Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

Users Online : 35191

AbstractMaterial and MethodsResultsDiscussionKey MessageReferencesDOI and Others
Article in PDF How to Cite Citation Manager Readers' Comments (0) Audio Visual Article Statistics Link to PUBMED Print this Article Send to a Friend
Advertisers Access Statistics Resources

Dr Mohan Z Mani

"Thank you very much for having published my article in record time.I would like to compliment you and your entire staff for your promptness, courtesy, and willingness to be customer friendly, which is quite unusual.I was given your reference by a colleague in pathology,and was able to directly phone your editorial office for clarifications.I would particularly like to thank the publication managers and the Assistant Editor who were following up my article. I would also like to thank you for adjusting the money I paid initially into payment for my modified article,and refunding the balance.
I wish all success to your journal and look forward to sending you any suitable similar article in future"



Dr Mohan Z Mani,
Professor & Head,
Department of Dermatolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
As an experienced dentist and an academician, I proudly recommend this journal to the dental fraternity as a good quality open access platform for rapid communication of their cutting-edge research progress and discovery.
I wish JCDR a great success and I hope that journal will soar higher with the passing time."



Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Original article / research
Year : 2011 | Month : November | Volume : 5 | Issue : 6 | Page : 1177 - 1181

Species Identification of Candida Isolates in Various Clinical Specimens with Their Antifungal Susceptibility Patterns

Shivanand Dharwad, Saldanha Dominic R.M.

M.D. Assistant Professor, Department of Microbiology, Jawaharlal Nehru Medical College, Nehru Nagar, Belgaum, Karnataka- 590010, India M. D. Associate Professor, Department of Microbiology, Kasturba Medical College, Mangalore, Karnataka- 575001, India

Correspondence Address :
Saldanha Dominic R.M.,
Department of Microbiology,
Kasturba Medical College,
Light House Hill Road, Mangalore,
Karnataka, India - 575 001.
Phone: +919845278907
E-mail: drdoms@gmail.com

Abstract

The Candida species are ubiquitous yeasts which are found on many plants and are a part of the normal flora of the alimentary tract of mammals and the mucocutaneous membranes of humans. Those that are a part of the normal flora can invade tissues and cause life-threatening diseases in patients whose cell mediated immunity is decreased by disease or iatrogenic intervention. The accurate species identification of Candida is important for the treatment, as not all species respond to the same treatment and also because of the problem of anti-fungal resistance.

The aims of the study were to isolate and identify the Candida species from clinical cases of candidiasis and to determine their anti-fungal susceptibility patterns and the predisposing conditions for candidiasis.

A total of 100 Candida isolates from various clinical specimens were identified by speciation on a chromogenic medium,HiChrome Candida differential agar. Susceptibility testing was carried out on 50 Candida isolates by using Amphotericin B, Fluconazole, Itraconazole, Voriconazole and Fluocytosine.

Candida albicans was the commonest species which was isolated (47%), followed by Candida tropicalis (30%). The Candida isolates were more susceptible to Amphotericin B (92%) and Fluocytosine (88%). Diabetes mellitus appeared to be the commonest predisposing factor for the Candida infections, followed by indiscriminate drug usage.

An increase in the predisposing conditions in recent years has resulted in an increasing incidence of Candida infections. Therefore, the species level identification of the Candida isolates, along with their anti-fungal susceptibility patterns can greatly influence the treatment options for the clinician and may have an impact on the patient care also.

Keywords

Candida albicans, non-albicans Candida, Fluconazole, Amphotericin B, Itraconazole, Fluocytosine, Voriconazole

Introduction
The Candida species are ubiquitous yeasts which are found on many plants and are a part of normal flora of the alimentary tract of mammals and the mucocutaneous membranes of humans (1). The overall carriage rate in healthy individuals has been estimated to reach 80%. The most commonly isolated Candida species from the gastrointestinal tract of humans is Candida albicans, followed by Candida tropicalis and Candida parapsilosis (2). Candida glabrata is most often isolated from the mouth. Candida spp. that are a part of the normal flora can invade tissues and cause lifethreatening diseases in patients whose cell mediated immunity is decreased by disease or iatrogenic intervention (3),(4),(5). In recent years, HIV infection has been identified as one of the most important predisposing conditions for candidiasis (6).

