|Ahead of print publication
Fungal profile and antifungal susceptibility pattern of candidiasis in esophageal cancer patients
Abhijit Talukdar1, Rashmisnata Barman2, Anupam Sarma3, Manigreeva Krishnatreya4, Jagannath Dev Sharma3, Amal Chandra Kataki5
1 Department of Surgical Oncology, Dr. B. Borooah Cancer Institute, Guwahati, Assam, India
2 Department of Microbiology, Dr. B. Borooah Cancer Institute, Guwahati, Assam, India
3 Department of Pathology, Dr. B. Borooah Cancer Institute, Guwahati, Assam, India
4 Department of Cancer Epidemiology and Biostatistics, Dr. B. Borooah Cancer Institute, Guwahati, Assam, India
5 Department of Gynecologic Oncology, Dr. B. Borooah Cancer Institute, Guwahati, Assam, India
Department of Microbiology, Dr. B. Borooah Cancer Institute, Guwahati, Assam
Source of Support: None, Conflict of Interest: None
Aim: This study was carried out to determine the fungal profile and antifungal susceptibility pattern in the brushing samples of candidiasis in patients with carcinoma of esophagus.
Materials and Methods: The study was carried out in the Departments of Microbiology and Surgical Oncology of a regional cancer center from January 2017 to December 2017. Samples were collected under all aseptic precaution and Clinical Laboratory Standards Institute guidelines 2017 was followed for antifungal susceptibility testing.
Results: A total of 132 endoscopy brushing samples were collected from histological proven esophageal cancer patients and processed for fungal culture. Of which, 75 (56.81%) samples showed culture positivity and were recruited. Candida albicans in 40 (53.33%), Candida krusei in 25 (33.33%), Candida tropicalis in 7 (9.33%), and Candida glabrata in 3 (4%) patients were seen. Among the 40 C. albicans isolates, all were sensitive to caspofungin – 40 (100%), 34 (85%) showed sensitivity to fluconazole, and 32 (80%) showed sensitivity to flucytosine. C. krusei and C. tropicalis showed 100% sensitivity to caspofungin, and C. glabrata isolates showed 100% resistance to caspofungin and 80% resistance to Amphotericin B.
Conclusion: The present study revealed the emergence of multidrug-resistant, nonalbicans Candida isolates in cancer esophagus patients with candidiasis in northeast India.
Keywords: Antifungal, candidiasis, carcinoma, esophagus
|How to cite this URL:|
Talukdar A, Barman R, Sarma A, Krishnatreya M, Sharma JD, Kataki AC. Fungal profile and antifungal susceptibility pattern of candidiasis in esophageal cancer patients. J Can Res Ther [Epub ahead of print] [cited 2020 Jul 3]. Available from: http://www.cancerjournal.net/preprintarticle.asp?id=264223
| > Introduction|| |
Mucosal candidiasis of the esophagus is a condition commonly seen in immunocompromised patients, and it has been reported to be associated with esophageal carcinoma. Candidiasis is a heterogeneous group of disorders mainly caused by Candida species, and C. albicans are the most common clinical isolates., It results in chronic recurrent infection, mainly confined to the mucosa and skin and rarely causes systemic disease or septicemia. Global Action Fund for Fungal Infection have recently documented that the burden of fungal disease in low- and middle-income countries have significantly increased in recent times and have far exceeded the current capacity of these countries to manage the infection burden. There are 20 recognized Candida species most commonly associated with health care-associated infection currently and candidiasis is now considered the fourth most common cause of hospital-acquired systemic infections. Although C. albicans is generally considered the major pathogen among the Candida species in India, in recent times, there is an increase in the prevalence of non-C. albicans species. Extensive prophylactic uses of antifungal in cancer patient have led to decrease in the proportion of C. albicans and increase in the population of nonalbicans Candida ( NAC) species. This is also associated with increase in the incidence of multidrug-resistant Candida species. Although these are mucocutaneous infections, in immunocompromised cancer patients, it can have serious systemic outcome.
