Uzm. Dr.Emsal Aydın

Eğitim ve Uzmanlık
Kayseri Erciyes Üniversitesi Tıp Fakültesi
İzmir Bozyaka Eğitim ve araştırma hastanesi


Omer Coskun 1, Emsal Aydın 2 , Sergülen Aydın 3 , Umit Savasci 4, Ahmet Karakas 1, Atıl Atilla 5, Inan Usta 6

1  Gulhane Military Hospital, Department of Infectious Diseases and Clinical Microbiology, Ankara, Turkey
2 Kars State Hospital, Hospital, Department of Infectious Diseases and Clinical Microbiology, Kars, Turkey
3 Kafkas University Hospital, Department of Family Medicine, Kars, Turkey
4 Sarıkamis Military Hospital, Department of Infectious Diseases and Clinical Microbiology, Kars, Turkey
5 Sarıkamis Military Hospital, Department of Orthopedia and Traumatology,  Kars, Turkey
6 Kars State Hospital, Hospital, Department of Dermatology , Kars, Turkey

Introduction: However the incidence of anthrax is diminishing in developed countries, it remains a public health problem in some rural areas of developing countries and especially of those who are interested in stockbreeding.

Material and Method: We examined the clinical features, therapy and outcome of 11 cases of cutaneous antrhrax diagnosed in Kars, Eastern Anatolia, Turkey, in the last two years.

Results: Of 11 patients reviewed, 4 were male and 7 were female. Age range was 14-69 years. All patients were intrested in stockbreeding and gave the history of direct contract to an infected animal. All lesions were in upper extremities and the predominantly affected region was hands. The lesions were painless vesicular ulcers with erythema and edema. In one case, lesion was disseminated to the whole arm and in an another to the neck. In laboratory analysis, increased sedimentation rates were found in all cases. Except one leucocytosis was not seen. 5 patients were treated with penicilin G and ciprofloxacin, 4 with amoxicillin clavunat and ciprofloxacin, 1 with ampicillin sulbactam and ciprofloxacin, 1 with benzathine penicilin and ciprofloxacin. All patients were discharged without any significant complication or morbidity.

Conclusion: Despite decreasing incidence, cutaneous anthrax should be kept in mind in rural areas whose main interest is stockbreeding.  Treatment with penicilin and/or ciprofoxacin is effective for cases with cutaneous anthrax without severe complication and/or morbidiity.






1Kars State Hospital, Infectious Diseases and Clinical Microbiology Service, Kars - 2Gulhane Military Medical Academy and School of

Medicine, Department of Infectious Diseases and Clinical Microbiology, Ankara - 3Ardahan Military Hospital, Department of Infectious

Diseases and Clinical Microbiology Ardahan - 4Ankara Military Hospital, Department of Obstetrics and Gynecology, Ankara - 5Bozyaka

Education and Research Hospital, Department of Microbiology and Clinical Microbiology, Izmir - 6Kafkas University Hospital,

Department of Family Medicine, Kars - 7Bozyaka Education and Research Hospital, Department of Infectious Diseases and Clinical

Microbiology, Izmir, - 8Dokuz Eylul University, Faculty of Medicine, Department of Infectious Diseases and Clinical Microbiology,

Izmir - 9Ege University, Faculty of Medicine, Department of Microbiology and Clinical Microbiology, Izmir, Turkey


In recent years, the number of patients belonging to the risk group of opportunistic fungal infection

has gradually been increasing(1). Correspondingly, not only new types of infectioncausing

fungi have grown, but also their number has dramatically risen(2). Nearly all of them are in

the form of nosocomial infection, and the frequency

of the infections that result from fungal factors has

gone up from 2/1000 to 3.8/1000(1). Of all the types

of opportunistic fungal infections, Candida species

are the most frequently isolated factors, and among

those, Candida albicans is the most prevalent on(3).

The increase in the morbidity and mortality

rates due to fungal infections stems from the lack of

empirical approach to effective antifungal treatment,

which is a consequence of insufficient application

of in vitro antifungal sensitivity tests(4).

Epidemiologically, it is suggested that every healthcare

center should determine and monitor the resistance

rates for the strains they isolate from their


This study aims not only to identify typology

of Candida species from patients’ samples gathered

in our microbiology laboratory from various clinics

of our hospital through conventional methods and

to determine their in vitro antifungal sensitivity

Acta Medica Mediterranea, 2014, 30: 561


Objectives: The purpose of this study is identify typology of candida species from patients’ samples, and determine their invitro

antifungal susceptibility.

Materials and methods: In this study, Candida species isolated from patients who applied to our laboratory between 2009-

2010 were included in order to identify the types of Candida and to carry out their antifungal sensitivity. The Candida species were

typed using germ tube test, corn meal Tween-80 and BBL CHROMagar medium, and API ID32C yeast identification system.

Antifungal drugs’ susceptibility of Candida species for amphotericin B, fluconazole, itraconazole, and voriconazole were conducted

through microdilution system.

Results: Of the 97 Candida species, 58.76% were identified as Candida albicans, other identified types were as follows: C.

parapsilosis (13.4%), C. glabrata (11.3%), C. tropicalis (5.15%) respectively. Antifungal drugs sensitivity tests results revealed

1.03% resistance to fluconazole and 4.12% to itracanazole, whereas no resistance was found to amphotericin B and voriconazole.

Conclusion: Target population for Candida has gradually been expanding. Therefore, it may be suggested that determining the

type of pathogen and running its susceptibility tests are significant factors that will enhance the success of the treatment before empirical

treatment against Candida infections is initiated.

