|Year : 2015 | Volume
| Issue : 2 | Page : 388-390
First experience of Candida non-albicans isolates with high antibiotic resistance pattern caused oropharyngeal candidiasis among cancer patients
Enayatollah Kalantar1, Seyed Mahmoud Amin Marashi1, Helen Pormazaheri1, Ellaheh Mahmoudi2, Shiva Hatami1, Maryam Agha Barari3, Mohammad Hadi Naseh4, Mojan Asadi5
1 Department of Microbiology and Immunology, School of Medicine, Karaj, Iran
2 Department of Pathobiology, School of Medicine, Karaj, Iran
3 Nursing and Midwifery School, Karaj, Iran
4 Deputy of Research, Alborz University of Medical Sciences, Karaj, Iran
5 Department of Oncology, Shahid Madani Hospital, Alborz University of Medical Sciences, Karaj, Iran
|Date of Web Publication||7-Jul-2015|
Department of Oncology, Shahid Madani Hospital, Alborz University of Medical Sciences, Karaj
Source of Support: The authors are thankful to Alborz University of Medical Sciences, Karaj, for providing the grant for the study (grant number 2181217), Conflict of Interest: None
Background and Aim: In cancer patients, Candida species can cause a variety of diseases particularly oropharyngeal candidiasis which is a common infection. In this study, an attempt has been made to determine susceptibility pattern of four antifungal agents against the Candida species isolated from cancer patients with oropharyngeal candidiasis.
Materials and Methods: Samples were taken from 50 cancer patients with oropharyngeal candidiasis by the physician, and isolation and identification of Candida spp. was done based on standard procedures. Antifungal resistance pattern was carried out according to CLSI guidelines, and 18s ribosomal RNA among Candida spp. was identified using multiplex polymerase chain reaction.
Results: Of the 50 patients, 18 (36%) were females and 32 (64%) were males; mean age was 38.4 years. Leukemia and lymphoma were the most frequent cancer types in the studied group, accounting for 17 (34%) and 12 (24%), respectively. A total of 29 Candida spp. were isolated from 29 cancer patients, of which 17 were C. albicans and 12 were C. non-albicans. All the Candida spp. were confirmed having 18s ribosomal RNA. Among all the Candida spp., C. non-albicans showed higher resistance pattern to amphotericin B (MIC 07 μg/ml) and ketoconazole (MIC = 05 μg/ml).
Conclusion: In conclusion, oropharyngeal Candidiasis is a serious infection among cancer patients. The isolated Candida spp. were resistant to common antifungal agents, which may lead to longer hospital stay, more expensive/toxic drugs and higher mortality. Therefore, interval surveillance is necessary in developing institutional guidelines.
Keywords: Antifungal resistance, cancer patients, Candida spp., oropharyngeal candidiasis
|How to cite this article:|
Kalantar E, Marashi SM, Pormazaheri H, Mahmoudi E, Hatami S, Barari MA, Naseh MH, Asadi M. First experience of Candida non-albicans isolates with high antibiotic resistance pattern caused oropharyngeal candidiasis among cancer patients. J Can Res Ther 2015;11:388-90
|How to cite this URL:|
Kalantar E, Marashi SM, Pormazaheri H, Mahmoudi E, Hatami S, Barari MA, Naseh MH, Asadi M. First experience of Candida non-albicans isolates with high antibiotic resistance pattern caused oropharyngeal candidiasis among cancer patients. J Can Res Ther [serial online] 2015 [cited 2020 May 31];11:388-90. Available from: http://www.cancerjournal.net/text.asp?2015/11/2/388/157307
| > Introduction|| |
Candida species are the most common cause of fungal infections among the cancer patients and therefore, among the fungi of medical concern, Candida spp. are of great concern. Candida is the predominant genus among the yeasts of the oral cavity and currently, oropharyngeal candidiasis is the most prevalent opportunistic infection among severely ill individuals and it is considered a marker of the progression of the immunological weakness among the cancer patients. ,
Indeed oropharyngeal candidiasis ranks as the most common fungal disease among cancer patients. 
The occurrence of oropharyngeal candidiasis varies all over the world, and its prevalence varies according to location, age of the patients, and other factors, and has been reported to range from 20−75%. 
Almost all surveys on fungal infections in cancer patients come from USA, Europe, and other developed countries, but recently well-known reports about this problem in Iran have been published. ,,
Although oropharyngeal candidiasis has been known to be caused by C. albicans, recently several scientists have reported the significant role played by non-Candida albicans as a causative agent; furthermore, these organisms have developed resistance to antibiotics. ,,
The emergence of antifungal resistance within Candida spp., particularly in cancer patients, requires regular investigations into antifungal resistance, which will help us get an updated knowledge about their antibiotic resistance pattern and may help the physician in selecting antibiotics for empirical therapy. In this study, an attempt has been made to determine susceptibility pattern of four antifungal agents against the Candida species isolated from cancer patients with oropharyngeal candidiasis.
| > Materials and methods|| |
This study was carried out between February 2013 and January 2014. Samples were taken by the physician from 50 cancer patients with oropharyngeal candidiasis. All samples were sent to Research Laboratory, School of Medicine, Alborz University of Medical Sciences and processed by standard methods for isolation and identification.
