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4th Edition of World Congress on Infectious Diseases

June 21-22, 2023 | Rome, Italy

June 21 -22, 2023 | Rome, Italy
Infection 2023

Hideliz Marie G Pascua

Speaker at World Congress on Infectious Diseases 2023 - Hideliz Marie G Pascua
Baguio General Hospital and Medical Center, Philippines
Title : Foreign fungus: Candida duobushaemulonii bloodstream infection in an immunocompromised host at Baguio General Hospital & Medical Center: A case report

Abstract:

Candida duobushaemulonii is a yeast that belongs to the Candida haemulonii species complex. Similar to Candida auris which is an emerging global health threat, C. duobushaemulonii is a major concern in the healthcare system as it is often multidrug resistant. Presenting the  1st reported case of C. duobushaemulonii in the Philippines. This is the case of an 80 year old German national, a long standing immunocompromised patient,  who received several cycles of broad spectrum antibiotics due to recurrent bouts of nosocomial infections who eventually presented with fungemia. Initial idenitification of the yeast revealed C.auris but on manual biochemical testing reveled C. duobushaemiulonii which was resistant to all available antifungal therapy in this institution and the Philippines for that matter. As healthcare professionals, we have to be vigilant in suspecting and diagnosing this rare fungal infection in order to give prompt and appropriate treatment. Therefore, it is vital to be vigilant in the proper identification and diagnosis of such opportunistic pathogen and to have the specific antimicrobial agents available.

Introduction:
Candidiasis remains as one of the top 5 healthcare-associated bloodstream infections in the world and still causes high mortality rates. It covers a wide range of diseases, from mild clinical infections to invasive and even disseminated forms. In humans, Candida species colonizes the skin, oropharynx and lower respiratory, gastrointestinal, and genitourinary tracts. (Yapar, 2014). Candida duobushaemulonii is a yeast that belongs to the Candida haemulonii species complex. Yeasts in this complex are closely related Candida auris, which is an emerging global health threat because it is often multidrug resistant (MDR) and can cause outbreaks in health care settings (Chawdhary 2014).  In the Philippines, there were no reports isolated C. duobushaemulonii bloodstream infections. We report the first documented case of Candida duobushaemulonii fungemia in the Philippines.

Case
The patient is an 80 year old male German national  who had been residing in the Philippines for about  ten years. His last travel back to Germany was on 2017. He was bedridden since February 2020 from a history of Cerebrovascular disease. He is a known diabetic who had recurrent admissions in our institution due to repeated bouts of pneumonia. His last admission was on June 2020 wherein he was managed as a case of nosocomial pneumonia on top of community acquired pneumonia, complicated UTI, infected sacral decubitus ulcer, UGIB drug induced and dementia and was discharged and improved. Interval history revealed intermittent episodes of productive cough with thick, white to yellowish sputum and noted a progression of the sacral ulcer prompting readmission on October 16,2021. He was septic and intubated upon admission and went into cardiopulmonary arrest however was revived. He underwent several debridement for his sacral ulcers and underwent tracheostomy.

During the course in the ward, he had several bouts of nosocomial infections such as Catheter Associated UTI (C. albicans), Ventilator Associated Pneumonioa ( Carbapenem resistant P. aeruginosa), and infected pressure ulcer (Carbapenem resistant P. aeruginosa). Culture guided therapy was initiated and he was pulled out of septic shock several times. Patient received the following antibiotics: amikacin, amphotericin B, aztreonam,  colistin, vancomycin, meropenem, polymyxin B however, despite culture guided therapy,  he succumbed to recurrent hospital infections and into septic shock. On the 120th hospital day, patient still showed no improvement. He had persistent hypotension hence fluconazole was started. Furthermore, blood cultures were collected from revealing Candida auris on two peripheral sites identified via Vitek 2 with no susceptibility testing. Fluconazole was shifted to amphotericin B as empiric therapy. The blood plate containing the fungal colonies was sent for manual biochemical testing and species identification which revealed Candida duobushaemulonii. Despite maximal medical management, his hypotension persisted, his immune response did not recover and overwhelming sepsis led to his demise.

