Download Candidemia in critically ill patients: Comparison in IC VS NIC

Burden of invasive fungal infections in
developing countries
Arunaloke Chakrabarti
Professor & In-Charge
Center for Advanced Research in Medical Mycology
& WHO Collaborating Center
Professor & Head, Department of Medical Microbiology
Postgraduate Institute of Medical Education & Research
Chandigarh – 160012, India
Outline
• Do we have true assessment on burden?
• What are the challenges in developing countries?
• What is the magnitude of the problem in population or
specific groups of patients?
• Where are we regarding Big ‘3’ in developing countries?
• Unique epidemiology for certain diseases in developing
countries
•
•
•
Prevalence of HAI – 15.5/100 patients, double than developed countries
The incidence in BSI – 34.2/1000 patient-days, triple the rate of USA
Risk of infection – 2-20 times more to industrialized nations, WHO,2008
True burden of invasive fungal infections in
developing countries
Case reported
No obligatory reporting
Lab identifies the pathogen
Competence of diagnosis limited
Sample submitted to lab
Very few mycology lab
Doctor collects sample
Sample from deep-tissue difficult
Persons goes to doctor
Patient visit to doctor low or late
Persons having symptoms
Symptoms & signs non-specific
Therefore, it is impossible to know the true burden
However, we predict high burden of fungal infections
Why we predict high
burden of fungal
disease in developing
countries?
• Tropical environment with >50% of world’s population
• Large economically deprived section
• Malnutrition
• Attend the hospital late in the course of disease
• Quackery practice
• Misuse of steroids & antibiotics over the counter
• Construction activities in hospital & maintenance
• Climate changes – Tsunami
One infection that may be diagnosed easily, supports it
Cryptococcal meningitis in HIV
Park et al. AIDS 2009; 23: 525
One infection that may be diagnosed easily, supports it
Cryptococcal meningitis in HIV
Sloan DJ. Clin Epidemiol 2014; 6:169
Mortality in HIV in sub-Saharan Africa
Park et al. AIDS 2009; 23: 525
Cryptococcosis
Developed nations
North America
Canada 0.05
USA 1.3
Europe
Latin America
Developing nations
Africa
South East Asia
Spain 0.03
Austria 0.06
Chile 0.12
Brazil 0.2
Nigeria 1.0
Senegal 1.2
Sri Lanka 0.05
Korea 0.07
France 0.15
UK 0.16
Ukraine 0.22
Trinidad 3.7
Jamaica 5.0
Tanzania 6.0
Zambia 7.1
Kenya 20.0
Vietnam 0.15
China 0.17
Nepal 0.6
Singapore 0.62
India 1.52
Thailand 4.2
Indonesia 23
New Zealand 0.3
Australia 6.4
0.05-0.5
0.5-5
5-25
Rate/105/yr
Posters: ICAAC 2014 (Washington DC)
ECCMID 2014 (Barcelona), TIMM 2013 (Copenhagen)
ECCMID 2013 (Berlin), ISHAM 2015 (Melbourne)
0.05-0.5
0.5-5
5-25
Rate/105/yr
Concern
The overwhelming number of cases & the enormous
influence of cryptococcosis on early mortality underscore a
major failure of health care provision in developing
countries, where there is too little access to effective
antifungal therapy, including the tools to control increased
intracranial pressure, too few clinical initiatives involving
meaningful clinical research, & inadequate investment from
public health, industry, government, private foundation &
other funding sources - Peter G Pappas
Editorial, Clin Infect Dis 2010; 50: 345
Which data are available in developing countries?
