|Year : 2015 | Volume
| Issue : 2 | Page : 247-251
Species distribution and antifungal susceptibility pattern of Candida causing oral candidiasis among hospitalized patients
Faseela Taivalap Shafi, Sunil Rao Padmaraj, Najla Pattanath Mullessery
Department of Microbiology, Yenepoya Medical College, Mangalore, Karnataka, India
|Date of Web Publication||16-Dec-2015|
Faseela Taivalap Shafi
Department of Microbiology, Yenepoya Medical College, Derlakatte, Mangalore - 575 018, Karnataka
Source of Support: None, Conflict of Interest: None
Background: Oral candidiasis is increasingly seen among hospitalized patients and is usually treated empirically. It can be the marker of systemic infection. Antifingal resistance is one of the emerging problems in candidiasis. Aim and Objectives: To study the distribution pattern of various Candida species among hospitalised patients with oral candidiasis, to detect the antifungal resistance among Candida and to assess the possible risk factors associated with those patients. Methods: Out of 300 patients screened, oral thrush material was collected from 36 patients having oral candidiasis. Candida spp. were isolated and identified. Antifungal susceptibility test was performed by disk diffusion method. Results: Candida albicans was the most frequently isolated species (64%). Highest resistance was seen with ketoconazole (18%). Except one C. tropicalis, all the isolates were sensitive to amphotericin B. All the patients were on broad spectrum antibiotic treatment. Diabetes mellitus was seen in 50 % of the patients. Other predisposing factors include tuberculosis, COPD, cancer and steroid treatment. Conclusion: Eventhough there is progressive shift from a predominance of C. albicans to non-albicans Candida species in candidiasis, C. albicans remains as the most important pathogen in oral candidiasis. Since azole resistance is increasing, accurate identification of Candida spp. and antifungal susceptibility testing is crucial for patient management and for facilitating hospital control measures.
Keywords: Antifungal susceptibility, azole, Candida, disk diffusion, oral candidiasis
|How to cite this article:|
Shafi FT, Padmaraj SR, Mullessery NP. Species distribution and antifungal susceptibility pattern of Candida causing oral candidiasis among hospitalized patients. Arch Med Health Sci 2015;3:247-51
|How to cite this URL:|
Shafi FT, Padmaraj SR, Mullessery NP. Species distribution and antifungal susceptibility pattern of Candida causing oral candidiasis among hospitalized patients. Arch Med Health Sci [serial online] 2015 [cited 2019 Jun 20];3:247-51. Available from: http://www.amhsjournal.org/text.asp?2015/3/2/247/171914
| Introduction|| |
Infections caused by Candida species are seen commonly in hospitalized patient. Oral candidiasis is one of the common types of candidiasis. Candida species lives commensally in the human oral cavity with high carriage rate (>70%). It causes opportunistic infections in immunocompromized hosts where the infection can spread through blood stream or gastrointestinal tract leading to severe infection with significant morbidity and mortality.  Among various species, C. albicans is regarded as the most prevalent one. But recently, non-albicans Candida (NAC) species are also emerging as pathogens. But there is difference in pathogenicity and antifungal susceptibility among different species. ,
The aim of this study was to identify Candida species isolated from the oral lesions of hospitalized patients, to determine their in vitro antifungal susceptibility and to investigate the possible risk factors associated with infection.
| Materials and Methods|| |
A total of 300 patients admitted in Yenepoya Medical College hospital, Mangalore, were screened for oral candidiasis. Specimens were collected only from those patients with white pseudomembrane in the oral cavity by using sterile cotton swab. Detailed history of patient including age, sex, and risk factors were collected.
