Emergency. 2018; 6 (1): e39 BR I E F RE P O RT Candidemia in Febrile Neutropenic Patients; a Brief Re- port Maysam Yousefi1,2, Davood Yadegarynia1, Ensieh Lotfali1,3∗ Zahra Arab-Mazar1, Ali Ghajari3, Alireza Fatemi1 1. Infectious Diseases and Tropical Medicine Research Center, Shahid Beheshti University of Medial Sciences, Tehran, Iran 2. Assistant professor of infectious diseases, Research Center of tropical and infectious diseases, Kerman University of medical sciences, Kerman, Iran 3. Department of Medical Parasitology and Mycology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran Received: February 2018; Accepted: June 2018; Published online: 19 June 2018 Abstract: Introduction: Febrile neutropenic patients are at risk of serious infections. The aim of the present study is to identify the frequency, species, and susceptibility patterns of candidemia in febrile neutropenic patients. Methods: This cross-sectional study was conducted on febrile neutropenic patients suspected with candidemia who had been referred to 3 educational hospitals during 9 months. Results: The blood samples of 80 febrile neutropenic patients with the mean age of 48±16.6 years were studied (60% female). Five (6.25%) episodes of candidemia were identified. The underlying disease was acute myeloid leukemia in 4 (80%) cases and all 5(100%) cases had central venous catheter and were receiving prophylactic ciprofloxacin and acyclovir. 100% of isolates were found to be susceptible to Voriconazole, 80% to Caspofungin, 60% to Amphotericin B, and 40% to Fluconazole. Conclusion: The frequency of candidemia among the studied febrile neutropenia patients was 6.25%, with 80% mortality rate, and the most frequently identified yeast was Candida albicans (100% susceptible to Voriconazole). Keywords: Candidemia; febrile neutropenia; antifungal agents; drug resistance, multiple, fungal © Copyright (2018) Shahid Beheshti University of Medical Sciences Cite this article as: Yousefi M, Yadegarynia D, Lotfali E, Arab-Mazar Z, Ghajari A, Fatemi A. Candidemia in Febrile Neutropenic Patients; a Brief Report. 2018; 6(1): e39. 1. Introduction F ebrile neutropenic patients are at risk of serious infec- tions (1). Generally, bacteria are responsible for blood- stream infections (BSIs), but, 8% of all cases of infec- tious agents are Candida spp. (2, 3). Candida spp. that cause candidemia are the fourth most common agent of BSIs and the fifth most common cause of nosocomial infection (4, 5). Candida albicans is the most important cause of BSIs; how- ever 45% are caused by non-albicans species such as Candida glabrata, Candida krusei, Candida parapsilosis, and Candida tropicalis (6, 7). It appears that infection caused by species of Candida is as- sociated with a high crude mortality rate, globally (40% in the ∗Corresponding Author: Ensieh Lotfali; Department of Medical Parasitology and Mycology, School of Medicine, Shahid Beheshti University of Medical Sci- ences, Tehran, Iran, Tel: +98-2122439963 Fax: +98-2122439964 E-mail: en- siehlotfali@sbmu.ac.ir. United States)(8). The epidemiology of candidemia has been extensively studied in developed countries, but there is a lack of data in developing ones. The aim of the present study is to identify the frequency, species, and susceptibility patterns of candidemia in febrile neutropenic patients. 2. Methods 2.1. Study design and setting This cross-sectional study was conducted on febrile neu- tropenic patients who had been referred to Khatam-al- Anbia, Shohadaye Tajrish, and Taleghani educational hos- pitals, Tehran, Iran, from November 2016 to August 2017. The Ethical Committee of Shahid Beheshti University of Medical Sciences approved this study under the code: IR.SBMU.RETECH.REC.1396.192. All enrolled participants were informed about the study and written informed consent was obtained from them. This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: www.jemerg.com M. Yousefi et al. 2 2.2. Participants Febrile neutropenic patients suspected of candidemia (based on clinical symptoms), referred to emergency departments or hospitalized in intensive care units (9) of the mentioned hospitals were enrolled to the study. Patients who had pro- longed fever in spite of receiving broad-spectrum antibiotics for more than four days were considered as suspicious to candidemia. Patients with chronic neutropenia were ex- cluded from this study since the incidence of neutropenia is unpredictable, and difficult to clearly identify and determine. There was not any sex or age limitation. 