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The frequency of opportunistic fungal infections in critically ill patients whose intensive care unit stays are prolonged due to coronavirus disease 2019 (COVID-19) is higher than in the period before COVID-19. We planned this study to improve the management of Candida infections by defining the Candida species, the etiology of infections caused by Candida species, and the antifungal susceptibility of the species. This retrospective study included patients older than 18 hospitalized in the intensive care unit (ICU) with a definitive diagnosis of COVID-19 for seven months (from March 2021 to September 2021). All study data that we recorded in a standard study form were analyzed with TURCOSA (Turcosa Analytics Ltd. Co., Turkey, www.turcosa.com.tr) statistical software. The patients were evaluated in four groups as group 1 (candidemia patients, n = 78), group 2 (candiduria patients, n = 189), group 3 (control patients, n = 57), and group 4 (patients with candidemia in urine cultures taken before Candida was detected in blood culture, n = 42). Candida species were identified using both conventional and VITEK ® 2 (BioMérieux, France) methods. The antifungal susceptibility of fungi was determined using the E test method. Of the 5,583 COVID-19 patients followed during the study period, 78 developed candidemia, and 189 developed candiduria. The incidence of candidemia (per 1,000 admissions) was determined to be 1.6. As a result of statistical analysis, we found that Candida albicans was the dominant strain in candidemia and candiduria, and there was no antifungal resistance except for naturally resistant strains. Candida strains grown in blood and urine were the same in 40 of 42 patients. Mortality was 69.2% for group 1, 60.4% for group 2, and 57.8% for group 3. Antifungals were used in 34 (43.5%) patients from group 1, and 95 (50.2%) from group 2. In the candidemia group without antifungal use, mortality was quite high (77.2%). Antifungal use reduced mortality in the group 2 ( p < 0.05). Length of ICU stays, comorbidity, broad-spectrum antibiotics, and corticosteroids are independent risk factors for candidemia in critically ill COVID-19 patients. Our study contributes to the knowledge of risk factors for developing COVID-19-related candida infections. The effect of candiduria on the development of candidemia in critically ill COVID-19 patients should be supported by new studies., (© 2022 Mine Altınkaya Çavuş and Hafize Sav, published by Sciendo.)

Background and Purpose: Candidemia remained important in the intensive care units (ICU) during the COVID-19 pandemic. This study aimed to investigate the clinical and laboratory data on candidemia in COVID-19 patients., Materials and Methods: The baseline characteristics, as well as laboratory and clinical findings of candidemia and non-candidemia patients, were compared. Candidemia was defined as the isolation of Candida spp. from blood cultures. The isolates were identified by VITEK® 2 (bioMérieux, France) commercial method. Antifungal susceptibility was assessed using the E-test method. Univariate and multiple binary logistic regression analyses were performed to compare the variables., Results: In total, 126 patients with the COVID-19 disease were included. Candidemia was diagnosed in 44 (35%) of the patients. The number of patients with diabetes mellitus and chronic renal failure was higher in the candidemia group. In the candidemia group, the duration of ICU stay of patients, the 30-day mortality rate, mechanical ventilation therapy, and systemic corticosteroids (Prednisone) usage were significantly higher in candidemia patients. Moreover, the median white blood cell, neutrophils, and lactate dehydrogenase were higher in the candidemia group.Univariate and multiple binary logistic regression analyses were performed to compare the variables. Isolated species were identified as Candida albicans (n=12, 41%), Candida parapsilosis (n=7, 24%), Candida glabrata (n=6, 21%), Candida tropicalis (n=3, 10%), and Candida dublinensis (n=1, 3%). In total, three isolates of six C. glabrata species had dose-dependent sensitivity to fluconazole, and one C. parapsilosis was determined to be resistant., Conclusion: The COVID-19 patients who are admitted to ICU have many risk factors associated with candidemia. The most common risk factors for the development of candidemia were mechanical ventilation, diabetes mellitus, neutrophilia, and low hemoglobin level. The most frequently isolated species was C. albicans . Moreover, caspofungin was found to be the most effective drug in vitro . No significant resistance pattern was detected against the isolated species. It should be noted that risk-stratified antifungal prophylaxis in the ICU is possible., Competing Interests: The authors declare that there are no conflicts of interest., (Copyright: © 2021, Published by Mazandaran University of Medical Sciences on behalf of Iranian Society of Medical Mycology and Invasive Fungi Research Center.)

