glucan, CVC removal, empirical antifungal drug used, and time to appropriate antifungal therapy were also collected if available.

RESULTS

Of 174 patients with candidemia, 35 (20.1%) were diagnosed with EFE, including 31 (17.8%) with chorioretinitis and 4 (2.3%) with vitritis. Bivariate analysis (EFE group vs. non-EFE group) found that Candida albicans candidemia (77.1 vs. 34.5%, P < 0.001), neutropenia (14.3 vs. 5.8%, P = 0.141), CVC placement (94.3 vs. 71.2%, P = 0.004), and the presence of shock (28.6 vs. 16.5%, P = 0.145) were each higher in the EFE group. Multivariate logistic regression analysis found C. albicans candidemia (adjusted odds ratio 6.48; [95% CI 2.63-15.95]) and CVC placement (7.55 [1.56-36.53]) to be significant risk factors for EFE.

CONCLUSIONS

Candida albicans is the most common causative agent for Candida EFE. Patients with candidemia and CVC placement should be closely monitored by ophthalmologists.

Biological Roles of Protein-Coding Tandem Repeats in the Yeast Candida Albicans

Tandem repeat (TR) DNA mutates faster than other DNA by insertion and deletion of repeats. Large parts of eukaryotic proteomes are encoded by ORFs containing protein-coding TRs (TR-ORFs, pcTRs) with largely unknown biological consequences. We explored these in the yeast Candida albicans, an opportunistic human pathogen. We found that almost half of C. albicans’ proteins are encoded by TR-ORFs. pcTR frequency differed only moderately between different gene (GO) categories. Bioinformatic predictions of genome-wide mutation rates and clade-specific differences in pcTR allele frequencies indicated that pcTRs (i) significantly increase the genome-wide mutation rate; (ii) significantly impact on fitness and (iii) allow the evolution of selectively advantageous clade-specific protein variants. Synonymous mutations reduced the repetitiveness of many amino acid repeat-encoding pcTRs. A survey, in 58 strains, revealed that in some pcTR regions in which repetitiveness was not significantly diminished by synonymous mutations the habitat predicted which alleles were present, suggesting roles of pcTR mutation in short-term adaptation and pathogenesis. In C. albicans pcTR mutation apparently is an important mechanism for mutational advance and possibly also rapid adaptation, with synonymous mutations providing a mechanism for adjusting mutation rates of individual pcTRs. Analyses of Arabidopsis and human pcTRs showed that the latter also occurs in other eukaryotes.

Vulvovaginal candidiasis: species distribution of Candida and their antifungal susceptibility pattern

BACKGROUND

Vulvovaginal candidiasis is a global issue of concern due to its association with economic costs, sexually transmitted infections, and ascending genital tract infection. The aim of this study was to determine species distribution and antifungal susceptibility pattern of Candida species causing vulvovaginal candidiasis.

METHODS

A cross sectional study was conducted from November 2015 to December 2016 at the Family Guidance Association of Ethiopia. Vaginal swabs collected from study subjects that were clinically diagnosed with vulvovaginal candidiasis were cultured. Yeast identification and antifungal susceptibility testing were determined by the automated VITEK 2 compact system. The association of vulvovaginal candidiasis with possible risk factors was assessed and analyzed using SPSS version 20.

RESULTS

The overall prevalence of vulvovaginal candidiasis was 41.4%. The association of vulvovaginal candidiasis was statistically significant with previous genital tract infection (p = 0.004), number of life-time male sex partners (p = .037), and number of male sex partners in 12 month (p = 0.001). Of 87 Candida isolates recovered, 58.6% were C. albicans while 41.4% were non-albicans Candida species. The highest overall drug resistance rate of Candida species was observed against fluconazole (17.2%), followed by flycytosine (5.7%). All Candida isolates were 100% susceptible to voriconazole, caspofungin, and micafungin. C. albicans, was 100% susceptible to all drugs tested except fluconazole and flycytosine with a resistance rate of 2% each drug. C. krusei, was 100 and 33.3% resistant to fluconazole and flycytosine, respectively.

