Medical records of all inborn neonates who developed Candida BSI over a period of 5 years (September 2010 to August 2015) were reviewed. Candida BSI was defined as at least one pure growth of Candida species in blood culture [8] within 72 hours of inoculation, in presence of clinical features suggestive of sepsis such as respiratory distress/apnea, tachycardia/bradycardia, poor perfusion, feeding intolerance, temperature instability, lethargy, or seizures [9]. Culture positivity within 14 days, with the same Candida species was considered to be the same infection episode [2]. The study protocol was approved by the Institute Ethics Committee.

Clinical and investigation details, treatments received, response to therapy and outcome were noted. For blood culture, paired samples were inoculated in sheep brain heart infusion broth (Himedia, Mumbai, India) in 1:10 dilution and incubated at 37°C for 48 h. Any growth observed was subcultured on 5% sheep blood agar, MacConkey’s agar, and Sabouraud’s dextrose agar (SDA) with chloramphenicol (0.05%). Species was identified by colony morphology on SDA, color production on chromogenic media, growth at 45°C, germ tube test, chlamydospore formation, and carbohydrate fermentation and assimilation tests. Antifungal susceptibility was determined by the Clinical Laboratory Standards Institute disk diffusion testing [10]. Statistical analysis was done using SPSS 16. Risk factors were analyzed by univariate and stepwise multivariate logistic regression analysis.

During the period of review, 13346 neonates were delivered and 3128 were admitted in the Neonatal Unit. Candida species was isolated in blood culture of 114 neonates (0.9% of total deliveries and 3.6% of total admissions); 4.9% of VLBW and 11.2% of extremely-low birth weight neonates developed candidemia. Speciation could be done in 82 isolates, C. Tropicalis, 32 (39%), C. albicans, 29 (35.4%), C. parapsilosis, 10 (12.2%), C. glabrata, 5 (6.1%), C. krusei, 4 (4.8%) and C. guilliermondii, 2 (2.4%).

NAC BSI was associated with lower mean gestational age. Common presentations of Candida BSI were lethargy, bleeding manifestations, intraventricular hemorrhage, feeding intolerance and pneumonia or apnea. Overall, the combined incidence of multi-system involvement including meningitis, renal candidiasis/urinary tract infection, septic arthritis, endocarditis, endophthalmitis and Fournier’s gangrene was higher with NAC than C. albicans, though no difference was observed in the incidence of individual morbidity. Mortality and mean duration of hospital stay were significantly higher in NAC (Table I). Positive sepsis screen was documented in only 18 (15.8%), but the incidence of raised C-reactive protein (>10 mg/L) and severe thrombocytopenia (<50000/µL) was high, 92 (80.7%) and 68 (59.6%), respectively.

TABLE I Details of Neonates With Candida Bloodstream Inection

On univariate analysis, risk factors significantly associated with NAC BSI were nil orally >5 days (OR 0.224, 95% CI 0.059, 0.842], mechanical ventilation >5 days (OR 0.187, 95% CI 0.039, 0.889), central line >7 days (OR 0.166, 95% CI 0.050, 0.543), intralipid infusion >7 days (OR 0.225, 95% CI 0.068, 0.740), and hospital stay >28 days (OR 0.217, 95% CI 0.079, 0.591). On step-wise logistic regression analysis, central line >7 days and hospital stay >28 days were independent predictors of NAC BSI (Table II).

TABLE II 	Step-wise Multiple Logistic Regression Analysis of Risk Factors for Candida 
Non-albicans (NAC) Blood Stream Infections

Intravenous fluconazole was the first empirical antifungal used on clinical suspicion of fungal sepsis and liposomal amphotericin B was the second line. Change of antifungal chemotherapy was based on clinical deterioration or susceptibility testing. No antifungal chemoprophylaxis was given. Voriconazole and caspofungin demonstrated 100% susceptibility, whereas overall sensitivity for amphotericin B, fluconazole and itraconazole were 86.6%, 68.3% and 67.1%, respectively. C. parapsilosis and C. tropicalis demonstrated least susceptibility to fluconazole and amphotericin B (Fig. 1). 41.2% of Candida isolates from the neonates who expired were resistant to both fluconazole and amphotericin-B.

Fig. 1 Percentage sensitivity of Candida spp. to antifungal drugs.

In the present study the incidence of Candida BSI was 0.9% of total deliveries and 3.6% of total admissions. C. tropicalis was the most commonly isolated Candida species, followed by C. albicans and C. parapsilosis. The incidence of mortality and duration of hospital stay were significantly higher in NAC BSI. Central line >7 days and hospital stay >28 days were independent predictors of NAC BSI. C. parapsilosis and C. tropicalis demonstrated higher resistance to fluconazole and amphotericin-B.

The major limitations of our study are its retrospective design, and failure to perform species identification in all cases. We observed a wide spectrum of multi-system involvement, long-term complications and species distribution. Emergence of NAC as a common cause of candidemia has been reported by previous Indian studies [8,11-13]. C. parapsilosis was identified as the most common fungal species in neonates in earlier reports, which is in contrast to our observation [8]. C. tropicalis is virulent and is the second leading cause of candidemia in adults, but is quite infrequent among neonates [14]. Overall, resistance to fluconazole and amphotericin B was similar to previous studies [8]. Compared to other Indian studies [8], mortality was less in our study, but high incidence of resistance to both fluconazole and amphotericin B amongst infants who died was noted.

To conclude, emergence of NAC species and their association with higher mortality and longer duration of hospital stay is a cause for concern. Higher resistance of C. tropicalis and C. parapsilosis to fluconazole and amphotericin B is alarming. Prevention of risk factors in susceptible neonates with early removal of central line, timely fungal culture, Candida speciation and susceptibility testing are necessary for appropriate institution of treatment and better outcome. Frequent empirical use of fluconazole and amphotericin B may be avoided as it may lead to a shift in species distribution and higher antifungal resistance.

Contributors: SB: was involved in study planning, design and writing of the manuscript. RK: was involved with the data collection, analysis and writing of the manuscript. RT: was involved with the microbiological analysis and writing of the manuscript. AK: was involved with the study planning and writing of the manuscript. All authors approved the final version of the manuscript. SB will act as the guarantor of the paper.

Funding: None; Competing interest: None stated

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