mycoses
Diagnosis,Therapy and Prophylaxis of Fungal Diseases
Original article
An investigation of Candida species isolated from blood cultures during 17 years in a university hospital 4 € Ozkan, € ırlı,3 O. lu,5 Emel Yılmaz,1 Solmaz C € rcu € og E. Kazak,1 H. Akın,1 B. Ener,2 D. Sıg E. Gu ß elebi,6 2 1 lar and Halis Akalın Sevim Akcßag 1 Department of Infectious Diseases and Clinical Microbiology, Faculty of Medicine, Uludag University, Go€ru€kle, Bursa, Turkey, 2Department of Medical Microbiology, Faculty of Medicine, Uludag University,Go€ru€kle, Bursa, Turkey, 3Department of Biostatistics, Faculty of Medicine, Uludag University, Go€ru€kle, Bursa, Turkey, 4Department of Microbiology, T.C. Ministry of Health Sßevket Yılmaz Hospital, Bursa, Turkey, 5Department of Infectious Diseases and Clinical Microbiology, Bursa Doruk Hospital, Yıldırım, Bursa, Turkey and 6Department of Pediatrics, Faculty of Medicine, Uludag University, Go€ru€kle, Bursa, Turkey
Summary
Candidemia is the most frequent manifestation observed with invasive candidiasis. The aim of this study was to analyse the trends of candidemia in a large tertiarycare hospital to determine the overall incidence during January 1996–December 2012, as well as to determine the susceptibility of 453 isolates according to the revised Clinical and Laboratory Standards Institute (CLSI) breakpoints. Candidemia episodes in adult and paediatric patients were retrospectively analysed from the laboratory data of Uluda g University Healthcare and Research Hospital. The 17-year period studied was divided into three periods (1996–2001, 2002–2007 and 2008– 2012) for better comparison, and candidemia incidence was determined by the ratio of total number of patients with candidemia per 1000 patients admitted to the hospital and per 10 000 patient days in these three periods. Redefined CLSI M27-A3 breakpoints were used for interpretation of antifungal susceptibility results. Candidemia incidence was determined as 2.2, 1.7 and 1.5 per 1000 admitted patients during 1996–2001, 2002–2007 and 2008–2012 respectively. A significantly decreased candidemia incidence was obtained in the third period. C. albicans (43.8%) was the most common candidemia agent, followed by C.parapsilosis (26.5%) in all three periods. According to the revised CLSI breakpoints, there was fluconazole resistance in C. albicans, C.parapsilosis, C.tropicalis and C.glabrata species (1.4%, 18.2%, 2.6% and 14.3% respectively). Almost all Candida species were found susceptible to voriconazole except one C.glabrata (7.1%) isolate. Candidemia is an important health problem. Local epidemiological data are determinative in the choice of appropriate antifungal treatment agents.
Key words: Candida species, candidemia, antifungal susceptibility.
Introduction
Correspondence: Esra Kazak MD, Department of Infectious Diseases and University, Go € ru €kle, Clinical Microbiology, Faculty of Medicine, Uludag Bursa 16059, Turkey. Tel.: +90 532 240 99 27. Fax: +90 224 295 00 99. E-mail: [email protected] Submitted for publication 19 January 2014 Revised 24 April 2014 Accepted for publication 23 May 2014
© 2014 Blackwell Verlag GmbH Mycoses, 2014, 57, 623–629
The widespread use of broad-spectrum antibiotics and an expanded number of immunocompromised patients have caused an increase in the incidence of candidiasis in recent years.1 Candida species, which colonise in mucocutaneous membranes immediately after birth, are members of normal flora located mainly in the gastrointestinal system.2 When their number and intensity increase in the flora, they can easily invade into the blood from damaged epithelial tissue following
doi:10.1111/myc.12209
E. Kazak et al.
surgical intervention or cytotoxic chemotherapy and cause candidemia. In addition, they also form biofilm layers on foreign body surfaces such as prosthesis or catheters.3,4 Rapidly progressive candidemia, which is difficult to diagnose and treat, increases mortality rates and costs as well as extends hospitalisation. In the United States of America (USA), C. albicans is the fourth most significant agent of bloodstream infection. The agents responsible for 97% of candidemia are C.albicans, C.glabrata, C.parapsilosis, C.tropicalis and C.krusei respectively.5 Species identification of candidemia would be beneficial in defining the risk factors, taking the necessary preventative measures and starting the appropriate treatment as soon as possible. This study aimed to define the incidence of candidemia and the distribution of Candida strains isolated from blood cultures during January 1996–December 2012 and retrospectively to interpret the in vitro antifungal susceptibility of 453 isolates according to the revised Clinical and Laboratory Standards Institute (CLSI) breakpoints.
