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7/31/2019 Candida Study 2009
1/13
ARTICLE
Mucosal Candida infection and colonisation as well as associated
risk factors in solid organ transplant recipients
L. Antoniewicz & D. Relijc & C. Poitschek& E. Presterl &
A. Geusau
Received: 18 October 2008 /Accepted: 14 March 2009# Springer-Verlag 2009
Abstract More detailed information on Candida colonisa-
tion and infection of the mucous membranes in organ
transplant recipients (OTR) is of particular interest. There-
fore, this issue was prospectively evaluated in 400 different
OTR in different posttransplantation periods as well as in
405 healthy age- and sex-matched controls. In addition,
possible risk factors and the clinical condition in the OTR
were evaluated. Independent of the transplanted organ there
is a statistically significant decrease in the number of
positive culture results, of symptomatic candidiasis and an
increase of isolated non-albicans Candida species
corresponding to length of the posttransplantation period.
No significant differences could be observed in the OTR in
association with different immunosuppressive regimen;
however, higher dosages of corticosteroids and tacrolimus
correlated with symptomatic candidiasis. As Candida spp.
may also cause systemic infection and dissemination,
additional knowledge about cofactors and associated strains
may have an impact on therapeutic decisions.
Introduction
Organ transplant recipients (OTR) are susceptible to infec-
tions, particularly to fungal infections, generally occurring
within the first 6 months after transplantation [1, 2]. The skin
and the mucous membranes may either be primarily affected
and/or indicative for generalized infection, thus taking
central position in the diagnosis and recognition of infections
in organ transplant recipients. Superficial infections may also
be restricted to the skin and mucous membranes in OTR.
The most common fungal infection of the mucous mem-
branes is thrush, highly prevalent during the first three
posttransplant months, gradually tapering off in the subse-
quent months of the first posttransplant year [3]. The most
common pathogen reported is C. albicans, but also non-
albicans Candida species have been described, among them
C. tropicalis, C. krusei, C. glabrata, and C. parapsilosis [4].
Candida is a true opportunist occurring on the surface of
mucous membranes as saprophytes and generally without
pathogenic potency. However, in the scenario of immuno-
suppression, colonisation with Candida spp. may cause not
only infection of the mucous membranes but may be
indicative for invasive disease and dissemination [5].
Epidemiological data on colonisation of the mucous
membranes due to Candida spp. and the respective clinical
manifestations in the different organ transplant patient
groups are rare. This study was designed to evaluate the
prevalence, the clinical signs and symptoms, and the
species spectrum of Candida colonisation in OTR as well
as to determine the associated risk factors and the relevance
of particular immunosuppressive regimens and the different
posttransplant periods.
Eur J Clin Microbiol Infect Dis
DOI 10.1007/s10096-009-0730-8
L. Antoniewicz : C. Poitschek: A. Geusau (*)
Department of Dermatology Division of Immunology,
Allergy and Infectious Diseases (DIAID),
Medical University of Vienna,
Waehringer Grtel 1820 ,
1090 Vienna, Austria
e-mail: [email protected]
D. Relijc
Department of Dermatology, Division of Specific Dermatology
and Environmental Dermatology, Medical University of Vienna,
Vienna Waehringer Grtel 1820,
1090 Vienna, Austria
E. Presterl
Department of Medicine I, Division of Infectious Diseases
and Tropical Medicine, Medical University of Vienna,
Vienna Waehringer Grtel 1820,
1090 Vienna, Austria
7/31/2019 Candida Study 2009
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Patients and methods
Data/strain collection and study population
Four hundred organ transplant recipients (kidney transplant
recipients [KTR], and similarly, heart [HTR], lung [LuTR], and
liver [LTR]), who had been transplanted at the organ transplant
unit of the Medical University of Vienna, were included
prospectively in the study between May 2005 and April 2007
(24 months). With regard to their posttransplantation period,
the patients were classified into three groups: (1) patients
within the first 6 months after transplantation, (2) in the period
between 6 and 18 months after transplantation, and (3) patients
in the period more than 18 months after transplantation.