Since fungal infections are the major cause of morbidity and mortality in cancer patients, early initiation of the correct antifungal therapy has been demonstrated to have a direct impact on the patient's outcome. Esophageal cancer is one of the leading sites of cancer in both men and women in this part of the country. Severe candida infections affect immunocompromised patients, but otherwise healthy controls are also infected. Antifungal susceptibility testing methods are available to detect antifungal resistance and to determine the best treatment for a specific fungus. Microdilution methods are the gold standard or reference techniques. Two organizations, the European Committee on Antibiotic Susceptibility Testing and the Clinical Laboratory Standards Institute (CLSI), have standardized methods to perform antifungal susceptibility testing. Commercially available automated methods do not require complex handling and are cost-effective alternative method to test antifungal agents in vitro against Candida isolates in routine laboratory practice. This study was carried out to determine the fungal profile and antifungal susceptibility pattern of candidiasis in brushing samples from patients with carcinoma of esophagus
| > Material and Methods|| |
The study has been approved by the Institutional Review Board of the institute where it was conducted. One hundred and thirty-two patients with carcinoma esophagus were included in this study. The present study was conducted for 1 year at a Regional Cancer Center in North east India. This was a prospective and observational hospital-based study carried out at the Department of Microbiology. All endoscopy brushing samples from carcinoma esophagus patients received from the Surgical Oncology Department from January 2017 to December 2017 were analyzed. The samples were collected as per hospital sample collection protocol. The clinical data were obtained from the requisition forms and respective case record of patients. All patients presented with progressive dysphagia and 23 patients presented with odynophagia.
All samples were processed as per standard microbiology laboratory standard operating procedures. Laboratory diagnosis of candidiasis was performed by (i) direct examination of clinical specimen to demonstrate fungal presence and (ii) isolation of the Candida in culture, its identification, and antifungal susceptibility. Direct microscopic examination was done by 10% potassium hydroxide (KOH) mount and gram staining, which revealed the presence of budding yeasts, pseudohyphae, and/or hyphae. Candida isolation and identification were done by standard conventional methods, i.e., inoculation of samples on Sabouraud dextrose agar media at 35° C for 48–72 h and incubating for 48–72 h, on which most clinically relevant yeast species grow within 48 h.
The species identification as well as antifungal susceptibility testing was performed with VITEK 2 compact automated system using VITEK-2 cards for identification of yeast and yeast-like organisms (ID-YST card). Antifungal susceptibility testing was carried out with VITEK 2 fungal susceptibility card (AST-YS07 kit). The inoculum suspension for VITEK2 was prepared in sterile saline to turbidity equal to a 2.0 McFarland standard by using the Biomerieux Densichek instrument. The standardized 2.0 McFarland inoculum suspension was placed into VITEK2 cassette along with a sterile polystyrene test tube and a yeast susceptibility test card for each organism. The loaded cassettes were placed into Vitek2 instrument, and the respective yeast suspension was diluted appropriately, after which the cards were filled, incubated, and read automatically. The time of incubation varied from 10 to 26 h based on the rate of growth in the drug-free control well, and the results were expressed as MICs in microorganisms per milliliter. Vitek 2 compact yeast susceptibility test (bioMérieux, Inc.) is an automated method of yeast species identification and antifungal susceptibility testing through the analysis of yeast growth. The system provides 64-well cards containing aliquots of amphotericin B, fluconazole, flucytosine, voriconazole, Caspofungin, and Micafungin, in a miniaturized version of the broth dilution method. The system integrates a software program which validates and interprets susceptibility test results according to CLSI clinical breakpoints based on the drug MIC values. Quality control has been ensured by testing the CLSI-recommended quality control strains, Candida parasilosis ATCC2209, and Candida krusei ATCC6258.
| > Results|| |
A total of 132 cancer patient's endoscopy brushing was collected from cancer esophagus patients. Eighty-five (64.64%) patients were males and 47 (35.35%) were female patients. Of 132 patients, 129 (97.6%) were >40 years and 3 (2.4%) patients were below 40 years of age.
