Author(s): Olaniran Olarinde
Candidiasis is by far the most common type of yeast infection, these fungi live on all surfaces of our bodies, under certain conditions, they can become so numerous to cause infections, particularly in warm and moist areas, typical affected areas in babies include the mouth and diaper areas, an in vitro antifungal evaluation study was carried out on 48 strains of Candida species isolated from children diapers using disc diffusion method with five different anti fungi drug such as Nystatin (50mcg), Amphotericin-B (50mcg). Fluconazole (10mcg), Miconazole (30mcg) and Viroconazole (1mcg), Candida albican 11 (22.9), Candida krusei 23 (47.9), Candida tropicalis 1 (2.1), and Candida glabrata 13 (27.1). Miconazole had the highest overall sensitivity 100.0% and the least Fluconazole 12.5 %. Fluconazole had the highest overall resistant 87.5 % and the least Miconazole 4.2 % in Sensitivity within the drugs, Nystatin: C. krusei had the highest 48.7 % and the least 2.6 %, Amphotericin B: C. krusei had the highest 48.7 % and the least C. tropicalis 2.6 %, Miconazole: C. krusei had the highest 45.7 % and the least C. tropicalis 2.2 %, Voriconazole: C krusei had the highest 47.4 % and the least C. albican 21.1% Fluconazole: C. glabrata had the highest 50.0 % and the least C. krusei 16.7, .in Sensitivity within Organisms: Candida albican: Miconazole had the highest sensitivity 100.0 % and the least Fluonazole 18.2%. C. krusei: Nystatin and Amphotericin B had 82.6% each, voriconazole 78.3%, and the least Fluconazole 4.3 %. C. tropicalis: Nystatin, Amphotericin B and miconazole had 100.0 each. C. glabrata: miconazole had 100.0 % and the least Fluconazole 23.1 %, in Resistance within drugs, Nystatin: C. krusei had the highest resistance 44.4 %, the least C. glabrata 22.2 %, Amphotericin B: C. krusei 44.4 %, the least C. albican 22.2 %, Miconazole: C. krusei 100.0 %, voriconazole: C. krusei 50.0 %, the least, 10.0% for both C. tropicalis and C. glabrata. Fluconazole: C. krusei 52.4 %, then the least C. tropicalis 2.4 %, in Resistance within organisms, in C. albican; fluconazole had the highest 81.8 %, Nystatin and Voriconazole 27.3 % each, C. krusei: Fluconazole had 95.7 % voriconazole 21.7 % while both Amphotericin B and Nystatin had 17.4 % each. C. tropicalis: Fluconazole and Voriconazole had 100.0 %, C. glabrata: Fluconazole had 76. % and the least 7.7 %. In conclusion, in this study, Miconazole which had the highest overall sensitivity to different Candida species is therefore recommended as the most suitable medication for the treatment of candidiasis.