Materials and methods Uluda g University Healthcare and Research Hospital is an 800-bed tertiary-care Joint Commission International accredited teaching institution. There are seven adult (Reanimation, Chest-Heart-Vascular Surgery, Cardiology, Plastic Surgery and Burns Unit, Neurology, Brain Surgery and Chest Diseases) and two (Neonatal and Paediatric) paediatric intensive care units (ICUs) as well as haematology and oncology wards and kidney, liver and bone marrow transplantation units. All blood cultures that have been collected are sent to the laboratory to incubate. Since 1990, the BACTEC 9000 automated blood culture system (Becton Dickinson, INC, Sparks, MD) has been used in the laboratory. Blood culture bottles positive for yeast were subcultured on Emmons’ modified Sabouraud dextrose agar (SDA 2%) and inhibitory mould agar (IMA) and incubated for 24–72 h at 35°C. The isolates were identified by germ tube production, morphology on cornmeal Tween-80 agar and/or chromogenic agar and analysis of biochemical patterns by API 20 AUX or API ID 32C (bioMerieux, Marcy I’Etoile, France) commercial systems.6 All candidemia data were obtained retrospectively from laboratory records in January 1996 and December 2012. Consecutive growth associated with the same attack in patients was treated as a single episode. In addition, data from adults/paediatrics and wards/
624
ICUs were considered separately. The incidence of candidemia was calculated as the ratio of total number of patients to 1000 hospitalised patients and 10 000 patient days. The most frequently seen Candida species were defined from the data obtained over 17 years. The period of 17 years was divided into three groups: 1996–2001, 2002–2007 and 2008–2012. The data from 2008–2012 were compared with the 1996– 2001 and 2002–2007 data of Candida cases evaluated in a study by G€ urc€ uo glu et al. [7] in our institution. In 2002, all the recipes should have been approved by infection control team at our hospital, so second period was important to see the effect of this application. In 2008, our hospital was accredited by Joint Commission International and to see the effect of better patients care after these data are also wanted to consider. The antifungal susceptibility data of 453 isolates was obtained from laboratory records. Refined CLSI M27-A3 breakpoints after 24-h incubation were used for antifungal susceptibility interpretations.8–11 Statistical analysis of the data was made with IBM SPSS Statistics 21 and the Epi Info 7.1.1.1 programme. Categorical variables were stated as numbers and percentages. In the comparison between groups, Pearson’s chi-squared test and Fisher’s exact test were used, and for the comparison of changes between years of the frequency, the chi-squared trend test was used. A value of a = 0.05 was accepted as the level of statistical significance.
Results In the 17-year period, the number of hospitalised patients was 583 079. There were 1035 candidemia attacks during the period and 1062 Candida species were isolated. Candidemia episodes associated with two different species were determined in nine patients in both the adult and paediatric groups during 2002– 2007 and in six adult and three paediatric patients during 2008–2012. The total isolated strains were C. albicans (n = 465, 43.8%), C. parapsilosis (n = 281, 26.5%), C. tropicalis (n = 89, 8.4%), C.krusei (n = 62, 5.8%), C. glabrata (n = 58, 5.5%) and other Candida species (n = 107, 10.1%) during the 17-year period. C. parapsilosis, C. krusei and C. pelliculosa in children and C. tropicalis, C. glabrata and C. kefyr in adults were seen significantly more. C. pelliculosa isolates were only seen in paediatric patients (Table 1). The distribution of the isolated species according to the years of the three separate periods is shown Table 2. C. albicans was the most frequently seen
© 2014 Blackwell Verlag GmbH Mycoses, 2014, 57, 623–629
Candidemia species, resistance and incidence
Table 1 Species distribution of candidemia during 1996–2012. Adults (%)
Paediatrics (%)
C. albicans C. parapsilosis C. tropicalis C. krusei C. glabrata Candida spp.*** C. kefyr C. guilliermondii C. lipolytica C. pelliculosa C. inscons/norva C. lusitaniae C. dubliniensis C. zeylanoides C. famata C. sake
313 161 68 23 49 25 23 7 3 0 4 1 3 1 1 1
152 120 21 39 9 16 3 3 5 7 2 2 0 0 0 0
Total
683
(45.8) (23.6) (10) (3.4) (7.2) (3.7) (3.4) (1) (0.4) (0) (0.6) (0.1) (0.4) (0.1) (0.1) (0.1)
(40.1) (31.7) (5.5) (10.3) (2.4) (4.2) (0.8) (0.8) (1.3) (1.8) (0.5) (0.5) (0) (0) (0) (0)
Total 465 281 89 62 58 41 26 10 8 7 6 3 3 1 1 1
379
P value 0.072 0.004* 0.013** 64
0.5 32 2 0.5 0.5
2 32 64 4 16
≤0.032–1 ≤0.032–2 ≤0.032–2 ≤0.032–1 ≤0.032–>4
0.125 0.5 0.25 0.125 0.064
0.25 1 1 0.5 0.5
≤0.032–0.125 ≤0.032–0.5 ≤0.032–1 ≤0.032–0.5 ≤0.032–1
≤0.032 0.25 0.064 ≤0.032 ≤0.032
0.125 0.5 0.25 0.125 0.25
MIC, minimal inhibitory concentration.
