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Dr Mohan Z Mani

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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."



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Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
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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.
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Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




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"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




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" 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 : 2022 | Month : April | Volume : 16 | Issue : 4 | Page : DC09 - DC14 Full Version

Isolation, Identification and Antifungal Susceptibility Testing of Candida Species: A Cross-sectional Study from Manipur, India


Published: April 1, 2022 | DOI: https://doi.org/10.7860/JCDR/2022/55695.16248
Urvashi Chongtham, Debina Chanu Athokpam, Rajkumar Manojkumar Singh

1. Associate Professor, Department of Microbiology, Jawaharlal Nehru Institute of Medical Sciences, Imphal, Manipur, India. 2. State Medical Officer (Microbiologist), Manipur Health Services, Directorate of Health Services, Imphal, Manipur, India. 3. Associate Professor, Department of Microbiology, Jawaharlal Nehru Institute of Medical Sciences, Imphal, Manipur, India.

Correspondence Address :
Dr. Rajkumar Manojkumar Singh,
Associate Professor, Department of Microbiology, Jawaharlal Nehru Institute of Medical Sciences, Porompat, Imphal East-795005, Manipur, India.
E-mail: rkmksingh@gmail.com

Abstract

Introduction: Candidiasis is an opportunistic infection which occurs due to indiscriminate and prolonged use of broad-spectrum antimicrobials, corticosteroids, immunosuppressive agents, diabetes mellitus, Human Immunodeficiency Virus (HIV), chronic renal failure, haemodialysis, renal transplantation or indwelling urinary catheter. Recently, Non-albicans Candida (NAC) species have replaced Candida albicans and emerged as an important opportunistic pathogens exhibiting decreased susceptibility to commonly used antifungal agents. Early speciation of Candida isolates along with their antifungal susceptibility testing not only will restrict the empirical use of antifungal agent but also greatly influence the treatment options for the clinicians.

Aim: To speciate Candida isolates from various clinical specimens and to determine their antifungal susceptibility pattern.

Materials and Methods: This study was a cross-sectional study carried out in the Mycology Section, Department of Microbiology, Jawaharlal Nehru Institute of Medical Sciences (JNIMS), Imphal, Manipur, India, from September 2016 to August 2018. Candida isolates were identified using standard microbiological procedures and speciation was done following conventional and HiCrome differential media. Antifungal susceptibility testing was determined by using Clinical and Laboratory Standards Institute (CLSI) disk diffusion method. Data analysis was done using descriptive statistics and Chi-square test.

Results: A total of 100 isolates were identified from different clinical specimens, which included 43 (43%) from sputum, 34 (34%) from urine, in majority. Highest age was 92 years and lowest age was one year from whom the isolates were detected and females (57%) outnumbered males (43%) patients. Predominant Candida isolates were Candida albicans (44%), Candida tropicalis (32%). Among the azoles, the most sensitive agent was voriconazole (86%) and least was ketoconazole (56%), 81% of the total isolates were found sensitive to amphotericin B.

Conclusion: The present study demonstrated that NAC spp. have surpassed Candida albicans and there is an increase in the resistance of the Candida isolates to commonly used antifungal agents. Therefore, this study highlights the need for speciation of Candida isolates upto species level and to determine the antifungal susceptibility pattern to decrease the morbidity and mortality of the patients.

Keywords

Antifungal agents, Candida albicans, Non-albicans Candida, Speciation

Candidiasis is the most common fungal disease found in humans affecting mucosa, skin, nails and internal organs of the body. It is caused by various species of yeast-like fungi belonging to genus Candida with Candida albicans as the representative species. Other pathogenic species include Candida tropicalis, Candida krusei, Candida glabrata, Candida guilliermondii, Candida parapsilosis, Candida lusitaniae, Candida kefyr, Candida rugosa, Candida dubliniensis and Candida viswanathii (1).

Candidiasis is an opportunistic infection occurring in presence of predisposing factors like extensive and prolonged administration of broad-spectrum antimicrobials, corticosteroids, immunosuppressive agents and cytotoxic drugs, diabetes mellitus, HIV, chronic renal failure, haemodialysis, renal transplantation or indwelling urinary catheter (2). Till recently, Candida albicans was considered as the most frequently isolated Candida species accounting for 60-80% of the fungal infections but NAC have now become predominant (3). NAC spp. such as Candida glabrata, Candida krusei and Candida tropicalis are emerging opportunistic pathogens and they exhibit varying degree of resistance, either intrinsic or acquired or both, to commonly used antifungal drugs (4). Indiscriminate and widespread use of fluconazole for the prophylaxis and treatment of candidiasis has led to a reduction of infections due to Candida albicans but that has led to the emergence of Candida infections caused by fluconazole resistant NAC (5).

