Speciation and antifungal susceptibility of candida isolates from diabetic foot ulcer patients in kenyatta national hospital

Abstract

Background Diabetic foot ulcer is the leading cause of diabetic related hospital admissions, amputations and mortality among diabetic patients. Chronic wounds are a concern to public health worldwide, and the effects are a warning to the economy. Diabetic foot ulcer wounds are prone to infection with candida species presenting as the principal fungal agent among other microorganisms. Identification of candida isolates to species level is essential and might reduce antifungal drug resistance, cost of treatment, morbidity and mortality among diabetic patients. Objective To determine the prevalence, species and antifungal susceptibility of candida species from diabetic foot ulcer patients receiving clinical services at kenyatta national hospital between june and august 2019 Methodology This was a cross-sectional study carried out at kenyatta national hospital among diabetic adult patients presenting with active foot ulcers. A total of 152 swabs were consecutively collected from 152 diabetic foot ulcer patients over a three month period, from june to august 2019. We collected clinical and socio-demographic data using a structured questionnaire. Growth on sabouraud dextrose agar was evaluated for colonial morphology, gram stain and germ tube. Species identification and antifungal susceptibility was determined using vitek - 2 system according to clsi m60 guideline. Data were retrieved and imported to whonet through baclink and analysis done using whonet version 5.6 and ibm spss statistics version 21. Results Sixty one percent of the participants were male. The mean age was 50.7 (sd=12.9) years. Out of 152 samples, a total of 36 candida species were isolated. Among these 46% were drug resistant, 11% multidrug resistant, 3% pandrug resistant and 40% susceptible to all the antifungal agents tested. Candida albicans was the most common species isolated with low incidence of resistance to echinocandins (26%) and triazoles (26%) but demonstrated high susceptibility to flucytosine (96%) and amphotericin b (81%). Candida lusitaniae and c. Dubliniensis were the predominant non albicans candida species and showed moderate resistance to voriconazole (50%) and amphotericin b (33%) respectively. Both showed 100% susceptibility to echinocandins, fluconazole and flucytosine. Eighty percent of the wounds demonstrated polymicrobial infections. Conclusion Candida species was isolated in a fifth of the participants and showed low resistance rates to the commonly administered antifungal agents such amphotericin b and fluconazole. However, we also noted a high number of the wounds to have mixed infection. There is need for inclusion of fungal diagnosis in diabetic foot ulcer infection, continuous antifungal resistance surveillance especially in candida species and strengthening of antifungal stewardship programmes to enhance patient care and management.