626
© 2014 Blackwell Verlag GmbH Mycoses, 2014, 57, 623–629
Candidemia species, resistance and incidence
Table 6 Resistance breakpoints.10,11
rates
according
to
revised
CLSI
Antifungal agents Species C. albicans n = 216 C. parapsilosis n = 126 C. tropicalis n = 39 C. glabrata n = 14 C. krusei n = 34
Revised Revised Revised Revised Revised
Fluconazole
Voriconazole
_Itraconazole
1.4% (n = 3) 18.2% (n = 23) 2.6% (n = 1) 14.3% (n = 2) –
0
6%1 (n = 13) 0.8%2 (n = 1) 0
0 0 7.1%3 (n = 1) 0
Epidemiological cut-off value >0.125 lg ml
1
Epidemiological cut-off value >1 lg ml
2
0
.
1
Epidemiological cut-off value >0.5 lg ml
3
1
0
. 1
.
intensive care unit, insufficient infection control precautions, that our hospital is a third-stage training hospital, the use of broad-spectrum antibiotics in healthcare institutions in our region, the transfer to our hospital of critical patients who have undergone various invasive approaches, treatment at our hospital for transplantation, an increased number of patients with haematological or oncological malignity and no limitation in the use of wide spectrum antibiotics in the period of 1996–2001.7 However, it was noticeable that there was a significant reduction in the period of 2008–2012 compared to 1996–2001. A more knowledgeable application of parenteral nutrition, the application of infection control precautions, improvements in the care of central venous catheters, limitations in the use of broad-spectrum antibiotics from 2002 and more extensive consultation on infectious diseases are thought to play a significant role in this reduction. Several international studies have reported that a stay in an intensive care unit is a basic risk factor in the development of candidemia. Different studies have stated that 30%–70% of all patients diagnosed with candidemia were hospitalised in ICU.16,18–20 According to the data of this study, 32.6%–44.8% of the candidemia cases comprised patients from ICUs. Previous studies have reported that significant changes have been determined in the candidemia agents, and apart from C. albicans, there were increases in infections associated with other Candida species.21–24 In a study including European countries in the period of 1997–1999, C. albicans (54%) was the leading candidemia agent. This was followed by C. glabrata (13.6%) and C. parapsilosis (13.3%).25 A similar order was reported in a
© 2014 Blackwell Verlag GmbH Mycoses, 2014, 57, 623–629
study conducted in Belgium covering 2001–2005 (C. albicans 58.8%, C. glabrata 22.2%, C. parapsilosis 9.6%).26 Between 2000 and 2003, the four leading candidemia agents in Turkey were reported as C. albicans (57.7%), C. tropicalis (20.2%), C. parapsilosis (12.5%) and C. glabrata (3.8%).16 In this study, C. albicans was the most frequently seen agent both in wards and ICUs in all three periods. Apart from C. albicans, the greater frequency of C. krusei in the first period is thought to originate from an epidemic associated with this agent. As shown in Table 1, there was a difference in the frequency of Candida species that were seen in paediatric and adult patients. In paediatric patients, apart from C. albicans, C. parapsilosis maintained its significance as an agent in all three periods. However, the decrease seen among periods in the C. parapsilosis rates is thought to be due to the effects of infection control precautions and improvements in catheter care, particularly in adult ICUs. On the other hand, as C. krusei, C. tropicalis and C. keyfr infections were found to be at higher rates in wards than in ICUs in our study, we believe that these data are important for the choice of empirical antifungal treatment. When the increase in the frequency of C. glabrata is considered, we know that there is controversy about the relationship between fluconazole usage and azoleresistant Candida infections.27,28 In addition, some antibiotics were found to be a risk factor for different Candida species.29 Unfortunately, we have no welldefined data for antifungal usage in our hospital. Knowing the prevalence of agents will be an indicator in the choice of antifungal agents, but in vitro antifungal susceptibility testing is also standardised internationally; its most important function is the detection of resistance.30 Both CLSI and EUCAST have established clinical breakpoints for azoles and echinocandins versus Candida species, and CLSI revised the clinical breakpoints very recently.31,32 According to the revised criteria, C. parapsilosis isolates have shown increased resistance to fluconazole (18.25%) in this study, which is a very interesting result. Although approximately 1% of blood stream C. parapsilosis isolates have fluconazole resistance according to population-based and sentinel surveillance surveys, there are some exceptionally higher frequencies (15%) reported in Sweden.1 Also, Dizbay et al. [33] in Turkey have determined 7.4% resistance to fluconazole among C. parapsilosis isolates in non-neutropenic patients; perhaps higher rates may be obtained by using revised breakpoints. Thus, more comprehensive susceptibility studies and a molecular approach may be necessary for our C. parapsilosis isolates.