The ethical clearance was taken from the Institutional Ethics Committee. Informed consent was taken from patients or patient party after explaining the purpose of collecting specimens. Specimens were inoculated into Sabouraud's dextrose agar (SDA) and HiCrome Candida agar, incubated at 37°C for 48 h. Isolates were identified by Gram's stain, cultural characteristics on HiCrome Candida agar, germ tube test, chlamydospore formation test, urease test, and sugar assimilation-fermentation tests [Figure 1]. ,,,
Antifungal susceptibility test to fluconazole (25 mg), itraconazole (10 mg), ketoconazole (10 mg), miconazole (50 mg), voriconazole (1 mg), and amphotericin B (20 mg) was performed by disk diffusion method as described by Clinical and Laboratory Standards Institute guidelines (CLSI guidelines) M44-A2 protocol. Mueller-Hinton agar supplemented with 2% dextrose was used for it. The plates were incubated for 18-24 h at 37 ± 2°C and the slowl growing isolates were again read after 48 h of incubation. Zone sizes were measured in millimeters, The zone diameter to the nearest whole millimeter, the point at which there is prominent reduction in growth were taken into consideration. Pinpoint microcolonies at the zone edge or large colonies within the zones were ignored when testing the azoles. The zone diameters were interpreted as per the approved CLSI M442-A2 guidelines [Figure 2]. , C. albicans (ATCC 90028) was used as control strain.
The data were analyzed by using Statistical Package for the Social Sciences (SPSS) version 16 (SPSS-Inc., Chicago, IL) for descriptive statistics.
| Results|| |
Among of 300 patients screened, 36 (12%) patients had clinical symptoms of oral candidiasis and oral swabs were collected from these patients. Among 36 oral candidiasis patients, many were from surgery ward (14), followed by medicine (13), medical intensive care unit (MICU) (7), and orthopedic ward (2) [Figure 3].
In a total of 36 samples that yielded the growth of Candida, single species were grown from 33 samples and mixed growth was seen in 3 samples. C. albicans was the predominant species (23). Other species include Candida tropicalis (5), Candida glabrata (3), Candida dubliniensis (2), Candida krusei (1), Candida lusitaniae (1), and Candida parapsilosis (1). Among three samples with multiple growths, C. albicans and C. glabrata were grown from two specimens. Three types of organisms were grown from one sample, which are C. albicans, C. tropicalis, and C. glabrata [Figure 4].
Antifungal susceptibility pattern of 40 isolates of Candida species is summarized in [Table 1]. Fluconazole resistance was seen among 15% of the isolates. Highest resistance was seen with ketoconazole (18%). In case of C. albicans, which was the most common isolate in our study, only 71% were sensitive to fluconazole. All the C. albicans strains were sensitive to amphotericin B but one C. tropicalis showed resistance to amphotericin B.
All the patients with oral candidiasis were on broad spectrum antibiotics for a minimum period of 5 days (100%). Diabetes mellitus was seen in 50% of the patients and other predisposing factors include tuberculosis, chronic obstructive pulmonary disease (COPD), cancer, steroid treatment. Majority of the patients had more than one risk factor (43%) [Table 2]. Oral candidiasis was seen more in the age group of 50-70 years (47%), followed by the age group of 30-49 years (25%). Six patients were of age above 70 years (17%) and four patients were of age 10-29 years (11%). Among the patients with oral candidiasis, majority were males (77%).
| Discussion|| |
Oral candidiasis is widely seen among hospitalized patients. It leads to local discomfort, altered taste sensation, dysphagia, esophageal overgrowth resulting in poor nutrition, slow recovery, and prolonged hospital stay. Immunosuppression is a risk factor for developing the oral lesions in hospitalized patients.  Oral candidiasis is considered as a sign of impaired local or systemic defense mechanisms.  The aim of the present study was to evaluate the distribution pattern of various species of Candida among patients with oral candidiasis and their susceptibility to antifungal drugs by disk diffusion method. In the present study, prevalence of oral candidiasis among hospitalized patient was 14%. This is almost like a previously reported study Okonkwo et al. in 2013, which reported a prevalence rate of 12.5% among human immunodeficiency virus (HIV) patients.  Numerous reports have documented an increased incidence of infection caused by Candida species among hospitalized patients. , It may be because of various epidemiologic factors. Candida species are frequently found in the hospital environment in food, air, floors, and other surfaces. They are also seen in hands of hospital personnel. In most cases of candidiasis, prior colonization has been shown to precede infection. The wide use of systemic antibiotics also contributes to the promotion of the oral candidiasis.  In our study also all the patients with oral candidiasis were on broad spectrum antibiotics treatment, which may be one of the reasons for oral candidiasis among them. Diabetes mellitus was observed as another important risk factor. Half of the patients with oral candidiasis studied were diabetic. The high content of glucose in the tissues of diabetics and impaired cell mediated immunity may be the reason for it. Oral candidiasis was seen more among adults compared to children in our study. The worsening of overall state of health, poor oral status, and the side effects of the main treatments used may be contributing, directly or indirectly, to the risk factors for Candida species colonization.