After isolation and identification based on the standard procedure, the antifungal resistance pattern was carried out according to CLSI guidelines. 
By multiplex polymerase chain reaction, identification of the 18s ribosomal RNA among Candida spp. was done using specific primers for the molecular identification of Candida spp.
All samples were cultured overnight at 37°C in PDA medium (Merck). Several methods are available for DNA extraction. Genomic DNA was isolated using reference protocol. 
PCR amplification of target DNA was done in a total volume of 25 μl. The reaction mixture contained 2.5 μl 10× amplification buffer [500 mM KCl, 100 mM Tris/HCl (pH 8.5), 1.0% Triton X-100], 0.5 μl 25 mM MgCl 2 , 0.3 μl each of 2.5 mM dNTPs (Fermentas), 0.5 μl forward and reverse primers for all genes (50 ng/μl), 0.2 μl Taq DNA polymerase (5 U/μl), and around 80−100 pg extracted DNA. PCR conditions were initial denaturation at 94°C for 4 min, followed by 30 cycles of 94°C for 1 min, 54°C for 1 min and 72°C for 1 min, with a final extension at 72°C for 10 min. Primer sequences used in this study are shown in [Table 1]. We designed primers by Alell ID 6 software. Amplified products were identified by agarose (1%) gel electrophoresis in 1× TBE, and stained by ethidium bromide.
| > Results|| |
During the study period, a total of 50 cancer patients participated in this study [Table 2] of which, 18 (36%) were females and 32 (64%) were males; ages ranged from 17 years to 72 years (mean, 38.4 years).
|Table 2: Demographic characteristics of cancer patients with oropharyngeal candidiasis|
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Leukemia and lymphoma were the most frequent cancer types in the studied group, accounting for 34% (17 patients) and 24% (12 patients), respectively. The mean weight of the patients was 73.2 kg (range, 52−97 kg).
A total of 29 Candida spp. were isolated from 29 cancer patients with oropharyngeal candidiasis, of which 17 were C. albicans and 12 were C. non-albicans.
[Figure 1] shows the gel electrophoresis of multiplex polymerase chain reaction, and identification of the 18s ribosomal RNA among Candida spp. using specific primers for the molecular identification of Candida spp.
|Figure 1: Gel electrophoresis of multiplex PCR for detection of the Candida albicans and Candida spp. 1 and 2 = Multiplex of C. albicans, 3 = PCR set up for C. albicans, 4 = Multiplex of Candida spp., N = negative control, M = Marker|
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[Table 3] shows interesting results on the antifungal resistance pattern of Candida spp. Among all the Candida spp., C. non-albicans showed a high resistance pattern to amphotericin B (MIC 07 μg/ml) and ketoconazole (MIC = 05 μg/ml).
|Table 3: Antibiotic resistance pattern of Candida spp. isolated from cancer patients with oropharyngeal candidiasis|
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| > Discussion|| |
Cancer patients have a very high incidence of infection during their management and this circumstance is an unavoidable consequence of advances in cancer treatment that have resulted in greatly increased survival; therefore, infection in cancer patients offers a particular clinical challenge because the pathogens are often unusual, and appropriate treatment must begin early in the course of the illness.
Rapid identification of candidiasis is important for the clinical management of severely ill individuals because of the possibility of a systemic infection. Furthermore, it may help the physician in selecting the antibiotics for empirical therapy. In contrast to other studies from Iran ,, in this study we isolated 9 non-Candida albicans, which were highly resistant to amphotericin B (MIC 07 μg/ml) and nystatin (MIC 05 μg/ml). Similar to our study, many international scientists also report the high prevalence and resistant to antifungal antibiotics by C. non-albicans, which caused oropharyngeal candidiasis. ,
Interestingly, in our study, resistance of all Candida spp. isolates to fluconazole was less (MIC 0.5 μg/ml), which is similar to that reported by other studies. , As per another report from Iran,  the reason for low fluconazole resistance could be explained by the fact that fluconazole was not prescribed to most cancer patients as a standard care in Iran. In conclusion, oropharyngeal Candidiasis is a serious infection among cancer patients. The isolated Candida spp. were resistant to common antifungal agents which may leads to longer hospital stay, more expensive/toxic drugs and higher mortality. Therefore, interval surveillance is necessary in developing institutional guidelines. Furthermore, based on the gel electrophoresis of multiplex polymerase chain reaction and identification of the 18s ribosomal RNA among Candida spp. using specific primers for its molecular identification, our study revealed that although C. albicans is the most prevalent cause of oropharyngeal candidiasis, C. Non-albicans showed a very high resistance pattern against amphotericin B and nystatin. Furthermore, systematic studies have shown that gram-positive and gram-negative bacteria are the leading causes of invasive bacterial disease in patients with cancer.