• Pan country hard data like France, Australia, Iceland is absent in
developing countries
• GAFFI-LIFE initiated country-wise data
 It is mere estimation from published studies
• Localized active surveillance in population
 Fungal rhinosinusitis prevalence in north India
• Multicentric active surveillance
 Candidemia data in many countries
• Multicentric laboratory surveillance
 Candidemia data by Asian Fungal Working Group
• Passive surveillance
 Not available as the disease is not notifiable
Invasive mycoses in developing countries
• Endemic (dimorphic) mycoses
• Opportunistic fungal infections
Dimorphic fungal infections
• Histoplasmosis
• Blastomycosis
• Coccidioidomycosis
• Paracoccidioidomycosis
• Penicilliosis
• Sporotrichosis
A new challenge
• 38y/F, native of Nepal, cleaner of farmhouse
• Presented with weight loss, mild fever, dyspnoea, left chest
pain
• She had multiple skin lesions on face and body (non-tender,
non-itching)
• Imaging of chest – bilateral lobular consolidation with necrotic
component (enhancing) on lt upper lobe & mediastinal
lymphadenopathy
• Clinically thought tuberculosis, sputum – neg; HIV – positive
• CT guided FNAC & skin biopsy
A new challenge
• Culture, microscopic morphology & molecular identification
confirmed it as Emmonsia pasteuriana
• Patient was treated with amphotericin B for 2 weeks
followed by itraconazole
Paracoccidioidomycosis
Queiroz-Telles & Escuissato. Semin Resp Crit Care Med 2011; 32: 764; Veira et al. Rev Soc Bras Med Trop 2014; 47: 63:
Lopez-Martinez et al. Mycoses 2014; 57: 525
Paracoccidioidomycosis
• Reporting the disease in high-endemic area
• Improvement in disease control & prevention
• Health education among farmers
• Increased rural exodus
Ballissimo-Rodrigues et al. Am J Trop Med Hyg 2011; 85: 546; Veira et al. Rev Soc Bras Med Trop 2014; 47: 63
Penicilliosis marneffei
Endemic area with
large number of
cases
Penicilliosis
• Prevalent in South-east Asia,
mainly in HIV infected
population
• Exact prevalence not known
• Ranking 3rd after
Duong TA. Clin Infect Dis 1996; 23: 125
tuberculosis & Cryptococcus
meningitis in Thailand; after
PCP & tuberculosis in Hong
Kong
• Incidence has come down
Penicilliosis in Vietnam
Lee et al. Clin Infect Dis 2011; 52: 945
after anti-retroviral therapy
Opportunistic fungal infections
Autopsy data at out center (PGI, Chandigarh, India)
IFIs
1%
23%
7%
42%
Aspergillosis
Candidiasis
Cryptococcosis
Mucormycosis
Pneumocystosis
Others
5%
22%
•
•
1983-2008 (26 years)
IFIs: 2.4% (365/15,040)
Hematological malignancies &
transplantation
Allogenic transplant
15.9
16
14
Rate of fungal infections (%)
14
12
9.2
10
8.9
7.8
7.4
8
6
4
2
0
USA
Italy
Brazil
Ref.- Mycoses. 2015 Jun;58(6):325-36
Clin Microbiol Infect 2013; 19: 745–751
Bone Marrow Transplant. 2015 Aug 17.
Clinical Infectious Diseases 2009; 48:265–73
China
Taiwan
India
Biol Blood Marrow Transplant 20 (2014) 872e880
Biol Blood Marrow Transplant. 2015 Jun;21(6);1117-26
Bone Marrow Transplant. 2004 Feb;33(3):311-5
Clinical Infectious Diseases 2007; 45:1161–70
IFI in AML/MDS patients
14
12.4
11
Rate of fungal infections (%)
12
10
8
6.6
5.7
6
3.8
4
Post transplant
2
Undergoing chemotherapy
0
USA
Italy
Brazil
Ref.- Am. J. Hematol. 88:283–288, 2013.
Clin Microbiol Infect 2013; 19: 745–751
PLoS ONE. 2015 10(6): e0128410.