Received January 18, 2014; Accepted January 24, 2014

against antifungal agents such as amphotericin B,

fluconazole, itraconazole, and voriconazole, but

also to guide empirical therapy as well as to provide

physicians a more rational approach in treatment

according to the obtained resistance profile.

Materials and methods

Candida Species

Isolated from the clinical samples collected

from hospitalized patients between August 2009

and March 2010, 97 Candida isolates were included

in the study. Parameters that may constitute risks

regarding fungal infections were noted in the

inspection form, such as the cause of hospitalization,

co-morbid diseases (hemodialysis, chronic diseases,

malignancy, immunosuppressive therapy,

coma, immobilization, etc.), hospitalization period,

department of the hospital, antibiotic and antifungal

medication usage, incidence of surgical intervention,

and other applications (urinary catheter, central

venous catheter, mechanical ventilation, parenteral

nutrition, transfusion). C. albicans ATCC

90028 ve C. crusei ATCC 6258 were used as control

origins in the study.

Typology of the Candida Species

The patient samples were cultured inSabouraud Dextrose Agar (SDA) and incubated at

37°C for 24-48 hours. In order to determine thetypes of isolated Candida specimens, results of

germ tube test, their morphological forms in cornmeal Tween 80 (Merck®) agar, and their color in

BBL CHROMagar (Becton-Dickinson®, USA)were evaluated. Unidentifiable strains were named

using API ID 32C commercial yeast identificationsystem, which provided rapid identification.

Taken by means of a needle, the Candidacolonies reproduced in SDA were dispersed in

tubes containing 0,5 ml human serum. As a result ofthe light microscope inspection of the samples incubated

at 37°C for 2.5-3 hours, structures whichwere found to originate from the mother cell and

which showed pinch-like extensions that had nosignificant bulging throughout their full-length

without a node or a narrowing in the starting pointwere evaluated as germ tubes. The strains that grew

germ tubes were identified as Candida albicans/dubliniensis(6).

Morphological properties of the Candidaspecies and whether or not they formed hyphae or

pseudo-hyphae have been evaluated according to their appearances in the corn meal Tween 80 agar

medium. For this purpose, samples were cultured from pure cultures. Culture lines were covered with

sterile lamellas and the media were incubated at 24- 26 °C for 48-72 hours. Examined under light microscope,

the media were subsequently evaluated in terms of reproduction patterns and the presence of

chlamydospore, pseudo-hyphae, blastoconidia and arthroconidia(6).

Additionally, candida samples were placed into BBL CHROMagar and incubated in 37 ºC for

48-72 hours. In the CHROMagar medium, green colonies were identified as C. albicans, light pink

flat colonies as C. krusei, pinkish violet colonies as C. glabrata or C. kefyr, and dark blue or steel blue

colonies as C. tropicalis(6). API ID 32C commercial kit, which is a standardized yeast identification system,

was used in order to classify the Candida strains that could not be identified in BBL

CHROMagar medium. Throughout the test, yeast identification procedures were followed as recommended

by the producer company.

Microdilution method

As to the susceptibility test, the medium and inoculums were prepared according to the criteria

specified by the M27-A2 of National Committee for Clinical Laboratory Standards (NCCLS). The

pure active ingredients of fluconazole (AppliChemGmbH®, Germany), itraconazole (AppliChem

GmbH®, Germany), voriconazole (Pfizer Pharmaceuticals®, New York), amphotericin B

(AppliChem GmbH®, Germany) as the antifungal agents. RPMI 1640 (Sigma Chemical Co®, St

Louis, Mo, USA) was used to prepare medium for

the microdilution method. 10,4 gr RPMI 1640 powder

medium was dissolved in 750 ml distilled water

and 34,53 gr powder morpholinopropanesulphonic

acid (MOPS) (Sigma Chemical Co®, St Louis, Mo,

USA) was added as the buffer substance. The mixture

was well stirred to dissolve the buffer. 1 molar

NaOH was added in the room temperature and fluid

medium was adjusted to 7.0 pH. More distilled

water was added in order to bring the total mass to

1 liter. The mixture was later filtered to sterilize and

it was stored at +4 °C until it was used(7).

Solvent DMSO (Dimethyl sulfoxide) (Sigma

Chemical Co®, Stlouis, MO, USA) was applied for

amphotericin B, itraconazole and voriconazole

while distilled water was used for fluconazole. The

prepared solutions were transferred to sterile tubes

of 1 ml each and stored at -70 °C. An U-bottomed

562 Emsal Aydin, Ahmet Karakas et Al

12x8 well microplate was used for each antifungal

and the name of the antifungal was recorded on the

microplate together with the date of the medium.

The prepared dilutions were distributed to the

columns vertically with 100 μl in each well. The

distributions were arranged to ensure that the lowest

medicine concentration was in the 10th well

whereas the highest concentration was placed in the

1st well(7).

The last well of the horizontal line (12th well)

on the microplate was specified as the sterility test

well and 200 μl RPMI 1640 was put into it. During

the test, nothing additional was deposited into this

well. 11th well of the microplate, however, was

specified as the reproduction test well. 100 μl

RPMI 1640 was put into this well and 100 μl of the

yeast containing solution was also added to it during

the test. These microplates were stored at -

70°C. After the same procedure was carried out for

four antifungal, a sufficient number of microplates

from each antifungal, that will be enough for the

number of strains to be studied, was taken out prior

to the study. Briefly, 10 different dilutions of each

antifungal were studied on every microplate(7).