| > References|| |
Colombo AL, Guimarães T, Camargo LF, Richtmann R, Queiroz-Telles Fd, Salles MJ, et al
. Brazilian guidelines for the management of candidiasis - a joint meeting report of three medical societies: Tropical. Braz J Infect Dis 2013;17:283-312.
Pappas PG, Rex JH, Sobel JD, Filler SG, Dismukes WE, Walsh TJ, et al.
Guidelines for treatment of candidiasis. Clin Infect Dis 2004;38:161-89.
Reichart PA, Samaranayake LP, Philipsen HP. Pathology and clinical correlates in oral candidiasis and its variants: A review. Oral Dis 2000;6:85-91.
Al-Abeid HM, Abu-Elteen KH, Elkarmi AZ, Hamad MA. Isolation and characterization of Candida spp. in Jordanian cancer patients: Prevalence, Pathogenic Determinants, and antifungal sensitivity. Jpn J Infect Dis 2004;57:279-84.
Afraseyabi Sh, Afkhamzadeh A, Sabori H, Verdi F, Khaksar N, Mosavei B, et al
. Oral candidiasis amongst cancer patients at Qods hospitals in Sanandaj. Afr J Clin Exper Microbiol 2011; 12:129-32.
Seyyed AA, Salari S, Rezaie S, Nejad NS, Hadizadeh S, Kamyabi H, et al.
Identification of Candida species isolated from oral colonization in Iranian HIV-positive patients, by PCR-RFLP method. Jundishapur J Microbiol 2012;5:336-40.
Hadizadeh S, Kamyabi H, Aghasi H. Identification of Candida
species isolated from oral colonization in Iranian HIV-positive patients, by PCR-RFLP method. Jundishapur J Microbiol 2012;5:336-40.
Shokohi T, Bandalizadeh Z, Hedayati MT, Mayahi S. In vitro
antifungal susceptibility of Candida
species isolated from oropharyngeal lesions of patients with cancer to some antifungal agents. JJM 2011;4(Supplement 1):S19-26.
Pfaller MA, Diekema DJ. Epidemiology of invasive candidiasis: A persistent public health problem. Clin Microbiol Rev 2007;20:133-63.
Ha YE, Peck KR, Joo EJ, Kim SW, Jung SI, Chang HH, et al
. Impact of first-line antifungal agents on the outcomes and costs of candidemia. Antimicrob Agents Chemother 2012;56:3950-6.
Clinical and laboratory standard institute reference method for broth dilution antifungal susceptibility testing of yeasts; approved standard- 3 rd
ed, M27-S3. National Committee for Clinical Laboratory Standards, Wayne, Pennsylvania, USA.; 2008.
Ligozzi M, Fontana M. Isolation of total DNA from bacteria and yeast. Afr J Biotechnol 2003;2:251-3.
Sanchez-Vargas LO, Ortiz-Lopez NG, Villar M, Moragues MD, Aguirre JM, Cashat-Cruz M, et al.
Oral Candida isolates colonizing or infecting human immunodeficiency virus-infected and healthy persons in Mexico. Clin Microbiol J 2005;43:4159-62.
Patel PK, Erlandsen JE, Kirkpatrick WR, Berg DK, Westbrook SD, Louden C, et al
. The changing epidemiology of oropharyngeal candidiasis in patients with HIV/AIDS in the era of antiretroviral therapy. AIDS Res Treat 2012;1-5.
Diekema DJ, Messer SA, Brueggemann AB, Coffman SL, Doern GV, Herwaldt LA, et al
. Epidemiology of candidemia: 3-year results from the emerging infections and the epidemiology of Iowa organisms study. J Clin Microbiol 2002;40:1298-302.
Hamza OJ, Matee MI, Moshi MJ Simon EN, Mugusi F, Mikx FH, et al
. Species distribution and in vitro
antifungal susceptibility of oral yeast isolates from Tanzanian HIV-infected patients with primary and recurrent oropharyngeal candidiasis. BMC Microbiol 2008;8:135.
Kuriyama T, Williams DW, Bagg J, Coulter WA, Ready D, Lewis MA. In vitro
susceptibility of oral Candida to seven antifungal agents. Oral Microbiol Immunol 2005;20:349-53.
[Table 1], [Table 2], [Table 3]