Antifungal Susceptibility Pattern of Candida Species among Cancer Patients Attending B.P Koirala Memorial Cancer Hospital, Chitwan

doi:10.21203/rs.3.rs-4694992/v1

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Antifungal Susceptibility Pattern of Candida Species among Cancer Patients Attending B.P Koirala Memorial Cancer Hospital, Chitwan

https://doi.org/10.21203/rs.3.rs-4694992/v1

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Background: Cancer is considered as a second most common cause of human death worldwide. The sufferers with most cancers are ongoing remedies for cell destruction which immediately lead them to at risk of infections because of their immune- compromised state. Among cancer patients, the fungal flora of the body imposes a greatest threat for own self. Antifungal resistance has been evolving lately as a burgeoning health care problem among Candida species. So, this study is aimed to explore the antifungal susceptibility pattern of Candida species among cancers patient.

Methodology: This study was a cross-sectional study carried out in the Microbiology laboratory of B.P Koirala Memorial Cancer Hospital, Bharatpur, Chitwan, Nepal. Standard microbiological techniques were used to identify Candida isolates, and HiCrome differential media were used for Candida speciation. Antifungal susceptibility testing was determined by using the Clinical and Laboratory Standards Institute (CLSI) disk diffusion method.

Results: 50 Candida positive samples were found out of a total of 680 samples processed. Of the 50 Candida isolates, the majority of them were isolated from urine 24 (48.0%) followed by Bal 10 (20%). Candida albicans 19(38%) was the most predominant species followed by Candida glabrata 12(24%), Candida tropicalis 11(22%), Candida krusei 8(16%), Candida. All isolates were highly sensitive to voriconazole with a susceptibility rate of rate 48(96%) The highest resistance was found for Clotrimazole 40(80%) followed by ketoconazole 35 (70%), amphotericin B 27(54%).

Conclusion: Candida albicans was the most common species responsible for Candida infections. The majority of the isolates were sensitive to voriconazole and resistance to clotrimazole. The high resistance rate to the commonly antifungal agent implicates continued antifungal- susceptibility surveillance needs to be conducted to monitor the antifungal susceptibility trends of Candida species among cancer patients.

Biological sciences/Microbiology/Antimicrobials

Biological sciences/Microbiology/Clinical microbiology

Biological sciences/Microbiology/Communities

Biological sciences/Microbiology/Fungi

Biological sciences/Microbiology/Infectious disease diagnostics

Antifungal drug

Cancer

Candida

drug resistance

Candidiasis is the most prevalent fungal infection in humans, affecting the mucosa, skin, nails, and internal organs. It is caused by a variety of yeast-like fungus in the genus Candida, with Candida albicans serving as the main species. Candida tropicalis, Candida krusei, Candida glabrata, Candida guilliermondii, Candida parapsilosis, Candida lusitaniae, Candida kefyr, Candida rugosa, Candida dubliniensis, and Candida viswanathii are among the other harmful species (1).

Cancer is a disorder of excessive cell growth that is caused by a series of inherited mutations that are harmful to both the parent cell and offspring cells (2). In cancer patients, body cells were developed in an uncontrolled way and procreate in other parts of the body (3). Cancer was the second main reason for loss of life globally, accounting for a predicted 9.6 million deaths, or one in six deaths, in 2018 (4).

Patients with cancer are more susceptible to Candida infections due to altered immunological mechanisms (5). Chemotherapy weakens cellular and humoral immune responses and directly damages mucosa (3). The host immune response is frequently changed by this course of treatment. For example, the study found that cancer patients had myeloperoxidase (MPO) deficiency and were at an increased risk of Candida infections (6). Another study discovered that thrombospondin-1 causes an imbalance in the host immune system, which reduces the ability of the fungus to be cleared up, spreads, and raises mortality (7).

