importance of candida species in nursery and intensive care units ( icus ) is increasingly being recognized .
candida species account for 9 - 13% of all blood isolates in neonatal intensive care units ( nicus ) .
although c. albicans has historically been the most frequently isolated species , infections caused by the nonalbicans candida have been diagnosed with increasing frequency in recent years , notably c. tropicalis , c. glabrata , and c. parapsilosis .
common use of broad - spectrum antibiotics , low birth weight ( lbw ) , prematurity , and intravenous catheter , etc . , makes neonates prone to candidemia . the incidence and associated mortality due to candidemia can be influenced by several factors including characteristic of the population at risk , standard of the health care facilities available , distribution of candida species , and prevalence of antifungal resistance .
the increased isolation rates of nonalbicans candida species and a gradual shift in the antifungal susceptibility profile have underlined the need to monitor laboratory data for possible emergence of resistance and to select most appropriate antifungal agent for therapy .
we have noticed an increased isolation rate of nonalbicans candida from neonatal septicemia cases over last few months .
so we are presenting our findings that were observed while investigating the causes of candidemia in a neonatal icu .
a total of 825 clinically suspected cases of neonatal septicemia were included in the study from june 2008-december 2008 .
demographic and clinical data such as age , sex , birth weight , antibiotic prophylaxis , presence of cvc , and clinical outcome of the neonates were noted from clinical records .
approximately 1 to 2 ml of blood was collected under aseptic precautions and inoculated in biphasic brain heart infusion medium .
colonies were identified up to the species level on the basis of morphology on corn meal agar , growth on hi- chrome candida agar , carbohydrate fermentation , and assimilation patterns .
all the isolates were screened for antifungal susceptibility testing by the disk diffusion ( dd ) method using fluconazole ( 25 g ) ( hi- media , mumbai ) on mueller - hinton agar ( mha ) supplemented with 2% glucose and methylene blue ( gmb ) 5 g / ml .
the broth micro dilution - minimum inhibitory concentration ( bmd - mic ) of the isolates was performed to the fluconazole using rpmi medium and mops buffer .
isolates showing mic  8 g / ml were regarded as susceptible , 16 - 32 g/ ml as dose - dependent susceptible and  64 g / ml as resistant .
the quality control test was performed by using c. parapsilosis ( atcc 22019 ) , c. krusei ( atcc 6258 ) , and c. albicans ( atcc 90028 ) .
all the neonates ( 100% ) were low birth weight ( between 1.0 - 1.5 kg ) , and had received prophylactic antibiotics .
other associated findings were presence of central venous line in 71% , prematurity 40% , perinatal asphyxia 31.2% , jaundice 27.8% , and meconium aspiration in 10.8% of neonates ; crude mortality rate was 50.1% .
majority of isolates were c. tropicalis ( 61.19% ) , followed by c. albicans ( 19.40% ) , c. glabrata ( 11.94% ) , c. parapsilosis ( 5.97% ) , and c. guillermondii ( 1.49% ) .
the result of in vitro susceptibility testing of candida isolates to fluconazole is shown in table 1 . by dd method , 89.55% of candida
the results of antifungal susceptibility testing by dd and bmd - mic were compared for fluconazole .
the dd testing performed in accordance with nccls m 44-a guidelines was comparable in 95.53% strains . a discrepancy between dd method and bmd - mic test result for susceptibility to fluconazole was noted in 4.47% strains .
in our study , isolation rate of candida from neonatal septicemia cases was 8.1% , which was lower than several other reports showing frequency of isolation in 13.6 - 19.6% cases . c. albicans was the predominant organism in the earliest population based study conducted during 1992 - 1993 by cdc usa .
but a notable feature of our study was the emergence of nonalbicans candida ( 80.59% ) as a major cause of neonatal candidemia .
c. tropicalis ( 61.19% ) was the most common species followed by c. albicans ( 19.40% ) , and c. glabrata ( 11.94% ) .
our findings are supported by other studies from the same geographical area that have documented predominance of nonalbicans candida over the c. albicans in neonatal septicemia .
antifungal susceptibility testing in our study revealed that all the candida isolates except c. glabrata were 100% sensitive to fluconazole , though , three isolates of c. tropicalis were found to be in the susceptible dose dependant ( sdd ) range with mic 16 g / ml , when tested by broth micro - dilution mic method .
in contrast to our study , several other indian studies have reported a high ( 18.75 - 24% ) fluconazole resistance against all the candida spp .
the results of dd susceptibility testing to fluconazole were compared by bmd - mic method .
overall , four strains of c. tropicalis were sdd by dd method that was reduced to three with bmd - mic method .
one strain of c. tropicalis that was resistant by dd method was found to be sdd with mic 16 g / ml . this result of our study emphasizes that dd method alone gives false resistance .
several risk factors have been cited as predisposing to candidemia in neonates including underlying illness , lbw , broad - spectrum antibiotic , asphyxia neonatorum , hyperalimentation , and total parentral nutrition . in our study ,
lbw and broad spectrum antibiotic were the most common associated findings present in 100% neonates with candidemia .
our study shows that nonalbicans candida has emerged as a major cause of neonatal candidemia .
routine susceptibility testing of candida isolates by dd method should be confirmed by bmd - mic method .
 aims : to know the distribution and antifungal susceptibility pattern of candida species in neonatal septicemia cases.materials and methods : in a prospective analysis blood samples from 825 clinically suspected cases of neonatal septicemia , collected aseptically , were cultured to look for the role of candida spp . in septicemia . 
 candida isolates were speciated by germ tube test , hi - chrome agar , sugar fermentation , and sugar assimilation tests using standard protocol . 
 all the candida isolates were tested for antifungal susceptibility to fluconazole by the disk diffusion ( dd ) method and broth micro dilution - minimum inhibitory concentration ( bmd - mic ) method using nccls guidelines.results:isolation rate of candida from neonatal septicemia cases was 8.1% . 
 most common isolate was c. tropicalis ( 61.19% ) , followed by c. albicans ( 19.40% ) , c. glabrata ( 11.94% ) , c. parapsilosis ( 5.97% ) and c. guillermondii ( 1.49% ) . 
 low birth weight and previous antibiotic prophylaxis was found in 100% cases . 
 crude mortality rate was 50.1% . by dd method 
 , 95.53% of the candida isolates were sensitive to fluconazole . a discrepancy between dd method and bmd - mic method 
 was noted in 4.47% strains . 
 one isolates each of c. tropicalis , c. albicans , and c. glabrata showed discrepancy.conclusion:nonalbicans candida has emerged as an important cause of neonatal septicemia . 
 routine susceptibility testing of candida isolates by dd method should be confirmed by bmd - mic method . 
 fluconazole can be used as empirical therapy for neonatal candidemia at our center . 
INTRODUCTION
MATERIALS AND METHODS
RESULTS
DISCUSSION
CONCLUSION