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In a study by Fothergill et al. [11] evaluating antifungal sensitivity with the revised new CLSI breakpoints, they reported that after revision, increased resistance to echinocandin and fluconazole was observed in Candida species and that the most significant change was in the increased resistance of C. glabrata to echinocandin. In this study, no increased resistance of C. glabrata to caspofungin was determined after revision. However, a significant increase was determined in C. krusei resistance to caspofungin. Although the CLSI has established breakpoints for all three echinocandins, EUCAST has not set caspofungin breakpoints and does not currently recommend caspofungin MIC testing for clinical decision making. This is due to unacceptably high variation among caspofungin MIC values from different centres; thus, EUCAST recommends anidulafungin MIC testing as a marker for the echinocandin class of drugs.34,35 In a study conducted by Arendrup et al.,[36] 13.1% of anidulafungin susceptible isolates were misclassified as intermediate or resistant by using revised CLSI breakpoints; furthermore, they found that misclassifications were most commonly observed for C. krusei (73.1% misclassified as I) and for C. glabrata (31.6% misclassified as I and 1.5% as R) isolates. Thus, it is necessary to test the resistant C. krusei isolates by using anidulafungin to determine the exact resistance. In conclusion, candidemia is a significant nosocomial health problem. Epidemiologic surveys that examine local and regional data can be used to develop empiric treatment strategies and are essential in tracking resistance trends. According to the data of this study, although the incidence of candidemia has decreased over the years in our hospital, it serves as a warning in terms of considering the relationship between the increase in the number of Candida species apart from C. albicans, the choice of antifungal, underlying factors and the use of prophylactic or empirical antifungals.
2
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Conflict of interest There is no conflict of interest for authors.
Funding
20
21
No competing financial interests exist.
22
References
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Edwards JE. Candida species. Epidemiologyandecology. In: Mandell G, Bennett J, Dolin R (eds), Mandell, Douglas, Bennett’s principles and practice of infectious diseases. Philadelphia, PA: Churchill LivingstoneElsevier, 2010: 3225–39. Eggimann P, Garbino J, Pittet D. Epidemiology of Candida species infections in critically ill non-immunosuppressed patients. Lancet Infect Dis 2003; 3: 685–702. Pfaller MA, Pappas PG, Wingard JR. Invasive fungal pathogens: current epidemiological trends. Clin Infect Dis 2006; 43: 3–14. Wisplinghoff H, Bischoff T, Tallent SM, Seifert H, Wenzel RP, Edmond MB. Nosocomial blood stream infections in US hospitals: analysis of 24,179 cases from a prospective nationwide surveillance study. Clin Infect Dis 2004; 39: 309–17. Reiss E, Shadomy HJ, Lyon GM. Fundamental medical mycology. New Jersey: Wiley-Blackwell. 2012: 42–45. G€ urc€ uo glu E, Ener B, Akalın H et al. Epidemiology of nosocomial candidaemia in a university hospital: a 12-year study. Epidemiol Infect 2010; 138: 1328–35. CLSI. Reference method for broth dilution antifungal susceptibility testing of yeasts: approved standard-third edition. CLSI document M27-A3. Wayne, PA: Clinical and Laboratory Standards Institute, 2008. CLSI. Reference method for broth dilution antifungal susceptibility testing of yeasts: third informational supplement. CLSI document M27-S3. Clinical and Laboratory Standards Institute, Wayne, PA, 2008. Pfaller MA, Diekema DJ. Progress in antifungal susceptibility testing of Candida spp. by use of Clinical and Laboratory Standards Institute broth microdilution methods, 2010-2012. J Clin Microbiol 2012; 50: 2846. Fothergill AW, Sutton DA, McCarthy DI, Wiederhold NP. The Impact of New CLSI Breakpoints on Antifungal Resistance in Candida Species. http://www.icaaconline.com/php/icaac2013abstracts/data/papers/ 2013/M/2013_M-1364.htm [accessed on 10 January 2014]. Fisher-Hoch SP, Hutwagner L. Opportunistic candidiasis: an epidemic of the 1980s. Clin Infect Dis 1995; 21: 897–904. Hajjeh RA, Sofair AN, Harrison LH et al. Incidence of bloodstream infections due to Candida species and in vitro susceptibilities of isolates collected from 1998 to 2000 in a population-based active surveillance program. J Clin Microbiol 2004; 42: 1512–7. Bassetti M, Trecarichi EM, Righi E et al. Incidence, risk factors, and predictors of outcome of candidemia. Survey in 2 Italian university hospitals. Diagn Microbiol Infect Dis 2007; 58: 325–31. Al-Tawfiq JA. Distribution and epidemiology of Candida species causing fungemia at a Saudi Arabian hospital, 1996-2004. International Journal of Infectious Diseases 2007; 11: 239–44. Yapar N, Uysal U, Yucesoy M, Cakir C, Yuce A. Nosocomial bloodstream infections associated with Candida species in a Turkish University Hospital. Mycoses 2005; 49: 134–8. G€ ultekin B, Eyig€ or M, Telli M, Aksoy M, Aydın N. A retrospective investigation of Candida species isolated from blood cultures during a seven-year period. ANKEM Derg 2010; 24: 202–8. Kibber CC, Seaton S, Barnes RA, Gransden WR. Management and outcome of bloodstream infections due to Candida species in England and Wales. J Hosp Infect 2003; 54: 18–24. Luzzati R, Amalfitano G, Lazzarini L, Soldani F. Nosocomial candidemia in nonneutropenic patients at an Italian tertiary care hospital. Eur J Clin Microbiol Infect Dis 2000; 19: 602–7. McMullan R, McClurg R, Xu J, Moore JE. Trends in the epidemiology of Candida bloodstream infections in Northern Ireland between January 1984 and December 2000. J Infect 2002; 45: 25–28. Garbino J, Kolarova L, Rohner P, Lew D. Secular trends of candidemia over 12 years in adult patients at a tertiary care hospital. Medicine (Baltimore). 2002; 81: 425–33. Richet H, Roux P, Champs CD, Esnault Y, Andremont A, French candidemia study group. Candidemia in French hospitals: incidence rates and characteristics. Clin Microbiol Infect 2002; 8: 405–12. Dimopoulos G, Ntziora F, Rachiotis G, Armaganidis A, Falagas ME. Candida albicans versus non-albicans intensive care unit-acquired bloodstream infections: differences in risk factors and outcome. Anest Analq 2008; 106: 523–9.