There have been concerns raised about the indiscriminate and excessive use of antifungal agents, which increases the emergence of antifungal resistance (8) .As a result of the change in drug susceptibility pattern of Candida species and the introduction of newer antifungal medications, in vitro susceptibility testing of antifungal agents has become more important for using specific and sensitive treatments. So that it is now more crucial than ever to isolate, characterize, identify, and test for Candida species in clinical specimens in order to control fungal infections. Four different species of Candida can be separated and isolated using the CHROMagar medium, which is a simple, quick, and reliable technique (9).Therefore this study will evaluate the Candida species and antifungal susceptibility pattern among cancer patients.

In the Department of Microbiology at the BP Koirala Memorial Cancer Hospital, a laboratory-based cross-sectional study was conducted from May 2022 to October 2022.A total of 680 distinct clinical specimens, from OPD and indoor patient was taken including blood, bronchoalveolar lavage (BAL), catheter tip, urine and sputum, were sent for laboratory analysis.

Wet mount, Gram stain, Sabouraud dextrose agar (SDA) culture, and urea hydrolysis testing were used to make preliminary diagnoses on the specimens (10). The investigation excluded isolates that were found to be different species of fungus than Candida. The samples were examined under a microscope for evidence of budding yeast cells with pseudohyphae and significant pus cells in order to determine the clinical significance of Candida isolates from sputum and urine(11). All samples were plated onto SDA slants and incubated aerobically at 37 °C for 24-48 hours.

For the blood culture, 8–10 ml of venous blood were aseptically collected and cultured in 45 ml of Brain Heart Infusion (BHI) broth. It was then incubated at 37 °C for up to 96 hours before being reported as no growth.

Any visible growth seen on the SDA slope was examined for species identification. A morphological examination, Gram staining, germ tube test, and urea hydrolysis test were carried out on an isolated colony. On CHROMagar, the yeasty, pasty, and creamy colony that underwent microscopic analysis and revealed Gram-positive budding yeast cells with pseudohyphae and a negative urea hydrolysis test was further processed for Candida speciation (12). Based on the growth pattern and color of the isolates using CHROMagar Candida (HiMedia, Mumbai, India), different species of Candida were identified (13) .

The color of colonies on CHROMagar was observed after 24-48 hours of incubation at 37 °C (C. albicans—light green, C. glabrata—cream to white, Candida krusei—purple, fuzzy, and C. tropicalis—blue to purple).

All Candida isolates were tested for antifungal susceptibility using the disc diffusion method, as indicated by the Clinical and Laboratory Standards Institute (CLSI) M44-A document guidelines(14).The turbidity was measured against the 0.5 McFarland Standard after the inoculum was made by suspending colonies of growth in 5 ml of sterile saline (15). Mueller-Hinton agar containing 2% glucose and 0.5 g/ml methylene blue was streaked evenly with a cotton swab dipped in the inoculum suspension (16).C. albicans ATCC 90028, C. tropicalis ATCC 750 were used as controls.

Fuconazole (10 mg), ketoconazole (10 mg), clotrimazole (10 mg), voriconazole(1μg) and Amphotericin B(100μg), itraconazole (10mg)

Antifungal discs were applied to the inoculation media. After the medium had been incubated at 37 °C for 24 hours, the zone of inhibition surrounding the disc was measured(17).

2.1 Inclusion and Exclusion criteria

2.1.1 Inclusion criteria

Cancer patients who are willing to participate

2.1.2 Exclusion criteria

Patients under the antifungal therapy

2.2 Management, Processing and Analysis of Data

Data Entry and Storage

Data were entered in Microsoft office Excel, which was then kept securely in designed laptop folder. Additionally, an external backup was kept.

2.3 Analysis of data

The IBM statistical package for Social Science (SPSS) Version 22 software was used to analyze the data.

3.1 Distribution of organisms isolated

Out of 680 samples, 630 (92.6%) had no growth, whereas 50 (7.4%) had positive for Candida species. These distributions were shown in pie-chart format Figure no 1.