Oral candidiasis is a common fungal infection, affecting the oral mucosa. The aim of this study was to investigate the epidemiology and antifungal susceptibility of Candida species isolated from the oral cavity of patients affected by oral candidiasis. Oral swabs were taken from 34 patients and were inoculated on to Sabouraud Dextrose Agar (SDA). The yeasts were preliminarily evaluated according to the growth (human serum) germ tube, chlamydospore formation, reproduction at 45 degrees C and colony characteristics on SDA medium. The commercial method Phoenix (Becton Dickinson, USA) was used for identification. Clinical and Laboratory Standards Institute (CLSI) reference M27-A3 microdilution method was applied for fluconazole (FLC), voriconazole (VRC), amphotericin B (AMB), ketoconazole (KTC), nystatin (NYT) antifungal susceptibility testing. A total of 34 Candida species were isolated and these species were identified as follows: 14 (41.2%) Candida albicans, 8 (23.5%) Candida glabrata, 8 (23.5%) Candida parapsilosis, 4 (11.8 %) Candida tropicalis. The geometric mean (GM) of the Minimum Inhibitory Concentration (MIC) for FLC, NYT, VRC, AMB, and KTC was 13.09 μg/mL, 4.77 μg/mL, 0.23 μg/mL, 0.20 μg/mL, 0.08 μg/mL, respectively. The most commonly isolated species was C. albicans. KTZ showed the lowest MIC value. NYT MIC values for non-albicans species were higher than for C. albicans ones.

Background and Purpose: Scedosporium apiospermum complex as a ubiquitous environmental mold is increasingly reported to cause an invasive fungal infection in immunosuppressive hosts. Herein, we present the case of an immunosuppressive 54 - year-old man who developed S. apiospermum complex lung infection and pulmonary adenocarcinoma., Case Report: The patient had some complaints of dyspnea and cough during a neutropenic episode. The computed tomography (CT) scan of the patient revealed pleural effusion. After culturing the pleural fluid sample, the fungus was identified by microscopic examination and ITS sequencing. In addition, antifungal susceptibility testing was performed using the M38-A2 microdilution method. The minimum inhibitory concentrations of amphotericin B, voriconazole, posaconazole, and caspofungin were obtained as > 64, 0.06, 0.06, and 0.03 µg/mL, respectively. Voriconazole (administered in two doses of 6 mg/kg and a maximum of 250 mg) was preferred for treatment. The patient received antifungal treatment for 2 months; however, he was lost to follow-up., Conclusion: Scedosporium apiospermum complex should be considered a cause of systemic fungal infections in neutropenic patients. Furthermore, the determination of the in vitro antifungal susceptibilities of clinical strains may contribute to the development of therapeutic approaches., (Copyright: © 2020, Published by Mazandaran University of Medical Sciences on behalf of Iranian Society of Medical Mycology and Invasive Fungi Research Center.)

Objective: Type 1 diabetes (T1D) is a disease characterized by severe insulin deficiency. In 2008 our group studied the prevalence of diabetes in adults between 20-80 years of age in Cyprus but data regarding this incidence in the pediatric population is lacking. The objective of this study was to report the incidence of T1D among permanent inhabitants aged 16 years or younger between 2001-2016 in Cyprus., Methods: This study was a retrospective analysis. The patients were mainly evaluated and recorded at Dr. Burhan Nalbantoğlu Hospital, Nicosia. Data was also reviewed from Famagusta Government Hospital, Kyrenia Government Hospital, Near East University Hospital and the Cyprus Turkish Diabetes Association., Results: A total of 107 subjects were diagnosed as T1D between 2001 and 2016 in the pediatric age group. Forty-nine (45.7%) were girls and 58 (54.3%) were boys. Of these 38.7% were resident in Nicosia, 30.2% Famagusta, 12.3% Kyrenia, 9.4% Guzelyurt and 7.5% Iskele. The proportion of newly diagnosed T1D was highest among children aged 9-12 years (35.5%) followed by children aged 5-8 years (32.7%). Newly diagnosed T1D most frequently presented in March and April. The overall mean incidence rate was 11.1/100,000 between 2001 and 2016. The incidence rates were similar and comparable among the years., Conclusion: This study is the first to analyze the incidence of T1D in Cyprus. Compared to other countries the incidence rate is intermediate. Our findings are similar to the incidence rates of T1D in South Cyprus and Turkey.

