Evaluation Of The Distribution Of Candida Species In The Blood Culture Of Icu Patients

Öz

Candidemia is an infectious disease caused by yeast fungi of the Candida (C.) species. It is one of the important bloodstream infections with high mortality and difficult to early diagnosis and treatment, mostly occurring in the intensive care units of hospitals. The incidence of candidemia-causing species can vary from country to country and even between hospitals in the same country. Candida albicans (C. albicans) is the most common cause of candidemia. However, in recent years, the incidence of candidemia due to non-albicans Candida species has increased. In this study, the distribution of Candida species detected in blood samples sent from patients with suspected candidemia from intensive care units to the Microbiology laboratory of Fırat University Faculty of Medicine between July 2017 and July 2022 was conducted retrospectively. The blood culture bottles delivered to our laboratory were placed in the BD BACTEC™ blood culture device. Gram positive fungal spores were searched in Gram staining done directly from blood culture bottles that gave a positive signal after 24 hours. Passages of 5% sheep blood agar medium (Oxoid, UK), eosin-methylene blue (EMB, Oxoid, UK) and Sabouraud Dekrose Agar (SDA, Oxoid, UK) were made from positive bottles. The cultures were evaluated for their growth at the end of their incubation at 35-37°C for 18-24 hours bacteriologically and 18-72 hours (sometimes 1 week) mycologically. Identification of microorganisms; Colony structures were performed based on Gram stain, germ tube test, conventional biochemical test results and matrix assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF MS) technique C.albicans species were detected in 208 (38%) and non-albicans Candida species in 335 (62%) of 543 blood cultures positive for Candida spp. Among non-albicans species, C. parapsilosis was most frequently isolated in 174 (32%) samples. C.albicans is still the most frequently isolated species from candidemia cases. However, non-albicans species continue to cause blood infections with increasing frequency in intensive care patients.

Anahtar Kelimeler

• Candida albicans
• MALDI-TOF MS
• Candida
• Sabouraud Dektroz Agar

Yoğun Bakım Hastalarının Kan Kültüründe Üreyen Candida Türlerinin Dağılımının Değerlendirilmesi

Öz

Kandidemi, Candida (C.) türü maya mantarları tarafından oluşturulan bir enfeksiyon hastalığıdır. Çoğunlukla hastanelerin yoğun bakım ünitelerinde ortaya çıkan erken tanısı ve tedavisi zor, mortalitesi yüksek önemli kan dolaşımı enfeksiyonlarındandır. Kandidemiye neden olan türlerin insidansı ülkeden ülkeye, hatta aynı ülkedeki hastaneler arasında değişebilmektedir. Kandidemi etkeni en sık Candida albicans (C. albicans)’dır. Ancak son yıllarda non-albicans Candida türleri ile gelişen kandidemi insidansında artış görülmeye başlanmıştır. Bu çalışmada Temmuz 2017- Temmuz 2022 tarihleri arasında Fırat Üniversitesi Tıp Fakültesi Mikrobiyoloji laboratuvarına yoğun bakım ünitelerinden kandidemi şüpheli hastalardan gönderilen kan örneklerinde saptanan Candida türlerinin dağılımı retrospektif olarak yapılmıştır. Laboratuvarımıza gelen kan kültür şişeleri BD BACTEC™ kan kültürü cihazına yerleştirilmiştir. 24 saat sonra pozitif sinyal veren kan kültür şişelerinden direk yapılan Gram boyamada Gram pozitif mantar sporları aranmıştır. Pozitif şişelerden %5 koyun kanlı agar besiyeri (Oxoid, İngiltere), eozin-metilen blue (EMB, Oxoid, İngiltere) ve Sabouraud Dektroz Agar (SDA, Oxoid, İngiltere) pasajları yapılmıştır. Kültürler bakteriyolojik olarak 18-24 saatlik, mikolojik olarak da 18-72 (bazen 1 hafta) saatlik 35-37°C’lik etüvdeki inkübasyonları sonunda üremeleri yönünden değerlendirilmiştir. Mikroorganizmaların tanımlanması; koloni yapıları, Gram boyama, germ tüp testi, konvansiyonel biyokimyasal test sonuçları ve matris destekli lazer desorpsiyon/iyonizasyon uçuş süresi kütle spektrometresi (MALDI-TOF MS) tekniğine dayalı olarak gerçekleştirilmiştir. Candida spp.yönünden pozitif 543 kan kültürünün 208’inde (%38) C. albicans, 335 (%62) ’inde non-albicans Candida türleri saptanmıştır. Non-albicans türlerden ise en sık 174 (%32) örnekte C. parapsilosis izole edilmişitir. Kandidemi olgularından halen en sık izole edilen tür C. albicans’tır. Ancak yoğun bakım hastalarında non-albicans türleri de artan sıklıkla kan enfeksiyonlarına yol açmaya devam etmektedir.