Here two types of Candida species were seen they are C. albicans and Non albicans. Non albicans were further classified into three type's namely C. krusei, C. glabrata and C. tropicalis. Out of 4 Candida isolated, C. albicans was reported highest of all contributing 19(38.0%) of total growth followed by C. glabrata of 12(24.0%). C. tropicalis was 11(22.0%) and krusei was 8(16.0%). Thus here C. albicans species were 19(38.0%) and Non albicans species were 31(62.0%) of total growth. These distributions were shown in table no 1. Now further results and discussion was based on total positive samples (50 positive samples among total 680samples).

Table no 1- Distribution of organisms isolated

Organisms isolated	Frequency	Percent
C. albicans	19	38.0%
C. glabrata	12	24.0%
C. tropicalis	11	22.0%
C. krusei	8	16.0%
Total	50	100%

3.2 Distribution of Candida species among sample

Candida species were mostly isolated from Urine sample 24(48%) followed by BAL sample 10(20%), Pus sample 6(12%) and sputum sample 5(10%) .Candida species Were reported from Blood sample 4(8%) and only 1(2%) isolated was report from Catheter Tube sample.

In urine sample C. albicans was reported on 9(37.5%) followed by C. tropicalis 7(29.17%) and C. glabrata 5(20.83%). C. krusei was least reported only on 3(12.5%) in urine sample. In BAL samples C.albican, C. glabrata and C. krusei was reported similar contributing 3(30%) of total Bal sample. C. tropicalis was isolated only in 1(10%) of Bal sample.In Blood samples C. albicans was contributing highest 2 (50%) among all spp. of Candida followed by C. krusei and C. tropicali s were equally isolated up to 1(25%) of each. None of blood samples were positive for C.glabrata. In Pus sample C. albicans was reported on 3(50%) followed by C. glabrata of 2(33.33%) and C. krusei 1(16.67%). None of Pus sample was positive for C. tropicalis. In sputum sample both C. albicans and C. glabrata were equally isolated up to 2(40%) followed by C. tropicalis of 1(20%). None of sputum sample was positive for C. krusei. In Catheter Tube only one C. tropicalis was isolated .those distribution were shown in Table no 2.

3.3 Antifungal pattern of Candida species

Voriconazole was shown the most sensitive against Candida out of 50 positive samples, accounting for 48(96%) of cases, followed by itraconazole 31(62%), fluconazole 26(52%), and amphotericin B 23(46%). The least sensitive drugs were ketoconazole, Clotrimazole with 13(26%) and 9(18%), respectively. Clotrimazole was discovered the most resistant against Candida, accounting for 40(80%), followed by ketoconazole 35(70%) and amphotericin B 27(54%). These distributions are shown in Table no 3 and Figure no 2.

3.4 Distribution of Candida species among cancer patient

Among the blood cancer patient three species of Candida was isolated equally 1(33.33%) those were C. albicans, C. krusei and C. tropicalis. None of blood cancer patient was reported for C. glabrata. Among the bone cancer patient only one C. albicans was reported. Among the Breast cancer patient, C. glabrata was reported on highest 3 (37.5%). Both C. glabrata and C. krusei were reported equally 2(25%) and least reported was C. krusei 1(12.5%). Among Cervical cancer 5 C. albicans was isolated. In colorectal cancer patients C. glabrata was isolated most by 3(60%) followed by C. albicans and C. tropicalis were isolated equally by 1(20%.) C. krusei species was not isolated in cervical cancer patient.

Similarly, in liver and ovary cancer patients only C. albicans was reported. In lung cancer patients C. glabrata species was isolated most by 5(41.6%). both C. albican ,C.krusei were equally isolated from lung cancer patient 3(25%) of each. In Prostate cancer only one specie i.e. C. tropicalis was seen. Similarly, for others cancer types and Isolated species were tabulated in Supplementary Table No 1.