Preparation of the stock yeast suspension

The stock Candida origins were placed in the

SDA. While the yeast suspensions were being prepared,

5-7 colonies from the 24-hour culture of

each origin in SDA were taken and their homogeneous

suspensions in sterile normal saline were

adjusted to 0,5 Mc Farland turbidity. The suspensions

were subsequently diluted with RPMI 1640

first in the ratio of 1/50 and later 1/20 in order to be

decreased to 2x density. Thus, 0,5-2.5x103 cell/ml

inoculum density was maintained. The prepared

suspension was evenly distributed to all the wells,

except for the 12th well, resulting in 100 μl for


Determining the incubation and minimal

inhibitor concentration (MIC) values

Microbes were incubated at 35 ºC for 48

hours. After it was found out that the microorganism

reproduction test well (11th well) produced

growth while no growth was observed in medium

test well (12th well), the MIC values were determined

according to the criteria recommended in

CLSI’s M27-A2 manual. The culture results in the

24th hour were also recorded. For amphotericin B,

the lowest concentration without any reproduction

was determined as MIC. As for fluconazole, itraconazole

and voriconazole, the lowest concentration

in which the turbidity significantly decreased

(~%50) according to reproduction test well was

identified MIC (7).


Table 1 illustrates the 97 Candida types isolated

from various samples and their distribution

according to clinical samples, and Table 2 shows

their distribution according to different clinical


The MIC values of the Candida types for fluconazole,

amphotericin B, itraconazole and

voriconazole determined by the microdilution test

Identification of candida species isolated from clinical samples... 563

Type Urine Blood Respiratory Track Operation Material Wound Total (n) %

C. albicans 21 12 17 5 2 57 58.76

C. parapsilosis 6 6 1 - 13 13.4

C. glabrata 8 2 1 - - 11 11.3

C. guilliermondii

3 1 - - - 4 5.15

C. interrmedia 1 - 1 - - 2 4.13

C. famata 1 - - - - 1 2.06

C. kefyr 1 - - - - 1 2.06

C. tropicalis 4 1 - - - 5 1.03

C. krusei - 2 - - - 2 1.03

C. sake - - 1 - - 1 1.03

Total 45 24 20 6 2 97 100.00

Table 1: The distribution of Candida types according to

clinical samples.










C. albicans 26 24 7 57

C. parapsilosis 4 2 7 13

C. glabrata 7 2 2 11

C. guilliermondii 1 2 1 4

C. intermedia 1 1 - 2

C. famata 1 - - 1

C. kefyr - 1 - 1

C. tropicalis 2 1 2 5

C. krusei 1 1 - 2

C. sake 1 - - 1

Toplam 44 34 19 97

Table 2: The distribution of the isolated Candida types

according to clinical departments.

are given in Tables 3-6 while their categorical antifungal

resistance distribution is presented in Tables


Of the working standard strains, MIC values

in C. krusei ATCC 6258 were found 64 μg/ml for

fluconazole, 0.125 μg/ml for voriconazole, 1 μg/ml

for amphotericin B, and 0.25 μg/ml for itraconazole.

Also, MIC values in C. albicans ATCC 90028

were 0.25 μg/ml for fluconazole, 0.03 μg/ml for

voriconazole, 0.25 μg/ml for amphotericin B, and

0.06 μg/ml for itraconazole.

The values that inhibit the reproduction of

50% of the isolates (MIC50) as well as 90% of the

isolates (MIC90) are demonstrated in Table 11.

According to the results in this table, increasing

resistance to fluconazole has been observed in nonalbicans.

564 Emsal Aydin, Ahmet Karakas et Al

Candida types

MIC Values (μg/ml)

64 32 16 8 4 2 1 0.5 0.25 0.125



C. albicans - - - 1 1 - 4 7 29 15 57

C. parapsilosis - - - - - - 1 8 3 1 13

C. glabrata - - - 2 5 1 1 4 - - 13

C. tropicalis - - - - - - 1 4 - - 5

C. guilliermondii

- - - - - - 1 2 1 - 4

C. intermedia - - - - - - - - 2 - 2

C. kefyr - - - - - - - - - 1 1

C. famata - - - - - - - 1 - - 1

C. sake - - - - - - - 1 - - 1

Total - - - 3 6 1 8 27 35 17 97

Table 3: MIC values of Candida types against fluconazole.

MIC Values (μg/ml)

Candida types 16 8 4 2 1 0.5 0.25 0.125 0.06 0.03



C. albicans - - - - 3 46 8 - - - 57

C. parapsilosis - - - - - 8 5 - - - 13

C. glabrata - - - - 4 6 1 - - - 11

C. tropicalis - - - - - 3 2 - - - 5

C. guilliermondii

- - - - - 1 3 - - - 4

C. krusei - - - - 1 1 - - - - 2

C. intermedia - - - - 1 1 - - - - 2

C. kefyr - - - - - 1 - - - - 1

C. famata - - - - - 1 - - - - 1

C. sake - - - - - 1 - - - - 1

Total 9 69 19 97

Table 4: MIC values of Candida types against

Amphotericin B.

MIC Values (μg/ml)

Candida types 16 8 4 2 1 0.5 0.25 0.125 0.06 0.03



C. albicans - - - - 1 1 5 7 32 11 57

C. parapsilosis - - - - - - 1 3 6 3 13

C. glabrata - - - 1 3 3 1 3 - - 11

C. tropicalis - - - - - 2 - 1 2 - 5

C. guilliermondii

- - - - - 1 1 1 1 - 4

C. krusei - - - - - 2 - - - - 2

C. intermedia - - - - - - - 1 - 1 2

C. kefyr - - - - - - - - 1 - 1

C. famata - - - - - - - 1 - - 1

C. sake - - - - - - 1 - - - 1

Total - - - 1 4 9 9 17 42 15 97

Table 5: MIC values of Candida types against itraconazole.