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Macplhail GL, Taylor GD, Buchanan-Chell M, Ross C, Wilson S, Kureishi A. Epidemiology, treatment and outcome of candidemia: a five-year review at three hospitals. Mycoses 2002; 45: 141–5. Tortorano AM, Peman J, Bernhardt H et al. Epidemiology of candidemia in Europe: resuts of 28-month European Confederation of Medical Mycology (ECMM) hospital-based surveillance study. Eur J Clin Microbiol Infect Dis 2004; 23: 317–22. Lagrou K, Verhaegen J, Petermans WE, Rijdt TD, Maertens J, Wijngaerden EV. Fungemia at a tertiary care hospital: incidence, therapy, distribution and antifungal susceptibility of causative species. Eur J Clin Microbiol Infect Dis 2007; 26: 541–7. Dery MA, Hasbun R. Fluconazole resistant Candida: mechanisms and risk factor identification. Curr Fungal Infect Rep 2011; 5: 23–28. Lee I, Zaoutis TE, Fishman NO, Morales KH, Nachamkin I, Lautenbach E. Risk factors for fluconazole resistance in patients with Candida glabrata bloodstream infection potential impact of control group selection on characterizing the association between previous fluconazole use and fluconazoleresistance. Am J Infect Control 2010; 38: 456–60. Ben-Ami R, Olshtain-Pops K, Krieger M et al. Antibiotic exposure as a risk factor for fluconazole-resistant Candida bloodstream infection. Antimicrob Agents Chemother 2012; 56: 2518–23. Cuenca-Estrella M, Rodriguez-Tudela JL. The current role of the reference procedures by CLSI and EUCAST in the detection of resistance
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to antifungal agents in vitro. Expert Rev Anti Infect Ther. 2010; 8: 267–76. Pfaller MA. Antifungal drug resistance: mechanisms, epidemiology, and consequences for treatment. Am J Med 2012; 125(suppl 1): S1– 13. Pfaller MA, Diekema DJ, Andes D et al. Clinical breakpoints for the echinocandins and Candida revisited: integration of molecular, clinical, and microbiological data to arrive at species-specific interpretive criteria. Drug Resist Update 2011; 14: 164–76. Dizbay M, Fidan I, Kalkancı A et al. High incidence of Candida parapsilosis candidaemia in non-neutropenic critically ill patients: epidemiology and antifungal susceptibility. Scand J Infect Dis 2010; 42: 114–20. Arendrup MC, Rodriguez-Tudela JL, Lass-Fl€ orl C et al. EUCAST technical note on anidulafungin. Clin Microbiol Infect 2011; 17: E18–20. Rodriguez-Tudela JL, Arendrup MC, Barchiesi F et al. EUCAST definitive document EDef 7.1: method for the determination of broth dilution MICs of antifungal agents for fermentative yeasts. Clin Microbiol Infect 2008; 14: 398–405. Arendrup MA, Pfaller MA, Danish Fungaemia Study Group. Caspofungin E test susceptibility testing of Candida species: risk of misclassification of susceptible isolates of C. glabrata and C. krusei when adopting the revised CLSI caspofungin breakpoints. Antimicrob Agents Chemother 2012; 56: 3965–8
629
Diagnosis,Therapy and Prophylaxis of Fungal Diseases
Original article
An investigation of Candida species isolated from blood cultures during 17 years in a university hospital 4 € Ozkan, € ırlı,3 O. lu,5 Emel Yılmaz,1 Solmaz C € rcu € og E. Kazak,1 H. Akın,1 B. Ener,2 D. Sıg E. Gu ß elebi,6 2 1 lar and Halis Akalın Sevim Akcßag 1 Department of Infectious Diseases and Clinical Microbiology, Faculty of Medicine, Uludag University, Go€ru€kle, Bursa, Turkey, 2Department of Medical Microbiology, Faculty of Medicine, Uludag University,Go€ru€kle, Bursa, Turkey, 3Department of Biostatistics, Faculty of Medicine, Uludag University, Go€ru€kle, Bursa, Turkey, 4Department of Microbiology, T.C. Ministry of Health Sßevket Yılmaz Hospital, Bursa, Turkey, 5Department of Infectious Diseases and Clinical Microbiology, Bursa Doruk Hospital, Yıldırım, Bursa, Turkey and 6Department of Pediatrics, Faculty of Medicine, Uludag University, Go€ru€kle, Bursa, Turkey
Summary
Candidemia is the most frequent manifestation observed with invasive candidiasis. The aim of this study was to analyse the trends of candidemia in a large tertiarycare hospital to determine the overall incidence during January 1996–December 2012, as well as to determine the susceptibility of 453 isolates according to the revised Clinical and Laboratory Standards Institute (CLSI) breakpoints. Candidemia episodes in adult and paediatric patients were retrospectively analysed from the laboratory data of Uluda g University Healthcare and Research Hospital. The 17-year period studied was divided into three periods (1996–2001, 2002–2007 and 2008– 2012) for better comparison, and candidemia incidence was determined by the ratio of total number of patients with candidemia per 1000 patients admitted to the hospital and per 10 000 patient days in these three periods. Redefined CLSI M27-A3 breakpoints were used for interpretation of antifungal susceptibility results. Candidemia incidence was determined as 2.2, 1.7 and 1.5 per 1000 admitted patients during 1996–2001, 2002–2007 and 2008–2012 respectively. A significantly decreased candidemia incidence was obtained in the third period. C. albicans (43.8%) was the most common candidemia agent, followed by C.parapsilosis (26.5%) in all three periods. According to the revised CLSI breakpoints, there was fluconazole resistance in C. albicans, C.parapsilosis, C.tropicalis and C.glabrata species (1.4%, 18.2%, 2.6% and 14.3% respectively). Almost all Candida species were found susceptible to voriconazole except one C.glabrata (7.1%) isolate. Candidemia is an important health problem. Local epidemiological data are determinative in the choice of appropriate antifungal treatment agents.