3.5 Distribution of organisms on types of Cancer treatment

Candida species were highly isolated from patient treating with chemotherapy 37(74%). Candida spp were least isolated from other therapy such as surgery 7(14%) and Radiation therapy 6(12%).

albicans was detected in 11(29.7%) of chemotherapy patients, followed by C. glabrata 10(27%), C. tropicalalis 8(21.6%), and C. krusei 8(21.6%).C.albicans was found in 4(66.7%) of radiation treatment patients, followed by C.tropicalis in 2(33.3%). C.glabrata and C.krusei were not found in radiation therapy patients. C.albicans was identified in 4(57.1%) of surgical treatment patients, followed by C.glabrata in 2(28.6%) of cases and C.tropicalis in 1(14.3%). C.krusei was not found in any of the surgery patients. These distributions are shown in tabulated format on Supplementary Table No 2.

3.6 Distribution of organisms on socio-demographic variables (Age,gender, religion, ethnicity and marital status)

Among the 50 positive Candida species, the age group 40–60 has the most 22(44%) followed by the age group 20–40. Only 2 (4%) was under 20 while 16 (32%) were over 60. Candida species was primarily isolated from female patients, accounting for 32 (64%)and the remainder 18 (36%) cases was male.

According to ethnicity, janajati committee 19 (38%) had the highest rate of Candida infection, followed by Brahmin 18 (36%) and Chhetri 11 (22%) and Dalit 2 (4%). Only 3 (6% of infections) occurred in the unmarried group, while 47 (94%) of the married group had Candida infection. Based on religion, Candida was mostly isolated from the Hindu population, 45 (90%) followed by Muslims 4 (8%), and Buddhists 1 (2%). These distributions are shown in tabulated format Supplementary Table No 3.

Table no 2 -Distribution of Candida species among sample

Sample type	Isolation
	C. albicans		C. glabrata		C. krusei		C. tropicalis		Total
	N	%	N	%	N	%	N	%
Bal	3	30	3	30	3	30	1	10	10(20%)
Blood	2	50	0	0	1	25	1	25	4(8%)
Catheter Tube	0	0	0	0	0	0	1	100	1(2%)
Pus	3	50	2	33.33	1	16.67	0	0	6(12%)
Sputum	2	40	2	40	0	0	1	20	5(10%)
Urine	9	37.5	5	20.83	3	12.5	7	29.17	24(48%)
									50(100%)

Figure no 2: Antifungal pattern of Candida species

Table No 3: Antifungal pattern of Candida species

Candida spp

Total

albicans

glabrata

krusei

tropicalis

Ketoconazole

intermediate

0.00%

18.20%

4.00%

resistant

73.70%

58.30%

75.00%

72.70%

70.00%

sensitive

26.30%

41.70%

25.00%

9.10%

26.00%

Itraconazole

intermediate

21.10%

25.00%

12.50%

9.10%

18.00%

resistant

15.80%

33.30%

12.50%

18.20%

20.00%

sensitive

63.20%

41.70%

75.00%

72.70%

62.00%

Voriconazole

intermediate

5.30%

0.00%

12.50%

0.00%

4.00%

sensitive

94.70%

100.00%

87.50%

100.00%

96.00%

Amphotericin B

resistant

57.90%

33.30%

62.50%

63.60%

54.00%

sensitive

42.10%

66.70%

37.50%

36.40%

46.00%

Clotrimazole

intermediate

5.30%

0.00%

2.00%

resistant

73.70%

91.70%

87.50%

72.70%

80.00%

sensitive

21.10%

8.30%

12.50%

27.30%

18.00%

Fluconazole

intermediate

0.00%

16.70%

0.00%

4.00%

resistant

52.60%

33.30%

62.50%

27.30%

44.00%

sensitive

47.40%

50.00%

37.50%

72.70%

52.00%

Total

100.00%

In recent years, there has been a striking rise in the prevalence of opportunistic yeast infections, particularly those brought on by endogenous human commensal Candida species, which has raised severe concerns in the medical community all over the world. Although Candida albicans has historically been the most common infection- causing agent, other species, including C. tropicalis, C. glabrata, C. krusei, and C. parapsilosis, have also been linked to systemic and mucosal candidiasis. C. albicans's antifungal susceptibility profile and pathogenicity factors a need for accurate and quick species because of variety identity since this directly influences the decision of treatment (18).