Disposable diapers were first produced in the 1940s, but were initially considered to be luxury items. It was not until the 1960s that they began to be used on a mass scale. By then, diapers were made with layers of cellulose, which made them more absorbent and resistant. (Ward et al, 2000, [1] Wolf R et al, 2000 [2]. However, they can also cause diaper dermatitis, also known as diaper rash, which can be associated with different infections, especially Candida infections. Klunk, et al, 2014 [3] The origin of these yeasts is directly related to the intestinal flora, and they have been isolated in children with oral and esophageal candidiasis (thrush). The clinical symptoms in these cases are more severe because the yeasts are excreted in the feces. (Hoppe et al., 1997 [4] Campbell et al., 1988 [5] Adalat et al., 2007 [6] Tüzün et al., 2015) [7] Candida infections commonly occur in warm moist body areas, such as underarms. Usually our skin effectively blocks yeast, but any breakdown or cuts in the skin may allow this organism to penetrate. A series of factors favor Candida infection in the diaper area. They are mostly acidophilic yeasts that thrive at skin pH, which is around 5.5, or 6.0 in newborns (owing to vernix caseosa and amniotic fluid), tending to normalize in a few days (Brook I,1992 [8] Hoppe J.E 1997 Ferrazzini, et al. 2003) [9] C. albican and other yeasts provide examples of perfect adaptation to pH changes, which is controlled by two genes: PHR2, which is activated in acidic environments and is deactivated when pH increases, and PHR1, which does the opposite, i.e. is activated at a high pH (neutral and basic levels) De Bernardis et al, 1998 [10] Another proven factor in developing fungi (yeasts and dermatophytes) is CO 2 levels, which are higher in the occlusive environment of standard disposable diapers and barely detectable in breathable diapers (Odio and Friedlander 2000 [11] Allen and King 1978 [12] Akin et al, 2001) [13] The primary treatment for Candida diaper rash involves antifungal topical treatment and decreasing moisture in the diaper area. Nystatin (Mycostatin), Clotrimazole (Lotrimin), and Miconazole (Micatin, Monistat-Derm) are topical over-the-counter (nonprescription) treatments of equal strength for treating Candida diaper dermatitis. Occasionally, other prescription antifungal creams, such as ketoconazole (Nizoral cream) and econazole (Spectazole) may be necessary. This research is aimed at knowing the sensitivity and resistivity patterns of some selected antifungal drugs on the isolated Candida species from the diaper rash.
Study area: The study was conducted at the Obafemi Awolowo University Teaching Hospital Complex (OAUTHC), Ile-Ife, southwest of Nigeria. This is a 600 bedded hospital that serves as referral center to about 5 neighboring states of the country.
Study population: A total of forty-eight (48) isolated species of Candida from the children diapers attending Dermatology Clinic of the OAUTHC Ile-Ife were used in this study. The study was conducted between September and December2018.
The Identification of the Candida species were carried out by plating each Candida species on the prepared Hi Chrome Candida Differential Agar (M1297A) in a Petri dish and incubated for 12 hours. After incubation, the organisms come up with the colour specific for each species as indicated by the Manufacturer to give (11 Candida albican, 23 Candida krusei, 1 Candida tropicalis and 13 Candida glabrata).There are no competing interests. The results were analyzed using SPSS package.
An in vitro evaluation study was performed using Disc diffusion method and five different anti fungi drug such as Nystatin (SD 271-1VL , 50mcg), Amphotericin-B (SD 270- 1VL, 50mcg). Fluconazole (SD 114- 1VL, 10mcg), Miconazole (SD 273- 1VL, 30mcg) and Viroconazole (SD 277- 1VL, 1mcg) were used.
In an in vitro evaluation study carried Out on 48 strains of Candida
isolated from children diapers, Candida albican 11 (22.9), Candida
krusei 23 (47.9), Candida tropicalis 1 (2.1), and Candida glabrata
13 (27.1).
Miconazole had the highest overall sensitivity 46 (100.0) followed
by Nystatin and amphotericin B 39 (81.3) each, Voriconazole 38
(79.2) and Fluconazole 6(12.5). Table 1.
Fluconazole had the highest overall resistant 42 (87.5),
Voriconazole 10(20.8) Nystatin and Amphotericin B 9(18.8) each
and Miconazole 2(4.2) figure 1.