C. albicans and seven other types of non-albicans Candida species were isolated from oral specimens in this study. As in case of most of the previous studies, C. albicans was the predominant species isolated. ,,,,,,,, Mixture of different Candida species was isolated from three patients which was also reported previously by others.  In case of mixed infection, C. albicans is a common agent as in previous study done by Batool. , According to literature, carriage of multiple species is a common phenomenon encountered in patients with oropharyngeal candidiasis.  In a study by Coco et al., it was suggested that coexistence of mixed species could aggravate the clinical condition that further complicate the treatment. 
Disk diffusion method of antifungal susceptibility test is a convenient and sensitive method of detecting antifungal susceptibility, and it could be an alternative to the microdilution reference method in the clinical laboratory to determine susceptibility of yeasts. 
Majority of the strains in our study were sensitive to fluconazole (64.5%) as in previous studies. ,, Previous studies also reported the higher rate of fluconazole resistance among oral C. albicans isolates. , Candida kruzei is intrinsically resistant to fluconazole and C. glabrata are intrinsically resistant or susceptible dose dependent. Previous studies have been reported resistance in C. glabrata to azole compounds, ranging from 3.6% to 64% among the species isolated from mucosal candidiasis. Since the number of C. glabrata isolates was fewer in the present study, it was not able to calculate the percentage of resistance.
| Conclusion|| |
Many species of the genus Candida have been emerging as cause of oral candidiasis but there is differences in drug susceptibility pattern among different species. Antifungal resistance also frequently observed in this area that demand the correct identification and antifungal susceptibility testing of the etiological agent for selecting best therapeutic option. Broad spectrum antibiotic treatment and diabetes are the important risk factors for oral candidiasis.
Financial support and sponsorship
This work was supported by grant from Yenepoya University (YU/Seed Grant/2013-021).
Conflicts of interest
There are no conflicts of interest.
| References|| |
Manikandan C, Amsath A. Isolation and rapid identification of Candida species from the oral cavity. Int J Pure App Biosci 2013;1:23-7.
Mohamed S. Biofilm formation and antifungal susceptibility of Candida isolates from various clinical specimens. Br Microbiol Res J 2013;3:590-601.
Pathak AK, Jain NR, Joshi R. Antibiogram of Candida species isolated from mono and multi-species oral candidal carriage using disk diffusion method. Saudi J Health Sci 2012;1:132-8.
Vijaya D, Harsha TR, Nagaratnamma T. Candida speciation using chrom agar. J Clin Diagn Res 2011;5:755-7.
Golia S, Reddy KM, Karjigi KS, Hittinahalli V. Speciation of Candida
using chromogenic and cornmeal agar with determination of fluconazole sensitivity. Al Ameen J Med Sci 2013;6:163-6.
Laboratory Manual for Diagnosis of Fungal Opportunistic Infections in HIV/AIDS Patients. World Health Organization. Regional Office for South East Asia. 2009. p. 60-75.
Bhavan PS, Rajkumar R, Radhakrishnan S, Seenivasan C, Kannan S. Culture and Identification of Candida albicans from vaginal ulcer and separation of enolase on SDS- PAGE. Int J Biol 2010;2:84-93.
Laboratory Manual for Diagnosis of Fungal Opportunistic Infections in HIV/AIDS Patients. World Health Organization. Regional Office for South East Asia. 2009. p. 60-75
Clinical and Laboratory Standards Institute. Zone Diameter Interpretive Standards, Corresponding Minimal Inhibitory Concentration (MIC) Interpretive Breakpoints, and Quality Control Limits for Antifungal Disk Diffusion Susceptibility Testing of Yeasts: Informational Supplement. CLSI Document M44-S3. 3 rd
ed. Villanova, PA: Clinical and Laboratory Standards Institute; 2009. p. M44-S3.