MIC Values (μg/ml)



16 8 4 2 1 0.5 0.25 0.125 0.06 0.03



C. albicans - - - - - - 1 1 - 55 57

C. parapsilosis - - - - - - - - - 13 13

C. glabrata - - - - - - 3 2 1 5 11

C. tropicalis - - - - - - - - 5 - 5

C. guilliermondii

- - - - - - - - - 4 4

C. krusei - - - - - - - - 1 1 2

C. intermedia - - - - - - - - - 2 2

C. kefyr - - - - - - - - 1 - 1

C. famata - - - - - - - - - 1 1

C. sake - - - - - - - - - 1 1

Total 4 3 8 82 97

Table 6: MIC values of Candida types against voriconazole.

Candida types



MIC Values (μg/ml)

≤8 μg/ml (S)

16-32 μg/ml


≥64 μg/ml(R)

C. albicans 57 57 - -

Non-albicans 40 38 1 1

Total 97 95 1 1

Table 7: Categorical resistance distribution of Candida

types against fluconazole.

S: Susceptible, S-DD: Dose-Dependent Susceptible, R: Resistant

In our current study, fluconazole MIC values

for 97 Candida isolates were obtained between

0.125 μg/ml and 64 μg/ml, while MIC50 and

MIC90 values were respectively 0.5 μg/ml and 4

μg/ml. Among the Candida spp., C. krusei was

assumed to be intrinsically resistant. However, an

increase was observed in the MIC values of C. albicans

and C. glabrata strains. While one of the C.

albicans strains produced a MIC value of 8 μg/ml

and another 4 μg/ml, MIC values of two C. glabrata

strains were found 8 μg/ml, five of them 4 μg/ml,

and one of them 2 μg/ml. MIC values of the rest

were either 1 μg/ml or less.

As for the Candida types that were included in

the study, MIC values of amphotericin B for all the

isolates were found between 0.25 μg/ml and 1

μg/ml whereas MIC50 and MIC90 values were correspondingly

0.5 μg/ml and 1 μg/ml. All of the

Candida isolates were found resistant not only to

amphotericin B (MIC≤1 μg/ml), but also to


Furthermore, MIC values of itraconazole for

the Candida strains studied were found between 2

μg/ml and 0.03 μg/ml as MIC50 and MIC90 values

were correspondingly 0.06 μg/ml and 0.5 μg/ml.

While 5 (5.15%) of the 97 Candida spp. proved

resistant to itraconazole, 17 (17.5%) were S-DD

(dose-dependent susceptible), and 75 (77.3%) were

susceptible. Of the resistant strains, four were C.

glabrata isolates and one was C. albicans isolate.

The highest resistance to itraconazole was found

among C. glabrata isolates (4.12%). Similarly, the

highest MIC value was obtained for C. glabrata (2



Normally, Candida species are microorganisms

that exist in human skin and mucosal

flora. They are present in mouth and gastrointestinal

tract of 30-50% of healthy individuals(

8). However, Candida infections as gained

significance due to their increasing rates

among infections that are related with medical

service. Yapar(9) specified candidemia incidences

as 3.38/1000 hospitalization days in

intensive care departments of a university hospital

between 2004 and 2008, Turkey.

Similarly, a threefold increase was identified

in fungal sepsis cases in USA between 1979

and 2000. What is more, it has been found out

that candidemia not only prolongs the hospital-

Identification of candida species isolated from clinical samples... 565

Candida types



MIC Values (μg/ml)

≤0.125 μg/ml(S)

0.25-0.5 μg/ml


≥1 μg/ml(R)

C. albicans 57 50 6 1

Non-albicans 40 25 11 4

Total 97 75 17 5

Table 8: Categorical resistance distribution of Candida

types against itraconazole.

S: Susceptible, S-DD: Dose-Dependent Susceptible, R: Resistant

Candida types



MIC Values (μg/ml)

≤1 μg/ml (S) 2 μg/ml


≥4 μg/ml (R)

C. albicans 57 57 - -

Non-albicans 40 40 - -

Total 97 97 - -

Table 9: Categorical resistance distribution of Candida

types against voriconazole.

S: Susceptible, S-DD: Dose-Dependent Susceptible, R: Resistant

Candida types



MIC Values (μg/ml)

≤1 μg/ml(D) ≥2 μg/ml (R)

C. albicans 57 57 -

Non-albicans 40 40 -

Total 97 97 -

Table 10: Categorical resistance distribution of Candida

types against Amphotericin B.

S: Susceptible, R: Resistant

Candida types n

MIC (μg/ml)

Fluconazole İtraconazole Voriconazole Amphotericin B


C. albicans 57 0,25 0,5 0,06 0,25 0,03 0,03 0,5 0,5

Nonalbicans 40 0,5 4 0,125 0,5 0,03 0,125 0,5 1

C. parapsilosis 13 0,5 1 0,06 0,25 0,03 0,03 0,5 0,5

C. glabrata 11 4 8 0,5 1 0,06 0,25 0,5 1

C. tropicalis 5 0,5 1 0,125 0,5 0,06 0,06 0,5 0,5

C. guilliermondii 4 0,5 1 0,125 0,5 0,03 0,03 0,5 1

C. krusei 2 0,5 0,5 0,03 0,06 0,5 1

Table 11: The MIC50 and MIC90 values of antifungals against

Candida types.

n: Number of Candida Isolates

ization period for about 30 days, but also accounts

for 38% of the mortality(10). In the retrospective

studies conducted in the same country, candidemiarelated

death rates have been reported to vary

between 46% and 75%(11).