Hence, speciation and antifungal susceptibility of clinical isolates of Candida has gained significance in the management of Candida infections. Although, several studies regarding the speciation and antifungal susceptibility patterns of Candida isolates have been reported across the globe including different regions of India (6),(7),(8),(9),(10),(11), such study is yet to be explored in Manipur, India. This study was taken up with the objective of generating data on different species of Candida, their characterisation upto the species level and to determine their antifungal susceptibility patterns.

Material and Methods

The study was a cross-sectional study which was carried out in the Department of Microbiology, Jawaharlal Nehru Institute of Medical Sciences (JNIMS), Imphal, Manipur, India, from September 2016 to August 2018. Informed written consent (prescribed format) was obtained from participating individuals. In case of minors, informed consent was taken from the parents/legal guardians. Privacy and confidentiality was maintained in all cases. Approval of ethical committee was obtained from the Institutional Ethical Committee (IEC) JNIMS vide no. Ac/06/IEC/JNIMS/2016(PGT) dated: Imphal, the 1st October, 2016.

Inclusion criteria: Patients of all age group and both sex with clinically suspected candidiasis, attending Outpatient and Inpatient Departments including intensive care units of JNIMS were included.

Exclusion criteria: Patients who were on antifungal treatment and refused to take part were excluded from the study.

Sample size calculation: Considering 95% confidence interval, 4% margin of error, Z score of 1.96 and prevalence rate of 4.03% (12), the sample size was taken 100 for the study using the following formula:

Sample size (n)=(z2pq)/d2 Where Z=Z-score, p=prevalence rate, q=(1-p), d=absolute allowable error.

Identification and Speciation of Candida Isolates

Clinical samples such as urine, blood, sputum, central line tip, oral swab, vaginal swab, nail clipping or skin scrapping were processed following standard techniques (13),(14).

Direct microscopy: Urine, sputum, oral swab, vaginal swab, nail clipping or skin scrapping were subjected to Potassium Hydroxide (KOH) wet mount for yeast cells with pseudohyphae and gram stain to look for gram positive, budding yeast cells with or without pseudohyphae, pus cells, epithelial cells or bacteria.

Culture: All the clinical samples were cultured on Sabouraud’s Dextrose Agar (SDA) and incubated at 25oC and 37oC. Regarding blood culture, 5-10 mL of blood for adults, 2-5 mL of blood for children, and 1-2 mL of blood for infants and neonates was inoculated first in 50-100 mL, 20-50 mL and 10-20 mL of Brain Heart Infusion (BHI) broth respectively and incubated at 37°C for seven days, examined daily for microbial growth (turbidity) followed by subculture on SDA and incubated at 37oC. On SDA, Candida produced creamy, smooth, pasty and convex colonies within 24-72 hours. Some species required more than three days to appear on culture medium.

Gram staining: Isolated colonies obtained on SDA were further subjected to gram staining to identify the budding yeast cell and pseudohyphae.

Urease test (13): A urease test was done to rule out Cryptococcus neoformans which is urease positive.

Criteria used to Indicate Candida Infection in Various Samples

Urine: Quantitative culture with colony count of >105 Colony-Forming Unit (CFU)/mL of urine is associated with infection in patients without indwelling catheters and >103 CFU/mL for catheterised patients. Pyuria usually supports diagnosis of Candida infection. Low colony counts in presence of pyuria were considered significant. Repeat isolation in same patient was also considered significant (4),(14).
Sputum: Considered acceptable on gram stain when 25 or more polymorphonuclear leukocytes were seen per oil immersion (100x) field with few (<10) squamous epithelial cells (15).
Blood: Candidemia is defined as presence of at least one positive blood culture containing pure growth of Candida species with supportive clinical features (14).
Central venous tip: Greater than 15 CFU on roll plate culture was considered positive of Catheter-Related Bloodstream Infection (CRBSI) (16).
Oral and vaginal swabs: Direct demonstration of pseudohyphae along with yeast cells using KOH wet mount or gram stain (16).

Speciation

Conventional methods: Germ tube test, demonstration of chlamydospore formation on Cornmeal agar with Tween 80, sugar fermentation test and sugar assimilation test were employed for speciation (1),(13).

Temperature test (Growth at 45°C): This test was used to differentiate Candida albicans (growth) from Candida dubliniensis (no growth). The temperature test was performed using Yeast-Peptone-Dextrose (YPD) broth, BHI and SDA, and incubated at 45ºC for 10 days (17).

HiCrome Candida differential agar: The Candida isolates were subcultured on HICROME Candida differential agar for species identification according to the manufacturer’s instructions (18).