In all 132 patients, Candida isolates were demonstrated in direct microscopic examination by 10% KOH mount and gram staining, which reveals the presence of budding yeasts, pseudohyphae, and/or hypha, and the isolates were identified up to species level by observing their color on the CHROMagar and with the help of microscopic observations of chlamydospore, blastopore, and pseudohyphae on corn meal agar.
The samples were processed for fungal culture and 75 (56.81%) samples showed culture positive. Organisms isolated were C. albicans in 40 (53.33%), C. krusei in 25 (33.33%), Candida tropicalis in 7 (9.33%), and Candida glabrata in 3 (4%) samples. C. albicans in 40 (53.33%) and C. krusei in 25 (33.33%) were most commonly encountered [Figure 1]. All C. albicans isolates were sensitive to caspofungin, 34 (85%) showed sensitivity to fluconazole, and 32 (80%) showed sensitivity to flucytosine whereas susceptibility pattern of the NAC species (C. krusei and C. tropicalis) showed 100% sensitivity to caspofungin. However, all C. glabrata isolates showed resistance to caspofungin, and 80% showed resistance to Amphotericin B. For NAC, C. krusei showed resistance to amphotericin B, fluconazole, flucytosine, voriconazole, and micafungin in 36%, 72%, 39%, 16%, and 47% of the cases, respectively. Moreover, C. tropicalis showed a resistance pattern of 70%, 10%, 0%, 38%, 26% and 22% to fluconazole, voriconazole, caspofungin, micafungin, amphotericin, and flucytosine, respectively [Table 1].
| > Discussion|| |
Candidiasis is often coexistent in patients with esophageal carcinoma. Candidiasis can develop secondary to malignancy possibly due to impaired antifungal host defense, and partly due to the mucosal damage. There is increasing evidence that Candida infection itself has carcinogenic properties and several reports have been published for the increased incidence of oral and esophageal squamous cell carcinoma in patients with chronic candidiasis. The present study aimed to isolate candida species alone. The incidence in males and females was around 65% and 36%, respectively. In the study by Kandhari and Rama Rao, the incidence in females was about 61%, while in males, it was only 38%.
In the present study, we found that C. albicans (53.34%) was the most common frequently encountered clinical isolate although a considerable increase in NAC (46.66%) species was observed in the present study. The predominant NAC isolated in our tertiary care center was C. tropicalis. Similar observation was seen in a study which reported 82 (48.8%) C. tropicalis isolates.
Several studies reported the emergence of antifungal resistance to azoles, which are been associated with multiple episodes of recurrence. Surveillance data of Center for Disease Control indicate that the proportion of Candida isolates that are resistant to fluconazole has remained fairly constant over the past 20 years. In the current study, 20% of C. albicans was observed to be resistant to fluconazole, and it was similar to another study that reported 15.5% of C. albicans were resistant to fluconazole. In the present study, resistances to fluconazole were seen in C. glabrata and C. krusei in 72% and 100%, respectively. Moreover, the C. glabrata isolates showed 100% resistance to caspofungin and 80% resistance to amphotericin B. Similar observation was seen in studies conducted by Alastruey-Izquierdo et al., where most cases of C. glabrata showed resistance and echinocandin was isolated. Other species such as C. albicans, C. tropicalis, and C. krusei were shown to have developed secondary resistance.
The antifungal resistance is an emerging problem, and intrinsic resistance of C. glabrata and C. krusei to fluconazole is well known. In these cases, appropriate treatment can be decided on the basis of species identification. This intrinsic resistance has justified the use of echinocandins as primary treatment, instead of fluconazole, in the empirical treatment of candidemia and invasive candidiasis in recently published guidelines.,
| > Conclusion|| |
The present study revealed the emerging antifungal resistance in clinical isolates of candidiasis in patients with cancer esophagus, mostly C. albicans. Caspofungin is a relatively new antifungal agent and all the Candida species were sensitive to it, but nonalbican candida species like C. glabrata have showed the emergence of resistance to this agent. Before starting empirical antifungal prophylaxis, brushings and culture should be done in patients with esophageal cancer and candidiasis.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| > References|| |
Delsing CE, Bleeker-Rovers CP, van de Veerdonk FL, Tol J, van der Meer JW, Kullberg BJ, et al.