Of all the invasive fungal infections, Candida

species and Aspergillus spp. are the most frequently

isolated fungal agents with 70-90% and 10-20%

respectively. The factor of 5-10% of all the healthcare-

related infections is Candida species. Although

C. albicans is the most commonly encountered

agent among infections that develop by Candida

species, an increase has also been reported in nonalbicans.

The rise in fluconazole use, and especially

in prophylactic azole use, is believed to be responsible

for this increase in Candida strains such as C.

parapsilosis, C. krusei, C. tropicalis, C. guilliermondii,

C.lusitaniae, and C. glabrata in particular(12).

In a meta-analysis report conducted on 7014

patients, it has been reported that parenteral antifungal

usage decreases 50% subsequent to azole

prophylaxis. Moreover, it has been noted that not

only the frequency of both superficial and deep

Candida infections, but also the rate of candidemiabased

secondary mortality has declined(13). On the

other hand, a significant increase has been observed

in the prevalence of non-albicans strains that carry

intrinsic resistance against azoles(14). Thus, this

underlines the importance of typology development

in terms of the selection of antifungals to be used in

the treatment(15).

The results of a 6,5-year-long study between

1997 and 2003 pointed out C. albicans as the most

frequently encountered Candida type despite an

decrease in its prevalence by 11% (%66.2).

According to the results of the same study, cases of

C. tropicalis went up by 2.9% and that of C. parapsilosis

by 3.1%. Following C. albicans, the most

common strains were C. glabrata (10.2%), C. tropicalis

(6.3%) and C. parapsilosis (5.6%)(16). A different

study which isolated 2074 candida strains from

blood cultures specified 54% of the strains as C.

albicans, 16% as C. glabrata, 15% as C. parapsilosis,

10% as C. tropicalis, and the rest as C. krusei,

C. guillermondii, C. lusitaniae and other strains(17).

In their study, Saracli et al. reported that C. albicans

constituted 48% of the 95 candida strains that were

isolated from the blood cultures while 31.8% were

C. parapsilosis, 9.8% were C. tropicalis, 4.6% were

C. glabrata, and 3.5% were C. krusei(18). Similarly,

of the 97 Candida strains in our study, 58.76% are

found to be C. albicans, 13.4% C. parapsilosis,

11.3% C. glabrata, 5.15% C. tropicalis, and the rest

to be correspondingly C. guillermondii, C. krusei,

C. intermedia, C. famata, C. kefyr and C. sake. As

to the clinical samples from which the Candida spp.

have been isolated, 45 out of 97 strains have been

obtained from urine, 24 from blood, 20 from respiratory

tract materials, six from operation excision

materials, and two from wounds. C. albicans has

proven the most frequently isolated Candida strain

practically from all clinical samples, which corresponds

with the earlier results reported in literature.

The varied incidence rates in different studies might

result from distribution of Candida strain, population

of the participant patients, and the geographical

characteristics of the area in which the study has

been conducted(14).

Although a standard method has already been

recommended, the problems about antifungal susceptibility

results are yet to be solved. MIC resistance

limit values of fluconazole, itraconazole, and

flucytosine for Candida strains are not conclusive,

either. The same is true for amphotericin B(19). This

stems from the ineffectiveness of the standard

method to distinguish amphotericin B susceptible

strains from resistant ones. As far as the azole

derivatives are concerned, 80% decrease in reproduction

is recognized as the susceptibility criteria

while determining the MIC values(20).

Results of a previously conducted study that

examined the fluconazole susceptibility of 559 C.

glabrata strains isolated from blood culture show

that 60% of the strains were susceptible to fluconazole,

31% were dose-dependent susceptible and 9%

were resistant(21). Coskun et al. have identified fluconazole

resistance rates as 75% for C. albicans and

28.6% for C. krusei, specifying their strains as primary

resistant(22). In a study carried out in Brazil,

antifungal susceptibility of Candida strains isolated

from blood cultures was investigated through

microdilution method, and the reported MIC value

ranges were as follows: 0.25-1μg/ml in C. albicans,

0.12-1μg/ml in C. parapsilosis, 0.5-1μg/ml in C.

tropicalis, 0.5-1μg/ml in C. glabrata, 0.5-1μg/ml in

C. krusei against amphotericin B; 0.12-8μg/ml in C.

albicans, 0.12-2μg/ml in C. parapsilosis; 0.12-

2μg/ml in C. tropicalis, 1-8μg/ml in C. glabrata,

and 16μg/ml in C. krusei against fluconazole.

Consequently, no resistance against fluconazole or

amphotericin B could be found in any strains(23).