Anahtar Kelimeler

• Candida
• Candida.albicans
• Sabouraud Dektroz Agar
• MALDI-TOF MS.
• Candida albicans
• MALDI-TOF MS

Kaynakça

1. Arendrup MC, Dzajic E, Jensen RH, Johansen HK, Kjaeldgaard P, Knudsen JD, et al. (2013) Epidemiological changes with potential implication for antifungal prescription recommendations for fungaemia: data from a nationwide fungaemia surveillance programme. Clin Microbiol Infect 19:E343–E353. 10.1111/1469-0691.12212
2. Barchiesi F, Orsetti E, Gesuita R, Skrami E, Manso E; Candidemia Study Group (2016) Epidemiology, clinical characteristics, and outcome of candidemia in a tertiary referral center in Italy from 2010 to 2014. Infection 44:205–213.
3. Buchan BW, Ledeboer NA (2013) Advances in identification of clinical yeast isolates by use of matrix-assisted laser desorption ionization–time of flight mass spectrometry. J Clin Microbiol 51:1359–1366
4. Chen S, Slavin M, Nguyen Q, Marriott D, Playford EG, Ellis D, Sorrell T; Australian candidemia study. Active surveillance for candidaemia, Australia. Emerg Infect Dis 2006; 12: 1508–1516. 10.3201/eid1210.060389
5. Chow JK, Golan Y, Ruthazer R, Karchmer AW, Carmeli Y, Lichtenberg DA, et al. (2008) Risk factors for albicans and non-albicans candidemia in the intensive care unit. Crit Care Med 36:1993–1998. 10.1097/ccm.0b013e31816fc4cd
6. Clancy CJ, Barchiesi F, Falconi DiFrancesco L, Morris AJ, Snydman DR, Yu VL, et al. Clinical manifestations and molecular epidemiology of late recurrent candidemia, and implications for management. Eur J Clin Microbiol Infect Dis. 2000;19(8):585–92. Epub 2000/10/03.
7. Colombo AL, Guimaraes T, Sukienik T, et al. Prognostic factors and historical trends in the epidemiology of candidemia in critically ill patients: an analysis of five multicenter studies sequentially conducted over a 9-year period. Intensive Care Med. 2014;40:1489–98.
8. Gonzalez de Molina FJ, Leon C, Ruiz-Santana S, Saavedra P Group CIS. Assessment of candidemia-attributable mortality in critically ill patients using propensity score matching analysis. Crit Care. 2012;16:R105.

