Investigating the Increasing Azole Resistance in Candida Infections Among Critically Ill Patients: Experience From a...

Candida species are among the most common fungal pathogens worldwide, with varied clinical presentations and manifestations in both immunocompetent and compromised individuals. In recent years, both global and Indian research have documented a progressive shift from Candida albicans to treatment-resistant non-albicans Candida (NAC)spp. Compared with Western countries, there is a dearth of information on invasive Candida infections in India. The azole group of drugs is most widely used for Candida infections, and this is the reason for the increasing resistance reported in this class of drugs. Recently, resistance to azoles has increased in Candida species, both in clinical settings and in vitro.

The present study aims to identify the spectrum of Candida species in clinical infections and to identify their sensitivity pattern to available antifungal agents.

The study was conducted over 24 months, from April 2023 to March 2025, on clinical samples received for routine culture and sensitivity testing. Antifungal sensitivity was tested according to the Clinical and Laboratory Standards Institute guidelines and interpreted. Demographic and other patient parameters were also assessed.

The results were analyzed using the Statistical Package for the Social Sciences version 22 software (SPSS Inc., Chicago, IL).

The total number of samples analyzed for fungal etiology during the specified time period was 382, of which 57.5% (n = 219) were contributed by blood, 29.2% (n = 112) by urine samples, and the remaining 13.3% (n = 51) by intra-abdominal samples, tissue, pus, and body fluids. Individually, C. albicans was higher in blood samples than in urine samples (43.5% vs. 41.7%). The overall resistance rates in blood isolates to fluconazole and voriconazole were reported as 21.4% and 5.6%, respectively. The trend of Azole resistance from 2023 to 2025 increased for fluconazole from 18.5% to 34.6% and for voriconazole from 5.7% to 10.2%. Echinocandin resistance, however, was not notable, ranging from 0.6% in 2023 to 1.6% in 2025.

Our study emphasizes the role of increased Candida isolates and resistance trends across various samples over the specified time period. C. albicans was the most commonly isolated Candida species overall, but the gradual shift of Candida species to non-albicans species (NAC) is very much pertinent in our study. Candida   auris remains undetected in blood and other invasive samples in the present study. Our study did not report any C. auris isolate. This may be due to the constant and strong reinforcement of enhanced infection control measures, including environmental decontamination and contact precautions. The present study showed a significant increase in antifungal susceptibility testing volumes over the study period, reflecting the growing clinical burden of Candida species. The potential rise in the azole group of drug resistance emphasizes the need for continued regional surveillance to track resistance trends. Expanding regional and global surveillance efforts and developing novel antifungal agents are crucial to addressing the challenges posed by rising multidrug-resistant Candida isolates in various clinical samples. Enhanced surveillance, antifungal stewardship programs, and innovation are very much essential to mitigate the public health impact of antifungal resistance and improve the clinical outcomes among patients.