The patients were evaluated according to an established
protocol. The data included: sex and age, age at the time of
transplantation, type of transplanted organ, as well as type and
daily dosage of immunosuppressive (IS) therapy. In addition,
it was evaluated whether the patients had had a rejection of
their organ or cytomegalovirus infection within the preceding
6 weeks of evaluation, whether they had neutropenia, an in-
situ central or peripheral intravenous catheter at the time of
evaluation, any bacterial infection, antibiotic therapy or a
surgical procedure within the preceding 3 weeks. Diabetes
mellitus, parenteral nutrition and whether and what type of
dentures the patient was wearing was also recorded.
Symptomatic oropharyngeal candidiasis was diagnosed
on the basis of the following criteria: xerostomia, burning
sensation of the oral mucous membranes, clinical signs of
erythematous or pseudomembranous, or hyperplastic can-
didal infection, dysphagia or cheilitis angularis. Symptom-
atic genital candidiasis was considered when burning
sensations, redness, thrush of the vaginal mucosa or the
glans penis and/or genital discharge were present.
Oral and genital swabs for microscopic and cultural
detection of Candida spp. were taken from every OTR
patient. Mouth and vaginal/penile specimens were exam-
ined microscopically using potassium hydroxide prepara-
tion (KOH) and were cultured in Sabouraud broth with
bacitracin (Merck, Darmstadt, Germany). Fungal cultures
were incubated at 37C for one week and evaluated daily. A
positive culture subsequently was transferred onto a rice agar
plate and a Sabouraud dextrose agar plate in parallel and
incubated for 2472 h at 30C. The presence of chlamydo-
spores microscopically indicated Candida albicans; further
species identification was performed by API system
(bioMerieux, LEtoile, France).
Furthermore, four clinical groups in the OTR were
distinguished:
1. Negative patients without clinical and microbiological
evidence for oropharyngeal/genital Candida infection
or colonisation
2. Colonised patients, i.e. asymptomatic patients with
positive cultures and negative smears
3. Facultative symptomatic patients characterized by the
fact that they were asymptomatic with smears yielding
hyphal elements, pseudohyphae and/or blastoconidia
chlamydospores representing a pathogenic form of
Candida with or without positive culture results
4. True infection was diagnosed when the patient was
symptomatic with a positive smear and culture result.
Asymptomatic patients with negative cultures but
positive smears were counted as facultative symptom-
atic. Patients exhibiting clinical symptoms with positive
cultures but negative smears or negative cultures but
positive smears were also regarded as symptomatic
patients.
Controls
Four hundred five healthy age- and sex-matched controlswere recruited at the Vienna General Hospital, either from
the ophthalmology or casualty ward, where they had been
either in- or outpatients seen on routine basis (e.g. routine
check after emergency) or for a presurgical visit (e.g.
cataract surgery). Subjects with the following conditions
were excluded: symptoms on the oral or genital mucosa,
intake or topical application of antifungals or antibiotics,
acute infections of skin or infectious diseases (e.g. hepatitis,
influenca), autoimmune diseases, immunosuppression ei-
ther induced or due to congenital or acquired immunode-
ficiency syndrome (HIV/AIDS). In each of the subjects two
body sites were sampled for culture (from the oral andvaginal mucosa/glans penis).
The study has been approved by the local ethical
committee of the Medical University of Vienna. An
informed consent was signed by patients and controls prior
to inclusion into the study.
Statistical analysis
Statistical analyses were done using SPSS 15.0 software for
Windows (SPSS Inc., Chicago, IL, USA). Categorical
variables were compared by Qui-square analysis or Fishers
exact test and quantitative variables by Mann-Whitney U-test. Binary logistic regression (method: enter) was used to
define associated risk factors for symptomatic infection and
colonisation and for non-albicans Candida isolation.
Results are presented in odd ratios with 95% confidence
intervals. Data was checked for colinearity. All p values are
two tailed and were considered statistically significant at
7/31/2019 Candida Study 2009
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of dentures, which were all coded as dummy variables.
Three statistical analyses were performed to analyse for
significant risk factors: positive versus negative culture
results, symptomatic versus asymptomatic patients and
Candida albicans versus non-Candida albicans spp. The
low number of symptomatic patients infected with non-
Candida albicans spp. did not allow the evaluation of all
risk factors in regression analysis [6].