2.3. Data gathering Demographic and clinical data were collected including age, sex, duration of stay in ICU, current history of broad- spectrum antibiotic therapy (for > 4 days), antifungal ther- apy, underlying diseases, and outcomes of sur–gical proce- dures. Source of data was the patient’s profile. An Assistant professor of infectious diseases (Dr. Yousefi) was responsi- ble for selecting suspected cases. Neutropenia was defined as neutrophil count <500/mm3 or <1000/mm3 with a predicted decrease to <500/mm3 and fever was defined as single eleva- tion in oral temperature to ≥ 38.30 ◦C or a temperature of ≥ 38 ÂřC for ≥ 1 hour (10). 2.4. Cultures 10 ml of venous blood sample were obtained for each pa- tient aseptically via venipuncture according to a standard technique by using a sterile syringe after skin disinfection. Culture vials were placed in the BACTEC 9120 System (Bec- ton Dickinson Microbiology Systems, Maryland, DE, USA), and were controlled automatically every 10 minutes. The BACTEC bottles that showed a sign of fungal growth were sub-cultured on the plates with the BHI agar (Merck, Ger- many) and Sabouraud Dextrose Agar with Chloramphenicol (SC) (Merck, Germany), separately. CHROM agar Candida medium (CHROM agar Microbiology, Paris, France) was used for sub-culture of isolates, incubated at 35 ◦C for 48 h and for preliminary species identification, production of specific colony colors were analyzed. ITS1 and ITS4 universal primers were used for polymerase chain reaction (PCR) and DNA se- quencing was also performed. 2.5. Susceptibility testing In vitro antifungal susceptibility test of the Candida iso–lates against amphotericin B (AMB) (Sigma-Aldrich, USA.), flu- conazole (FLU) (Sigma-Aldrich, USA.), voriconazole (VOR) (Pfizer Central Research, UK), and caspofungin (CAS) (Merck, USA.) were performed using micro-dilution method. 2.6. Statistical analysis Statistical analyses were performed using SPSS software ver- sion 21.0. The findings were reported using descriptive statis- tics such as mean ± standard deviation or frequency and per- centage. 3. Results: 153 blood samples were collected from 80 febrile neu- tropenic patients (38 blood samples from emergency depart- ments and 115 from ICUs). The mean age of the patients was 48±16.6 years (60% female). Five (6.25%) episodes of candidemia were identified during the study period. Baseline characteristics and outcome of patients with positive blood Culture are summarized in ta- ble 1. The underlying disease was acute myeloid leukemia in 4 (80%) cases and all 5(100%) cases had central venous catheter and were receiving prophylactic ciprofloxacin and acyclovir. The mean dura-tion of hospital and ICU stay in patients with candidemia were 42±5.4 and 26±4.9 days, re- spectively. Table 2 shows the in vitro susceptibility of 5 Candida spp. strains against antifungal agents. 100% of isolates were found to be susceptible to Voriconazole, 80% to Caspofungin, 60% to Amphotericin B, and 40% to Fluconazole. 4. Discussion Based on the findings, the frequency of candidemia among the studied febrile neutropenia patients was 6.25%, with 80% mortality rate, and the most frequently identified yeast was Candida albicans (100% susceptible to Voriconazole). The fourth most common pathogen isolated from the blood of ICU patients is Candida albicans, with an attributed mor- tality range between 20–30%. (11-13). However, during re- cent years, the incidence of Candida spp. infections other than Candida albicans has significantly increased and Can- dida parapsilosis is currently one of the main causes of inva- sive candidiasis (14-16). The estimated rate of candidemia among ICU admitted pa- tients is between 0.5–32 cases per 1,000 admissions (17, 18). Ghahri et al. identified Candida parapsilosis as