Key words: Candida species, candidemia, antifungal susceptibility.
Introduction
Correspondence: Esra Kazak MD, Department of Infectious Diseases and University, Go € ru €kle, Clinical Microbiology, Faculty of Medicine, Uludag Bursa 16059, Turkey. Tel.: +90 532 240 99 27. Fax: +90 224 295 00 99. E-mail: [email protected] Submitted for publication 19 January 2014 Revised 24 April 2014 Accepted for publication 23 May 2014
© 2014 Blackwell Verlag GmbH Mycoses, 2014, 57, 623–629
The widespread use of broad-spectrum antibiotics and an expanded number of immunocompromised patients have caused an increase in the incidence of candidiasis in recent years.1 Candida species, which colonise in mucocutaneous membranes immediately after birth, are members of normal flora located mainly in the gastrointestinal system.2 When their number and intensity increase in the flora, they can easily invade into the blood from damaged epithelial tissue following
doi:10.1111/myc.12209
E. Kazak et al.
surgical intervention or cytotoxic chemotherapy and cause candidemia. In addition, they also form biofilm layers on foreign body surfaces such as prosthesis or catheters.3,4 Rapidly progressive candidemia, which is difficult to diagnose and treat, increases mortality rates and costs as well as extends hospitalisation. In the United States of America (USA), C. albicans is the fourth most significant agent of bloodstream infection. The agents responsible for 97% of candidemia are C.albicans, C.glabrata, C.parapsilosis, C.tropicalis and C.krusei respectively.5 Species identification of candidemia would be beneficial in defining the risk factors, taking the necessary preventative measures and starting the appropriate treatment as soon as possible. This study aimed to define the incidence of candidemia and the distribution of Candida strains isolated from blood cultures during January 1996–December 2012 and retrospectively to interpret the in vitro antifungal susceptibility of 453 isolates according to the revised Clinical and Laboratory Standards Institute (CLSI) breakpoints.
Materials and methods Uluda g University Healthcare and Research Hospital is an 800-bed tertiary-care Joint Commission International accredited teaching institution. There are seven adult (Reanimation, Chest-Heart-Vascular Surgery, Cardiology, Plastic Surgery and Burns Unit, Neurology, Brain Surgery and Chest Diseases) and two (Neonatal and Paediatric) paediatric intensive care units (ICUs) as well as haematology and oncology wards and kidney, liver and bone marrow transplantation units. All blood cultures that have been collected are sent to the laboratory to incubate. Since 1990, the BACTEC 9000 automated blood culture system (Becton Dickinson, INC, Sparks, MD) has been used in the laboratory. Blood culture bottles positive for yeast were subcultured on Emmons’ modified Sabouraud dextrose agar (SDA 2%) and inhibitory mould agar (IMA) and incubated for 24–72 h at 35°C. The isolates were identified by germ tube production, morphology on cornmeal Tween-80 agar and/or chromogenic agar and analysis of biochemical patterns by API 20 AUX or API ID 32C (bioMerieux, Marcy I’Etoile, France) commercial systems.6 All candidemia data were obtained retrospectively from laboratory records in January 1996 and December 2012. Consecutive growth associated with the same attack in patients was treated as a single episode. In addition, data from adults/paediatrics and wards/
624
ICUs were considered separately. The incidence of candidemia was calculated as the ratio of total number of patients to 1000 hospitalised patients and 10 000 patient days. The most frequently seen Candida species were defined from the data obtained over 17 years. The period of 17 years was divided into three groups: 1996–2001, 2002–2007 and 2008–2012. The data from 2008–2012 were compared with the 1996– 2001 and 2002–2007 data of Candida cases evaluated in a study by G€ urc€ uo glu et al. [7] in our institution. In 2002, all the recipes should have been approved by infection control team at our hospital, so second period was important to see the effect of this application. In 2008, our hospital was accredited by Joint Commission International and to see the effect of better patients care after these data are also wanted to consider. The antifungal susceptibility data of 453 isolates was obtained from laboratory records. Refined CLSI M27-A3 breakpoints after 24-h incubation were used for antifungal susceptibility interpretations.8–11 Statistical analysis of the data was made with IBM SPSS Statistics 21 and the Epi Info 7.1.1.1 programme. Categorical variables were stated as numbers and percentages. In the comparison between groups, Pearson’s chi-squared test and Fisher’s exact test were used, and for the comparison of changes between years of the frequency, the chi-squared trend test was used. A value of a = 0.05 was accepted as the level of statistical significance.