1) Candida albicans: Light green coloured smooth colonies.
2) Candida dubliniensis: Dark green coloured smooth colonies.
3) Candida tropicalis: Blue to metallic blue coloured raised colonies.
4) Candida glabrata: Cream to white smooth colonies.
5) Candida krusei: Purple fuzzy colonies.
6) Candida guilliermondii: Light pink to pink colonies.
7) Candida parapsilosis: Light pink colonies.

Antifungal susceptibility testing: This was done by disk diffusion method according to CLSI (formerly NCCLS), 2009, M44-A2 guidelines using commercially available 6 mm antifungal discs (Himedia, Mumbai, India) such as fluconazole 25 μg, voriconazole 1 μg, amphotericin B 20 μg, itraconazole 10 μg and ketoconazole 30 μg (19).

Due to the lack of defined breakpoints for itraconazole, ketoconazole and amphotericin B arbitrary values based on other studies and manufacturer (HIMEDIA, Mumbai) guidelines were employed (16),(20).

Interpretive Categories

Susceptible (S): The susceptible category implied that an infection due to the strain might be appropriately treated with the dose of antimicrobial agent recommended for that type of infection and infecting species, unless otherwise contraindicated.

Susceptible-Dose Dependent (S-DD): The susceptible-dose dependent category included isolates with antifungal agent Minimum Inhibitory Concentration (MIC) that approached usually attainable blood and tissue levels and for which response rates might be lower than for susceptible isolates.

Resistant (R): This category included those resistant strains which were not inhibited by the usually achievable concentrations of the agent with normal dosage schedules or when zone diameters had been in a range where clinical efficacy had not been reliable in treatment studies (Table/Fig 1) (16),(19),(20).

Quality control: Every batch of media prepared was checked for sterility by incubating at 37°C for 24 hours. Candida albicans American Type Culture Collection (ATCC) 90028 was used as quality control strain for the antifungal susceptibility testing.

Statistical Analysis

Data collected was entered in Microsoft excel sheet. Data was analysed using descriptive statistics. Analytical statistics such as Chi-square (χ2) was done to test for association. A p-value <0.05 was taken as significant.

Results

During the study period of two years, 100 isolates were identified from different clinical specimens, which included 43 (43%) from sputum and 34 (34%) from urine as shown in (Table/Fig 2). A 28 isolates were collected from Outpatient and 72 from Inpatient Department.

Of the 100 isolates, 27 (27%) were obtained from the age group of >70 years and least number of 5 (5%) isolates was seen in age <10 years (5%). Mean±standard deviation age was 49.49±24.04 years median was 51.5 years. Highest age, from whom the isolate was detected, was found to be 92 year and lowest age to be one year. Female (57%) outnumbered male (43%) participants as shown in (Table/Fig 3).

The most common risk factor was found to be prolonged antibiotic therapy (26%) followed by pregnancy (23%), diabetes (21%), HIV (16%) as depicted in (Table/Fig 4). Gram stain smears and various isolates of Candida spp. on HICROME agar are shown in (Table/Fig 5),(Table/Fig 6),(Table/Fig 7).

Candida albicans comprised of 44% of the total isolates whereas the NAC spp. comprised of 56% of the total isolates. Among the NAC, Candida tropicalis (32%) was the most predominant species and least was Candida glabrata and Candida parapsilosis (4%) as shown in (Table/Fig 8).

Maximum isolate of Candida albicans were from sputum 20 (46.5%) out of 43 and that of Candida tropicalis were from urine 14 (41.2%) out of 34 as shown in (Table/Fig 9).

Among the antifungals, the most sensitive agent was voriconazole (86%) and least was observed with ketoconazole (56%) as shown in (Table/Fig 10). Chi-squares (χ2) of fluconazole, voriconazole, itraconazole, ketoconazole and amphotericin B are 37.556, 13.546, 25.157, 13.546 and 24.189, respectively with degrees of freedom of 12 in all the antifungal agents. The findings were significant for fluconazole (p-value <0.001), itraconazole (p-value=0.014) and amphotericin B (p-value=0.019), and insignificant for voriconazole (p-value=0.331) and ketoconazole (p-value=0.331).

Discussion

Candida spp. has been increasingly emerged as principal pathogens of opportunistic infections in healthcare settings. Therefore, early isolation, speciation and antifungal susceptibility testing are essential for the clinicians to choose the best therapeutic approach for the patients to reduce morbidity and mortality. Majority of the isolates in this study were obtained from sputum (43%) followed by urine (34%). This might be due to the fact that the presence of fungi (both yeasts and moulds) in sputum has been of increasing interest since the advent of antibiotics and steroids as common therapeutic agents. Moreover, Candida spp. are reported as seventh most common nosocomial pathogen in hospital settings causing 25% of all Urinary Tract Infections (UTI) in some of the previous studies (21). Gopi A and Murthy NS observed that predominant isolates were from sputum (41.6%) and urine samples (20.4%) (22). However, studies by Shaik N et al., and Joseph K et al., recovered maximum number of isolates from urine (60% and 46.9%, respectively) followed by respiratory samples (17.3% and 20.4%, respectively) (7),(23).