Results
Demographic data study patients and controls
Of the 400 OTR, 151 (37.8%) were KTR, 116 (29.0%)
HTR, 91 (22.8%) LuTR and 42 patients (10.5%) were LTR
(Table 1). Most of the study participants were between 40
and 79 years old. Mean age of the OTR was 56 years (55.9
in NTR, 58.2 in HTR, 52.1 in LuTR, 58.4 in LTR) (median
58, range 59.1) and 56.7 years in the controls (median 57.1,
range 66). Mean age at transplantation was 50.8 years;
mean time after transplantation was 5.2 years (NTR 5.4;
HTR 7.0, LuTR 2.5, LTR 5.2) (median 3.8, range 26.7). Of
the patients, 256 were male and 144 female, which
corresponds to a male to female ratio of 1:1.8; there was
about a same sex distribution among the controls (259 males,
146 females). Thirty-nine of the patients (28 KTR, 7 LuTR,
and 4 HTR) had been re-transplanted at a mean time of
9.1 years after their first procedure. The distribution with
regard to the posttransplantation period was as follows: 87
OTR were in the early posttransplantation period
(
7/31/2019 Candida Study 2009
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Genital symptoms were present in 35 (9%) patients,
characterized by burning/stinging sensations (63%), genital
discharge (16%), redness (symptomatic 9%, asymptomatic
5%), and coverings on the vaginal mucosa or the surface of
the glans penis (symptomatic 2%, asymptomatic 5%). In 19
of the symptomatic patients culture and smear were negative,
and they were excluded from the group of symptomatic
genital candidiasis. Nine of the 35 patients exhibited two,
and 26 of the 35 patients, one of the listed symptoms.
The distribution of mucosal Candida manifestations
according to the four defined clinical groups (negative,
colonised, facultative symptomatic, symptomatic) in the
different OTR and posttransplantation periods in compari-
son to the healthy controls is shown in Table 1 and Fig. 1a,
b. In OTR, the number of patients with positive cultures
(with and without symptoms) is dependent on the post-
transplantation period, i.e. there was a decreased number of
positive culture results with the lengths of the posttrans-
plantation period which applied both for the oral and
genital site and was statistically significant. In the first 6
months after transplantation, Candida spp. could be
isolated in 70% of the OTR from the oral site and in 31%
from the genital area, which is significantly more frequent
compared to OTR in the late posttransplantation period
(oral: 18 months: 70%/54%, p=0.03; genital:
18 months: 31%/12%, p =0.001). This
remained statistically significant in the regression analysis,
indicating a two-fold risk for a positive culture from the
oral mucosa, and three-fold from the genital area for
patients in the early period compared to long term OTR
(Tables 2 and 3).
There was no significant difference with regard to
positive cultures when the late posttransplantation period
(>18 months after transplantation) was compared to the
controls who had colonisation in 54% (n=142) on the oral
and in 12% (n=59) on the genital mucosa, respectively
(oral: OTR/Co 54% vs 51%, p = n.s.; genital: OTR/Co 12%
vs 15%, p = n.s.). However, 6070% of those with positive
cultures in the group of OTR were symptomatic or
facultative symptomatic. When the OTR were analysed all
together and compared to the controls, they had signifi-
cantly more frequent positive culture results from the oral,
but not from the genital site (oral: OTR/Co: 60%/51%, p=
0.014; genital: OTR/Co: 18%/15%, p = n.s.). The effect
was more pronounced in the early posttransplantation
period and statistically significant for both sites when this
posttransplantation period was analysed and compared to
the results in the controls (oral:
7/31/2019 Candida Study 2009
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However, with length of the posttransplantation period, there
was an increasing percentage of these strains which was
significant, in particular when the long-term transplant
patients were compared (oral mucosap = n.s.; genital mucosa
p=0.005) (Fig. 2, see Tables 2 and 3) and for the genital
site (OTR vs Co oral: 11% vs 11%, p = n.s.; genital: 53%
vs Co: 29%, p=0.022). C. albicans was the predominant
cause for symptomatic infections. However, the proportion
Fig. 1 Candida infection or
colonisation with regard to the
four defined clinical groups
(negative, colonised, facultative
symptomatic, symptomatic) and
the risk factors posttransplanta-
tion period, transplanted organs
and daily dosage of steroids and
tacrolimus in comparison to
healthy controls
Eur J Clin Microbiol Infect Dis
7/31/2019 Candida Study 2009
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Table2
Thedistributionofage,se
x,posttransplantationperiod,thetypeofO
TRandtheriskfactors
Riskfactors
Positivecultures(vsnegativeculture)
Symptomatic(vscolonised+
fak.sympt.)
