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© 2020 Ankara Microbiology Society. All rights reserved.Bloodstream infections due to yeast species especially Candida spp. have been reported to be important healthcare associated infections with high mortality and morbidity rates. Candidemia causes prolonged hospital stays as well as increased cost. In order to prevent or treat these life-threatening bloodstream infections successfully, nationwide epidemiological data should be available about the etiological agents of these infections. Multi-centre national epidemiological data on yeast bloodstream infections in Turkey is lacking. A retrospective study was designed and data from six different centres in Turkey between 2011 and 2016 years were gathered and analysed for the distribution and frequency of yeast species in order to assist clinicians in their choice of early and appropriate antifungal therapy. All laboratories used automated blood culture systems for the isolation of blood strains. All the participating centres performed the identification of their own isolates by conventional methods using germ tube test, morphology on corn meal agar with tween 80 and chromogenic media and the identification was confirmed by API 20C AUX, API ID 32C or matrix-assisted laser desorption/ionization time of flight mass spectrophotometry (MALDI-TOF MS) systems. The analysis of the results was performed on the basis of intensive care units (ICUs), other inpatient clinics (OICs) and totally all clinics (ACs). Totally 2547 yeast isolates were determined from six participating centres during six years. According to the total ACs results, Candida albicans was the most prevalent species (43.1%), followed by Candida parapsilosis complex (29.1%), Candida glabrata (10.1%), Candida tropicalis (7.5%), Candida krusei (2.4%) and Candida kefyr (1.6%) and the remaining (6.2%) of them consisted of other yeast species. The distribution of the Candida species did not show statistically significant difference between the years, however the increase of C.parapsilosis complex in 2016 was statistically significant, (p= 0.02). During the study period, totally 1054 yeast isolates were obtained from the ICUs of the centres. C.albicans predominated with 476 (45.2%) isolates and C.parapsilosis complex (28.7%), C.glabrata (10.7%) and C.tropicalis (7.3%) were the other leading species in ICUs. Among 1493 isolates of the OICs of six centres participated in the study, C.albicans was the most prevalent species with 622 (41.7%) isolates. The other frequent species of OICs were C.parapsilosis complex (29.5%), C.glabrata (9.6%) and C.tropicalis (7.6%) resembling ICU results. It can be concluded that C.albicans is still the leading cause of bloodstream infections in the six different centres located in various geographical areas of Turkey.

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Yoğun bakım üniteleri (YBÜ)'nde bir haftadan daha uzun süre yatan hastalarda Candida türleri ile kolonizasyon oranı %80'in üzerine çıkmakta ve kolonize hastaların ortalama %10'unda invazif hastalık gelişmektedir. Yoğun bakım hastalarında invazif kandidiyaz (İK), septik şok ve yüksek mortalite ile seyrettiğinden hızlı tanı ve tedavinin önemi büyüktür. Bu çalışmada, İK gelişme riski yüksek olan ve erken antifungal tedaviden fayda görecek olan yoğun bakım hastalarında, Candida kolonizasyon indeksi (CI) ve Candida skoru (CS) belirlenerek; invazif enfeksiyon ile CI ve CS arasındaki ilişkinin değerlendirilmesi amaçlanmıştır. Çalışmaya, Nisan 2014-Temmuz 2015 tarihleri arasında Kayseri Eğitim ve Araştırma Hastanesi, Anestezi Bölümü Yoğun Bakım Ünitesinde yedi gün ve daha uzun süre yatmış olan 80 hasta (34 kadın, 46 erkek; yaş aralığı: 12-92 yıl, yaş ortalaması: 69.57 ± 16.30) dahil edilmiştir. Hastaların hiçbirinde nötropeni mevcut değildir. YBÜ'ne yatıştan sonra her hastadan, 0. gün ve daha sonra da her hafta boğaz, burun, cilt (koltuk altı), idrar, rektal sürüntü ve kan kültürleri alınmıştır. Candida suşlarının izolasyonu ve tanımlanması, konvansiyonel mikolojik yöntemler ile yapılmıştır. CI değeri, kan kültürü dışında kültür pozitif bölgelerin sayısının kültür yapılan bölge sayısına oranı