CONCLUSIONS

High prevalence rate of vulvovaginal candidiasis and observation of high prevalence rate of non-albicans Candida species in the present study substantiate, the importance of conducting continuous epidemiological surveys to measure changes in species distribution from C. albicans to non-albicans Candida species in Ethiopia. Although, fluconazole still appeared to be active against all isolates of C. albicans and non-albicans Candida species high resistance rate of C. krusei against the drug may demonstrate a search for alternative antifungal drugs when treating vulvovaginal candidiasis caused by C. krusei.

Cost-effectiveness of de-escalation from micafungin versus escalation from fluconazole for invasive candidiasis in China

AIMS

Guidelines on treating invasive candidiasis recommend initial treatment with a broad-spectrum echinocandin (e.g. micafungin), then switching to fluconazole if isolates prove sensitive (de-escalation strategy). This study aimed to evaluate the cost-effectiveness of de-escalation from micafungin vs escalation from fluconazole from a Chinese public payers perspective.

MATERIALS AND METHODS

Cost-effectiveness was estimated using a decision analytic model, in which patients begin treatment with fluconazole 400 mg/day (escalation) or micafungin 100 mg/day (de-escalation). From Day 3, when susceptibility results are available, patients are treated with either fluconazole (if isolates are fluconazole-sensitive/dose-dependent) or micafungin (if isolates are resistant). The total duration of (appropriate) treatment is 14 days. Model inputs are early (Day 3) and end-of-treatment mortality rates, treatment success rates, and health resource utilization. Model outputs are costs of health resource utilization over 42 days, incremental cost per life-year, and incremental cost per quality-adjusted life-year (QALY) over a lifetime horizon.

RESULTS

In the base-case analysis, the de-escalation strategy was associated with longer survival and higher treatment success rates compared with escalation, at a lower overall cost (-¥1,154; -175 United States Dollars). Life-years and QALYs were also better with de-escalation. Thus, this strategy dominated the escalation strategy for all outcomes. In a probabilistic sensitivity analysis, 99% of 10,000 simulations were below the very cost-effective threshold (1 × gross domestic product).

LIMITATIONS

The main limitation of the study was the lack of real-world input data for clinical outcomes on treatment with micafungin in China; data from other countries were included in the model.

CONCLUSION

A de-escalation strategy is cost-saving from the Chinese public health payer perspective compared with escalation. It improves outcomes and reduces costs to the health system by reducing hospitalization, due to an increase in the proportion of patients receiving appropriate treatment.

Gene editing in clinical isolates of Candida parapsilosis using CRISPR/Cas9

Candida parapsilosis is one of the most common causes of candidiasis, particularly in the very young and the very old. Studies of gene function are limited by the lack of a sexual cycle, the diploid genome, and a paucity of molecular tools. We describe here the development of a plasmid-based CRISPR-Cas9 system for gene editing in C. parapsilosis. A major advantage of the system is that it can be used in any genetic background, which we showed by editing genes in 20 different isolates. Gene editing is carried out in a single transformation step. The CAS9 gene is expressed only when the plasmid is present, and it can be removed easily from transformed strains. There is theoretically no limit to the number of genes that can be edited in any strain. Gene editing is increased by homology-directed repair in the presence of a repair template. Editing by non-homologous end joining (NHEJ) also occurs in some genetic backgrounds. Finally, we used the system to introduce unique tags at edited sites.

Candidemia in the elderly: What does it change?

BACKGROUND

Candidemia is a life-threatening fungal infection and it can affect patients of all ages. Characterization of candidemia in the elderly is lacking.

METHODS

We performed a retrospective study of adults (≥ 18 years) with candidemia diagnosed in our center in 2010-2015. Demographics, comorbidities, clinical and microbiologic characteristics, antifungal treatment and outcome were compared between older (≤65 years) and younger (>65 years) patients.