It was a hospital based cross-sectional, quantitative type of study. 680 Samples were collected and processed in the Microbiology laboratory of BPKMCH, Bharatpur, Chitwan, Nepal. The samples were collected from the patients attending OPD or admitted to the hospitals. Among them 280 (41.17%) were male and 400 (58.82%) were females. In our study, out of total 680 samples processed, 92.64%(n = 630) were reported no growth, while 7.3% (n = 50) had growth respectively.NACs 31(62%) was the main pathogen in our investigation when compared to C. ablican 19(38%) which is almost opposite to prior studies done by Maheronnaghsh et al. they found that out of 74 Candida isolates, with 75.5% Candida albicans and 24.5% non-albicans species (19). In our investigation, the prevalence of NACs 31(62%) was in the following order: C. glabrata 12(38.70%) C. tropicalis 11(35.48%) and C. krusei 8(25.80%) of the 680 total sample processed. This finding was contrariety to studies done by Maheronnaghsh et al which was found that C. tropicalis was the most common Non-Albicans species (9.4%), followed by C. krusei (7%), C. glabrata (5.4%), and C. kefyr (2.7%) (20). The most prevalent species of C. glabrata among NACs in clinical samples is an important finding of our investigation. Because of the high occurrence of increasing resistance of this species to commonly used antifungal drugs, this might be a serious threat.

Out of 50 Candida species, 24 (48%) of the urine samples, 10 (20%) of the BALsamples, 6 (12%) of the pus samples, 5(10%) of the sputum samples, and 4 (8%) of the blood samples had found in our study. which discovered that the majority of Candida species were present in urine samples. This finding is similar to the previous study by Patel et al, Out of 219, 78 (35.62%) of the urine samples, 10 (4.57%) of the pus, 20 (9.13%) of the BAL, 32 (14.61%) of the sputum, and 10 (4.57%) of the samples from other sites (21). Candida is demonstrated to be a prominent pathogen for UTI (urinary tract infection) under these circumstances because it has a stronger bond to the mucosal epithelial cells of the urinary tract than other fungi species (21).

Of the 50 positive isolated in our study, females had a greater prevalence of Candida infection than men 32(64%) than 18(36%); this finding was similar to the study done by Chung et al., which reported that 34829 positive sample female were higher in number 31707(91%) than male 3122(8.92%) (22). As a result, we conducted additional research and focused on candidiasis to determine whether Candida infection association in female cancer patient.

In our study age between 40 to 60 years has 22(44%) of Candida infection followed by 20–40 age group 16(32%), age group over 60 and under 20 has less number of Candida infection 10(20%), 2(4%).Those finding was similar to research by Chung et al, they reported that Candida infections were most common in patients 20–49(79.9%) 50–64(11.5%) and over 65 (8.80%) (23). This is because solid cancer such as breast cancer, followed by lungs cancer and colorectal cancer, is the most common cancer in people in age range 20–40 and 40–60 in our study (24).In our investigation Candida species Was mostly isolated from patient treating with chemotherapy 37(74%). Among the chemotherapy patients at C. glabrata, C. albicans, C. krusei, and C. tropicalis were found to be 11(29.7%), 10(27.0%), 8(21.6%), and

8(21.6%), respectively.In our study the higher number of isolate were C. glabrata followed by Candida albicans among chemotherapy patient. Whereas research done by Jabalameli Z et al on chemotherapy patient, which found that out of 12 Candida species C. albicans, 6 (50%); C. krusei, 3 (25%); and C. tropicalis, 3 (25%) were the three most common Candida species (20). That means Candida infection is higher in chemotherapy patient because chemotherapy-induced depression of innate immune cells and weakened epithelial barriers, which are the body's first-line defenses against fungal infections (25).