| Ogranisms | Frequency (%) | Nystatin (Sens) % | Amphotericin B (Sens) % | Miconazole (Sens) % | Voriconazole (Sens) % | Fluconazole (Sens) % |
|---|---|---|---|---|---|---|
| Candida albican | 11.0 (22.9) | 8.0 (16.7) | 9.0 (18.8) | 11.0 (22.9) | 8.0 (21.1) | 2.0 (4.2) |
| Candida Krusei | 23.0 (47.9) | 19.0 (39.6) | 19.0 (39.6) | 21.0 (43.8) | 18.0 (47.4) | 1.0 (2.1) |
| Candida tropicalis | 1.0 (2.1) | 1.0 (2.1) | 1.0 (2.1) | 1.0 (2.1) | 0.0 (0) | 0.0 (0.0) |
| Candida glabrata | 13.0 (27.1) | 11.0 (22.9) | 10.0 (20.8) | 0.0 (0.0) | 12.0 (35.0) | 3.0 (6.3) |
| Total | 48.0 (100) | 39 (81.3) | 39.0 (81.3) | 46.0 (100) | 38.0 (79.2) | 6.0 (12.5) |
Figure 1: General antifungal percentage resistant pattern of Candida species isolated from children diaper
Nystatin: C. krusei had the highest 48.7%, C. glabrata 28.2%, and the least 2.6% Amphotericin B: C. krusei had the highest 48.7%, C. glabrata 25.6% and the least C. tropicalis 2.6% Miconazole: C. krusei had the highest 45.7%, C. glabrata 28.3%, and the least C. tropicalis 2.2% Voriconazole: C krusei had the highest 47.4%, C. glabrata 13.6% and the least C. albican 21.1% Fluconazole: C. glabrata had the highest (50.0%, C. albican 33.3%, and the least C. krusei 16.7%. Table 2
Table 2: Sensitivity pattern of Candida species isolated from children diaper and the percentage within the Antifungal drugs used| Ogranisms | Frequency (%) | Nystatin (Sens) % | Amphotericin B (Sens) % | Miconazole (Sens) % | Voriconazole (Sens) % | Fluconazole (Sens) % |
|---|---|---|---|---|---|---|
| Candida albican | 11(22.9) | 8.0 (20.5) | 9.0 (23.1) | 11.0 (23.9) | 8.0 (21.1) | 2.0 (33.3) |
| Candida Krusei | 23(47.9) | 19.0 (48.7) | 19.0 (48.7) | 21.0 (45.7) | 18.0 (47.4) | 1.0 (16.7) |
| Candida tropicalis | 1(2.1) | 1.0 (2.6) | 1.0 (2.6) | 1.0 (2.2) | 0.0(0) | 0(0.0) |
| Candida glabrata | 13(27.1) | 11.0 (28.2) | 10.0 (25.6) | 13.0 (28.3) | 12.0 (31.6) | 3.0 (50.0) |
| Total | 48 (100) | 39.0 (100) | 39.0 (100) | 46.0 (100) | 38.0 (100) | 6.0 (100) |
Candida albican: Miconazole had the highest sensitivity 100.0%, Amphotericin B 81.8%, Hystatin and voriconazole 72.7% each and the least Fluonazole 18.2%. C. krusei: Nystatin and Amphotericin B had 82.6% each, voriconazole 78.3%, and the least Fluconazole 4.3%. C. tropicalis: Nystatin, Amphotericin B and miconazole had 100.0 each. C. glabrata: miconazole had 100.0% voriconazole 92.3%, Nystatin 84.6% and the least Fluconazole 23.1%. Table 3.
Table 3: Sensitivity pattern of Candida species isolated from children diaper and the percentage within the Organisms| Ogranisms | Frequency (%) | Nystatin (Sens) % | Amphotericin B (Sens) % | Miconazole (Sens) % | Voriconazole (Sens) % | Fluconazole (Sens) % |
|---|---|---|---|---|---|---|
| Candida albican | 11(22.9) | 8.0 (72.7) | 9.0 (81.8) | 11.0 (100.0) | 8.0 (72.7) | 2.0 (18.2) |
| Candida Krusei | 23(47.9) | 19.0 (82.6) | 19.0 (82.6) | 21.0 (91.3) | 18.0 (78.3) | 1.0 (4.3) |
| Candida tropicalis | 1(2.1) | 1.0(100.0) | 1.0(100.0) | 1.0(100.0) | 0.0(0.0) | 0.0(0) |
| Candida glabrata | 13(27.1) | 11.0 (84.6) | 10.0 (76.9) | 13.0 (100.0)) | 12.0 (92.3) | 3.0 (23.1) |
| Total | 48 (100) | 39.0 (81.3) | 39.0 (81.3) | 46.0 (95.8) | 38.0 (79.2) | 6.0 (12.5) |
Nystatin: C. krusei had the highest resistance 44.4%, C.albican 33.3% the least C. glabrata 22.2%, Amphotericin B: C. krusei 44.4%, C. glabrata 33.3%, then the least C. albican 22.2%, Miconazole: C. krusei 100.0%, voriconazole: C. krusei 50.0% C. albican 30.0%, the least, 10.0% for both C. tropicalis and C. glabrata. Fluconazole: C. krusei 52.4%, C.glabrata 23.8% then the least C. tropicalis 2.4%. Figure 2