RESULTS

Among 302 patients with candidemia identified during the study period, 188 (62%) belonged to the elderly group. Comorbidities were significantly more frequent in older patients and included chronic pulmonary diseases, cardiovascular diseases, diabetes mellitus, and chronic renal failure (p ranging from <0.0001 to 0.017). A significantly higher proportion of older patients had septic shock (p = 0.040) at the time of candidemia. Candida albicans accounted for 53% of isolates and there were no significant differences between patients' age and Candida species. Thirty-day mortality was significantly higher in older (45%) than in younger (28%) patients (p = 0.003). Factors associated with a significant higher proportion of death in the elderly included older age (i.e.: old-old), being hospitalized in ICU rather than in other wards, suffering from chronic pulmonary diseases, the presence of septic shock, multiple organ failure, dialysis and being infected with C. glabrata (p ranging from <0.0001 to 0.034). On multivariate analysis septic shock (HR 1.744 [CI95% 1.049-2.898], p = 0.032) and multiple organ failure (HR 2.242 [CI95% 1.070-4.698], p = 0.032) were independently associated with a higher risk of death. The probability of 30-days survival of older patients was significantly reduced when compared to that of younger patients (p = 0.005) who did not receive any treatment. In the elderly, there was a trend toward higher MICs for fluconazole/C. albicans, fluconazole/C. glabrata, amphotericin B/C. albicans, and caspofungin/C. glabrata.

CONCLUSIONS

In our study, we found that elderly patients with Candida bloodstream infections are characterized by a high mortality rate. In particular, the lack of any antifungal therapy as well as the occurrence of septic shock increased significantly the overall mortality. Additionally, we found that there was a trend of higher MIC for specific drug/Candida combination.

Antifungal Susceptibility and Risk Factors in Patients with Candidemia

OBJECTIVE

This study aimed to investigate the antifungal susceptibility, typology, and risk factors of candidemia among adult and pediatric inpatients at a university hospital.

MATERIALS AND METHODS

A case-control study was designed, and data collected between December 2013 and December 2014 were retrospectively evaluated. The case group consisted of patients with candidemia. The control group was selected from the inpatients that did not develop candidemia but were admitted in the same clinic and during the same period as the candidemia group. The diagnosis of candidemia was based on a compatible clinical picture and positive blood culture of Candida spp. The demographic characteristics, sequential organ failure assessment (SOFA) scores, comorbidities, use of invasive devices, antibiotics administered, and duration of antibiotic uses were compared between both the groups.

RESULTS

Out of the 84 patients, 42 (50%) were included in the case group, and the remaining 42 (50%) were included in the control group. Out of all the patients, 31 (36.9%) were female, and 53 (63.1%) were male. When the clinical findings of the case and control groups were compared, the prevalence of nosocomial infections, sepsis, candiduria, and fever was statistically significantly higher in the case group. Among the isolated group in the study, 22 (52.4%) were identified as C. albicans, while the others were non-albicans Candida strains. The C. albicans strain (4.5%) was resistant to fluconazole, while 7 among the non-albicans Candida strains (35%) were resistant to fluconazole. In the case group, abdominal surgery, CVP catheter presence, TPN, endotracheal intubation, frequency of blood transfusion, and SOFA scores were significantly higher than the control groups. The logistic regression test demonstrated that TPN and blood transfusion are the most important risk factors for candidemia (OR=8.14 and OR=5.96, respectively).

CONCLUSION

The invasive Candida infections continue to be a major health problem in Turkey and in our hospital. Particularly, it was observed that it is important to perform invasive procedures, antibiotic administration and parenteral nutrition carefully in patients hospitalized in the ICU.

Epidemiology, Risk Factors, and Outcomes of Candida albicans Versus Non-albicans Candidemia in Nonneutropenic Patients

Background:

Candidemia is a major cause of morbidity and mortality in hospitalized patients.

Objectives:

To describe the epidemiology of and risk factors for non-albicans candidemia (NAC) in nonneutropenic adults and the impact of NAC on patient outcomes and treatment cost.