Out of 50 positive samples in our investigation, Voriconazole was shown to be the most effective against Candida, accounting for 48(96%) of instances. Itraconazole 31(62%) was next, followed by fluconazole 26(52%), and amphotericin B 23(46%). The least sensitive drugs were ketoconazole and clotrimazole, with sensitivity ratings of 13 (26%) and 9 (18%) respectively. Which was similar in a research conducted by Jangla et al found that out 60 Candida species voriconazole was sensitive to 55(91.66%) followed by Itraconazole 37(61.67%), Fluconazole 29(49.8%), and Ketoconazole 28(47%), respectively (26).

Our study showed Voriconazole is an effective drug 48(96%) where as 94% sensitive to Voriconazole was found in a similar study done by Badiee and Alborzi et al (27) .92% by Khan et al (28). 83% by Shafi FT et al (29) respectively. Voriconazole has broad-spectrum action against pathogenic yeasts, including isolates that are inherently fluconazole-resistant, such as Candida krusei. It has a high clinical efficacy in individuals with fluconazole-resistant Candida infections (30). Despite the fact that voriconazole was determined to be beneficial in the study, practicing the surveillance with a monitor is necessary.

In our study the drug shown to be the most resistant against Candida was clotrimazole, which accounted for 40(80%) of the resistance. Ketoconazole 35(70%), amphotericin B 27(54%) and fluconazole 22(44%) were next in line. Clotrimazole was reported to be the most resistant among C.glabrata at up to 11(91.7%) followed by C.kruseri 7(87.5%).Our findings significantly contrast with those of Mukesh Azad et al who found that just 15% of Candida isolated were resistant to clotrimazole (31) ,whereas khan M et a who found that just 59.5% of Candida isolates were resistant to clotrimazole (32). Clotrimazole is currently widely used as a first-line topical antifungal in immunocompromised patients for the prevention or treatment of mucosal candidiasis. Chronic and repeated usage of clotrimazole to treat immunocompromised people predisposes to developing resistance (33).

These findings suggest the rapid increase in resistance among Candida species for clotrimazole and need for speciation and antifungal susceptibility before treatment with antifungal drug.

C. albicans was shown to be the most common species responsible for Candida infections in our investigation. Voriconazole and itraconazole, two regularly used antifungal medications, showed a high degree of sensitivity, whereas ketoconazole and clotrimazole were the least effective against C. albicans and NAC spp. Thus, the study highlights the requirement for Candida isolate speciation and suggests antifungal susceptibility testing for all clinical isolates. For the proper selection of antifungal medication, it is clinically crucial to identify different isolates of Candida to their species level along with antifungal sensitivity patterns.

ASM	American Society of Microbiology
AMR	Antimicrobial Resistance
ATCC	American Type Culture Collection
BaSO₄	Barium Sulphate
BHIB	Brain Heart Infusion broth
BPKMCH	Bishweshwar Prasad Koirala Memorial Cancer Hospital
CLSI	Clinical and Laboratory Standards Institute
GMB	Glucose with Methylene blue
GTT	Germ Tube Test
IRC	Institutional Review Committee
HAI	Hospital-acquired Infection
HPF	High power field
HIV	Human-Immunodeficiency Virus
KOH	Potassium Hydroxide
LCB	Lactophenol Cotton Blue
MDR	Multidrug Resistant
Mg	Milligram
MHA	Mueller Hinton Agar
MIC	Minimum Inhibitory Concentration
ml	Milliliter
NACS	Non-albican Candida species
OPD	Outpatient department
PDA	Potato Dextrose Agar
QC RPM SDA	Quality Control Rotation per minute Sabouraud dextrose agar
SPP.	Species
SPSS	Statistical Package for the Social Sciences
UTI	Urinary tract infection
QC	Quality Control
ZOI	Zone of Inhibition

Availability of Data

The datasets of the current study will be available from the corresponding author upon reasonable request.