Clinically relevant members of the fungal genus, Fusarium , exhibit an extraordinary genetic diversity and cause a wide spectrum of infections in both healthy individuals and immunocompromised patients. Generally, Fusarium species are intrinsically resistant to all systemic antifungals. We investigated whether the presence or absence of the ability to produce biofilms across and within Fusarium species complexes is linked to higher resistance against antifungals. A collection of 41 Fusarium strains, obtained from 38 patients with superficial and systemic infections, and three infected crops, were tested, including 25 species within the Fusarium fujikuroi species complex, 14 from the Fusarium solani species complex (FSSC), one Fusarium dimerum species complex, and one Fusarium oxysporum species complex isolate. Of all isolates tested, only seven strains from two species of FSSC, five F . petroliphilum and two F . keratoplasticum strains, recovered from blood, nail scrapings, and nasal biopsy samples, could produce biofilms under the tested conditions. In the liquid culture tested, sessile biofilm-forming Fusarium strains exhibited elevated minimum inhibitory concentrations (MICs) for amphotericin B, voriconazole, and posaconazole, compared to their planktonic counterparts, indicating that the ability to form biofilm may significantly increase resistance. Collectively, this suggests that once a surface adherent biofilm has been established, therapies designed to kill planktonic cells of Fusarium are ineffective., Competing Interests: The authors report no conflicts of interest. The authors alone are responsible for the content and the writing of the paper.

Invasive aspergillosis (IA) is an increasingly important cause of morbidity and mortality particularly in paediatric patients. Early diagnosis and the initiation of efficacious antifungal treatments could affect the prognosis of these patients. The aim of this study was to determine the clinical contribution of Galactomannan (GM) screening in paediatric patients. We reviewed the records of all in-patients, and followed up, in the various units at the Medical Faculty Children's Hospital of Erciyes University (Kayseri, Turkey), those who had at least one GM assay result from August 2009 to April 2012. Paediatric patients were classified as proven, probable or possible, according to the European Organization for Research and Treatment of Cancer/Mycoses Study Group (EORTC/MSG). Twenty-five patients, with proven IA (n=3), probable IA (n=9) and possible IA (n=13) were included in the study. The GM antigen assay results were analysed in 158 blood samples from 47 patients. At the cut-off value of 0.5 ng/ml, the sensitivity was 68% [95% confidence interval (CI); 47-85]; specificity, 77% (95% CI; 55-92). To obtain more accurate results with GM testing, the diagnosis of IA should be confirmed by clinical investigation and the factors causing false positivity of the test should also be considered.

Haemophilus influenzae can cause invasive and severe infections in both adults and children such as otitis media, sinusitis, pneumonia, meningitis and bacteremia. The emerging antibiotic resistance in recent years against ampicillin and several other antibiotics among strains of H. influenzae gives cause for serious concern. Here, we investigate ß-lactamase (BL) activity in clinical isolates of H. influenzae, profile their resistance to antibiotics, and characterize the clonal relationship of the isolates. Antibiotic susceptibilities of 92 clinical isolates of H. influenzae (March 2011-May 2012) were determined using the disk diffusion method according to the Clinical & Laboratory Standards Institute (CLSI), and BL activity was detected using the nitrocefin disk method. The Rep-PCR method was used to characterize clonality of the isolates. All strains were found to be susceptible to levofloxacin and cefotaxime. Four isolates out of 92 (4.3%) were found resistant to ampicillin, one isolate (1.1%) was resistant to amoxicillin/clavulanic acid, 21 isolates (22.8%) were resistant to trimethoprim-sulfamethoxazole (SXT), and three isolates (3.3%) showed BL activity. One strain was BL-negative but resistant to ampicillin. The three isolates with BL activity and four isolates with resistance to ampicillin did not have a clonal relationship. Three distinct clones [clone A (with subclones A1 and A2), clone B, and clone C] were identified among the SXT-resistant strains. Most of the H. influenzae isolates in this study were susceptible to the antibiotics while SXT resistance was relatively more prevalent, which suggests that significant obstacles in the therapeutic use of antibiotics against H. influenzae strains are not expected in our region.

Background: Aspergillus species cause a wide range of diseases in humans, including allergies, localized infections, or fatal disseminated diseases. Rapid detection and identification of Aspergillus spp. facilitate effective patient management. In the current study we compared conventional morphological methods with PCR sequencing, rep-PCR, and matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF-MS) for the identification of Aspergillus strains., Materials and Methods: A total of 24 consecutive clinical isolates of Aspergillus were collected during 2012-2014. Conventional morphology and rep-PCR were performed in our Mycology Laboratory. The identification, evaluation, and reporting of strains using MALDI-TOF-MS were performed by BioMérieux Diagnostic, Inc. in Istanbul. DNA sequence analysis of the clinical isolates was performed by the BMLabosis laboratory in Ankara., Results: Samples consisted of 18 (75%) lower respiratory tract specimens, 3 otomycosis (12.5%) ear tissues, 1 sample from keratitis, and 1 sample from a cutaneous wound. According to DNA sequence analysis, 12 (50%) specimens were identified as A. fumigatus, 8 (33.3%) as A. flavus, 3 (12.5%) as A. niger, and 1 (4.2%) as A. terreus. Statistically, there was good agreement between the conventional morphology and rep-PCR and MALDI-TOF methods; kappa values were κ = 0.869, 0.871, and 0.916, respectively (P < 0.001)., Conclusion: The good level of agreement between the methods included in the present study and sequence method could be due to the identification of Aspergillus strains that were commonly encountered. Therefore, it was concluded that studies conducted with a higher number of isolates, which include other Aspergillus strains, are required., (© 2016 Wiley Periodicals, Inc.)