Candida albicans and related species which are pathogenic for humans, become resistant to the anti-fungal agents, in particular to the azole compounds, by the expression of the efflux pumps that reduce drug accumulation, the alteration of the structure or concentration of the anti-fungal target proteins and by the alteration of the membrane sterol composition. The clinical consequences of the anti-fungal resistance can be seen as the treatment failure in the patients and as the change in the prevalence of the Candida species which causes the infection (7),(8).

Accurate species identification is important for the treatment of the Candida infections, as the non-albicans species of Candida continue to be increasingly documented and as not all the species respond to the same treatment (4). The increase in the predisposing conditions in recent years has resulted in ac(o2n) current increase in the numbe(3r )of patients who suffer from candidiasis.

Hence, this study was undertaken to speciate Candida from the clinical cases of candidiasis, to determine the susceptibility of the Candida species to Fluconazole, Itraconazole, Fluocytosine, Voriconazole and Amphotericin B, and to analyze the predisposing conditions for candidiasis.

Material and Methods

A total of 100 Candida isolates from various clinical specimens (high vaginal swabs, blood, urine, exudates, biomedical devices, skin scrapings and nail clippings) were taken up for the study. A detailed clinical history was taken with regards to the age of the patient, sex, underlying disease/ conditions, immunodeficiencies, the Human immunodeficiency virus (HIV) status, diabetes mellitus, pregnancy, malnutrition, any ongoing treatment, burns, cancer and the type of candidiasis.

The various clinical specimens were collected and processed as per the standard microbiological procedures. The Candida isolates which were obtained were further speciated by the germ tube test, chlamydospore formation on corn meal agar and inoculation on chromogenic medium. The chromogenic medium, HiMedia CHROM agar®, has chromogenic substances which helps in the rapid identification of the Candida species, based on the reactions between the specific enzymes of the different species and the chromogenic substances. As per the colour code which is provided with the chromogenic media, C. albicans produces blue-green colonies, C. tropicalis produces dark blue- blue grey colonies, C. glabrata produces white to cream coloured colonies and C. krusei produces pale pink to purple, rough colonies.

Anti-fungal susceptibility testing (9),(10) was done for fifty isolates of Candida by using ATB Fungus 3® of Biomérieux. The ATB Fungus 3 strip enables the determination of the susceptibility of the Candida isolates to the antifungal agents in a semi-solid medium under conditions which are similar to the European Committee on Antibiotic Susceptibility Testing (EUCAST) and the Clinical and Laboratory Standards Institute (CLSI) recommendations. The antifungals which were tested, included Fluconazole, Voriconazole, Itraconazole,Fluocytosine and Amphotericin B. The inoculated strips were used in duplicate (c and C) were read visually after incubation at 37°C for 24 hours. For each antifungal agent, the reading of the strips was started with the lowest concentration and the growth score was recorded for each of the wells and compared with the control wells as follows:

No reduction in growth 4 Slight reduction in growth 3 Distinct reduction in growth 2 Very weak growth 1 No growth 0

For Amphotericin B, the minimum inhibitory concentration (MIC) of the Candida species corresponded to its lowest concentration, thus enabling complete growth inhibition.

For Fluconazole, Itraconazole and Voriconazole, as the possibility of a trailing growth existed, the MIC corresponded to the lowest concentration of the anti-fungal agent, with which a score of 2, 1 or 0 was obtained.

For Fluocytosine, a growth was looked for and was quantified in both the wells and tested for two concentrations; the interpretation of the growth for the anti-fungals is as mentioned in (Table/Fig 1).

The results which were obtained, gave an MIC and classified the strain as sensitive, intermediate or resistant.

The anti-fungal breakpoints which were used were as recommended by the CLSI guidelines in mg/L (Table/Fig 2).

Results

A total of 100 clinical isolates of Candida from various clinical specimens were processed during the study period. A total of 38 isolates were obtained from high vaginal swabs (Table/Fig 3), followed by blood (16), urine (12), sputum (11) and others (23).

