Candida

Alarmingly: CDC STATISTICS

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most common fungal pathogen worldwide.

The CDC has ranked it as the 4th leading pathogen in

causing nosocomial bloodstream infections.
Account for 80% of nosocomial fungal infections
Account for 30% of deaths from nosocomial
infections
Surgical and neonatal intensive care units are dense
sources of spread of Candida infections.
Moreover, 75% of women will suffer from a yeast
infection at least once in their life, 45% experience
recurrence .
In the U.S., Vaginitis accounts for 10 million visits to
the physician each year. C. albicans is also

Candida

Candida albicans is the most frequently (50%)

isolated in human fungal infections.
C. albicans is also the most abundant and
significant of all the Candida related species, and
they are part of the normal endogenous microbial
flora. Infection are believed to be endogenous in
origin, and the organism may be recovered from
Oropharynx, GIT, GUT, and Skin
However, C. albicans and related species are
frequently recovered from hospitals, foods, counter
tops, medical equipment and so on.
A healthy host is typically extremely resistant to the
potentially pathogenic effects of C. albicans.
However, when slight alterations of the hosts
environment occurs, a harmless commensal
organism can turn into agents of severely inflicting
illnesses.

Candida

Widespread yeast
Several species of Candida may be etiological agents.
Most commonly:
Candida albicans
Rarely
C. tropicalis.
C. krusei.
C. parapsilosis
C. pseudotropicalis, (kefyr)
C. glabrata,(Torulopsis)
C. dublinsense
All are ubiquitous and occur naturally on humans,
especially
C. albicans which is recognised as a commensal of the
mucosal membrane of the gastrointestinal tract.

Candida
Candidiasis is a primary or secondary
mycotic infection caused by members of the
genus Candida.
The clinical manifestations may be acute,
subacute or chronic to episodic.
Involvement may be localized to the mouth,
throat, skin, scalp, vagina, fingers, nails,
bronchi, lungs, or the gastrointestinal tract.
systemic as in septicemia, endocarditis and
meningitis.
In healthy individuals, Candida infections
are usually due to impaired epithelial
barrier functions and occur in all age
groups, but are most common in the
newborn and the elderly. They usually

Candida
Immunocompromised
Most commonly manifested in patients with HIV-AIDS
infections.
Cancer and leukemia .
Oral candidiasis is often a clue to acute primary
infection.

Public Concerns
Increasing resistance to drug therapies due to
antibiotics and antifungal.
Types of candida infection:
Intertriginous, paronychia, onychomycosis,
perleche, vulvovaginitis, thrush, pulmonary
infection, eye infection, endocarditis, meningitis,
fungemia, and disseminated infection.

Common opportunistic fungal

infections
in HIV/AIDS

Candidiasis is the most common fungal

infection found in HIV/AIDS patients.
Extensive esophageal candidiasis is an
AIDS-defining infection. But oral
candidiasis, unless very extensive and
causing symptoms unequivocally, is not
diagnostic of AIDS.
It is of prognostic value only as its
presence indicates progression of
immunodeficiency.
Vulvovaginal candidiasis, though not
unequivocally shown to occur more
frequently in AIDS patients, nevertheless

Candida

Gram stains of smears show gram-positive

budding Yeast-like fungus, the bud becomes
elongated to form pseudohyphae ( except
C.glabrata) and pseudo mycelium.
C.albicans is non capsulated, urease +ve (except
C.glabrata)
Facultative anaerobes, favors moist surfaces.
Round, oval or elongated.
Reproduction by budding or binary fission.
Complete / incomplete budding.
Non-fastidious
In a wet mount, masses of budding cells and
fragments of mycelium are seen.

Gram-Stain
Candida albicans
retaining crystal
violet stain from
routine gram
stain taken from
SAB Agar

Candida

Candida species are readily isolated on most

laboratory media (Sabouraud Dextrose Agar
& Blood Agar).
Only Candida albicans is capable of germtube production.
Germ-tube production occurs at the beginning
of true hyphae formation.
In lab diagnostics, this feature is key to
identifying a sample with strains of C.
albicans.
C. albicans can also be recognized for its
production of a typical asexual spore called a
chlamydoconidium .