9. Jeffery-Smith A, Taori SK, Schelenz S, Jeffery K, Johnson EM, Borman A, Candida auris Incident Management Team , Manuel R, Brown CS. Candida auris: a review of the Literature. Clin Microbiol Rev. 2017;31. pii: e00029-17.
10. Jung DS, Farmakiotis D, Jiang Y, Tarrand JJ, Kontoyiannis DP. Uncommon Candida Species Fungemia among Cancer Patients, Houston, Texas, USA. Emerg Infect Dis. 2015;21(11):1942–50. 10.3201/eid2111.150404
11. Khan Z, Ahmad S, Al-Sweih N, Joseph L, Alfouzan W, Asadzadeh M. Increasing prevalence, molecular characterization and antifungal drug susceptibility of serial Candida auris isolates in Kuwait. PLoS One 2018; 13: e0195743 10.1371/journal.pone.0195743
12. Kollef M, Micek S, Hampton N, Doherty JA, Kumar A. Septic shock attributed to Candida infection: importance of empiric therapy and source control. Clin Infect Dis. 2012;54(12):1739–46.
13. Lamoth F, Lockhart SR, Berkow EL, Calandra T (2018) Changes in the epidemiological landscape of invasive candidiasis. J Antimicrob Chemother. 73 (suppl 1):i4–i13. 10.1093/jac/dkx444.
14. Laverdiere M, Labbe AC, Restieri C, Rotstein C, Heyland D, Madger S, et al. (2007) Susceptibility patterns of Candida species recovered from Canadian intensive care units. J Crit Care 22:245–250. 10.1016/j.jcrc.2006.10.038
15. Lockhart SR, Iqbal N, Cleveland AA, Farley MM, Harrison LH, Bolden CB, et al. (2012) Species identification and antifungal susceptibility testing of Candida bloodstream isolates from population-based surveillance studies in two U.S. cities from 2008 to 2011. J Clin Microbiol 50:3435–3442. 10.1128/jcm.01283-12
16. Lortholary O, Renaudat C, Sitbon K, Desnos-Ollivier M, Bretagne S, Dromer F, et al. (2017) The risk and clinical outcome of candidemia depending on underlying malignancy. Intensive Care Med 43:652–662. 10.1007/s00134-017-4743-y.
17. Macphail GL, Taylor GD, Buchanan-Chell M, Ross C, Wilson S, Kureishi A (2002) Epidemiology, treatment and outcome of candidemia: a five-year review at three Canadian hospitals. Mycoses 45:141–145. 10.1046/j.1439-0507.2002.00741.
18. Marriott DJ, Playford EG, Chen S, et al. Determinants of mortality in non-neutropenic ICU patients with candidaemia. Crit Care. 2009;13:R115. Miranda LN, van der Heijden IM, Costa SF, Sousa AP, Sienra RA, Gobara S, et al. Candida colonisation as a source for candidaemia. J Hosp Infect. 2009;72(1):9–16. Epub 2009/03/24.
19. Nucci M, Anaissie E. Revisiting the source of candidemia: skin or gut? Clin Infect Dis. 2001;33(12):1959–67. Epub 2001/11/10.
20. Pfaller M, Diekema D, Gibbs D, Newell VA, Ellis D, Tullio V, et al. (2010) Results from the ARTEMIS DISK Global Antifungal Surveillance Study, 1997 to 2007: a 10.5-year analysis of susceptibilities of Candida species to fluconazole and voriconazole as determined by CLSI standardized disk diffusion. J Clin Microbiol 48:1366–1377. 10.1128/JCM.02117-09
21. Pfaller MA, Diekema DJ, Gibbs DL, Newell VA, Ellis D, Tullio V, Rodloff A, Fu W, Ling TA, and the Global Antifungal Surveillance Group (2010) Results from the ARTEMIS DISK global antifungal surveillance study, 1997 to 2007: a 10.5-year analysis of susceptibilities of Candida species to fluconazole and voriconazole as determined by CLSI standardized disk diffusion. J Clin Microbiol 48:1366–1377
22. Pfaller MA, Diekema DJ, Gibbs DL, Newell VA, Meis JF, Gould IM, Fu W, Colombo AL, Rodriguez-Noriega E, and the Global Antifungal Surveillance Group (2007) Results from the ARTEMIS DISK global antifungal surveillance study, 1997 to 2005: an 8.5-year analysis of susceptibilities of Candida species and other yeast species to fluconazole and voriconazole determined by CLSI standardized disk diffusion testing. J Clin Microbiol 45:1735–1745
23. Playford EG, Eggimann P, Calandra T. Antifungals in the ICU. Curr Opin Infect Dis. 2008;21(6):610–9.
24. Posteraro B, De Carolis E, Vella A et al (2013) MALDI-ToF mass spectrometry in the clinical mycology laboratory: identification of fungi and beyond. Expert Rev Proteomics 10:151–164
25. Sendid B, Ducoroy P, Francois N et al (2013) Evaluation of MALDI-ToF mass spectrometry for the identification of medically-important yeasts in the clinical laboratories of Dijon and Lille hospitals. Med Mycol 51:25–32
26. Shields RK, Nguyen MH, Clancy CJ (2015) Clinical perspectives on echinocandin resistance among Candida species. Curr Opin Infect Dis 28:514–522. 10.1097/QCO.0000000000000215
27. Tsai MH, Hsu JF, Yang LY, Pan YB, Lai MY, Chu SM, Huang HR, Chiang MC, Fu RH, Lu JJ. Candidemia due to uncommon Candida species in children: new threat and impacts on outcomes. Sci Rep. 2018. October 15;8(1):15239 10.1038/s41598-018-33662.
28. Vena A, Bouza E, Valerio M, Padilla B, Paño-Pardo JR, Fernández-Ruiz M, Díaz Martín A, Salavert M, Mularoni A, Puig-Asensio M, Muñoz P; CANDIPOP Project. Candidemia in non-ICU surgical wards: Comparison with medical wards. PLoS One. 2017 Oct 18;12(10):e0185339. doi: 10.1371/journal.pone.0185339. PMID: 29045423; PMCID: PMC5646772.
29. Wang H, Fan Y-Y, Kudinha T et al (2016) A comprehensive evaluation of the Bruker Biotyper MS and Vitek MS matrix-assisted laser desorption ionization–time of flight mass spectrometry systems for identification of yeasts, part of the National China Hospital Invasive Fungal Surveillance Net (CHIF-NET) study, 2012 to 2013. J Clin Microbiol 54:1376–1380
30. Wang H, Xiao M, Chen SC et al (2012) In vitro susceptibilities of yeast species to fluconazole and voriconazole as determined by the 2010 National China Hospital Invasive Fungal Surveillance Net (CHIF-NET) study. J Clin Microbiol 50:3952–3959
31. Wisplinghoff H, Bischoff T, Tallent SM, Seifert H, Wenzel RP, Edmond MB. Nosocomial bloodstream infections in US hospitals: analysis of 24,179 cases from a prospective nationwide surveillance study. Clin Infect Dis. 2004;39(3):309–17.
32. Zhang L, Xiao M, Wang H, Gao R, Fan X, Brown M, Gray TJ, Kong F, Xu YC, Warnock DW (2014) Yeast identification algorithm based on use of the Vitek MS system selectively supplemented with ribosomal DNA sequencing: proposal of a reference assay for invasive fungal surveillance programs in China. J Clin Microbiol 52:572–577.