Association of esophageal candidiasis and squamous cell carcinoma. Med Mycol Case Rep 2012;1:5-8.
Kliemann DA, Pasqualotto AC, Falavigna M, Giaretta T, Severo LC. Candida
esophagitis: Species distribution and risk factors for infection. Rev Inst Med Trop Sao Paulo 2008;50:261-3.
Domingues-Ferreira M, Grumach AS, Duarte AJ, De Moraes-Vasconcelos D. Esophageal cancer associated with chronic mucocutaneous candidiasis. Could chronic candidiasis lead to esophageal cancer? Med Mycol 2009;47:201-5.
Asmundsdóttir LR, Erlendsdóttir H, Gottfredsson M. Increasing incidence of candidemia: Results from a 20-year nationwide study in Iceland. J Clin Microbiol 2002;40:3489-92.
Patel GP, Simon D, Scheetz M, Crank CW, Lodise T, Patel N. The effect of time to antifungal therapy on mortality in candidemia associated septic shock. Am J Ther 2009;16:508-11.
Consolidated Report of Population Based Cancer Registries (2012-2014). National Cancer Registry Programme. Bengaluru: Indian Council of Medical Research; 2015.
Guidelines of National Committee for Clinical Laboratory Standards; 2002.
Barry AL, Pfaller MA, Brown SD, Espinel-Ingroff A, Ghannoum MA, Knapp C, et al.
Quality control limits for broth microdilution susceptibility tests of ten antifungal agents. J Clin Microbiol 2000;38:3457-9.
Larone DH. Medically Important Fungi: A Guide to Identification. 4th
ed. Washington, DC: American Society for Microbiology Press; 2002.
Kandhari KC, Rama Rao KM. Clinical and laboratory studies on cutaneous candidiasis. Indian J Dermatol Venereol 1969;35:102-7.
Agarwal S, Manchanda V, Verma N, Bhalla P. Yeast identification in routine clinical microbiology laboratory and its clinical relevance. Indian J Med Microbiol 2011;29:172-7.
] [Full text]
Carvalhinho S, Costa AM, Coelho AC, Martins E, Sampaio A. Susceptibilities of candida albicans mouth isolates to antifungal agents, essentials oils and mouth rinses. Mycopathologia 2012;174:69-76.
Vallabhaneni S, Cleveland AA, Farley MM, Harrison LH, Schaffner W, Beldavs ZG, et al.
Epidemiology and risk factors for echinocandin nonsusceptible Candida glabrata
bloodstream infections: Data from a large multisite population-based candidemia surveillance program, 2008-2014. Open Forum Infect Dis 2015;2:ofv163.
Mahdavi Omran S, Rezaei Dastjerdi M, Zuashkiani M, Moqarabzadeh V, Taghizadeh-Armaki M.In vitro
antifungal susceptibility of Candida
species isolated from Iranian patients with denture stomatitis. Biomed Res Int 2018;2018:3086586.
Alastruey-Izquierdo A, Melhem MS, Bonfietti LX, Rodriguez-Tudela JL. Susceptibility test for fungi: Clinical and laboratorial correlations in medical mycology. Rev Inst Med Trop Sao Paulo 2015;57 Suppl 19:57-64.
Adhikary R, Joshi S. Species distribution and anti-fungal susceptibility of candidaemia at a multi super-specialty center in Southern India. Indian J Med Microbiol 2011;29:309-11.
] [Full text]
Cornely OA, Bassetti M, Calandra T, Garbino J, Kullberg BJ, Lortholary O, et al.
ESCMID* guideline for the diagnosis and management of Candida
diseases 2012: Non-neutropenic adult patients. Clin Microbiol Infect 2012;18 Suppl 7:19-37.
Ullmann AJ, Akova M, Herbrecht R, Viscoli C, Arendrup MC, Arikan-Akdagli S. ESCMID* guideline for the diagnosis and management of Candida
diseases 2012: Adults with haematological malignancies and after haematopoietic stem cell transplantation (HCT). Clin Microbiol Infect 2012;18 Suppl 7:53-67.