Ethical approval

The research has complied with all the relevant national regulations and institutional policies and has been approved by the Institutional Research Committee (IRC) of BP Koirala Memorial Cancer Hospital (letter of approval Registration No: 60/2022).

Consent

Written informed consent was taken from all the participants involved in the study.

Funding

No funding is involved.

Conflicts of Interest

The authors declare no conflict of interest.

Author Contribution

Author Contributions:Promish Neupane: conceived and designed the study, collected and analyzed the data, and wrote the manuscript.Bishnu Raj Tiwari : contributed to the study design, data analysis, and interpretation, and provided critical revisions to the manuscript.Niranjan Shrestha: contributed to the data collection, analysis, and interpretation, and provided substantial edits to the manuscript.Prashant Pandit : contributed to the study design, provided expertise in and critically reviewed the manuscript for intellectual content.Alina Sharma: contributed to the data analysis and interpretation, and provided important feedback on the manuscript drafts.Asta Ram Khagi: Methodology, Software, Validation, Formal analysis, Investigation, Resources, Data curation, Writing - review & editing, Visualization, Supervision.Pradip Hamal : Validation, Investigation, Resources, Data curation, Writing - review & editing, Visualization, Supervision.Kedar Devkota : Conceptualization, Methodology, Validation, Resources, Writing - review & editing, Visualization.All authors approved the final version of the manuscript for submission and agree to be accountable for all aspects of the work.

Acknowledgement

With due respect, I acknowledge my supervisor Prof. Dr. Bishnu Raj Tiwari, Schoolof health sciences, Pokhara University, and Mr. Asta Ram Khagi, Technical-in- charge for the Department of Pathology, B.P Koirala Memorial Cancer Hospital(BPKMCH) for their constant encouragement, guidance, and advice throughout thisstudy. I also take the opportunity to thank them for their enthusiasm andencouragement that inspired me during this journey. I’m thankful to the respected Dean, Dr. Amar Nagila, School Director, Mrs. BimalaBhatta for providing essential academic, technical and financial support. Warmgratitude to Mr. Ganesh Dhakal, Faculty Co-ordinator for M. Sc. MM/MB for hissupport and encouragement. Special thanks to Mr. Bipin Chapagain for his endlesshelp and encouragement. I’m thankful for Assoc. Prof. Dr. Komal Prasad Malla forsupport for plagiarism check. It gives me immense pleasure to thank all the facultymembers and staff of our faculty. I’ve equally contented with Mr. Pradip Hamal and Mr. Keshav Paudel for theircontinuous support and guidance throughout the study. Without their effort, it wouldbe impossible to conduct this study. Similarly, it is our honor to thank all the staffs ofthe Department of Microbiology BPKMCH for all their continuous support whilecarrying out this study. I’m thankful to those patients and their relatives who tooktheir time and contributed to my research; their countless help and support are thebasis for this study. I would also like to acknowledge BPKMCH and PokharaUniversity for providing me with a platform to conduct this research. Lastly, I regardall of those who supported me in any aspect during the thesis work.

Data Availability

The datasets of the current study will be available from the corresponding author upon reasonable request.

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Antifungal Susceptibility Pattern of Candida Species among Cancer Patients Attending B.P Koirala Memorial Cancer Hospital, Chitwan

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Abstract

Figures

1. Introduction

2. Methods

2.1 Inclusion and Exclusion criteria

2.2 Management, Processing and Analysis of Data

2.3 Analysis of data

3. Results

3.1 Distribution of organisms isolated

3.2 Distribution of Candida species among sample

3.3 Antifungal pattern of Candida species

3.4 Distribution of Candida species among cancer patient

3.5 Distribution of organisms on types of Cancer treatment

3.6 Distribution of organisms on socio-demographic variables (Age,gender, religion, ethnicity and marital status)

4. Discussion

5. Conclusion

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