Methods:

We conducted a retrospective cohort analysis comparing demographics and risk factors for Candida albicans candidemia (CAC) versus NAC in 144 nonneutropenic patients with candidemia over a 6 year period (1997–2002) at Detroit Receiving Hospital.

Results:

Candida species distribution included albicans (50%), parapsilosis (13%), tropicalis (10%), and glabrata (13%). Predominant species varied by patient care unit, with C. glabrata more common in the medical intensive care unit (ICU) and C. parapsilosis in the burn ICU. In multivariate analysis, NAC was associated with the absence of antibiotic use at the onset of candidemia, recent history of solid tumor, and male sex, NAC was not associated with an increase in mortality or length of stay compared with CAC, but was found to have a higher cost of antifungal therapy ($2030 vs $780; p = 0.05).

Conclusions:

The epidemiology of candidemia is complex and varies among the different patient care units. Specifically, patients appear less likely to develop NAC if they are receiving antibiotics at the onset of candidemia. Increased awareness of risk factors for NAC can be used to guide adequate initial antifungal therapy.

Sequence-identification of Candida species isolated from candidemia

Background:

Candida species are the most prevalent cause of invasive fungal infections such as candidemia. Candidemia is a lethal fungal infection among immunocompromised patients worldwide. Main pathogen is Candida albicans but a global shift in epidemiology toward non-albicans species have reported. Species identification is imperative for good management of candidemia as a fatal infection. The aim of the study is to identify Candida spp. obtained from candidemia and determination of mortality rate among this population.

Materials and Methods:

The study was performed during February 2014 to March 2015 in Tehran, Iran. Two-hundred and four blood cultures were evaluated for fungal bloodstream infection. Identification of isolates was carried out using phenotypic tests and polymerase chain reaction sequencing technique.

Results:

Twenty-two out of 204 patients (10.8%) had candidemia. Candida parapsilosis was the most prevalent species (45.4%), followed by C. albicans (31.8%) and Candida glabrata (22.7%). Male to female sex ratio was 8/14.

Conclusions:

The emergence of resistant strains of Candida species should be considered by physicians to decrease the mortality of this fatal fungal infection by appropriate treatment.

Epidemiology of Methicillin-ResistantStaphylococcus aureusand Vancomycin-ResistantEnterococcusin a Rural State

Background.

Most data on methicillin-resistantStaphylococcus aureus(MRSA) and vancomycin-resistant Enterococcus (VRE) isolates come from large tertiary care centers. Infection control personnel need to understand the epidemiology of MRSA and VRE across the continuum of care, including small rural hospitals, to develop effective control strategies.

Objective.

To describe the epidemiology of MRSA and VRE in Iowa.

Setting.

Fifteen hospitals in Iowa.

Methods.

Between July 1998 and June 2001, a total of 1,968S. aureusisolates and 1,845Enterococcusisolates from patients infected with these pathogens were examined. Multivariate models were developed to evaluate patient and institutional risk factors for MRSA infection and VRE infection.

Results.

The proportion ofS. aureusisolates resistant to methicillin was 31%, and the proportion ofEnterococcusisolates resistant to vancomycin was 6%. Independent risk factors for MRSA infection included residence in a long-term care facility, age of more than 60 years, hospitalization in a hospital with less than 200 short-term care beds, and acquiring the infection in the hospital. Independent risk factors for VRE infection included use of a central venous catheter, residence in a long-term care facility, acquisition of infection in the hospital, and hospitalization in a hospital with more than 200 short-term care beds.

Conclusions.

In Iowa, the epidemiology of MRSA differ from those of VRE. MRSA has become established in small rural hospitals. Effective MRSA control strategies may require inclusion of all hospitals in a state or region.

