Prevalence of Candidiasis Infection & Antifungal Susceptibility Pattern at Tertiary Care Hospital, Jaipur

Background: Candida species are among the most common fungal pathogens. They are ubiquitous yeasts found on plants and form the microbiota of the alimentary tract of mammals and the mucocutaneous membranes in humans. Methods: A total of 90 clinical samples were collected from Mahatma Gandhi Medical College & Hospital, Jaipur over a period of one year. Primary identification is done by the direct smear examination by Gram’s staining and KOH mount and then further sub-cultured on SDA media. Results: Out of 90 clinical specimens collected, most common form of Candidiasis seen was Candiduria type followed by blood cultures, swab, Endotracheal tube, sputum and Bronchialveolar lavage. The maximum number of patients were found in the age group of 21-30 years, followed by 51-60 years. Out of 90 patients, 48 (53.3%) were males and 42 (46.6%) were females. C. tropicalis (44.4%) was the predominant species followed by C. albicans and other species of Candida. Original Research Article Sharma et al.; JPRI, 32(28): 8-13, 2020; Article no.JPRI.61957 9 Among 90 samples, 32% were Candida albicans and remaining 68% were Non albicans Candida species. Conclusion: The study found that C. tropicalis was sensitive against Micafungin & Caspofungin, showing a 100% sensitivity. Candida albicans showed 100% sensitivity against Flucytosine.


INTRODUCTION
In the last few years, the incidence of mycotic infections has progressively increased [1]. During the last three decades Candidiasis has become the most commonly diagnosed yeast-related infection worldwide. Candida species are members of the microbiota under specific circumstances they have the ability to turn themselves into pathogenic fungi causing superficial, cutaneous or systemic infections. In most cases Candida species are responsible for nosocomial infections. The major risk factors for opportunistic fungal infections are the prolonged hospitalization, the extended use of antibiotics, use of intravenous catheters and the low birth weight in case of premature neonates [2].
Candidiasis is a fungal infection due to any type of Candida species. The most common species implicated was C. albicans recently, while the incidence of non-albicans Candida species (NAC) has risen dramatically [3]. In recent decades, several countries around the world have witnessed a change in the epidemiology of Candida infections, characterized by a progressive shift from a predominance of C. albicans to NAC species [4]. New antifungal agents with low toxicity and broad-spectrum fungicidal activities are needed for effective management of the infections.

Collection of Specimens
A total of 90 clinically suspected cases of Candidiasis patients attending the various departments of MGMC&H, Jaipur for a period of one year were included in this study. Various types of clinical specimens such as Blood, urine, Sputum, Oral swabs, stool, high vaginal swab, catheter tips, pus wound swabs, central line tips, endotracheal tube tips, Sterile body fluids, bronchioalveolar lavage, CSF were collected from OPD, ICU's and other wards of MGMC&H, Jaipur. The clinical samples collected were transported to microbiology lab as soon as possible.

Antifungal Susceptibility Testing
Antifungal susceptibility testing of antifungal drugs was done by VITEK-2.

DISCUSSION
In this study, we have shown the potential clinical importance of species level identification as Candida species and its antifungal susceptibility. The most common clinical sample was urine in 48 (53.3%) patients. Our observations were similar with the studies of Deorukhkar et al. [6] where urine samples were in majority (34.6%). Studies which were done earlier by Pfaller et al [7], who reported Candida species as the seventh most common nosocomial pathogen and as that which caused 25% of all urinary tract infections. In this study out of total 90 cases from various clinical isolates, 48 patients (53.3) were males and 42 were female patients (46.6%) and maximum number of patients was reported in the age group of 21-30 years of age. The present study coincides with the [8] reported the male predominance in his study with Candida infections more common in the age groups of 51-60 years. The present study coincides with the [9] who reported the most common isolated species was Candida tropicalis (44.4%) followed by Candida albicans (32.2%). The present study is in agreement with the study of [10] who also found C.tropicalis to be the most frequent isolate from various specimen. Mohamed et al. [11] who also found C.tropicalis was the most common (28.9%) followed by C. albicans (26.2%) and other species of Candida. In the present study Non-albicans Candida were isolated at a higher rate (58%) than Candida albicans (42%) which in agreement with the findings of the studies by Mokaddas et al. [12] which also showed the Non albicans Candida incidence (60.5%) to be higher than that of Candida albicans (39.5). The similar findings also matched with the study by [13] where Non Candida albicans species were 64.2% and C.albicans was 36%.
Antifungal resistance among Candida is useful because apart from tracking and detection of resistance, it also gives clues to emerging threats of new resistance strains. This helps in assessing empirical treatment recommendation. Among these, most prevalent species was Candida tropicalis (44.4%). Out of 40 cases of C.tropicalis, 5% showed resistance against fluconazole, 1 showed foriconazole resistance, 2.5% showed resistance against amphotericin-B and 2.5% showed Flucytosine resistance. These results coincides with the [14] who found in this study that fluconazole was the most resistant antifungal drug against Candida isolates. Similar findings were in agreement with [15] who also reported Fluconazole resistance among the hospitalized patients.
C. tropicalis was found to be 100% sensitive against Micafungin and Caspofungin. Similar results from [11] who also reported 100% micafungin sensitivity and caspofungin sensitivity against C.tropicalis. Therefore, we can consider that the best antifungal drugs could be micafungin & caspofungin.

CONCLUSION
In this study, C. tropicalis was found to be the predominant Candida species from various specimen followed by C.albicans. Finally, this study concludes that C.tropicalis was found to be 100% sensitive against Micafungin and Caspofungin. Flucytosine showed 100% sensitivity against Candida albicans. Therefore, this study suggests that we can consider that the best antifungal drugs could be micafungin & caspofungin for the treatment of Candidiasis infection.

CONSENT AND ETHICAL APPROVAL
As per university standard guideline, participant consent and ethical approval have been collected and preserved by the authors