Candida auris is what was initially identified in our microbiology laboratory using the VITEK2. Because this organism is reportable to the national reference laboratory of the country due to the healthcare burden it brings, the isolated species was regrown and was sent to an outside laboratory for confirmation via fungal culture and drug susceptibility testing. C. auris and C. duobushaemulonii are almost alike in microbiological properties. The final isolated candida species turned out to be Candida duobushaemulonii which is also a rare fungal isolate in the Philippines. The identification of Candida duobushaemulonii was done in an outside lab using The Vitek 2 automated identification system (bioMérieux) and was confirmed using biochemical testing. 

It is important to note that this paper was written with the consent of the patient’s partner as the patient was encephalopathic.

Discussion
This is the first reported case of C.duobushaemulonii in the Philippines. Despite  extensive literature search in medical search engines such as PubMed etc, I have not come across any reports on this organism. However, I have come across similar cases from international journals such as Primary deep cutaneous candidiasis caused by Candida duobushaemulonii in a 68-year-old man: the first case report and literature review by Szu-Yun et al., Deep tissue invasion was confirmed by skin histopathology examination. The pathogen was initially identified as C. haemulonii using the VITEK® 2 system for microbial identification, but was later determined to be C. duobushaemulonii based on sequencing of the internal transcribed spacer region of ribosomal DNA and D1/D2 region of 26S rDNA.

On the issue of drug Multi Drug Resistance and cases on fungemia,  a journal published Ramos et al on Emerging Multidrug-Resistant Candida duobushaemulonii Infections in Panama Hospitals: Importance of Laboratory Surveillance and Accurate Identification similiar case was noted in Panama wherein 17 isolates were obtained from 14 patients at six hospitals. Ten patients, including three children, had bloodstream infections, and MICs for fluconazole, voriconazole, and amphotericin B were elevated. Another fungal infection caused by this organism in an immunocompromised patient is written by Frias-De-Leon et al. entitled Superficial candidosis by Candida duobushaemulonii: An emerging microorganism

Wherein molecular reidentification of two clinical isolates that was recovered from a patient with total dystrophic onychomycosis and isolate from a patient with mucocutaneous candidiasis. patients had diabetes mellitus as baseline disease. These isolates were initially identified as C. haemulonii by the VITEK® 2 system but were later determined to be C. duobushaemulonii based on the amplification and sequencing of a 115-bp fragment of the region of 26S rDNA.

C. duobushaemulonii is an emerging opportunistic fungi which can be an agent for hospital acquired outbreaks especially for immunocompromised patients with prolonged hospital stay. It is a reportable organism to the national health authority and therefore should not be taken for granted. It is typically multi drug resitant and with high level of resistance typically to amphotericin B and azoles. Due to its complex phenotype only molecular-based methods guarantee their accurate identification in most fungal isolates for that matter. Globally C. duobushaemulonii imposes a great threat to the health care community since it can cause ac wide array of  invasive infections including blood stream infection such as this encountered to our patient. Furthermore, this pathogen co exists with other pathogenic bacteria which causes a rapid decline in the health status of the patient leading to poor prognosis. This infection is  an emerging global health  threat and therefore once with high index of suspicion, we must be vigilant to be quick in its identification and immediately report and alarm the national health authority. In our institution, the initial identified organism from the blood isolates was Candida auris, being it a rare isolate, we sent the colonies identified to an outside laboratory for susceptibility testing which later on revealed C. duobushaemulonii using the Vitek 2  which is a compact system uses a fluorogenic methodology for organism identification and a turbidimetric method for susceptibility testing using a 64 well card that is barcoded with information on card type, expiration date, lot number and unique card identification number which identifies some species of different organism for our patient revealed C. duobushaemulonii. Susceptibility testing was done using only antimicrobial available which were Voriconazole, Amphotericin B to which the organism is resistant  with and Minimum Inhibition concentration of  8 and 16 ug/ml respectively (Fig. 4). Fluocytosine was included, which had an MIC of 1ug/l interpreted as susceptible. However, the said antifungal is not currently available in the Philippines. The interplay of the unavailability of the specific treatment along with his overwhelming sepsis lead to the demise of the patient.

Conclusion
As health care professionals, we must always consider the possibility of opportunistic pathogens such a C. duobushaemulonii especially for patients with prolonged hospital stay, chronic broad spectrum antibiotic usage and in an immunocompromised state. A high index of suspicion for such infections is vital. We must always practice antimicrobial stewardship to avoid multi drug resistant pathogens which is a consequence of prolonged antibiotic use. C. duobushaemulonii is a reportable organism to the national health authority as it imposes a heavy burden in the health care system.

Biography:

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