In another study, 99% of the 206 strains were

observed susceptible to amphotericin B. Only one

C. krusei strain was reported to be moderately sus-

566 Emsal Aydin, Ahmet Karakas et Al

ceptible to amphotericin B. As to fluconazole: in C.

albicans, 109 strains were susceptible, 4 strains

were moderately susceptible, and 5 were resistant;

in C. glabrata, 9 strains were moderately susceptible,

and 4 strains were resistant; and in other candida

strains, 11 strains were dose-dependent susceptible,

and 6 strains were resistant(24). The results of

our current study reveal an increasing resistance to

fluconazole in non-albicans strains. Of all the

Candida spp, C. krusei has been acknowledged as

intrinsic resistant. What is more, a rise has been

observed in the MIC values of C. albicans ve C.

glabrata strains. According to the results of our

study, MIC values of amphotericin B are between

0.25 and 1 μg/ml for all isolates, while MIC50 is

0.5 μg/ml and MIC90 is 1 μg/ml. The entire

Candida isolates are found susceptible to amphotericin

B (MIC≤1 μg/ml). The results of our study

comply with the previous results of similar research

in literature.

In another study, which observed antifungal

effectiveness of voriconazole against Candida

strains using the microdilution method, the MIC

value ranges were reported as ≤0.015- 0.03 mg/l for

C. albicans, 0.03-1mg/l for C. glabrata, ≤0.015-0.06

mg/l for C. tropicalis, 0.12-0.25 mg/l for C. krusei,

and ≤0.015-0.03mg/l for C. parapsilosis. As for all

114 Candida strains, the MIC value range was

obtained between ≤0.015 and 1 mg/l(25). In line with

the literature, the results of our study have shown

amphotericin B and voriconazole as the most effective

antifungals’ drugs. On the other hand, some

decrease has been noted in the effectiveness of

azole-group antifungals, which have been included

in the current study, particularly against non-albicans.


In consequence, target patient population of

Candida has gradually been expanding. Thus, this

has increased the significance of Candida spp.,

which causes mortality and morbidity at least as

much as bacterial pathogens. Therefore, it may be

suggested that determining the type of pathogen

and running its susceptibility tests are significant

factors that will enhance the success of the treatment

before empirical treatment against Candida

infections is initiated.


1) Fridkin SK, Jarvis WR: Epidemiology of nosocomial

fungal infections. Clin Microbiol Rev 1996; 9: 499-511.

2) Serefhanoglu K, Timurkaynak F, Can F, Cagir U,

Arslan H, Ozdemir FN: Risk factors for candidemia

with non-albicans Candida spp. in intensive care unit

patients with end-stage renal disease on chronic

hemodialysis. J Formos Med Assoc 2012; 111: 325-


3) Pfaller MA, Jones RN, Doern GV, Sader HS, Hollis RJ,

Messer SA: International surveillance of bloodstream

infections due to Candida species: frequency of occurrence

and antifungal susceptibilities of isolates collected

in 1997 in the United States, Canada, and South

America for the SENTRY Program. The SENTRY

Participant Group. J Clin Microbiol 1998; 36: 1886-


4) Cuenca-Estrella M, Gomez-Lopez A, Cuesta I,

Zaragoza O, Mellado E, Rodriguez-Tudela JL:

Frequency of voriconazole resistance in vitro among

Spanish clinical isolates of Candida spp. According to

breakpoints established by the Antifungal

Subcommittee of the European Committee on

Antimicrobial Susceptibility Testing. Antimicrob

Agents Chemother 2011; 55: 1794-1797.

5) Pfaller MA, Rex JH, Rinaldi MG: Antifungal susceptibility

testing: technical advances and potential clinical

applications. Clin Infect Dis 1997; 24: 776-784.

6) Koneman EW, Allen SD, Janda WM, Schreckenberger

PC, Winn WC, Woods GL, Procop GW: Mycology. in

Koneman EW (ed): Koneman’s Color Atlas and

Textbook of Diagnostic Microbiology. USA: Lippincott

Williams and Wilkins, 2006; 1151-1244.

7) Clinical and Laboratory Standards Institute: Reference

method for broth dilution antifungal susceptibility testing

of yeast. Approved Standard, 2nd ed, Wayne, CLSI

document M27-A2, 2002.

8) Gammelsrud KW, Sandven P, Hoiby EA, Sandvik L,

Brandtzaeg P, Gaustad P: Colonization by Candida in

children with cancer, children with cystic fibrosis, and

healthy controls. Clin Microbiol Infect 2011; 17: 1875-


9) Yapar N. Epidemiology of invasive fungal infections in

Turkey. In: Congres Proceedings Book. 4th Turkey

EKMUD Congress, Istanbul, Turkey, May 2012; 9-12,

90-91 (In Turkish).


10) Wey SB, Mori M, Pfaller MA, Woolson RF, Wenzel

RP: Risk factors for hospital-acquired candidemia. A

matched case-control study. Arch Intern Med 1989;

149: 2349-2353.

11) Pfaller MA, Diekema DJ: Epidemiology of invasive

candidiasis: a persistent public health problem. Clin

Microbiol Rev 2007; 20: 133-163.

12) Marino E, Gallagher JC: Prophylactic antifungal

agents used after lung transplantation. Ann

Pharmacother 2010; 44: 546-556.

13) Bow EJ, Laverdiere M, Lussier N, Rotstein C, Cheang

MS, Ioannou S: Antifungal prophylaxis for severely

neutropenic chemotherapy recipients: a meta analysis

of randomized-controlled clinical trials. Cancer 2002;

94: 3230- 3246.

Identification of candida species isolated from clinical samples... 567

14) Eggimann P, Garbino J, Pittet D: Epidemiology of

Candida species infections in critically ill non-immunosuppressed

patients. Lancet Infect Dis 2003; 3: 685-


15) Rex JH, Pfaller MA, Walsh TJ, Chaturvedi V, Espinel-

Ingroff A, Ghannoum MA, Gosey LL, Odds FC,

Rinaldi MG, Sheehan DJ, Warnock DW: Antifungal

susceptibility testing: practical aspects and current

challenges. Clin Microbiol Rev 2001; 14: 643-658.