Non-albicans(vsC.albicans)
Oralmucosa
Genitalarea
Oralmucosa
Genitalarea
Oralmucosa
Genitalarea
Positive
Negative
Positive
Negative
Sympt.
Colon.
Sym
pt.
Colon.
Non-a.
Albicans
Non-a.
Albicans
Age(y)
2039
28
15
9
34
7
23
3
10
1
27
1
8
65.10%
34.90%
20.90%
79.10%
23.30%
76.70%
23.10%
76.90%
3.60%
96.40%
11.10%
88.90%
4059
106
79
39
146
36
78
7
42
13
93
15
24
57.30%
42.70%
21.10%
78.90%
31.60%
68.40%
14.30%
85.70%
12.30%
87.70%
38.50%
61.50%
6079
104
67
24
147
42
77
6
29
9
95
9
15
60.80%
39.20%
14.00%
86.00%
35.30%
64.70%
17.10%
82.90%
8.70%
91.30%
37.50%
62.50%
Sex
Male
139
117
33
223
53
107
4
42
11
128
9
24
54.30%
45.70%
12.90%
87.10%
33.10%
66.90%
8.70%
91.30%
7.90%
92.10%
27.30%
72.70%
Female
100
44
39
105
33
71
12
39
13
87
16
23
69.40%
30.60%
27.10%
72.90%
31.70%
68.30%
23.50%
76.50%
13.00%
87.00%
41.00%
59.00%
PostTxperiod
18
m
142
120
32
230
46
115
10
38
17
125
17
15
54.20%
45.80%
12.20%
87.80%
28.60%
71.40%
20.80%
79.20%
12.00%
88.00%
53.10%
46.90%
Trans-plantedorgan
KTR
93
58
27
124
33
68
6
29
9
84
10
17
61.60%
38.40%
17.90%
82.10%
32.70%
67.30%
17.10%
82.90%
9.70%
90.30%
37.00%
63.00%
HTR
59
57
17
99
25
46
6
20
6
53
7
10
50.90%
49.10%
14.70%
85.30%
35.20%
64.80%
23.10%
76.90%
10.20%
89.80%
41.20%
58.80%
LuTR
59
32
21
70
21
41
4
24
5
54
6
15
64.80%
35.20%
23.10%
76.90%
33.90%
66.10%
14.30%
85.70%
8.50%
91.50%
28.60%
71.40%
LTR
28
14
7
35
7
23
0
8
4
24
2
5
66.70%
33.30%
16.70%
83.30%
23.30%
76.70%
0.00%
100.00%
14.30%
85.70%
28.60%
71.40%
Diabetesmellitus
None
196
138
54
280
71
145
12
61
21
175
18
36
58.70%
41.30%
16.20%
83.80%
32.90%
67.10%
16.40%
83.60%
10.70%
89.30%
33.30%
66.70%
Yes
43
23
18
48
15
33
4
20
3
40
7
11
65.20%
34.80%
27.30%
72.70%
31.30%
68.80%
16.70%
83.30%
7.00%
93.00%
38.90%
61.10%
Eur J Clin Microbiol Infect Dis
7/31/2019 Candida Study 2009
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of non-albicans strains compared to C. albicans strains
isolated from symptomatic and colonised patients increased
in long-term transplant patients. This is true in particular for
the genital area where non-albicans strains comprised over
50% of the positive cultures (Table 4).
Associated factors for colonisation and symptomatic
candidiasis in OTR
Types of immunosuppressive therapy Most of the patients
had a combined immunosuppressive (IS) regime, usually a
triple combination therapy containing corticosteroids plus a
calcineurin inhibitor, i.e. cyclosporine (CSA) or tacrolimus
(TAC), plus an antiproliferative drug, i.e. mycophenolat-
mofetil (MMF) or azathioprin (Aza), or a regimen containing
an mTOR antagonist (Fig. 3a). The regimen (mono-, double-
or triple-drug combination therapy) and the dosages of the
various drugs were dependent on the type of organ trans-
planted and significantly different in the different organ
recipients (p
7/31/2019 Candida Study 2009
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mucosa were marginally nonsignificant (positive cultures:
10 mg/d: 60% vs 83%; p = ns). A non
significant trend towards more frequent oral candidiasis in
patients with high Tacrolimus dosages could be observed
(symptomatic: 10 mg/d: 25% vs 53%; p = n.s.).