the most prevalent Candida spp. from the blood samples of patients with candidemia in Iran; but this was not the case in our study (14). According to antifungal susceptibility tests, the most active antifungal drug in isolated candida species was VOR; this re- sult was similar to a study by Labbe et al. (19). A study by Pfaller et al. on in vitro susceptibility results for 1,184 isolates showed that VOR was considerably more po- tent than FLU (4). We also found similar results showing that 100% of candida isolates were sensitive to VOR. This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: www.jemerg.com 3 Emergency. 2018; 6 (1): e39 Table 1: Baseline characteristics and outcome of patients with positive blood Culture Variables Case 1 Case 2 Case 3 Case 4 Case 5 Sex Female Female Female Male Male Age (year) 61 34 26 48 71 Hospitalization (day) 44 50 34 43 38 ICU admission (day) 28 35 23 24 21 Underlying disease AML AML AML AML ALL Prophylaxis Ciprofloxacin + + + + + Acyclovir + + + + + Fluconazole + – + – + Itraconazole – + – + – Co-trimoxazole – – – – + Medical device CVC CVC CVC CVC MV, CVC Candida Spp. C. albicans C. albicans C. albicans C. albicans C. glabrata Outcome Died Died Survived Died Died ICU: intensive care unit; CVC: central venous catheter; MV: mechanical ventilation; ALL: acute lymphoblastic leukemia; AML: acute myeloid leukemia. Table 2: In vitro susceptibility test results of the 5 Candida spp. strains against 4 antifungal agents. Antifungal agent Susceptible Dose dependent Resistant Fluconazole 2 (40) 3 (60) 0 (0) Voriconazole 5 (100) 0 (0) 0 (0) Amphotericin B 3 (60) 1 (20) 1 (20) Caspofungin 4 (80) 0 (0) 1 (20) Data were reported as number (%). This investigation showed that FLU has the highest MIC GM (2.3); this result is similar to the study by Lobbe et al. that re- ported the highest MIC for FLU compared to other azole an- tifungal drugs such as VOR, ravuconazole, itraconazole, and posaconazole (19). A study by Pappas PG et al. proposed that in patients with positive blood cultures that become positive more than 48 hours after collection, FLU should probably be avoided; and it is more likely that patients are infected by Candida glabrata (20). A delay of ≥12 hours in the initial empiric antifungal treat- ment was associated with higher hospital mortality (21). It seems that empiric antifungal therapy needs to be started early in order to decrease morbidity and mortality. 5. Limitations This study had several limitations including the short dura- tion of survey followed by a low number of positive patients. Therefore, it was difficult to compare and interpret the find- ings, especially antifungal susceptibility patterns. However, based on the findings of this study, candidemia should be considered a significant problem in febrile neutropenic pa- tients. 6. Conclusion Based on the finding, the frequency of candidemia among the studied febrile neutropenia patients was 6.25%, with 80% mortality rate, and the most frequently identified yeast was Candida albicans (100% susceptible to Voriconazole). 7. Appendix 7.1. Acknowledgements The authors would like to express their gratitude to those who participted in data collection in selected hospitals. This article has been extracted from the thesis written by Dr. Maysam Yousefi in School of Medicine, Shahid Beheshti Uni- versity of Medical Sciences. 7.2. Author contribution Ensieh Lotfali, Davood Yadegarynia, Meysam Yousefi de- signed the study. Zahra Arab-Mazar participated in acqui- sition of data. Ali Ghajari and Alireza Fatemi participated in management of data. All authors approved the final version of the manuscript to be published. 7.3. Funding/Support We would like to express our gratitude to Infectious Dis- eases and Tropical Medicine Research Center, Shahid Be- This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: www.jemerg.com M. Yousefi et al. 4 heshti University of Medical Sciences for financially support- ing this research. 7.4. Conflict of interest The authors declare that they have no conflicts of interest. References 1. Talcott JA, Siegel R, Finberg R, Goldman L. 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