Results In the 17-year period, the number of hospitalised patients was 583 079. There were 1035 candidemia attacks during the period and 1062 Candida species were isolated. Candidemia episodes associated with two different species were determined in nine patients in both the adult and paediatric groups during 2002– 2007 and in six adult and three paediatric patients during 2008–2012. The total isolated strains were C. albicans (n = 465, 43.8%), C. parapsilosis (n = 281, 26.5%), C. tropicalis (n = 89, 8.4%), C.krusei (n = 62, 5.8%), C. glabrata (n = 58, 5.5%) and other Candida species (n = 107, 10.1%) during the 17-year period. C. parapsilosis, C. krusei and C. pelliculosa in children and C. tropicalis, C. glabrata and C. kefyr in adults were seen significantly more. C. pelliculosa isolates were only seen in paediatric patients (Table 1). The distribution of the isolated species according to the years of the three separate periods is shown Table 2. C. albicans was the most frequently seen
© 2014 Blackwell Verlag GmbH Mycoses, 2014, 57, 623–629
Candidemia species, resistance and incidence
Table 1 Species distribution of candidemia during 1996–2012. Adults (%)
Paediatrics (%)
C. albicans C. parapsilosis C. tropicalis C. krusei C. glabrata Candida spp.*** C. kefyr C. guilliermondii C. lipolytica C. pelliculosa C. inscons/norva C. lusitaniae C. dubliniensis C. zeylanoides C. famata C. sake
313 161 68 23 49 25 23 7 3 0 4 1 3 1 1 1
152 120 21 39 9 16 3 3 5 7 2 2 0 0 0 0
Total
683
(45.8) (23.6) (10) (3.4) (7.2) (3.7) (3.4) (1) (0.4) (0) (0.6) (0.1) (0.4) (0.1) (0.1) (0.1)
(40.1) (31.7) (5.5) (10.3) (2.4) (4.2) (0.8) (0.8) (1.3) (1.8) (0.5) (0.5) (0) (0) (0) (0)
Total 465 281 89 62 58 41 26 10 8 7 6 3 3 1 1 1
379
P value 0.072 0.004* 0.013** 64
0.5 32 2 0.5 0.5
2 32 64 4 16
≤0.032–1 ≤0.032–2 ≤0.032–2 ≤0.032–1 ≤0.032–>4
0.125 0.5 0.25 0.125 0.064
0.25 1 1 0.5 0.5
≤0.032–0.125 ≤0.032–0.5 ≤0.032–1 ≤0.032–0.5 ≤0.032–1
≤0.032 0.25 0.064 ≤0.032 ≤0.032
0.125 0.5 0.25 0.125 0.25
MIC, minimal inhibitory concentration.
626
© 2014 Blackwell Verlag GmbH Mycoses, 2014, 57, 623–629
Candidemia species, resistance and incidence
Table 6 Resistance breakpoints.10,11
rates
according
to
revised
CLSI
Antifungal agents Species C. albicans n = 216 C. parapsilosis n = 126 C. tropicalis n = 39 C. glabrata n = 14 C. krusei n = 34
Revised Revised Revised Revised Revised
Fluconazole
Voriconazole
_Itraconazole
1.4% (n = 3) 18.2% (n = 23) 2.6% (n = 1) 14.3% (n = 2) –
0
6%1 (n = 13) 0.8%2 (n = 1) 0
0 0 7.1%3 (n = 1) 0
Epidemiological cut-off value >0.125 lg ml
1
Epidemiological cut-off value >1 lg ml
2
0
.