China
Taiwan
Eur J Haematol. 2008 Nov;81(5):354-63
Tumour Biol. 2015 Feb;36(2):757-67
Liver transplant
14.8
Rate of fungal infections (%)
16
13.5
13
14
12
9.8
10
8
6
4.7
4
2
0
USA
Italy
Brazil
China
Ref.- Clinical Infectious Diseases 2010; 50:1101–1111
Clin Microbiol Infect 2013; 19: 745–751
Ann Transplant. 2012 Dec 31;17(4):59-63
Taiwan
Transplant Proc. 2014 Sep;46(7):2314-8
Tumour Biol. 2015 Feb;36(2):757-67
Chang Gung Med J. 2008 Jan-Feb;31(1):74-80
Renal transplant
13
Rate of fungal infections (%)
14
12
10
7.8
8
6.1
6
4
1.3
2
0
USA
Italy
Brazil
Ref.- J Clin Med Res. 2015;7(6):371-378
Mem Inst Oswaldo Cruz. 2011 May;106(3):339-45
Clinical Infectious Diseases 2010; 50:1101–1111
India
Clinical Infectious Diseases 2007; 45:1161–70
Nephrol Dial Transplant. 1993;8(2):168-72
Heart transplant
4
Rate of fungal infections (%)
4
3.2
3.5
2.7
3
2.5
2
1.5
1
0.5
0
USA
Brazil
Ref.- Clinical Infectious Diseases 2010; 50:1101–1111
Clinical Infectious Diseases 2007; 45:1161–70
Taiwan
Am J Infect Control. 2010 Mar;38(2):162-3
Transplantation Proceedings, 42, 952–954 (2010)
Lung transplant
23
Rate of fungal infections (%)
25
20
16.5
15
10
5
0
USA
Ref.- Clinical Infectious Diseases 2010; 50:1101–1111
Transplantation Proceedings, 40, 822–824 (2008)
Brazil
Clin Transplant 2015: 29: 311–318
The big ‘3’
•Candidiasis
•Aspergillosis
•Mucormycosis
Candidiasis
Candidemia – comparing to global scenario
0.2-0.5/1000 discharges
0.8/1000 discharges
J Clin Microbiol 2005; 43:1829 & 4434
J Clin Microbiol, 2004; 42: 1519
1-12/1,000 admissions
Jpn J Med Mycol 2008; 49: 165
2.49/1000 admission
J Clin Microbiol, 2006; 44: 2816
0.09-0.36/1000 admissions
Emerg Infect Dis., 2006; 12: 1562
India & Brazil – candidemia rate 7-20 times more common
Candidemia
Developed nations
North America
Canada 4.8
USA 8.0
Atlanta 19.75
Europe
Nordic 1.4
Austria 2.6
Netherland 2.6
France 3.8
Belgium 5.0
Developing nations
Ukraine 5.0
Ireland 6.3
UK 7.5
Denmark 8.6
Argentina 1.1
Trinidad 5.0
DR 5.0
Jamaica 5.0
Spain 10.7
Chile 5.0
Israel 5.0
Africa
Latin America
Middle East
Nigeria 0.6
Zambia 4.0
Jordan 5.0
Saudi Arabia 10.0
Kenya 5.0
Egypt 5.0
South East Asia
India
540
Korea 1.5
Sri Lanka 2.3
China 5.0
Mongolia 5.0
Vietnam 5.0
Singapore 5.1
Thailand 13.3
Indonesia 63.0
Brazil
249
Australia 1.87
New Zealand 4.27
1-3
3-6
6-9
>9
Rate/105/yr
Posters: ICAAC 2014 (Washington DC)
ECCMID 2014 (Barcelona), TIMM 2013 (Copenhagen)
ECCMID 2013 (Berlin), ISHAM 2015 (Melbourne)
Rate/105/yr
1-3
3-6
6-65
66-250
>250
Candidemia in Asia (2010-2011)
Country
No. of hospitals
No. of
candidemia
Incidence/1000
discharges
China
9
310
0.38
Hong Kong
1
30
0.25
Singapore
1
73
0.15/1000
patient days
Thailand
3
130
1.31
India
3
333
1.94
Taiwan
6
1104
2.93
Total
25
1601
1.22
ICU
25
370
11.7
Tan et al. Clin Microbiol Infect 2015; online 20 June 2015
SIHAM Candidemia Network
April 2011 – Sept 2012
27 Centres:
• 11 Government sector
• 16 Private sector
1400 Candidemia cases:
• 858 Males
• 542 Females
Mortality
• Overall 40.0%
• attributable 22.8%
6.51 candidemia cases/
1000 ICU admissions
Chakrabarti et al. Intensive Care
Med 2015; 41: 285
Time to Candidemia (ICU Days)
Western data 23 days
China-Scan study
10days
Guo et al. J Antimicrob Chemother
2013; 68: 660
Right skew &
Mean: 10.8 days
Spectrum of non-albicans Candida species
Quindos G. Rev Iberoam Micol 2014; 31: 42
Candidemia data in six Asian countries
Tan et al. Clin Microbiol Infect 2015; online 20 June 2015
Comparison of C. tropicalis candidemia across regions
Candida species isolated during recent study on 27 ICUs
Intra-abdominal candidiasis
Candida in acute pancreatitis
• Fungal infection of necrotizing pancreatitis has worst
outcome that those of bacterial infection
• 335 patients with acute pancreatitis investigated
• True infection in 22 (6.6%), possible infection in 19 (5.7%)
• Grade E pancreatitis, prophylactic fluconazole, sepsis are
significant risk factor
• Lead to ↑hospital stay & mortality (51%)
Chakrabarti et al. Surgery today 2007; 37: 207-11
Candida peritonitis
Developed nations
North America
Canada 0.8
Europe
UK 0.14
Ukraine 0.75
Belgium 0.75
Latin America
Ireland 1.0
Netherland 0.9
Austria 0.9
Spain 1.25
Argentina 0.4
Jamaica 0.75
Trinidad 0.75
DR 0.75
Chile 0.8
Developing nations
Africa
Nigeria 0.2
Egypt 0.8
Zambia 2.0
Kenya 2.0
Middle East
Jordan 0.8
Saudi Arabia 1.6
South East Asia
Sri Lanka 0.3
Korea 0.75
China 1.4
Singapore 1.4
Mongolia 2.0
0.1-0.5
0.5-1
1-1.5
Rate/105/yr
Posters: ICAAC 2014 (Washington DC)
ECCMID 2014 (Barcelona), TIMM 2013 (Copenhagen)
ECCMID 2013 (Berlin), ISHAM 2015 (Melbourne)
0.1-0.5
0.5-1
1-1.5
1.5-2
Rate/105/yr
Aspergillosis
Invasive aspergillosis - magnitude
• No hard systematic data available
• Leading cause of IFI in Thailand (J Med Assoc Thai 2007; 90:
895), Korea (Transplant Infect Dis 2010; 12: 309)
• Autopsy data – 1% of all autopsies & 42% of all
invasive mycoses
• Also occurs in so called immunocompetent host (6-14%)
• A. flavus more prevalent in eye, CNS infections & fungal
sinusitis in tropical climate
Invasive Aspergillosis
Developed nations
North America
Canada 2.0
Latin America
Europe
Ukraine 1.42
France 1.6
Spain 2.7
Netherland 3.4
Developing nations
Austria 4.1
Belgium 6.1
Ireland 7.0
UK 8.15
DR 0.8
Chile 1.7
Brazil 4.5
Africa
Nigeria 0.1
Kenya 0.6
Middle East
Jordan 1.3
Saudi Arabia 7.6
Egypt 10.7
South East Asia
Sri Lanka 1.0
Thailand 1.4
Mongolia 3.1
Korea 3.5
Nepal 4.0
Singapore 7.6
China 11.9
Vietnam 15.9
New Zealand 4.9
1-5
5-10
10-15
Rate/105/yr
Posters: ICAAC 2014 (Washington DC)
ECCMID 2014 (Barcelona), TIMM 2013 (Copenhagen)
ECCMID 2013 (Berlin), ISHAM 2015 (Melbourne)
1-5
5-10
10-15
Rate/105/yr
Chronic pulmonary aspergillosis - underlying diseases
Common underlying
diseases
• Pulmonary tuberculosis (16%)