16) Pfaller MA, Diekema DJ, Rinaldi MG, Barnes R, Hu

B, Veselov AV, Tiraboschi N, Nagy E, Gibbs DL:

Results from the ARTEMIS DISK Global Antifungal

Surveillance Study: a 6.5-year analysis of susceptibilities

of Candida and other yeast species to fluconazole

and voriconazole by standardized disk diffusion testing.

J Clin Microbiol 2005; 43: 5848-5859.

17) Pfaller MA, Diekema DJ, Jones RN, Messer SA, Hollis

RJ: Trends in antifungal susceptibility of Candida spp.

isolated from pediatric and adult patients with bloodstream

infections: SENTRY Antimicrobial Surveillance

Program, 1997 to 2000. J Clin Microbiol 2002; 40:


18) Saracli MA, Gumral R, Gul HC, Gonlum A, Yildiran

ST: Species distribution and in vitro susceptibility of

Candida bloodstream isolates to six new and current

antifungal agents in a Turkish tertiary care military

hospital, recovered through 2001 and 2006. Mil Med

2009; 174: 860-865.

19) Wanger A, Mills K, Nelson PW, Rex JH: Comparison

of Etest and National Committee for Clinical

Laboratory Standards broth macrodilution method for

antifungal susceptibility testing: enhanced ability to

detect amphotericin B-resistant Candida isolates.

Antimicrob Agents Chemother 1995; 39: 2520-2522.

20) Arthington-Skaggs BA, Motley M, Warnock DW,

Morrison CJ: Comparative evaluation of PASCO and

national committee for clinical laboratory standards

M27-A broth microdilution methods for antifungal drug

susceptibility testing of yeasts. J Clin Microbiol 2000;

38: 2254-2260.

21) Pfaller MA, Messer SA, Boyken L, Tendolkar S, Hollis

RJ, Diekema DJ: Variation in susceptibility of bloodstream

isolates of Candida glabrata to fluconazole

according to patient age and geographic location. J

Clin Microbiol 2003; 41: 2176-2179.

22) Coskun O, Besirbellioglu AB, Yildiran ST, Gonlum A,

Pahsa A: In vitro susceptibilities of candida species isolated

from candidemic patients againts amphotericin B

and fluconazole. Mikrobiyol Bull (Bul) 2001; 35: 565-


23) Antunes AG, Pasqualotto AC, Diaz MC, d'Azevedo PA,

Severo LC: Candidemia in a Brazilian tertiary care

hospital: species distribution and antifungal susceptibility

patterns. Rev Inst Med Trop Sao Paulo 2004; 46:


24) Nawrot U, Nowicka J, Juszczak K, Gusin B:

Susceptibility to antifungal agents of Candida species

isolated from paediatric and adult patients with haematological

diseases. Mycoses 2005; 48: 385-390.

25) Rubio MC, de Ocariz IR, Gil J, Benito R, Rezusta A:

Potential fungicidal effect of voriconazole against

Candida spp. Int J Antimicrob Agents 2005; 25: 264-



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Ardahan Military Hospital,

Department of Infectious Diseases and Clinical Microbiology,

7500, Ardahan


568 Emsal Aydin, Ahmet Karakas et Al


Emsal Aydın1, Güney İmre1, Aytaç Kaplan1, Eray Atalay2, Okan Alpak3, Esragül Akıncı1, Ayten Kadanalı1, Hürrem Bodur1

1Kafkas Üniversitesi Tıp Fakültesi, Enfeksiyon Hastalıkları ve Klinik Mikrobiyolojik Anabilim Dalı

2Kafkas Üniversitesi Tıp Fakültesi, İç Hastalıkları Anabilim Dalı

3Kafkas Üniversitesi Tıp Fakültesi, Mikrobiyoloji Anabilim Dalı

Giriş: Bruselloz ülkemizde özellikle kırsal kesimde yaygın olan zoonotik bir hastalıktır. Periferal eklemlerde görülen brusella artriti, brusellozun nadir görülen bir komplikasyonu olması nedeniyle tanısı atlanabilmektedir. Bu olgu sunumunda, sekonder enfeksiyon gelişmesi nedeniyle tanısı geciken brusella artriti olgusu sunulmaktadır.

Olgu: Sol dizinde ağrı, şişlik ve ısı artışı yakınmaları ile acil servise başvuran 17 yaşındaki erkek hasta septik artrit tanısı ile yatırıldı. Fizik muayenesinde ateşi 38 derece, tansiyonu 110/70 mmHg, nabzı 90/dk idi. Laboratuvar tetkiklerinde beyazküre sayısı 8500/mm3 (%75 nötrofil), CRP: 14,75 mg/dl, sedimantasyon: 29 mm/saat olarak bulundu. Diğer tetkikleri normaldi. Anamnezde köy sütü tüketme öyküsü vardı. Sol dizde skar izi olan hastaya 6 yıl önce travma nedeniyle stür atılmıştı. Hasta septik artrit tanısı ile kliniğe yatırıldı ve artrosentez yapıldı. Eklem sıvısında MRSA üremesi üzerine vankomisin 2x1 gr İV başlandı. Ancak hastanın yakınmaları devam etti. Bunun üzerine hastaya üç defa daha artrosentez yapıldı. Alınan eklem sıvılarında üreme saptanmadı.  Epidemiyolojik öyküsü olması nedeniyle son alınan eklem sıvısında brusella serolojisine bakıldı. Rose Bengal testi pozitif, brusella tüp aglutinasyon 1/320 olarak sonuçlandı ve hastada brusella artriti düşünülerek streptomisin 1x1 gr, doksisiklin 2x100 mg ve rifampisin 1x600 mg başlandı. Tedavi öncesi kan kültürleri alındı. Kandan brusella tüp aglutinasyonu çalışıldı ve 1/160 bulundu. Hastanın eklem mayisinden kan kültür şişesine yapılan kültüründe henüz daha üreme olmadı. Brusella tedavisi altında ateşi düşen ve şikayetleri gerileyen hastanın tedavisi devam etmektedir.