Candida albicans was the commonest species which was isolated (47%), followed by C. tropicalis (30%), C. krusei (14%) and C. glabrata (9%).

A higher incidence of C. albicans was found in the high vaginal swabs (HVS) and urine. A high incidence of C. tropicalis was found in the high vaginal swabs and sputum and a high incidence of C. glabrata was found in the high vaginal swabs, whereas C. krusei was found more in blood (Table/Fig 4).

Candidiasis was most common in the age group of greater than 18 years up to 45 years (54%) (Table/Fig 5), followed by the age group of greater than 60 years (22%).

The rate of isolation of the Candida species was more in females than in males (Table/Fig 6).

An analysis of the risk/predisposing factors in patients from whom the Candida species were isolated, showed that 32% had underlying diabetes mellitus, that 22% were on multiple antibiotics and that 12% had a history of catheter usage (Table/Fig 7).

Fifty isolates of Candida were subjected to anti-fungal susceptibility testing (Table/Fig 8). Sixty percent of the Candida isolates were

found to be sensitive to Fluocytosine and Voriconazole, whereas 56% of the isolates were sensitive to Amphotericin B. Itraconazole (48%) and Fluconazole (32%) were found to be less sensitive against Candida. The highest resistance (32%) was seen against Fluconazole.

Discussion

Candidiasis is a primary or secondary infection which involves a member of the genus, Candida. The clinical manifestations of the disease are extremely varied, ranging from acute, subacute and chronic to an episodic involvement. It may be localized to the mouth, lungs or the gastrointestinal tract, or may become systemic as in septicaemia, endocarditis and meningitis.

A total of 100 Candida isolates from various clinical specimens were included in our study, of which high vaginal swabs showed the highest number of isolates (38%), followed by blood (16%) and urine (12%). Studies which were done earlier by Pfaller et al, have reported Candida species as the seventh most common nosocomial pathogen hospital wide and as that which caused 25% of all the urinary tract infections. These findings were confirmed in the most recent study which was conducted by them for the SENTRY Antimicrobial Surveillance Programme.

C. albicans was the most frequently isolated species. Many other species of Candida are also being reported in the current literature [11, 12]. In this study as well, the most frequently isolated species was C. albicans, accounting for 47% of the infections, followed by C. tropicalis (30%), C. krusei (14%) and C. glabrata (9%) respectively.

Comparative studies on different Candida species which were isolated in their studies by different researchers showed that the isolation of C. albicans was the highest in each of them, except in Chakrabarti’s study (13), which showed that the isolation of C. tropicalis was the highest (42%) and that the isolation of C. albicans was 25%. Dastidher (72.8%), Gupta D (64%) and Mokaddas et al (39.5%) found C. albicans to be the commonest isolate (14).

Studies over the years have shown that there is a considerable increase in the non-albicans Candida isolates. Our study showed that non-albicans Candida were isolated at a higher rate (53%) than C. albicans (47%), which was in agreement with the findings of the studies by Mokaddas et al, who also showed the non-albicans Candida incidence (60.5%) to be higher than that of C. albicans (39.5%) (14). A study by Chakrabati A also showed non-albicans Candida to have a higher incidence (75%) than C. albicans (25%). These findings seem to suggest that non-albicans Candida are emerging as important pathogens.

The speciation of Candida is important to provide a database for a given area of study. The choice of antifungals is also dependent on the species of Candida. The azoles being effective againstC. albicans and C. tropicalis, are found to be ineffective against C. krusei and C. glabrata. Other studies which have reported on the epidemiology of candidaemia, have stressed the importance of the speciation of Candida, as it provides accurate information on the disease incidences and the trends in most of the infections (11), (12). Frazer, Victoria J and co-workers reported the importance of the association of candidaemia which was caused by various species of Candida with the disease outcome. Studies which were conducted by them, showed that in patients with sustained candidaemia, the mortality which was associated with the non-albicans Candida species was higher, with a statistical significance. It is important however, to clearly differentiate between Candida which occur as contaminants and those which occur as pathogens (11).

