Title : Prevalence, antifungal susceptibility patterns, and associated factors of Candida species among HIV-positive individuals with oropharyngeal infections attending Mekelle health facilities of Tigray, Northern Ethiopia

Abstract:

Background: Oropharyngeal candidiasis (OPC) is the most common opportunistic infection encountered among human immunodeficiency virus-infected patients and is considered an independent predictor of immunodeficiency in patients with acquired immunodeficiency syndrome (AIDS). Though Candida albicans is the most frequently isolated species from the oropharyngeal lesions, the change in spectrum of Candida species as a causative agent of oropharyngeal candidiasis and increased antifungal drug resistance among HIV infected individuals has made the identification of Candida species and assessment of its drug resistance pattern necessary for routine patient care.

Objective: The study aimed to determine the distribution and antifungal susceptibility pattern of Candida species among HIV positive oropharyngeal patients.

Method: A cross-sectional study was conducted among 381 HIV positive individuals with oropharyngeal infection from September 2023 to May 2024. Socio-demographic data on clinical risk factors and oral swabs were collected from the study participants. Collected swab samples were transported to the Microbiology laboratory and were cultured on Sabouraud dextrose agar with chloramphenicol. All the isolates were characterized using germ tube and HiCrome Candida agar tests. The antifungal susceptibility patterns of all Candida species were determined using the disk diffusion method, and data were analyzed using STATA version 13.0.

Result: Among the 381 study participants, the overall Candida species isolation rate was 59.8% (228/381). A total of 240 Candida isolates were recovered, among these C. albican was the most predominant species, 151(62.9%). Among the non-albican Candida species, the most predominant species were Candida glabrata 47(19.6%), followed by Candida tropicalis 26 (10.8%) and Candida krusei 16 (6.7%). Isolated Candida species were from HAART naïve and those on HAART were 127(52.9%) and 113 (47.1%), respectively. Age group 40-49 years (p = 0.019), previous history of antifungal drug treatment (p=0.039), CD4 counts < 200 cells/mm3 (p=0.003),
HAART naïve (p=0.000), body mass indices <15.9 kg/m2 (p=0.002), WHO clinical stage III (p=0.023) and TB co- infection (0.041) were significantly associated with Candida species isolates. Antifungal susceptibility testing was performed on all Candida species isolates, and 12.9% and 9.2% of them showed resistance to fluconazole and ketoconazole, respectively. The lowest rate of resistance was against nystatin 0.8%.

Conclusion: Candida species isolation in this study was (59.8%). both Candida albicans (62.9%) and non-albicans (37.1%) were isolated from a significant number of the study participants. Although not the same for all Candida species and antifungal drug types, our results showed that non-albican Candida species drug resistance, especially to azole groups (fluconazole and ketoconazole) are increasing. On the other hand, nystatin was a relatively less resistant antifungal agent. Therefore, early identification of the etiologic agent and antifungal susceptibility testing should be practiced to improve treatment outcomes and prevent the emergence of drug resistance.

Keywords: Antifungal susceptibility, Candida species, Ethiopia, Oropharyngeal, and HIV.