Background: Due to the failure of available antifungal agents in the treatment of candidemia and the toxic activities of these drugs, a lot of researches are being conducted to develop new nontoxic and effective antifungal agents for optimal control of fungal pathogens. The aim of this study is to evaluate the in vitro antifungal activity of propolis against yeasts isolated from the blood cultures of intensive care unit patients., Methods: Seventy-six strains were included in this study. The in vitro antifungal activity of propolis, fluconazole (FLU), and itraconazole (ITR) was investigated by the microdilution broth methods (CLSI guidelines M27-A3 for yeast). The propolis sample was collected from Kayseri, Turkey., Results: Of the 76 isolates, 33 were identified as Candida albicans while 37 were C. parapsilosis, three were C. tropicalis, and three were identified as C. glabrata. The geometric mean range for MIC (μg/ml) with regard to all isolates was 0.077 to 3 μg/ml for FLU and ITR, and 0.375 to 0.70 μg/ml for propolis. It was shown that propolis had significant antifungal activity against all Candida strains and the MIC range of propolis was determined as 0185 to 3 μg/ml., Conclusion: This study demonstrated that propolis had significant antifungal activity against yeasts isolated from blood culture compared with FLU and ITR. The propolis MIC in azole-resistant strains such as C. glabrata was found lower than the FLU MIC., (© 2015 Wiley Periodicals, Inc.)

Background/aim: This study compared the genotypes and virulence factors of Candida species isolated from oral cavities of healthy individuals and patients with diabetes mellitus (DM)., Materials and Methods: A total of 142 healthy individuals and 73 diabetic patients participated in this study. Study populations were classified into 4 groups as follows: Group I - Healthy, without caries; Group II - Healthy, with caries; Group III - DM, with caries; Group IV - DM, without caries. Diabetic patients' blood glucose and hemoglobin A1c concentrations were determined. Identification of Candida species was performed with conventional methods. Biofilm production, proteinase, phospholipase, and esterase were analyzed. The genetic diversity of Candida species was established using rep-PCR., Results: The most isolated species was Candida albicans. There were statistical differences in terms of isolated Candida frequency between healthy subjects and diabetic patients. There was no statistical difference between the virulence factors of groups. Twelve genotypes were determined. While there were statistical differences in aerobe biofilm production, proteinase, and phospholipase activity between genotypes, there were no statistical differences in anaerobe biofilm production and esterase activity between genotypes., Conclusion: Diabetes has no effect on the activities of virulence factors of Candida species. Different genotypes of Candida albicans exhibited different virulence activities.

The aim of this study is to compare conventional methods, chromogenic agar, [corrected] VITEK2 YST card and VITEK®MS system for the identification of Candida strains isolated from blood cultures. Fifty-four strains were identified according to conventional methods, chromogenic agar, [corrected] VITEK2 YST card and VITEK®MS. Sequencing was used as the reference method. The 54 strains included 32 Candida parapsilosis, 19 Candida albicans, 1 Candida glabrata and 2 Candida tropicalis according to the reference method. One C. albicans and one C. glabrata isolate were misidentified as C. parapsilosis by chromogenic agar. [corrected]. Two C. parapsilosis and three C. albicans isolates were misidentified by VITEK2 YST card. Chromogenic agar, [corrected] VITEK2 YST card and VITEK®MS identified correctly 96.2%, 90.7% and 100% of all strains, respectively. We found that the chromogenic agar, [corrected] VITEK2 YST card and VITEK®MS system are easy, rapid and accurate alternative methods for the identification of yeast species in the clinical microbiology laboratory.