Though candidiasis can occur at all ages, studies by Dalal PJ and Kelkar SS at Mumbai showed the highest incidence of candidiasis to be in the age group of 21-40 years (15). These findings were in concurrence with those of our study, where the age group of >18 years up to <45 years was that which had the highest incidence of candidiasis.

In our study, the incidence of candidiasis was higher in females than in males. In a similar study by Kandhari KC et al, the incidence was found to be higher in females (61.2%) than in males (38.8%). This could be due to the higher number of samples which were collected from female patients.

We have studied the association of the risk factors in all the 100 patients from whom the Candida species were isolated. As can be seen in (Table/Fig 7), diabetes mellitus was the most frequently associated risk factor. Experimental evidence in vitro shows that a glucose concentration of 150mg/100ml increases the growth of Candida (16). This may probably hold true in the human body, that an increase in the concentration of glucose in the tissues, blood and urine promotes the growth of Candida. A comparison of the incidence of diabetes among the cases of candidiasis is shown in (Table/Fig 9). Kandhari KC et al found 11 cases of diabetes in a total of 54 cases of candidiasis, with an incidence of 20.4%. Shroff PS studied 150 patients with cutaneous candidiasis and found 22 patients to be diabetic. The findings of the present study correlated well with those of other studies, as in our study, 32 out of the 100 cases of candidiasis showed an incidence of 32%. A history of multiple drug usage was the second most frequently associated risk factor (22%). The drugs which were incriminated were mainly corticosteroids, antibiotics and contraceptive pills (17),(18). According to Rippon (19), there is some effect of the antibiotics on the host tissue, which predisposes it to invasion by the organism, and the antibiotics itself may stimulate the growth of Candida. The most important effect of antibiotics is the elimination and alteration of the bacterial flora that holds the population of Candida in check. Winner and Hurley, in 1964, have found considerable evidence (clinical and experimental) in support of the enhancement of the development of candidiasis by systemic antibiotics and corticosteroids. They demonstrated a 21-30% increase of the Candida infections when a patient was treated with antibiotics.

Since the advent of the contraceptive pill, there has been a controversy about the predisposing role of oral contraceptives in candidial vulvovaginitis. Bourg suggested that progestational steroids, by causing changes which were similar to those which were found in pregnancy, might be responsible for an increased incidence of candidiasis among the patients who took oral contraceptive pills (20). Jackson and Spain found that the chances of a patient having vaginal candidiasis were significantly less among those which used a combination regimen. These hormones probably act by promoting changes which are similar to those which are seen in the luteal phase of the menstrual cycle and in early pregnancy. In the present study, four patients were on oral contraceptives and ten patients who had intrauterine devices had vulvovaginitis, out of the 38 cases which were studied. It has been established that the prevalence of genital candidiasis increases in pregnancy. The high hormone level leads to a proportional increase in the glycogen content of the vagina, thus producing a favourable environment for the growth of Candida. Undoubtedly, the reduced glucose tolerance and the increased incidence of glycosuria render some patients more susceptible to candidiasis (16).

In the present study, eight pregnant women had candidiasis. The occurrence of candidial vulvovaginitis is also important from another viewpoint. There is a real risk of transmission of the infection to the newborn infant. In a study by Woodruff et al, it was found that maternal infection resulted in a 35 times greater chance of the child developing oral thrush than a baby which was born of a non-infected mother. The other significant risk factors were the presence of urinary and indwelling catheters (in 12%), sepsis (in 10%) and HIV infection in about 7%. Studies have shown that patients with underlying risk factors such as those which are mentioned in (Table/Fig 7), are at an increased risk of developing blood stream infections which are caused by Candida (21). In our study, the second most common specimen was blood. During the past decade, there has been increasing appreciation of the significance of candidaemia. Dismissal of the isolation of the Candida species from a single blood culture as a skin contaminant has been questioned as a potentially hazardous interpretation (22). The dogma that two blood cultures are required to confirm the significance of the first blood culture is being questioned. This could lead to a delay in administering potentially life saving therapy. It is said that all blood cultures that yield Candida species must be considered to be significant until they have been proved otherwise.