Shaheen MA, Taha M. Species identification of Candida isolates obtained from oral lesions of hospitalized and non hospitalized patients with oral candidiasis. Egyptian Dermatol Online J 2006;2:1-13.
Okonkwo EC, Alo MN, Nworie O, Orji JO, Agah MV. Prevalence of oral Candida albicans infection in HIV sero-positive patients in Abakaliki. Am J Life Sci 2013;1:72-6.
Campos de Pinho Resende J, Franco GR, Rosa CA, Hahn RC, Hamdan JS. Phenotypic and genotypic identification of Candida spp. isolated from hospitalized patients. Rev Iberoam Micol 2004;21:24-8.
Sánchez-Vargas LO, Ortiz-López NG, Villar M, Moragues MD, Aguirre JM, Cashat-Cruz M, et al
. Point prevalence, microbiology and antifungal susceptibility patterns of oral Candida isolates colonizing or infecting Mexican HIV/AIDS patients and healthy persons. Rev Iberoam Micol 2005;22:83-92.
Nejad BS, Rafiei A, Moosanejad F. Prevalence of Candida species in the oral cavity of patients with periodontitis. Afr J Biotechnol 2011;10:2987-90.
Back-Brito GN, Mota AJ, Vasconcellos TC, Querido SM, Jorge AO, Reis AS, et al
. Frequency of Candida spp. in the oral cavity of Brazilian HIV- positive patients and correlation with CD4 cell counts and viral load. Mycopathologia 2009;167:81-7.
Mane A, Panchvalli S, Bembalkar S, Risbud A. Species distribution and antifungal susceptibility of oral Candida colonising or infecting HIV infected individuals. Indian J Med Res 2010;131:836-8.
Letica FP, Gene C, Goldschmidt ME, Engelmeier RL. Colonization of Candida species in denture wearers with emphasis on HIV infection: A literature review. J Prosthet Dent 2005;93:288-93.
Giammanco GM, Melilli D, Pizzo G. Candida pararugosa isolation from the oral cavity of an Italian denture wearer. Res Microbiol 2004;155:571-4.
Suryawanshi H, Ganvir SM, Hazarey VK, Wanjare VS. Oropharyngeal candidosis relative frequency in radiotherapy patient for head and neck cancer. J Oral Maxillofac Pathol 2012;16:31-7.
Nayak S, Kavitha B, Sriram G, Saraswathi TR, Sivapathasundharam B, Dorothy AL. Comparative study of Candida by conventional and CHROM agar method in non-denture and denture wears by oral rinse technique. Indian J Dent Res 2012;23:490-7.
Gutiérrez J, Morales P, González MA, Quindós G. Candida dubliniensis, a new fungal pathogen. J Basic Microbiol 2002;42:207-27.
Grimoud AM, Lodter JP, Marty N, Andrieu S, Bocquet H, Linas MD, et al
. Improved oral hygiene and candida species colonization level in geriatric patients. Oral Dis 2005;11: 163-9.
Coco BJ, Bagg J, Cross LJ, Jose A, Cross J, Ramage G. Mixed Candida and Candida glabrata population associated with the pathogenesis of dentures stomatitis. Oral Microbiol Immunol 2008;23:377-83.
Kirkpatrick WR, Turner TM, Fothergill AW, McCarthy DI, Redding SW, Rinaldi MG, et al
. Fluconazole Disk diffusion susceptibility testing of Candida species. J Clin Microbiol 1998;36:3429-32.
Babin D, Kotigadde S, Rao PS, Rao TV. Clinico-mycological profile of vaginal candidiasis in a tertiary care hospital in Kerala. Int J Res Biol Sci 2013;3:55-9.
Jeddy N, Ranganathan K, Devi U, Joshua E. A study of antifungal drug sensitivity of Candida isolated from human immunodeficiency virus infected patients in Chennai, South India. J Oral Maxillofac Pathol 2011;15:182-6.
Wabe NT, Hussein J, Suleman S, Abdella K. In vitro
antifungal susceptibility of Candida albicans
isolates from oral cavities of patients infected with human immunodeficiency virus in Ethiopia. J Exp Integr Med 2011;1:265-71.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2]