Germ tube (GT) test

The germ tube test is used for presumptive
identification of Candida albicans. It is a
rapid screening test wherein the production
of germ tubes within 2 hours in contact with
the serum is considered as indicative of
Candida albicans.
Procedure

(1) Ensure that the test starts with a fresh growth

from a pure culture.
(2) Make a very light suspension of the test
organism in 0.5 ml of sterile serum (pooled human
serum or fetal calf serum). The optimum Inoculum is
105-106 cells per ml.
(3) Incubate at 37C for exactly 2 hours.
(4) Place 1 drop from the incubated serum on a slide
with a cover slip. Observe under the microscope for
production of GTs.

Germ tube (GT) (+ &-)

Candida albicans

This ability to assume various forms may be related to the

pathogenicity of this organism.
The yeast form is 10-12 microns in diameter, gram positive,
and it grows overnight on most bacterial and fungal media.
It also produces germ tubes, and pseudohyphae may be
formed from budding yeast cells that remain attached to
each other.
Spores may be formed on the pseudomycelium. These are
called chlamydospores and they can be used to identify
different species of Candida
1- Candida albicans number one fungal isolate in
laboratory
Germ tube: positive within 3 hours (95% of time)
CMT: Clustered blastoconidia at septa of pseudohyphae,
terminal chlamydoconidia
CHO assimilation: sucrose positive
Other medically important species that can cause
opportunistic infections:
2- Candida glabrata

Candida

A host may become highly susceptible to C.

albicans when the following defense
mechanisms are challenged:
Intact mucocutaneous barriers.
Phagocytic cells, polymorphonuclear leukocytes, monocytic cells,
complement system, immunoglobulins, cell-mediated immunity.
Mucocutaneous protective bacterial flora .
Impaired salivary gland function can predispose to oral candidiasis

There are many risk factors that can stage

the scene for susceptibility, these include:
Granulocytopenia, & bone-marrow transplantation.
Organ transplant.
Other factors are smoking
Dentures predispose to infection with candida in as many as 65% of
elderly people wearing full upper dentures.
General and invasive surgical procedures, catheters.
Chemotherapy, radiation therapy.
The use of corticosteroids, oral contraceptives, broad-spectrum
antibiotics.

Colony on Sabouraud Dextrose

Agar (SDA)
Most commonly used medium.
Since antibacterials do not inhibit fungi,
including candida, the use of media
containing antibacterials is helpful in the
isolation of candida, especially from
specimens which are not sterile (e.g. skin,
sputum and urine).
Most strains grow well at 37C or @ room
temperature (22-25C). Young colonies are
white with a soft consistency; the surface
and margins of the colonies are smooth.

Colony on Sabouraud Dextrose Agar

(SDA) & on Blood Agar
C. albicans

Candida
albicans on
SabouraudDextrose
Agar at 48
hours at
30C

typical cream coloured,

smooth surfaced, waxy
colonies.

Chlamydospore &
Blastoconidia
C. albicans can also be recognized for its

production of a typical asexual spore

called a Chlamydospore
(chlamydoconidium)
Culturing Candida on a nutritionally poor
media. Along side of the pseudohyphae,
Candida albicans develops also
blastoconidia around the area of the
septa (division). These appear as
smaller round grape-like clusters.

CHROMagar Candida
Yeasts can also be cultivated from clinical
specimens on the selective and differential
medium called CHROMagar Candida, which
uses a chromogenic mixture that allows
selective isolation of yeasts and
simultaneously identifies colonies of C.
albicans, C. tropicalis, C. glabrata and
Candida krusei.
This medium has proven to be useful for
detection of mixed cultures of Candida sp.
within a single specimen.
CHROMagar Candida plate showing
chromogenic colour change for C. albicans
(green), C. tropicalis (blue), C. parapsilosis

CHROMagar Candida
Growth of
C. albicans (A and B),
C. krusei (C and D),
C. tropicalis (E and F)
C. glabrata (G and H)
On CHROMagar
Candida.

Sugar fermentation test

Inoculate heavy growth onto sugar fermentation tubes
containing the appropriate sugars and Durhams tubes.
Incubate at 24C up to 1 week.
Examine tubes at 48 hours intervals for acid production
(yellow/pink color) and gas formation (in Durhams tubes).
Production of gas indicates fermentation .
The reactions are read as A/G for each sugar separately.
Specimen is inoculated beneath broth so that it is
completely covered.
Bromcresol purple is the indicator.
Acid production turns purple to yellow. Gas is detected by
appearance of bubbles trapped in the fermentation tube.
Observe every 48 hours for 14 days.