• Nontuberculous
•
•
•
•
•
•
mycobacterial infection (14%)
Allergic bronchopulmonary
aspergillosis ± asthma (12%)
Treated lung cancer (10%)
Pneumothorax (often related to
a bulla) (10%)
Chronic obstructive pulmonary
disease (10%)
Community acquired pneumonia
requiring hospitalization (8%)
Sarcoidosis (stage II/III) (7%)
Uncommon underlying
diseases
• Rheumatoid arthritis with
pulmonary nodules (3%)
• Ankylosing spondylitis (rarely)
• Thoracic surgery (5%)
• Asthma (2%)
• Radiotherapy to the thorax or
chest wall
• Invasive pulmonary aspergillosis
• Cannabis lung
• Pneumoconiosis
• Histoplasmosis
• Silicosis
Smith et al Eur Respir J 2011; 37: 865-872
Developed nations
Europe
Ireland 3.1
Austria 4.7
UK 5.8
Spain 9.18
Developing nations
Chronic pulmonary Aspergillosis
Belgium 22.7
Ukraine 109.1
Latin America
Africa
Brazil 6.2
Trinidad 8.2
Argentina 8.5
Egypt 1.6
Tanzania 24.0
Senegal 35.0
Jamaica 11.2
Chile 25.0
DR 52.0
Nigeria 43.0
Kenya 144.0
Zambia 173.3
Middle East
Saudi Arabia 3.4
Jordan 5.4
South East Asia
Sri Lanka 13.0
China 19.5
Thailand 20.1
India 24.0
Nepal 24.2
Mongolia 42.0
Vietnam 61.0
Korea 146.1
New Zealand 15.7
1-15
15-50
50-175
Rate/105/yr
Posters: ICAAC 2014 (Washington DC)
ECCMID 2014 (Barcelona), TIMM 2013 (Copenhagen)
ECCMID 2013 (Berlin), ISHAM 2015 (Melbourne)
1-15
15-50
50-175
Rate/105/yr
Global burden of CPA
Denning et al. Bull WHO 2011; 89: 864
CPA burden in India
Total population in 2011
1,210,569,573
Incident TB cases
2,130, 602
Annual pulmonary TB case alive at 1 year
1,438,157
Estimated annual CPA cases after PTB
92,042 (7.6/100,000)
5-year estimated CPA prevalence
290,147
5-year estimated CPA prevalence rate
24/100,000
Agarwal et al. PLoS One 2014; 9: e114745
Fungal rhinosinusitis in India
Recent study in north India – 1.4% adult suffer from CRS,
8.1% of them are FRS (0.11% of population)
Mucormycosis
Mucormycosis
•
•
•
Japan, National data
Yamazaki T et al. JCM 1999; 37: 1732
1969-1994 (26 years)
IFIs: 2.9% (17,064/5,94,263)
Mucormycosis: 0.1%
19%
•
•
•
5%
1983-2008 (26 years)
IFIs: 2.4% (365/ 15,040)
Mucormycosis: 0.6%
37%
5%
1%
35%
4%
Aspergillosis
7%
42%
Mucormycosis
Candidiasis
22%
Cryptococcosis
•
•
1989-2003 (15 years)
IFIs: 31% (314/1017)
4% 4%
36%
Pneumocystosis
23%
Our Institute data
(Courtesy Prof. A Das)
57%
Others
7%
MD Anderson, Hematology malignancy
Chamilos G et al. Haematologica 2006; 91: 986
Mucormycosis
Developed nations
North America
Canada 0.12
Europe
Spain 0.04
France 0.1
Ukraine 0.2
Latin America
Brazil 2.1
Ireland 0.2
Netherland 0.2
Austria 0.3
Developing nations
Africa
Kenya 0.2
Senegal 0.2
Middle East
Jordan 0.02
South East Asia
Korea 0.02
Vietnam 0.12
China 0.2
Singapore 0.2
Sri Lanka 0.2
Nepal 0.3
India 14.0
0.02-0.2
0.2-2
2-20
Rate/105/yr
Posters: ICAAC 2014 (Washington DC)
ECCMID 2014 (Barcelona), TIMM 2013 (Copenhagen)
ECCMID 2013 (Berlin), ISHAM 2015 (Melbourne)