ile hesaplanmış; CI> 0.2 ise fungal kolonizasyon, CI>= 0.5 ise yoğun kolonizasyon olarak kabul edilmiştir. CS değeri ise; total parenteral nütrisyon (TPN) (+0.908 puan), cerrahi (+0.997 puan), çok bölgede kolonizasyon (+1.112 puan) ve ciddi sepsis (+2.038 puan) bileşenleri dikkate alınarak tespit edilmiş; CS eşik değeri >2.5 olarak kabul edilmiştir. Çalışmamızda, 80 hastadan toplam 1009 kültür (ortalama: 13 kültür/hasta) alınmış, bunlardan 365 (%36.2)'inde maya üremesi olmuştur. Buna göre, değerlendirilen 80 hastadan 68 (%85)'inin en az bir örneğinde maya üremesi saptanmıştır. Kan kültürlerinin hiçbirinde mantar üremesi gözlenmemiştir. Maya üremesi olan 365 örneğin 184 (%50.4)'ünden C.albicans, 66 (%18)'sından C.glabrata, 42 (%11.5)'sinden C.parapsilosis, 12 (%3.3)'sinden C.tropicalis, üçünden (%0.8) C.kefyr ve birinden (%0.3) C.krusei izole edilmiş; altı (%1.6) örnekte diğer mayalar (3 Saprochaete capitata, 3 Trichosporon spp.) ve 51 (%13.9) örnekte birden fazla etken üremiştir. Maya kolonizasyonunun en fazla rektal sürüntü (%27.4), idrar (%23.3) ve boğaz sürüntüsü (%22.5) örneklerinde olduğu gözlenmiştir. CI değeri, hastaların %65 (52/80)'inde > 0.2 ve %25 (20/80)'inde >= 0.5 olarak; CS değeri ise hastaların sadece %2.5 (2/80)'inde > 2.5 olarak bulunmuştur. Yapılan istatistiksel değerlendirmede, fungal kolonizasyon (CI> 0.2) ile cinsiyet (p=0.032) ve yatış süresi (p=0.004) arasında; yoğun kolonizasyon (CI>= 0.5) ile cinsiyet (p=0.008) ve yaş (p=0.012) arasında anlamlı ilişki tespit edilmiştir. Buna karşın, altta yatan hastalık varlığı, APACHE II skoru, Glasgow koma skalası, invazif girişimler, geniş spektrumlu antibiyotik kullanımı, bakteriyel enfeksiyon varlığı, hemodiyaliz, transfüzyon ve önceden hastanede yatış öyküsü ile Candida kolonizasyonu arasında istatistiksel olarak anlamlı bir ilişki saptanmamıştır. Çalışmamızda, fungal kolonizasyon ile C.albicans, C.glabrata, C.parapsilosis ve C.albicans/C.glabrata pozitifl iği arasında istatistiksel olarak anlamlı ilişkinin bulunması (sırasıyla; p=0.001, p=0.002, p=0.008 ve p=0.028), Candida suşlarının tür düzeyinde tanımlanmasının önemini vurgulamıştır. Hastalarımızda İK gelişmemesinin nedeni, Candida CI ve CS değerlerinin düşük olması ile açıklanabilir. Sonuç olarak, İK gelişimi açısından yüksek risk altında olan yoğun bakım hastalarının, CI ve CS değerlerinin takip edilmesi yararlı olacaktır. Ancak verilerimizin, çok merkezli ve daha fazla sayıda hastanın dahil edildiği çalışmalarla desteklenmesinin gerekli olduğu açıktır. The colonization rate of Candida spp. reaches up to 80% in patients who reside in intensive care units (ICUs) more than a week, and the mean rate of development of invasive disease is 10% in colonized patients. Since invasive candidiasis (IC) in ICU patients presents with septic shock and high mortality rate, rapid diagnosis and treatment are crucial. The aim of this study was to assess the relationship between invasive infection and the determination of Candida colonization index (CI) and Candida score (CS) in patients admitted to ICU who are at high risk for IC and likely to benefi t from early antifungal therapy. A total of 80 patients (34 female, 46 male; age range: 12-92 years, mean age: 69.57 ± 16.30) who were in ICU over seven days or longer of Anesthesia Department of Kayseri Education and Research Hospital between April, 2014 and July, 2015 were included in the study. None of the patients were neutropenic. After admission, throat, nose, skin (axillary region), urine, rectal swab and blood cultures have been collected weekly beginning from day zero. Isolation and identifi cation of Candida strains were performed by using conventional mycological methods. CI was calculated as the ratio of the number of culturepositive distinct body sites (except blood culture) to the total number of body sites cultured. CI> 0.2 was considered as fungal colonization, while CI>= 0.5 as intensive colonization. CS value was calculated according to the components including total parenteral nutrition (TPN) (plus 0.908 points), surgery (plus 0.907 points), colonization in multiple areas (plus 1.112) and severe sepsis (plus 2.038 points), and cutoff value for CS was accepted as >2.5. In