Over the past decades, there has been a rise in cases of candidiasis, the prevalent source of yeast infections that result in a variety of mucocutaneous disorders that can be serious or non-fatal.¹²  Globally, C. albicans is the most commonly isolated organism from invasive candidiasis cases.⁵ However, growing recovery of the Non-albicans Candida (NAC) from patients over the past several decades has given rise to a new hazard. The NAC species with the most reports are C. tropicalis, C. parapsilosis, C. krusei, and C. glabrata.¹³ The clinical manifestations of infections brought on by numerous NAC spp. typically include some NAC developing resistance over time, becoming established against conventional antifungals, or both.^14,15 Few Candida spp. like C. glabrata and C. krusei are cross-resistant to triazoles like fluconazole. Different pathogenic Candida species have comparable clinical symptoms that cannot be identified.¹⁶ C. auris causes outbreaks of invasive infections in healthcare facilities, resistance to some other antifungals, and also its intrinsic resistance property can cause multi-drug resistance phenomenon.^17–23

A study in Karnataka (2014) by Tellapragada et al.²⁴ Vulvovaginal Candidiasis (VVC) was most frequently caused by C. albicans (61%) and C. glabrata (20%), whereas C. tropicalis (46%) was predominant in bloodstream infections (BSI). Another study by Mohandas et al. in Manipal reported 50% C. krusei and 25% C. albicans from the symptomatic UTI cases. Further, they also demonstrated a frequency of 74.19% C. albicans and 25.8% NAC from the salivary sample.²⁵ In all clinical samples, C. krusei isolate was predominant, while the C. albicans isolates (41.37%) were commonly isolated from respiratory tract infection (RTI).²⁵ Also, a study from Nepal (2017) stated 90% of the Candida spp. were reported from sputum and urine, showing a higher prevalence of Candida spp. from UTI and RTI.¹⁰ Nowadays, a standard genotypic method for Candida spp. identification is generally used due to being less time-consuming, but conventional techniques are considered the gold standard.²⁶ Numerous studies have recommended using CHROM agar Candida for the primary isolation of Candida spp. and their rapid identification.²⁷ The additional advantage of using CHROMagar for primary isolation is the ability to identify different species of Candida from the clinical sample containing mixed species of Candida.²⁸ In our study, all conventional techniques were used to identify Candida isolates like Germ tube, CHROMagar, biochemical methods and Dalmau plate technique in which, 32.14% were identified as C. albicans, followed by C. tropicalis (12.5%), C. pelliculosa (4.46%), C. parapsilosis (0.89%), C. glabrata (1.78%), C. krusei (1.78%) C. rugosa (0.89%). Rajeevan et al., ²⁹ in Tamil Nadu stated that in blood sample 75% of NAC species were reported. In our study, out of 112 isolates, 12.5% of C. pelliculosa was the principal etiology identified from blood, and afterward, C. tropicalis (9.82%). In contrast to our findings, other studies from India reported C. tropicalis (35-45%) as the major causative agent isolated from blood.^30-32 To date, multiple risk factors such as low birth weight, low gestational age, long-term hospitalization, sustained blood alkalosis, surgeries, and inappropriate use of antibiotics are noted for increased cases of C. pelliculosa. Hospital-acquired infections due to C. pelliculosa were documented in various clinical units such as pediatric intensive care units, nurseries, surgical intensive care units, and hematology wards.^33,34

Antifungal susceptibility testing (AST) of Candida isolates by MIC method helps the clinician in the treatment of critically ill patients and is further helpful for generating clinical guidelines for the better management of treatment. A study from Karnataka (2014) found that all Candida isolates were susceptible to flucytosine and amphotericin B, but reduced susceptibility was noted in voriconazole for C. parapsilosis (64%) and C. tropicalis (79%). Fluconazole intermediate-susceptible isolate was seen in 6% C. albicans isolated from Vulvovaginal Candidiasis.²⁴ The present study reports C. albicans and C. tropicalis showed 100% susceptibility to voriconazole, and micafungin. In agreement to previous findings,²⁴ we also found intermediate susceptibility to C. albicans (18.18%) whereas, resistance to fluconazole noted for C. tropicalis (15%) and C. pelliculosa (11.11%).

In our study a high prevalence of NAC was noted in blood sample among which the most predominant etiology was C. pelliculosa. As in literature, Most C. pelliculosa infections occur in preterm children with exceptionally low birth weights as the rare fungus dwells mostly in soil, lakes, fermented foods, and industrial pollution. Correct identification for Candida spp. plays significant role in diagnosing the disease and its prevalence. A study by Kaur et al., (2016) (Saudi Arabia) studied the comparison of a yeast identification by conventional techniques and VITEK-2. Out of 172 Candida spp., Vitek 2 appropriately recognized 90.12% of Candida spp., 2.32% were identified correctly with low discrimination, and 7.56% isolated were misidentified. In our study, VITEK identified the isolates to their species level with proper discrimination. A study by Ahmad et al. (2012) (Kuwait)³⁵ showed that molecular methods are less time-consuming and accurate than the conventional and VITEK systems. Our study focused on the identification of isolates through VITEK and conventional methods. The AST of various isolates in our study resistance was shown by C. albicans (9.1%) to amphotericin-B, whereas C. tropicalis isolates (15%) were resistant to fluconazole and (5%) to amphotericin B followed by C. pelliculosa (11.11%) showed resistance to fluconazole. The rest of the isolates were susceptible dose-dependent and susceptible to the tested antifungals as stated in the study, whereas a study from Nepal showed 86% resistance to the isolated Candida species where ketoconazole demonstrated the highest level of resistance. Further sensitive isolates were reported in clotrimazole, miconazole and fluconazole correspondingly.¹⁰

The lack of molecular methods for identifying and isolating Candida spp. limits our investigation and may result in the lack of some species that warrant attention. In our study, we performed VITEK ID and VITEK-AST for small number of sample. Thus, for studying the prevalence, there is a need for screening a larger number of samples.