Antifungal testing aspects The in vitro susceptibility testing of antifungal agents is becoming increasingly important because of the introduction of new antifungal agents and the recovery of clinical isolates that exhibit inherent or developed resistance to Amphotericin B, Fluocytosine, the azole group of drugs or Nystatin during chemotherapy. In the present study, antifungal susceptibility testing was done for 50 Candida isolates by using ATB Fungus 3 of Biomérieux. The C. albicans isolates were 100% susceptible to Amphotericin B and Fluocytosine and showed 22% resistance to Fluconazole. The Candida tropicalis isolates were 87.5% susceptible to Fluocytosine, Amphotericin B, Itraconazole and Voriconazole and showed 25% resistance to Fluconazole. The Candida krusei isolates were 80% susceptible to Amphotericin B, Itraconazole and Voriconazole, and showed 60% resistance to Fluconazole and 40% resistance to Fluocytosine. The C. glabrata isolates were 100% susceptible to Amphotericin B and showed 66.66% resistance to Itraconazole and 33.33%

resistance to Fluconazole. The findings of the present study correlate with those of Yonghao Xu et al’s study in which C. krusei showed 40% resistance to Fluconazole and C. glabrata showed 9.3% resistance and 100% resistance to Fluocytosine respectively (23). The findings of the present study also correlated with those of a study by Jin-Sol Lee et al, in which C. glabrata showed 38% resistance to Itraconazole and C. krusei showed 100% resistance to Fluconazole (24). C. krusei and C. glabrata showed high resistance to Fluconazole and Itraconazole respectively, probably due to their innate resistance to these drugs.

To conclude, an increase in the predisposing conditions in recent years has resulted in an increasing incidence of Candida infections. Therefore, the species level identification of the Candida isolates along with their antifungal susceptibility patterns can greatly influence the treatment options for the clinician and may have an impact on the patient care.

Key Message

Candida spp., though they are a part of the normal flora, can cause infections in immunocompromised patients. In recent years, HIV infections, diabetes mellitus, multiple drug use and biomedical device usage have been identified as the commonly encountered risk factors for the Candida infections. The emergence of drug-resistant candidiasis is posing a serious threat to the patient care. Amphotericin B is effective against the non-albicans species of Candida. The species identification of the Candida isolates, along with the identification of their anti-fungal susceptibility patterns can influence the treatment options for the clinician and have a beneficial impact on the patient care.

