it is the third most common cause of late onset sepsis in nicu patients and accounts for 9 - 13% of blood stream infections ( bsi ) in neonates . although candida albicans has historically been the most frequently isolated species , recently non - albicans candida ( nac ) have emerged as important opportunistic pathogen , notably candida tropicalis , c. parapsilosis , c. krusei , and c. glabrata . there is growing evidence suggesting a role of increasing use of azole agents in this epidemiological shift . several of these nac species exhibit intrinsic resistance to traditional triazoles like fluconazole ( flk ) and may also demonstrate cross resistance to newer triazoles . this makes it imperative to perform both speciation and antifungal susceptibility ( afs ) of all the yeast isolates from blood or otherwise . number of factors including the use of indwelling devices , broad spectrum antibiotics , low birth weight ( lbw ) , prematurity , total parenteral nutrition ( tpn ) , gastrointestinal surgery , artificial ventilation , and/or history of fungal colonization contribute to the risk . preterm , very low birth weight ( vlbw ) : 1,500 g ; extremely low birth weight ( elbw ) : 1,000 g ; and critically ill infants are at highest risk of invasive candida infections candida spp . can also spread through vertical transmission from maternal flora or via horizontal transmission from hands of healthcare workers ( hcw ) . clinical presentation of candidemia resembles sepsis syndrome and to establish a clinical diagnosis is difficult . respiratory insufficiency , feeding intolerance , abdominal distention , temperature instability , lethargy , and decreased perfusion are the various clinical manifestations associated . candida bsis are associated with very high crude mortality of over 60% , while attributable mortality may be as high as 49% . the incidence and associated mortality due to candidemia can be influenced by several factors including the population at risk , healthcare facility standards , candida spp . the local epidemiological knowledge is critical in terms of prevention and management of invasive candida infections . we were noticing an increase in the isolation rate of nac species over last few months from cases of neonatal septicemia , which prompted us to undertake the present study , to examine the prevalence and epidemiology of neonatal candidemia at our hospital . we also correlated our results with the associated risk factors and the clinical presentation of the neonates . this prospective study was conducted between january 2012 and december 2012 in the departments of microbiology and pediatrics of our rural tertiary care and referral center in uttarakhand state , india . prior to the sample collection , approval from institutional ethical committee and written informed consent from patient 's guardian were obtained . from a total of 548 neonates ( age > 28 days , admitted to nicu with clinical suspicion of septicemia ) blood samples were collected into bactec peds plus / f culture vials of an automated blood culture system ( bactec 9120 , becton dickinson , usa ) and only those which yielded pure growth of candida spp . candidemia was defined as the presence of at least one positive blood culture containing pure growth of candida spp . with supportive clinical features . candidemia was attributed to the mortality of the neonate expired within 3 days of a positive blood culture . any growth indicated was subcultured on 5% sheep blood agar , macconkey 's agar , and sabouraud 's dextrose agar ( sda ) with chloramphenicol ( 0.05% ) and incubated at 37c . preliminary identification was done by colony morphology on sda , chromogenic media ( hichrome , himedia pvt . ltd . ) , growth at 45c , germ tube test , chlamydospore formation , and was confirmed by carbohydrate fermentation and assimilation tests . afs was performed for flk ( 25 mg ) , itraconazole ( itr , 10 mg ) , and amphotericin b ( amb , 100 units ) using disc diffusion method on muller - hinton agar supplemented with 2% glucose and methylene blue ( 5 mg / ml ) . zone diameters were interpreted as per the approved national committee for clinical laboratory standards ( nccls ) guidelines quality control for afs was performed using c. albicans - atcc 90028 and c. parapsilosis - atcc 22019 . statistical analysis was done using statistical package for social sciences ( spss ) version 11 and the prevalence of organisms was determined and expressed in percentage . statistical analysis was done using statistical package for social sciences ( spss ) version 11 and the prevalence of organisms was determined and expressed in percentage . . pure growth of bacteria and mixed growth of bacteria and yeast were isolated from 207/381 ( 54.33% ) and 42/381 ( 11.02% ) of the cases , respectively . of the total 132 neonates included in the study 73 ( 55.30% ) the average gestational age was 32.2 weeks ( 30 - 39 weeks ) and average birth weight was 1.2 kg ( 0.93 - 2.21 kg ) . were responsible for 80.30% , whereas 19.70% of the cases were caused due to c. albicans . c. parapsilosis ( 25.0% ) , and c. tropicalis ( 21.97% ) were the predominant nac species isolated , followed by c. glabrata ( 14.39% ) and c. krusei ( 10.61% ) [ table 1 ] . afs results showed 65.91% isolates sensitive to flk , 73.49 % to itr , and 96.21% to amb . five isolates ( one c. tropicalis , two c. krusei , and two other candida spp . ) were found resistant to amb . nac species , especially c. glabrata and c. krusei were more resistant to azoles , particularly flk , than c. albicans [ table 2 ] . characterization of various candida species isolated from blood ( n = 132 ) antifungal susceptibility profile of candida isolates ( n = 132 ) among the risk factors observed for candidemia [ table 3 ] , prematurity ( 73.49% ) and lbw ( 67.42% ) were the commonest followed by indwelling catheters ( 64.39% ) and broad spectrum antibiotic use ( 61.36% ) . failure to thrive ( 71.21% ) , feed intolerance ( 65.91% ) , and respiratory distress ( 63.64% ) were the most common clinical presentations seen [ table 4 ] . crude mortality due to candidemia was 34.85% as 46/132 of neonates died within 72 h of the candidemia diagnosis . additional 13 ( 9.85% ) neonates died post 72 h of the diagnosis of candidemia , so were not included in crude mortality . potential risk factors for candidemia among neonates ( n = 132 ) various clinical presentations observed in cases of neonatal candidemia ( n = 132 ) in the present study nac species accounted for 80.30% of the cases of neonatal candidemia , whereas c.albicans was responsible for 19.70% of cases . striking feature of the present study was isolation of c. parapsilosis ( 25.0% ) and c. tropicalis ( 21.97% ) as the most common nac species . although c. parapsilosis is less virulent , but under certain conditions ( iv catheters , high iv glucose concentrations ) virulence may increase many folds and it is relatively difficult to eradicate this organism . this subsequently has pharmacotherapeutic and pharmacoeconomic implication as to treat such infections is quite difficult . c. parapsilosis is an emerging fungal pathogen and the major threat for neonates in nicu as it frequently colonizes the hands of hcw , has high affinity for intravascular devices , and parenteral nutrition . in the present study , 64.39 and 55.30% of patients were on indwelling catheters and tpn respectively , out of these , 14 patients had c. parapsilosis candidemia which is 42.42% of all the c. parapsilosis isolates . higher affinity of c. parapsilosis to adhere on foreign material and ability to form biofilms are important factors for the development of fungemia . outbreaks of c. parapsilosis bsi in nicus have been previously reported . c. tropicalis causes infections with high mortality in adults and children with hematological malignancies or in immunocompromised individuals . once introduced into the immunocompromised host , c. tropicalis may be more virulent than c. albicans and can rapidly progress from colonization to invasion . it is the second leading cause of candidemia in adults , but is quite infrequent among neonates . however , what we speculate is that premature and lbw infants have an immature immune system and may behave like an immunocompromised adult patient in this regard . in the present study , c. parapsilosis and c. tropicalis have emerged as predominant species accounting for 46.97% of infected neonates . high degree of resistance to azoles was seen among c. krusei ( 78.57% ) and c. glabrata ( 63.16% ) . previous studies have reported that resistance to azole compounds among c. glabrata species can range from 3.6 to 64% . a significant proportion of c. tropicalis isolates were resistant to azoles especially flk . although resistance to amb was quite low ( 3.79% ) , but is a matter of concern as emergence of such isolates may pose serious therapeutic challenges and also increases risk of nosocomial infection . a noteworthy feature observed was that 3/46 neonates who died were infected with these amb resistant strains . combinations of various risk factors are known to be strongly associated with development of candidemia , and our results also suggest the same . the major risk factors identified in our study were prematurity , lbw , indwelling catheters , and broad spectrum antibiotic therapy . more than 65% of our cases were either premature or lbw , highlighting the significant burden of this disease among such infants . use of multiple invasive devices ( catheters , endotracheal tubes ) or surgery causes break in the skin / mucosal integrity , which predisposes these sites for colonization / infection by candida spp . broad spectrum antibiotics ranging two to four in number were being administered to most of the neonates in the present study . antibiotics promote fungal overgrowth at the expense of normal bacterial flora and encourage translocation of yeast across the intact mucosa . the risk of candidemia is known to increase exponentially with each class of antimicrobial used . tpn induces gut mucosal atrophy and has immunosuppressive effects which again predisposes individual for infection . c. parapsilosis has higher affinity towards parenteral nutrition , and can be responsible for outbreaks in nicus . the hands of hcw and environmental surfaces are newly appreciated potential reservoirs for nosocomial strains of candida spp . even though candidemia is associated with prolonged hospitalization , we found that most of the fatal cases occurred in infants > 3 weeks of age and had lbw compared with the ones who survived . given that infants of this age have decreased immunity , their host response to candida may have contributed to mortality . it has been observed that clearance of fungemia is directly proportional to catheter removal as soon as candidemia is detected and failure to do so is a risk factor for death . also removal of catheter alone is not sufficient and administration of antifungal agents is equally important as early treatment with antifungals is associated with enhanced survival . however in the present study , both these factors were frequent as majority of neonates who died had delay in the initiation of therapy and catheter retention for < 48 h after diagnosis of candidemia which may have contributed to the high mortality . based on high perinatal risk factors for early onset sepsis , the current hospital antibiotic policy recommends empiric use of ampicillin - gentamicin for neonates born within the facility and cefotaxime - amikacin for neonates reffered from elsewhere . long - term use of these broad spectrum antibiotics must have created a negative pressure and favorable environment for candida spp . to flourish . this substantiates the need of prophylactic antifungals to be used in a set up where continuous upsurge in the incidence of candidemia is seen . candidemia in neonates is an ominous prognostic sign and is an important entity in our hospital . preventive measures such as use of filters for parenteral nutrition , prophylactic antifungal use , and a restrictive policy of antibiotic use to decrease candida colonization / infection rates should be implemented to reduce the morbidity and mortality associated with these infections . reporting of fungal bsi and the spectrum of species involved are essential measures in any icu in order to implement appropriate preventive and therapeutic strategies . though powered to detect significant risk factors for fungal sepsis , this is a single center study and our findings may not be generalizable to other institutions . additional studies are necessary to validate our findings and define more accurately the reservoirs , mode of transmission , emergence of new species , and their sensitivity patterns . epidemiological data of our study can serve as a template for the development of local guidelines for prevention and appropriate treatment of neonatal candidemia .
background : candida species are one of the most common causes of blood stream infections among neonates and account for 9 - 13% of such infections . although candida albicans remains the most common fungal isolate from neonatal candidemia , longitudinal studies have detected a shift towards non - albicans candida ( nac ) species.aim:to examine the prevalence and epidemiology of candidemia among infants admitted to our hospital.materials and methods : blood samples were collected from 548 neonates and only those which yielded pure growth of candida spp . 
 were included in the study . 
 the isolates were identified as per standard mycological techniques and antifungal susceptibility ( afs ) was done by disc diffusion method.results:of the total 132 neonates included in the study , nac species were responsible for 80.30% cases with c. parapsilosis ( 25.0% ) and c. tropicalis ( 21.97% ) as the most predominant species ; whereas 19.70% of cases were caused by c. albicans . 
 afs results revealed that 65.91 , 73.49 , and 96.21% isolates were sensitive to fluconazole ( flk ) , itraconazole ( itr ) , and amphotericin b ( amb ) , respectively.conclusion:candidemia in neonates is an ominous prognostic sign and is an important entity in our hospital . 
 strict infection control strategies , appropriate preventive and therapeutic measures such as prophylactic antifungal use and a restrictive policy of antibiotic use should be implemented .