Excess Mortality, Hospital Stay, and Cost Due to Candidemia: A Case-Control Study Using Data From Population-Based Candidemia Surveillance

Objective:

To determine the mortality, hospital stay, and total hospital charges and cost of hospitalization attributable to candidemia by comparing patients with candidemia with control-patients who have otherwise similar illnesses. Prior studies lack broad patient and hospital representation or cost-related information that accurately reflects current medical practices.

Design:

Our case-control study included case-patients with candidemia and their cost-related data, ascertained from laboratory-based candidemia surveillance conducted among all residents of Connecticut and Baltimore and Baltimore County, Maryland, during 1998 to 2000. Control-patients were matched on age, hospital type, admission year, discharge diagnoses, and duration of hospitalization prior to candidemia onset.

Results:

We identified 214 and 529 sets of matched case-patients and control-patients from the two locations, respectively. Mortality attributable to candidemia ranged between 19% and 24%. On multivariable analysis, candidemia was associated with mortality (OR, 5.3 for Connecticut and 8.5 for Baltimore and Baltimore County;P< .05), whereas receiving adequate treatment was protective (OR, 0.5 and 0.4 for the two locations, respectively;P< .05). Candidemia itself did not increase the total hospital charges and cost of hospitalization; when treatment status was accounted for, having received adequate treatment for candidemia significantly increased the total hospital charges and cost of hospitalization ($6,000 to $29,000 and $3,000 to $22,000, respectively) and the length of stay (3 to 13 days).

Conclusion:

Our findings underscore the burden of candidemia, particularly regarding the risk of death, length of hospitalization, and cost associated with treatment (Infect Control Hosp Epidemiol2005;26:540-547).

Ethnicity and Other Possible Risk Factors for Candidemia at 3 Tertiary Care University Hospitals in Hawaii

A total of 108 cases of candidemia detected in 3 tertiary care university hospitals in Hawaii between January 2001 and December 2002 were retrospectively reviewed. Candida albicans, Candida glabrata, and Candida tropicalis accounted for 28% of the cases. Mortality among Filipino patients was significantly higher than that among other ethnic groups (71% vs 48%; P<.05).

Invasive candidiasis in intensive care units in China: Risk factors and prognoses of Candida albicans and non-albicans Candida infections

BACKGROUND

To investigate the risk factors and prognoses of patients with invasive Candida albicans and non-albicans Candida (NAC) infection in intensive care units (ICUs) in China.

METHODS

Between November 2009 and April 2011, we performed a prospective study of critically ill patients with invasive Candida infection from 67 ICUs across China to compare the risk factors and mortality between patients with C albicans and NAC infection.

RESULTS

There were 306 patients with proven invasive Candida; 244 cases (a total 389 Candida isolates) were sent to laboratory for strain identification (C albicans, 40.1%; NAC, 59.9%). More patients admitted for surgery or trauma had NAC infection than C albicans infection. C albicans infection was more common in patients with subclavian vein catheters or peritoneal drainage tubes. Compared with patients with C albicans infection, patients with NAC infection had longer antifungal therapy (P < .001), longer ICU (P = .004) or hospital stay (P = .002), and slightly higher mortality (38.4% vs 29.6%), but the difference was not significant (P = .17).

CONCLUSIONS

C albicans remains the most common pathogen in candidiasis in critical care patients. However, the number of NAC infections exceeded C albicans infections. Compared with patients with C albicans infection, patients with NAC infection had heavier disease burdens.

Antifungal drug resistance among Candida species: mechanisms and clinical impact

The epidemiology of Candida infections has changed in recent years. Although Candida albicans is still the main cause of invasive candidiasis in most clinical settings, a substantial proportion of patients is now infected with non-albicans Candida species. The various Candida species vary in their susceptibility to the most commonly used antifungal agents, and the intrinsic resistance to antifungal therapy seen in some species, along with the development of acquired resistance during treatment in others, is becoming a major problem in the management of Candida infection. A better understanding of the mechanisms and clinical impact of antifungal drug resistance is essential for the efficient treatment of patients with Candida infection and for improving treatment outcomes. Herein, we report resistance to the azoles and echinocandins among Candida species.