References

1.
Odds FC. Candida and candidosis: A Review and Bibliography. 2nd ed. London: Baillière Tindall; 1988.
2.
Warren NG, Hazen KC. Candida, Cryptococcus and other yeasts of medical importance. In: Murray PR, Baron EJ, Pfaller MA, Tenover FC, Yolken RH, editors. Manual of Clinical Microbiology. 7th ed. Washington: ASM Press; 1999.
3.
Chakraborti A, Singh K, Das S. The changing face of nosocomial candidaemia. Ind J Med Microbiol 1999; 17: 160-6.
4.
Page BT, Kurtzman CP. Rapid identification of the Candida species and other clinically important yeast by flow cytometry. J Clin Microbiol 2005; 43: 4507-14.
5.
Chakraborti A, Chander J, Kasturi P, Panigrahi D. Candidaemia. A 10 year study in an Indian teaching hospital. Mycoses 1992; 35: 47-50.
6.
Fichtenbacim TBN, Saveedra M, Slayinsky J, Swoboda R, Wozniak K, Arribas A et al. The in vivo virulence of the Candida albicans isolates which caused infections in people who were infected with the human immunodeficiency virus. J Infect Dis 2000; 182: 955-9.
7.
Koga-Ito CY, Lyon JP, Vidotto V, de Resende MA. The virulence factors and the antifungal susceptibility of Candida albicans which was isolated from oral candidosis patientsand control individuals. Microbiologica 2006; 161: 219-23.
8.
White TE, Holeman S, Mirels LF, Stevens DA. Resistance mechanisms in the chemical isolates of Candida albicans. Antimicrob Agents Chemother 2002; 46: 1704-13.
9.
Cuenca- Estrella M, Mellado E, Gomez-Lopez A. Evaluation of the commercial method, ATB Fungus 2, for the in vitro detection of antifungal resistance and its correlation with the reference method of the European Committee on Antibiotic Susceptibility Testing (EUCAST) and the Biomérieux micromethod of the NCCLS. Poster 1514, 45th Annual ICAAC, New Orleans, September 2005.
10.
Durussel C, Parreno D, Nougier L, Monnin V, Zambardi G, Bille J.et al A comparative study of various methods, (NCCLS M27- A2, EUCAST) and ATB Fungus 2 (Biomérieux) for the in vitro antifungal susceptibility testing of Candida spp. Clin Microbiol Infect 2004; 10 (Suppl.3): 112-3.
11.
Pfaller MA. Nosocomial candidiasis: the emerging species reservoirs and the modes of transmission. Clin Infect Dis 1996; 22: 89-94.
12.
Nguyen MH, Peacock JE, Morris AJ, Tanner DC, Nguyen ML, Snydman Dr et al. The changing face of candidaemia: the emergence of the non- C. albicans species and antifungal resistance. Am J Med 1996; 100 (6): 617-23.
13.
Chakraborti A, Ghosh A, Batra R, Kaushal A, Roy P, Singh H. Antifungal susceptibility patterns of the non-albicans Candida species and the distribution of the species which were isolated from candidaemia cases over a 5 year period. Indian J Med Res 1996; 104: 171-6.
14.
Mokaddas EM, Al-Sweih NA, Khan ZU. The species distribution and the antifungal susceptibility of Candida bloodstream isolates in Kuwait: A 10 year study. J Med Microbiol 2007; 56: 255-9.
15.
Dalal PJ, Kelkar SS. Clinical patterns of Candida infections in Bombay. Indian J Dermatol Venereol Leprol 1980; 46 (1): 31-2.
16.
Warnock DW, Speller CD, Milne JD, Hilton AL, Kershaw PI. The epidemiological investigation of patients with vulvovaginal candidiasis: Application of a resistogram method for the strain differentiation of Candida albicans. Br J Vener Dis 1979; 55: 357-61.
17.
Sealing MS. The role of antibiotics in the pathogenesis of Candida infections. Am J Med 1986; 40: 887-909.
18.
Henry B, Fahlberg WJ. The potentiating effect of hydrocortisone acetate and tetracycline on monilial infection in mice. Antibiot Chemother 1960; 10: 114-20.
19.
Rippon JW. Candidiasis and the pathogenic yeasts. In: Martin Wonseiwicz editors. Medical Mycology. 3rd. Philadelphia: WB Saunders Company; 1988.
20.
Sobel JD. The epidemiology and pathogenesis of recurrent vulvovaginal candidiasis. Am J Obstet Gynecol 1985; 152: 924-35.
21.
Fraser VJ, Jones M, Dunkel J, Storfer S, Medoff G, Dunagan WC et al. Candidaemia in a tertiary care hospital: Epidemiology, risk factors and predictors of mortality. Clin Infect Dis 1992; 15(3): 414-21.
22.
Richardson MD, Carlson P. Culture and non-culture based diagnostics for Candida species. In: Calderone RA editors. Candida and Candidiasis. Washington: ASM Press; 2002: 387-94.
23.
Xu Y, Chen L, Li C . Susceptibility of clinical isolates of Candida species to fluconazole and the detection of the C. albicans ERG11 mutation. J Antimicrob Chemother 2008; 61: 798-804.
24.
Lee JS, Shin JH, Lee K, Kim MN, Shin BM, Uh Y et al. Species distribution and susceptibility to azole antifungals of Candida bloodstream isolates from eight university hospitals in Korea. Yonsei Med J 2007; 48: 779-86.

DOI and Others

JCDR/2011/1597

JCDR is now Monthly and more widely Indexed .
  • Emerging Sources Citation Index (Web of Science, thomsonreuters)
  • Index Copernicus ICV 2017: 134.54
  • Academic Search Complete Database
  • Directory of Open Access Journals (DOAJ)
  • Embase
  • EBSCOhost
  • Google Scholar
  • HINARI Access to Research in Health Programme
  • Indian Science Abstracts (ISA)
  • Journal seek Database
  • Google
  • Popline (reproductive health literature)
  • www.omnimedicalsearch.com