Figure 2: Resistant pattern of Candida species isolated from children diaper in percentage (%) within the Antifungal drugs used
The highest resistance was seen in C. albican; fluconazole 81.8%, Nystatin and Voriconazole 27.3% each, C. krusei: Fluconazole had 95.7% voriconazole 21.7% while both Amphotericin B and Nystatin had 17.4% each. C. tropicalis: Fluconazole and Voriconazole had 100.0%, C. glabrata: Fluconazole had 76.% Amphotericin B 23.1% and the least 7.7%. Figure 3
Figure 3: Resistant pattern of Candida species isolated from children diaper in percentage (%) within the Organisms
Plate1: Pure culture of Candida albican (Green) isolated from Children diaper on Hi Media Chrome Agar (M1297A). Plate 2: Pure culture of Candida tropicalis (blue) isolated from children diaper on Hi Media Chrome Agar (M1297A). Plate 3: Pure culture of Candida krusei (purple) isolated from children diaper on Hi Media Chrome Agar (M1297A). Plate 4: Pure culture of Candida glabrata (whitish/creaming) isolated from children diaper on Hi Media Chrome Agar (M1297A).
An invitro evaluation study was carried out on 48 strains of
Candida spp isolated from children diapers in ile ife, In this
study miconazole had the highest overall sensitivity 100.0%
and the least was fluconazole 12.5%, this was in conjunctions
with the report from world health organization that fluconazole
resistance was indeed more common in non Candida albican
species and this may pose negative signal since fluconazole was
not that expensive and well tolerated medication that is given
orally (WHO 2014). C. krusei is more sensitive to Nystatin 48.7%
Amphotericin B 48.7%, Miconazole 45.7%, Voriconazole 47.4%
while the C. glabrata is more sensitive to fluconazole 50% within
the drugs used in the study. Within the organism used, C. albican
had the highest sensitivity 100% Amphotericin B 81.8%, Nystatin
and Voriconazole 72% and Fluconazole 18.2 %, this was in line
with the findings of Jasem et al, 2014 in which the sensitivity
to Voriconazole was higher with 94.3% but on the contrary, the
sensitivity to Fluconazole 67.9% was more than what we got.
The highest resistance in the study was seen with Fluconazole
87.5 % whereas In the study done by Jasem et al, 2014 it was
35.8% and also, according to the work done by the CDC on the
resistivity of the Candida isolates, where 70.0 % resistance was
seen with C. glabrata and C. krusei but in the study it was seen
with C. tropicalis and C. krusei. To all drugs used in the study,
C. krusei had the highest resistance of 44.4 % on Nystatin and
Amphotericin B, 100 % Miconazole, 50.0 % C. albican, 52.4
% fluconazole and 50.0 % Voriconazole. The resistance among
the Candida species used was seen with Fluconazole, where C.
albican had 81 %, C. krusei had 95.7 %, C. tropicalis had 100%, and C. glabrata had 76 %. The most common cause of candida
infection C. albican in the study done by Mohamadi et al, 2014
had Nystatin to be 100% sensitive to C. albican whereas in the
study it was found to be 72.7 % showing that there is increase in
the resistivity to the drug.
In conclusion, in this study, over all resistance to different Candida species, Miconazole (100.0), Nystatin and amphotericin B (81.3) each, Voriconazole (79.2) and Fluconazole (12.5) which implies that Fluconazole that is commonly used had 87.5 resistance, it is therefore recommended according to the study that Miconazole is the most suitable medication for the treatment of especially diaper rash induce candidiasis. [14-19].