0.02-0.2
0.2-2
2-20
Rate/105/yr
Mucormycosis
• India – reported highest incidence
• Next common - brazil
• Reported in tsunami survivors
(Andresen et al. Lancet 2005; 365: 876; Snell
& Tavakoli Plast Reconsstr Surg 2007; 119: 448)
• Majority cases in India, China are associated with
diabetes (Slain & Chakrabarti Med Mycol 2012; 50: 18)
• 35 cases of consecutive 22,316 diabetics (1.6
cases/1000 diabetics); 48.6% diabetic ketoacidosis
• The mean informed duration of diabetes was 6.7±4.6 y
before acquiring mucormycosis
• Compliance to anti-diabetic therapy is also poor
• 23% patients in our study were ignorant of underlying
diabetes before reporting with mucormycosis in our
hospital (Chakrabarti A et al. Postgrad Med J 2009; 85: 573-581)
Prevalence of mucormycosis in diabetics in India
• Computational model
Reviewed all literature for past five decades (1960-2012)
Prevalence - 0.14/1000 population – ranges - 137,807 &
208,177, mean - 171,504 (SD: 12,365.6; 95% CI:
195,777-147,688) – 70 times to generally accepted
rates
Attributable mortality - mean of 65,500/year (38.2%)
[Chakrabarti et al. Poster number 1044, 23rd ECCMID, Berlin, 2013].
Human pathogenic Mucorales in different series
India
India
Europe
France
Italy
Chakrabarti & Singh. Mycoses 2014; 57 (Suppl. 3) 1-6
Asian garden has many new flowers!
Saksenaea vasiformis
Rhizopus homothallicus
Apophysomyces elegans
Thamnostylum lucknowense
Pneumocystis
Developed nations
North America
Canada 0.2
Developing nations
Europe
Latin America
Africa
South East Asia
Ireland 0.8
UK 0.9
France 1.0
Chile 4.3
Trinidad 30.0
Brazil 39.6
Egypt 0.15
Senegal 9.4
Tanzania 22.0
Korea 0.42
Vietnam 0.67
Nepal 1.3
Belgium 1.1
Spain 3.4
Ukraine 13.5
Jamaica 41.0
Nigeria 48.0
Kenya 70.0
Zambia 230.0
Singapore 1.6
China 1.8
Thailand 2.6
New Zealand 1.55
0.1-1
1-10
10-100
Rate/105/yr
Posters: ICAAC 2014 (Washington DC)
ECCMID 2014 (Barcelona), TIMM 2013 (Copenhagen)
ECCMID 2013 (Berlin), ISHAM 2015 (Melbourne)
0.1-1
1-10
10-100
>100
Rate/105/yr
Certain unique fungal diseases
in developing countries
Distribution of Pythiosis
Southern, 8%
Eastern,
3%
Northern, 16%
Central, 46%
Northeastern,
27%
Pythiosis in Thailand
Slides courtesy – Ariya Chindanporn
Trichosporonosis
• After Japan frequently encountered in Thailand, Taiwan
• Thailand
 6% of all fungemia cases & cannot be distinguished from candidemia
(Anunnatsiri et al. Int J Infect Dis 2009; 13: 90)
 Majority cases in ICUs, with malignancies, CVC, antibiotic exposure
(Ruan et al. CID 2009; 49: e11)
• Taiwan
(Ruan et al. CID 2009; 49: e11)
 84% positive for T. asahii, then T. dermatis, T montevideense
• Other than fungemia, pulmonary, soft tissue infection &
meningitis
Cladophialophora bantiana brain abscess
Place
No. of
cases
Male/
Female
ImmunoMortality
compromised
DAmB
LAmB Voriconazole
Asia
71
(India 62)
79:21
34%
53%
50%
8%
16%
Other
than