A similar trend was observed for CSA; however, this was
not statistically significant (symptomatic, oral mucosa:
250 mg/d: 23% vs 44%; p = n.s.).
For corticosteroids, symptomatic oral candidiasis is more
frequent in the >10 mg daily dosage population (5 mg/d
vs >10 mg/d: 29% vs 54%; p =0.004). This applies also for
patients with a positive culture from the genital area
(5 mg/d vs >10 mg/d: 13% vs 38%; p
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Table4
DistributionofCandidastrainsinOTR,thethreeposttransplantation
periodsandincontrols
Cultureresults
Organtransplantrecipients(OTR)
Controls
18m
All
Colonised
Symptomatic
Colonis
ed
Symptomatic
Colonised
Symptomatic
Colonised
Symp
tomatic
n
%
n
%
n
%
n
%
n
%
n
%
n
%
n
%
n
%
Oralmucosa
C.albicans
34
97.1%
25
96.2%
22
8
8.0%
9
90.0%
93
88.6%
32
86.5%
149
90.3%
66
90.4%
184
88.9%
C.glabrata
1
2.9%
0
0.0%
2
8
.0%
0
0.0%
7
6.6%
3
8.1%
10
6.1%
3
4.1%
10
4.8%
C.parapsilosis
0
0.0%
1
3.8%
1
4
.0%
0
0.0%
3
2.8%
0
0.0%
4
2.4%
1
1.4%
3
1.4%
C.
tropicalis
0
0.0%
0
0.0%
0
0
.0%
0
0.0%
0
0.0%
2
5.4%
0
0.0%
2
2.7%
4
1.9%
C.
krusei
0
0.0%
0
0.0%
0
0
.0%
1
10.0%
0
0.0%
0
0.0%
0
0.0%
1
1.4%
3
1.4%
C.
lusitaniae
0
0.0%
0
0.0%
0
0
.0%
0
0.0%
1
1.0%
0
0.0%
1
0.6%
0
0.0%
1
0.5%
C.
dubliniensis
0
0.0%
0
0.0%
0
0
.0%
0
0.0%
0
0.0%
0
0.0%
0
0.0%
0
0.0%
2
1.0%
C.norvegensis
0
0.0%
0
0.0%
0
0
.0%
0
0.0%
1
1.0%
0
0.0%
1
0.6%
0
0.0%
0
0.0%
Genitalarea
C.albicans
20
83.3%
3
100.0%
6
6
0.0%
3
100.0%
13
48.1%
2
40.0%
39
63.9%
8
72.7%
42
71.2%
C.glabrata
3
12.5%
0
0.0%
4
4
0.0%
0
0.0%
6
22.2%
2
40.0%
13
21.3%
2
18.2%
8
13.6%
C.parapsilosis
1
4.2%
0
0.0%
0
0
.0%
0
0.0%
4
14.8%
1
20.0%
5
8.2%
1
9.1%
5
8.5%
C.
tropicalis
0
0.0%
0
0.0%
0
0
.0%
0
0.0%
0
0.0%
0
0.0%
0
0.0%
0
0.0%
1
1.7%
C.
krusei
0
0.0%
0
0.0%
0
0
.0%
0
0.0%
3
11.1%
0
0.0%
3
4.9%
0
0.0%
1
1.7%
C.
lusitaniae
0
0.0%
0
0.0%
0
0
.0%
0
0.0%
1
3.7%
0
0.0%
1
1.6%
0
0.0%
0
0.0%
C.