our study, overall 1009 cultures (mean: 13 cultures per patient) were taken from 80 patients, and yeast growth was detected in 365 (36.2%) of them. Accordingly, among 68 (85%) of 80 patients included, in at least one sample, yeast growth was determined. No yeast growth was observed in the blood cultures. Of 365 yeast-positive cultures, C.albicans was isolated from 184 (50.4%), C.glabrata from 66 (18%), C.parapsilosis from 42 (11.5%), C.tropicalis from 12 (3.3%), C.kefyr from three (0.8%), and C.krusei from one (0.3%) samples, whereas six (1.6%) samples yielded other yeasts (3 Saprochaete capitata, 3 Trichosporon spp.) and 51 (13.9%) samples yielded multiple yeast growth. The highest colonization rates were detected in rectal swabs (27.4%), urine (23.3%) and throat (22.5%) samples. CI value was found as >0.2 in 65% (52/80), and >=0.5 in 25% (20/80) of the patients, whereas CS value was >2.5 in only 2.5% (2/80) of the patients. In the statistical evaluation, signifi cant correlations were found between fungal colonization (CI> 0.2) and gender (p=0.032) and length of stay in ICU (p=0.004), and between intensive colonization (CI>= 0.5) and gender (p=0.008) and age (p=0.012). However, the correlation between Candida colonization and the presence of underlying diseases, APACHE II score, Glasgow coma scale, invasive procedures, use of extended-spectrum antibiotics, presence of bacterial infections, haemodialysis, transfusion and history of previous hospitalization was not statistically signifi cant. Our results have also indicated a statistically signifi cant relationship between fungal colonization and the positivity of C.albicans, C.glabrata, C.parapsilosis ang C.albicans/C.glabrata (p=0.001, p=0.002, p=0.008 and p=0.028, respectively), emphasizing the importance of species-level identifi cation of Candida isolates. The reason of lacking of IC development in our patients may be explained by their low CI and CS values. In conclusion, monitoring of ICU patients who are at high risk for IC in terms of CI and CS would be benefi cial. However it is clear that our data need to be supported by multi-center and high-scale studies.

Most common early diagnostic tool of IFI in high risk Hematology patients is galactomannan (GM) test. False positivity has beenobserved with TZP and other antibiotics. Widely usage of generic drugs has been continued owing to a significant cost advantageover original brand.The aim of this study is to compare the interaction of original and generic TZP formulations in terms of galactomannan test positivity.In January- February period, GM index was negative for all 35 patients who were receiving TZP. In that period, original TZP was usedfor patients in our institute.On the other hand, of 50 patients who were receiving TZP, GM index of 46 (92%) was above 0.5 in May. In that month, one typegeneric TZP was used for patients in our institute. Of the patients, 33 was male (66%), 27 were relapse diseases, 14 were newdiagnosis, and 9 were on remission. Allogeneic hematopoietic stem cell transplantation was performed in 9 and autologous HSCTin 12 patients. Fifteen patients were not neutropenic on GM test time. Thirty patients were receiving an antifungal agent whichwas including posaconazol in 10, fluconazole in 10, voriconazole in 8, and caspofungin in 2 patients pre GM test. In 13 (31.7%) of41 patients performed computed tomography (CT) scan, invasive fungal infection was supported by CT scan image. Moreover, therate of CT scan was more frequent (87% vs. 25%) in GM positive patients than those GM negative (p=0.016). This may lead moreunnecessary expenses of time and money. Mean GM positivity duration after beginning of TZP was 2.98±1.6 day, and mean GMnegativity time after discontinuation of TZP was 4.62±3.1 day.It was performed an analysis on GM levels of two generic and one original TZP. One of generic formulation had high GM levels(Figure 1).In conclusion, generic formulations of drugs are used in developing countries, but it should be cautious about unexpectedinteractions. High rate GM test positivity caused by generic formulation of TZP may lead unexpected high cost such as CT scan,maybe unnecessary antifungal treatment