Asia
53
66:39
49%
79%
47%
22%
20%
Chakrabarti et al. Med Mycol 2015 (in press)
Fusariosis in Brazil
High rate of IFI in AML &
myelodysplasia(n=237),
HSCT (n=700)
Nucci et al. Clin Microbiol Infect 2013; 19: 745
Stories of outbreaks
Outbreaks of unusual fungemia in India
• Pichia anomala (379 babies)
• Kodamaea ohmeri (38 cases)
• Candida auris/haemulonii
• Pichia fabianii (21 cases)
• C. guilliermondii
• C. lusitaniae
• C. dubliniensis
• C. inconspicua
• C. famata
• C. rugosa
• C. norvegensis
Pichia anomala fungemia outbreaks
Series
Place of outbreak
No. of
Type of
patients
patients
Murphy et al., 1986
Liverpool, UK
8
Pediatric
Yamada et al., 1995
Japan
4
Pediatric
Rio de Janeiro, Brazil
24
Pediatric
Chandigarh, India
379
Pediatric
Aragao et al., 2001
Sao Paulo, Brazil
8
Pediatric
Kalenic et al., 2001
Croatia
8
Adult
Mestroni et al., 2003
La Plata, Argentina
4
Adult
Brazil
17
Pediatric
Ankara, Turkey
4
Pediatric
Thuler et al., 1997
Chakrabarti et al., 2001
Pasqualotto et al., 2003
Kalkanci et al., 2010
Reasons for majority outbreaks
• High yeast hand carriage rate (46-80%)
• Horizontal transmission
• Too many patients in hospital
• Compromise in healthcare
Candida auris (haemulonii) in India
• From Sir Ganga Ram Hospital – C. haemulonii (15.5%) of
all candidemia cases (Oberoi JK, et al. Indian J Med Res 2012; 136: 997-1003)
• Sensitivity – AMB – 28%, FLU – 0%, ITR – 0%, VOR – 64%
• Extremes of age, central line, mechanical ventilation, malignancy are
significantly associated
• Next, Max hospital – 14 cases of C. haemulonii fungemia
• Then, PGIMER, Chandigarh – multiple cases; MIC50 – AMB – 16g/ml,
FLU – 64, ITR – 4, VOR – 8
• Sequencing showed majority of the isolates are C. auris
• Candidemia network – 5.2% isolates from 19 of 27 ICUs
C. auris - a new threat in developing countries
Summary
• Prevalence of fungal disease is vey high with unique spectrum
of agents
• Among endemic fungi, penicilliosis & paracoccidioidomycosis
are restricted in developing countries
• Prevalence of opportunistic fungal infection is alarming
• Among yeast, C. tropicalis & C. parapsilosis more common
• Aspergillosis – real incidence not known; A. flavus prevalent in
tropical area
• Mucormycosis – high incidence in India, Brazil, China;
association with diabetes; wide spectrum of agents
Summary
• P. insidiosum, C. bantiana, Fusarium, Trichosporon
infections are common in certain geographical location
• Outbreaks due to unusual fungi are disturbing
• Awareness among clinicians is still lacking; few
laboratories in majority countries
• Epidemiology of candidiasis indicates requirement of
adequate resourcing for infection control
Future need
Thank you!
• More awareness
• Diagnostic mycology lab. in every tertiary center
• We need clinical mycologists
• Training program across developing countries
• Mycology research
• Systematic epidemiology study