Majority of the Candida isolates was obtained from age group of >70 years (27%) and least seen in <10 years (5%) of age. Similar findings were found by Joseph K et al., and Goel R et al., (23),(24). Predominance of Candida spp. in elderly group in current study might be due to the presence of significant co-morbid conditions like diabetes, chronic obstructive pulmonary disease and prolonged antibiotic therapy.

The present study showed female preponderance (53%) which might be attributed to more number of cases in female with UTI, pregnancy, vaginitis, prolonged contact with water in housewives as in case of onychomycosis. Similar findings were observed by Amar CS et al., and Khandari KC and Rama KM (25),(26). However, male preponderance has been reported by Patel LR et al., (27).

In this study, the NAC spp. (56%) had predominance over Candida albicans (44%). Among the NAC spp., Candida tropicalis was the most common accounting for 32%. Similar findings were observed by previous literature (6),(10),(28),(29), as shown in (Table/Fig 11). However, some authors in their studies (8),(9),(30),(31), also observed a significant predominance of Candida albicans over NAC spp (Table/Fig 11) (6),(7),(8),(9),(10),(11),(28),(29),(30),(31),(32),(33),(34).

In the present study, it was observed that prolonged antibiotic therapy was the most common predisposing risk factor accounting for 26% followed by diabetes (21%) and HIV (16%). Chakrabarthi A and Shivaprakash MR observed higher rate of Candida infections in those patients with antibiotics administration of more than seven days and receiving three or more antibiotics (35). Administration of broad spectrum antibiotics suppresses the endogenous micro flora, permitting fungal overgrowth and any impairment of mucosal immunity is a potential threat for dissemination of Candida. Similarly Kandhari KC and Rama KM found higher occurrence of candidiasis in those individuals with diabetes and HIV (26). The occurrence of Candida infections in diabetic patients might be due to hyperglycaemic environment which favours immune dysfunction thereby increasing the susceptibility to infections.

In the present study, disc diffusion method for antifungal susceptibility testing of Candida isolates was used. Among the azoles, voriconazole showed the maximum sensitivity of 86%, was the most sensitive and least in ketoconazole (56%). It has also been observed that all the C. krusei were resistant to fluconazole as they are intrinsically resistant to fluconazole. However, amphotericin B in the present study showed a sensitivity of 81% and resistance of 8%. Similar sensitivity patterns were found by other studies as depicted in (Table/Fig 12) (29),(30),(32),(36). Better susceptibility patterns have been observed by Bhaskaran R et al., Chen J et al. Deepthi KN et al., Chakraborty M et al., Sabhapandit D et al., and Gade N et al., (Table/Fig 12) (9),(11),(28),(29),(30),(31),(32),(33),(34),(36),(37),(38).

The strength of this study was speciation of seven species of Candida employing conventional and HiCrome differential media, and their antifungal susceptibility testing using disk diffusion method as per CLSI guidelines could be carried out.

Limitation(s)

Advance automated systems like Vitek 2 Compact and molecular methods for molecular characterisation of Candida isolates at the subspecies level could not be accessed due to lack of infrastructure. There is no interpretative zone size for antifungal drugs by disc diffusion method other than fluconazole and voriconazole as per CLSI guidelines. Hence susceptibility zone size was followed and was interpreted based on manufacturer’s guidelines and previous studies for ketoconazole, itraconazole and amphotericin B.

Conclusion

The present study showed that even in Manipur, there is a changing trend of increased incidence of NAC over Candida albicans. An increase in the predisposing conditions in the recent years has resulted in an increasing incidence of Candida infections. Therefore early speciation of Candida isolates not only will restrict the empirical use of antifungal agent but also greatly influence the treatment options for the clinicians and thus will be beneficial for the patients as some Candida species are intrinsically resistant to some antifungal. Extensive study is required in our state to know the prevailing Candida spp. which may in turn help to develop guidelines on empiric therapy for invasive fungal infections.

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DOI and Others

DOI: 10.7860/JCDR/2022/55695.16248

Date of Submission: Feb 14, 2022
Date of Peer Review: Mar 08, 2022
Date of Acceptance: Mar 25, 2022
Date of Publishing: Apr 01, 2022

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Feb 18, 2022
• Manual Googling: Feb 21, 2022
• iThenticate Software: Mar 24, 2022 (19%)

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