Sonuç: Ülkemizde endemik olan brusellozun periferal artrit gibi nadir görülen komplikasyonları zaman zaman atlanabilmektedir. Bu olgu sunumunda ilk alınan eklem mayide MRSA üremesi olması nedeniyle ilk aşamada bruselloza yönelik tetkikler yapılmamıştır. Tedavi başarısızlığı sonucunda daha sonraki aşamalarda bruselloz serolojine bakılmıştır. Bu olgu ile, özellikle hastalığın endemik olduğu kırsal kesimde, brusellozun nadir görülen komplikasyonularının akılda tutulmasının erken tanıda önemli olduğu sonucuna varmak mümkündür. 


Emsal Aydın1, Aytaç Kaplan1, Güney İmre1, Okan Alpak2, Sergülen Aydın3, Esragül Akıncı1,

Ayten Kadanalı1, Hürrem Bodur1

1Kafkas Üniversitesi Tıp Fakültesi, Enfeksiyon Hastalıkları ve Klinik Mikrobiyolojik Anabilim Dalı

2Kafkas Üniversitesi Tıp Fakültesi, Mikrobiyoloji Anabilim Dalı

3Kafkas Üniversitesi Tıp Fakültesi, Aile Hekimliği Anabilim Dalı

Giriş: Tüberküloz, tedavi edilmediğinde mortalitesi yüksek bir enfeksiyon hastalığıdır. Ülkemizde endemiktir ve en sık görülen formu pulmoner tüberkülozdur. Ancak tanı yöntemlerinin spesifik olması nedeniyle akla gelmediğinde atlanabilen bir hastalıktır. Bu olgu sunumunda,  hastanede uzun süre akciğer enfeksiyonu nedeniyle yatırılan ve akciğer tüberkülozu tanısı geç konulduğu için aldığı antibiyotik tedavilerinden yarar görmeyen bir olgu sunulmuştur.

Olgu: 83 yaşında erkek hasta pnömoni nedeniyle başka bir merkezde yoğun bakım ünitesinde 60 gün boyunca hospitalize edilerek tedavi edilmiş. Antibiyotik tedavisi altındayken tekrarlayan ateşleri olmuş. Akciğer enfeksiyonu yer değiştirici tarzda alevlenmelerle seyretmiş. Her defasında hastane kökenli pnömoni olarak değerlendirilmiş ve tedavileri ona göre planlanmış. Yatışı sırasında gelişen hastane enfeksiyonları nedeniyle çeşitli antibiyotik tedavileri almış. Ara ara klinik durumunun ağırlaşması nedeni ile yoğun bakımda yatırılmış.  Ancak hastanın yakınmalarının gerilememesi ve genel durumunun daha kötüleşmesi üzerine hastanemize sevk edilmiş. Hastanemize kabuldeki fizik muayenesinde genel durumu orta-kötü, halsiz görünümde, ateşi 37.6 derece, tansiyonu 130/90 mmHg, solunum sayısı 24/dakika idi. Her iki hemitoraks solunuma eşit katılıyordu. Sağ hemitoraksta bütün alanlarda ronküs ve kaba raller mevcuttu. Akciğer grafisinde parankim alanlarında konsolidasyon ve bilateral plevral efüzyon tespit edildi. Laboratuvar tetkiklerinde WBC: 15400/mm3 (%91 nötrofil), CRP:14,38mg/dl idi. Anamnezde eşlik eden başka bir hastalığı yoktu. Genel durumunun kötü olması nedeniyle hasta yoğun bakım ünitesine alındı. Geldiği merkezde başlanan meropenem tedavisine devam edildi. Kan kültüründe MRSA ürediği için başlanmış olan teikoplanin linezolid ile değiştirildi. Ancak ateşi devam etti ve genel durumu giderek kötüleşti. Bunun üzerine balgamda ARB istendi. Balgamda ARB pozitif (+++) saptanması üzerine hastaya akciğer tüberkülozu tanısı konularak dörtlü anti-tüberküloz tedavi başlandı  (izoniyazid 1x300 mg, rifampisin 1x600 mg, etambutol 1x1500 mg ve morfozinamid 1x2500 mg). İzlemde hastanın ateşi düştü. Enfeksiyon parametreleri geriledi. Halsizlik yakınması düzeldi ve iştahı açıldı. Genel durumu düzelen hasta servise alınarak izole edildi. Hastanın dörtlü anti-tüberküloz tedavisi halen devam etmektedir.

Sonuç: Akciğer tüberkülozu halk sağlığın tehdit eden bulaşıcı bir hastalıktır. Bulaşı önlemede erken tanı ve tedavi oldukça önemlidir. Bu nedenle, özellikle antibiyotik tedavisine yanıtsız pnömoni hastalarında, altta yatan risk faktörü olmasa da, akciğer tüberkülozu açısından hasta tetkik edilmelidir.