Sugar/nitrate assimilation test (auxanographic method)

Disc impregnation
Prepare yeast nitrogen base (YNB)/ yeast carbon base (YCB), for nitrate test
Prepare a yeast suspension from a 24-48-hours-old culture in 2 ml of YNB by
adding heavy Inoculum.
Add this suspension to the 18 ml of molten agar (cooled to 45C) and mix well
in a sterile McCartney bottle (24 ml capacity).
Pour the entire volume into a 90 ml Petri dish.
Allow the media to solidify at room temperature.
Now place the various carbohydrate-impregnated discs onto the
surface of the agar plate.
Incubate plates at 37C for 3-4 days.
Presence of growth around discs is considered positive for that particular
carbohydrate.
Growth around glucose disc is recorded first as it serves as a positive control.
For the nitrate assimilation test, yeast suspension is prepared in YCB instead
of YNB.
In addition, a disc of peptone is used as positive control and one of KNO3 as
test.

Oral Candidiasis
1- Acute oral candidiasis is rarely
seen in healthy adults but may occur
in up to 5% of newborn infants, and
10% of the elderly. Clinically, white
plaques that resemble milk curd form
on the buccal mucosa and less
commonly on the tongue, gums, the
palate or the pharynx (ulcers).
Symptoms may be absent or include
burning or dryness of the mouth, loss
of taste, and pain on swallowing.

Oral Candidiasis
A- Oral candidiasis in an infant showing
characteristic patches of a creamy-white to
grey pseudomembrane composed of
blastoconidia and pseudohyphae of C. albicans.
Note the mouth of normal newborn infants has
a low pH which may promote the proliferation
of C. albicans.
The infections are usually acquired during the
birth process from mothers who had vaginal
thrush during pregnancy.
Clinical symptoms may persist until a balanced
oral flora has been established.

Oral
Candidiasis
Oral candidiasis can be classified as follows:
Acute candidiasis
Acute pseudomembranous candidiasis
(thrush):
is characterized by extensive white
pseudomembranous consisting of
desquamated epithelial cells, fibrin, and
fungal hyphae. These white patches
occur on the surface of the labial and
buccal mucosa
Acute atrophic (erythematous)
candidiasis.
Associated with a burning sensation in
the mouth or on the tongue. The tongue
may be bright red
Chronic candidiasis
Chronic hyperplastic candidiasis
(candidal leukoplakia): Occurs on the
buccal mucosa or lateral border of the
tongue as speckled or homogenous white
lesions .

Candidiasis
2- Chronic Candida onychomycosis
Although not life-threatening, onychomycosis (a fungal
infection of the nail, usually caused by a dermatophyte)
Candida nail infections occur in patients with chronic
mucocutaneous candidiasis, and are caused by C. albicans. The
organism invades the entire nail plate.
Often causes complete destruction of nail tissue and is seen in
3- Vulvovaginal candidiasis is a common condition in women,
often associated with:
The use of broad-spectrum antibiotics
The third trimester of pregnancy
Low vaginal pH and
Diabetes mellitus.
4- Orophargneal candidiasis may progress to Oesophageal
candidiasis
Manifestation of AIDS.

Laboratory Diagnosis

The doctor will suspect an infection based

on the symptoms in different areas.
Samples:

Oral swap, vaginal discharge, skin scraping & nail clipping.

Lab. diagnosis
A. Wet preparation
B. Gram stain will show the typical hyphae/spores.
C. SDA & Blood agar
D. Identification tests ??????????????????????????
Vulvovaginal candidiasis
The pelvic exam will typically show inflammation and a
white discharge in the vagina and around the vaginal
opening.
The pH is acid/ normal; lactobacilli still present

Treatment
When treating immunosuppressed patients it is often
not possible to correct the underlying predisposing
conditions that would prevent candidiasis.(pregnancy)
Oral Fluconazole is currently the drug of choice for
controlling oropharangeal candidiasis in AIDS patients.
Emergence of Fluconazole resistant strains of C.
albicans.
For oral candidiasis in infants, Nystatin suspension is
usually used.
In older children and adults miconazole oral gel.
Nystatine drops may also be used
These medications include:
Clotrimazole (Canesten),
Miconazole (Monistat),
Nystatin (mycostatin ) are mostly used for candidiasis.
Flucytosine is also very effective against candida

Preventing
Basically, healthy individuals do not
get candidiasis, therefore the key
strategy in preventing a recurrence is
to correct the underlying
predisposing conditions that allow
Candida to cause an infection,
especially those affecting the immune
system. Where this is not possible, ie,
in AIDS patients, then recurrence can
only be prevented by prophylaxis.