1. Ward DB, Fleischer AB Jr, Feldman SR, Krowchuk DP
(2000) Characterization of diaper dermatitis in the United
States. Arch Pediatr Adolesc Med. 154: 943-946.
2. Wolf R, Wolf D, Tüzün B, Tüzün Y (2000) Diaper dermatitis
Clin Dermatol. 18: 657-660.
3. Klunk C, Domingues E, Wiss K (2014) An update on diaper
dermatitis Clin Dermatol. 32: 477-487.
4. Hoppe JE (1997) Treatment of oropharyngeal candidiasis and
candidal diaper dermatitis in neonates and infants: review and
reappraisal. Pediatr Infect Dis J. 16: 885-894.
5. Campbell RL, Bartlett AV, Sarbaugh FC, Pickering LK (1988)
Effects of diaper types on diaper dermatitis associated with
diarrhea and antibiotic use in children in day-care centers.
Pediatr Dermatol. 5:83-87.
6. Adalat S, Wall D, Goodyear H (2007) Diaper dermatitis frequency and contributory factors in hospital attending
children. Pediatr Dermatol. 24: 483-488.
7.Tüzün Y, Wolf R, Bağlam S, Engin B (2015) Diaper (napkin)
dermatitis: a fold (intertriginous) dermatosis. Clin Dermatol.
33: 477-482.
8.Brook I (1992) Microbiology of secondarily infected diaper
dermatitis. Int J Dermatol. 31: 700-702.
9.Hoppe JE (1997) Treatment of oropharyngeal candidiasis and
candidal diaper dermatitis in neonates and infants: review and
reappraisal. Pediatr Infect Dis J. 16: 885-894.
10.Ferrazzini G, Kaiser RR, Hirsig-Cheng SK, Wehrli M,
Della Casa V, Pohlig G Gonser S, Graf F, Jörg W.(2003)
Microbiological aspects of diaper dermatitis. Dermatology.
206: 136-141.
11.De Bernardis F, Mühlschlegel FA, Cassone A, Fonzi WA
(1998) The pH of the host niche controls gene expression
in and virulence of Candida albicans. Infect Immun. 66:
3317-3325.
12.Odio M, Friedlander SF (2000) Diaper dermatitis and
advances in diaper technology. Curr Opin Pediatr. 12: 342-
346.
13.Allen AM, King RD (1978) Occlusion, carbon dioxide, and
fungal skin infections. Lancet. 18 :360-362.
14.Mohamadi J, Motaghi M, Panahi J, Havasian MR, Delpisheh
A, Azizian M, Pakzad I (2014) Anti-fungal resistance in Candida isolated from oral and diaper rash candidiasis in
neonates. Bioinformation. 10: 667-670.
15.Pfaller MA, Diekema DJ, Gibbs DL, et al (2010) Results
from the ARTEMIS DISK global antifungal surveillance
study, 1997 to 2007: a 10.5-year analysis of susceptibilities
of Candida species to fluco
nazole and voriconazole
as determined by CLSI standardized disk diffusion. J Clin
Microbiol. 48: 1366-1377
16.Pfaller MA, Messer SA, Moet GJ, Jones RN, Castanheira
M (2011) Candida bloodstream infections: comparison of
species distribution and resistance to echinocandin and azole
antifungal agents in intensive care unit (ICU) and non-ICU
settings in the SENTRY Antimicrobial Surveillance Program
(2008-2009) Int J Antimicrob Agents. 38: 65-69
17.Yapar N (2014) Epidemiology and risk factors for invasive
candidiasis. Ther Clin Risk Manag. 10: 95-105.
18.WHO Antimicrobial Resistance: Global Report on
Surveillance. 2014. [Accessed June 21, 2017]. Available
from: http://www.who.int/drugresistance/documents/
surveillancereport/en/
19.White TC, Marr KA, Bowden RA ( 1998) Clinical, cellular,
and molecular factors that contribute to antifungal drug
resistance. Clin Microbiol Rev. 11: 382-402.