1
Epidemiological cut-off value >0.5 lg ml
3
1
0
. 1
.
intensive care unit, insufficient infection control precautions, that our hospital is a third-stage training hospital, the use of broad-spectrum antibiotics in healthcare institutions in our region, the transfer to our hospital of critical patients who have undergone various invasive approaches, treatment at our hospital for transplantation, an increased number of patients with haematological or oncological malignity and no limitation in the use of wide spectrum antibiotics in the period of 1996–2001.7 However, it was noticeable that there was a significant reduction in the period of 2008–2012 compared to 1996–2001. A more knowledgeable application of parenteral nutrition, the application of infection control precautions, improvements in the care of central venous catheters, limitations in the use of broad-spectrum antibiotics from 2002 and more extensive consultation on infectious diseases are thought to play a significant role in this reduction. Several international studies have reported that a stay in an intensive care unit is a basic risk factor in the development of candidemia. Different studies have stated that 30%–70% of all patients diagnosed with candidemia were hospitalised in ICU.16,18–20 According to the data of this study, 32.6%–44.8% of the candidemia cases comprised patients from ICUs. Previous studies have reported that significant changes have been determined in the candidemia agents, and apart from C. albicans, there were increases in infections associated with other Candida species.21–24 In a study including European countries in the period of 1997–1999, C. albicans (54%) was the leading candidemia agent. This was followed by C. glabrata (13.6%) and C. parapsilosis (13.3%).25 A similar order was reported in a
© 2014 Blackwell Verlag GmbH Mycoses, 2014, 57, 623–629
study conducted in Belgium covering 2001–2005 (C. albicans 58.8%, C. glabrata 22.2%, C. parapsilosis 9.6%).26 Between 2000 and 2003, the four leading candidemia agents in Turkey were reported as C. albicans (57.7%), C. tropicalis (20.2%), C. parapsilosis (12.5%) and C. glabrata (3.8%).16 In this study, C. albicans was the most frequently seen agent both in wards and ICUs in all three periods. Apart from C. albicans, the greater frequency of C. krusei in the first period is thought to originate from an epidemic associated with this agent. As shown in Table 1, there was a difference in the frequency of Candida species that were seen in paediatric and adult patients. In paediatric patients, apart from C. albicans, C. parapsilosis maintained its significance as an agent in all three periods. However, the decrease seen among periods in the C. parapsilosis rates is thought to be due to the effects of infection control precautions and improvements in catheter care, particularly in adult ICUs. On the other hand, as C. krusei, C. tropicalis and C. keyfr infections were found to be at higher rates in wards than in ICUs in our study, we believe that these data are important for the choice of empirical antifungal treatment. When the increase in the frequency of C. glabrata is considered, we know that there is controversy about the relationship between fluconazole usage and azoleresistant Candida infections.27,28 In addition, some antibiotics were found to be a risk factor for different Candida species.29 Unfortunately, we have no welldefined data for antifungal usage in our hospital. Knowing the prevalence of agents will be an indicator in the choice of antifungal agents, but in vitro antifungal susceptibility testing is also standardised internationally; its most important function is the detection of resistance.30 Both CLSI and EUCAST have established clinical breakpoints for azoles and echinocandins versus Candida species, and CLSI revised the clinical breakpoints very recently.31,32 According to the revised criteria, C. parapsilosis isolates have shown increased resistance to fluconazole (18.25%) in this study, which is a very interesting result. Although approximately 1% of blood stream C. parapsilosis isolates have fluconazole resistance according to population-based and sentinel surveillance surveys, there are some exceptionally higher frequencies (15%) reported in Sweden.1 Also, Dizbay et al. [33] in Turkey have determined 7.4% resistance to fluconazole among C. parapsilosis isolates in non-neutropenic patients; perhaps higher rates may be obtained by using revised breakpoints. Thus, more comprehensive susceptibility studies and a molecular approach may be necessary for our C. parapsilosis isolates.
627
E. Kazak et al.
In a study by Fothergill et al. [11] evaluating antifungal sensitivity with the revised new CLSI breakpoints, they reported that after revision, increased resistance to echinocandin and fluconazole was observed in Candida species and that the most significant change was in the increased resistance of C. glabrata to echinocandin. In this study, no increased resistance of C. glabrata to caspofungin was determined after revision. However, a significant increase was determined in C. krusei resistance to caspofungin. Although the CLSI has established breakpoints for all three echinocandins, EUCAST has not set caspofungin breakpoints and does not currently recommend caspofungin MIC testing for clinical decision making. This is due to unacceptably high variation among caspofungin MIC values from different centres; thus, EUCAST recommends anidulafungin MIC testing as a marker for the echinocandin class of drugs.34,35 In a study conducted by Arendrup et al.,[36] 13.1% of anidulafungin susceptible isolates were misclassified as intermediate or resistant by using revised CLSI breakpoints; furthermore, they found that misclassifications were most commonly observed for C. krusei (73.1% misclassified as I) and for C. glabrata (31.6% misclassified as I and 1.5% as R) isolates. Thus, it is necessary to test the resistant C. krusei isolates by using anidulafungin to determine the exact resistance. In conclusion, candidemia is a significant nosocomial health problem. Epidemiologic surveys that examine local and regional data can be used to develop empiric treatment strategies and are essential in tracking resistance trends. According to the data of this study, although the incidence of candidemia has decreased over the years in our hospital, it serves as a warning in terms of considering the relationship between the increase in the number of Candida species apart from C. albicans, the choice of antifungal, underlying factors and the use of prophylactic or empirical antifungals.
2
3
4 5
6 7
8
9
10
11
12 13
14
15
16
17
18
19
Conflict of interest There is no conflict of interest for authors.
Funding
20
21
No competing financial interests exist.
22
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