Introduction: The aim of study was to investigate the virulence factors of phospholipase, proteinase, esterase production and biofilm formation in Candida species isolated from patients with candidemia, and to assess their relationship with Candida genotypes derived after repetitive sequence-based polymerase chain reaction (rep-PCR) fingerprinting., Methodology: Fifty-two strains were identified to species level according to conventional methods and sequencing. The DiversiLab system was used for the genotyping. Enzyme activities and biofilm formation were evaluated using microbiological methods., Results: The 52 strains were identified as follows: 29 C. parapsilosis, 19 C. albicans, 2 C. glabrata, and 2 C. tropicalis. Phospholipase and proteinase activities were observed to have statistically significant differences between C. albicans and non-albicans Candida (NAC) strains (p < 0.05), with C. albicans strains showing higher virulence. Rep-PCR revealed eight major genotypes (A-H).The 19 C. albicans and the 33 non-albicans Candida isolates yielded seven (A-G) and four (A, B, C, H) genotypes, respectively. C. albicans strains were not shown to have a predominant genotype and showed higher phospholipase and proteinase activitiy than did NAC, regardless of genotype. Genotype H (52%) was the predominant genotype for the NAC including 27 C. parapsilosis strains, but the majority of strains showed low virulence., Conclusions: NAC species were the most common causative agent for candidemia. Genotyping showed low transmission of C. albicans strains, but transmission of C. parapsilosis was high. In candidemia, several Candida virulence factors may be responsible at the same time. However, different genotypes of Candida strains showed different virulence activity.

The aim of this investigation was to determine the bacterial load on used instruments and to evaluate the relationship between the bacterial load and the holding time prior to cleaning. Thirty six sets were evaluated to establish the average number of bacteria per square centimeter. For the experimental study, three different bacteria were prepared in sheep blood and used to contaminate sterile stainless steel pieces with the surface of 10 cm(2). After incubation at room temperature for 2, 4, 6, 8, 12, 24, 36, and 48 h, colonies were counted and compared to time zero. Bacterial counts were between 10 and 250 CFU/cm(2), depending on the operation site. Bacterial load was found to have increased after 6 h. An increase of 3log10 CFU/cm(2) was measured after 12 h. It is imperative to clean surgical instruments in the first 6 h to ensure effective disinfection and sterility.

The clinical and laboratory diagnosis of cerebral aspergillosis (CA) is problematic and mortality is quite high, even in cases receiving appropriate treatment. Therefore, an early and accurate diagnosis may prove to be life saving in patients with the diagnosis of CA. In this report, a case of CA which developed in a pediatric patient with acute lymphoblastic leukemia (ALL) is presented. Upon development of neutropenia and focal seizures in the left arm during implementation of the ALL treatment protocol, brain MRI was performed in the patient and nodular lesions compliant with brain abscess were detected in the frontal lobe, left cerebellum and the cingulate gyrus on the superior aspect of the left corpus callosum. Direct assessment of brain tissue revealed fungal elements, while consecutive serum galactomannan (GM) values were determined as 3.39 ng/ml and 0.72 ng/ml, and the consecutive serum (1x3)-beta-D-glucan (BG) values were 93 pg/ml and 356 pg/ml. Negative serum real-time polymerase chain reaction (RtPCR) and positive tissue RtPCR were determined, with growth of Aspergillus fumigatus in the culture. Treatment was initiated with amphotericin B and voriconazole; upon disappearance of symptoms and negative control serum BG and GM values, the patient was discharged with recommendations. In conclusion, this case is presented with the objective of indicating the significance of serological and molecular methods used in the early diagnosis of patients with CA.

In this study, nine patients with Graves' ophthalmopathy with positive clinical activity score (CAS), who were either unresponsive or not suitable for glucocorticoid treatment, were given 100 microg of octreotide three times daily, subcutaneously, for three months. The mean age was 49+/-13 years. All patients were under either propylthiouracil or methimazole therapy and were euthyroid for at least one month prior to the start of the octreotide treatment. The mean degree of proptosis as measured with the Hertel exophthalmometer decreased slightly after the treatment (22.0+/-3.0 vs 19.6+/-2.4 for the right eye and 22.2+/-1.9 vs 20.2+/-2.2 for the left eye; p<0.05). The mean activity score decreased from 3.2+/-0.8 to 1.7+/-1.1 (p<0.005) and the mean score of eye signs according to the NOSPECS classification showed improvement with octreotide therapy (3.2+/-0.7 vs. 2.2+/-1.4; p<0.05). Seven patients responded favorably to octreotide treatment. In the remaining two no improvement was observed. Four of the responders could be followed up for 20 months after the treatment and all maintained the favorable state of eye findings obtained with octreotide. We conclude that octreotide seems to be a safe and effective drug in Graves' ophthalmopathy, especially in improving soft tissue involvement, and can be used in patients who are unresponsive to glucocorticoid treatment or who cannot use these drugs for some reason.