dubliniensis
0
0.0%
0
0.0%
0
0
.0%
0
0.0%
0
0.0%
0
0.0%
0
0.0%
0
0.0%
1
1.7%
C.norvegensis
0
0.0%
0
0.0%
0
0
.0%
0
0.0%
0
0.0%
0
0.0%
0
0.0%
0
0.0%
1
1.7%
Oralmucosa
C.albicans
34
97.1%
25
96.2%
22
8
8.0%
9
90.0%
93
88.6%
32
86.5%
149
90.3%
66
90.4%
184
88.9%
non-albicans
1
2.9%
1
3.8%
3
1
2.0%
1
10.0%
12
11.4%
5
13.5%
16
9.7%
7
9.6%
23
11.1%
Genitalarea
C.albicans
20
83.3%
3
100.0%
6
6
0.0%
3
100.0%
13
48.1%
2
40.0%
39
63.9%
8
72.7%
42
71.2%
non-albicans
4
16.7%
0
0.0%
4
4
0.0%
0
0.0%
14
51.9%
3
60.0%
22
36.1%
3
27.3%
17
28.8%
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nutrition and in situ peripheral venous devices were present
in a small number of patients (n =9) only. The same applied
to preceding CMV infection (n=12) and neutropenia (n=
14). A central venous catheter in the OTR (n=24) was
significantly associated with oral candidiasis (42% with
versus 20% without, p=0.02), but was excluded from theanalysis in order to prevent a bias in the logistic regression
model because all those patients were in the first post-
transplantation period. Bacterial infection (n =54) was
always associated with antibiotic intake and could therefore
not be analyzed separately. Our evaluation of associated
factors therefore concentrated on antibiotic intake (therapy
and prophylaxis, n=147), diabetes mellitus (n=66), and, for
the oral mucosa, wearing of dentures (n=199) (Table 2).
The distribution/percentage of patients with diabetes
mellitus in the different transplant groups and posttrans-
plantation periods was similar. When analyzed in the
regression analysis, genital colonisation with Candida spp.in OTR was significantly associated with diabetes mellitus
(p =0.006) with an overall more than two-fold increased
risk compared to patients without diabetes mellitus (Tables 3
and 4). Antibiotic therapy consisted of prophylactic intake
as well as high-dose treatment for relevant bacterial
infections. In the analysis, we used the factor antibiotic
treatment as one risk factor regardless of the type of
regimen or the dosage (therapeutic or prophylactic). We
evaluated all OTR together, as there was an equal
distribution of these subgroups in each of the OTR groups
and posttransplantation periods (data not shown). Antibiotic
intake had an impact on symptomatic oropharyngeal
candidiasis (39% with versus 28% without) and genital
colonisation (26% with versus 13% without), but for both
conditions regression analysis and qui-square analysisshowed no significance (Table 3). Patients wearing dentures
had an almost two-fold higher risk for being colonised at
the oral mucosa than those without (66% versus 53%, p=
0.01) (Tables 2 and 3).
Discussion
Fungal infections in OTR are a significant cause of
morbidity and mortality. The most common fungal infec-
tion in OTR is candidiasis. Like intensive care-unit patientsand HIV-infected individuals with CD4 depletion, iatro-
genic immunosuppressed transplant patients are more likely
to develop candidiasis of the mucous membranes and
comprise, compared to the normal population, higher rates
of colonisation [79]. Apart from that, recent epidemiolog-
ical data suggest the emergence of non-albicans Candida
species and resistant Candida species as well as fungi other
than Candida in these patients [10]. Within the frame of our
prospective study we were able to investigate a substantial
Fig. 2 Distribution of C. albi-
cans and non-C. albicans spe-
cies in the three
posttransplantation periods in
comparison to healthy controls
Fig. 3 Distribution of immuno-
suppressive therapy combina-
tions in all OTR (a) and in the
different transplanted organs (b).
(1xIS: one immunosuppressant;
2xIS: two immunosuppressants;
cortisone + 1xIS: cortisone plus
one immunosuppressant)
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number of transplant patients who had received different
organs including hearts, kidneys, lungs and livers and who
were in different time periods after transplantation. We also
evaluated the spectrum of Candida species isolated in our
population. In addition, we had precise information about
their IS-regimes and possible risk factors. For the first time,
genital swabs were evaluated concomitantly from such a
big sample size. The comparison with a representative
control group gives us reliable information about factors
associated with transplantation. Thus far, this is the largest
prospective study in transplant patients with regard to
Candida colonisation and mucosal Candida infection [5,
11, 12].
Candida spp. are saprophytes on mucous membranes
without pathogenetic potency for humans under normal
conditions. Therefore, isolation of Candida spp. in culture
is not necessarily an indication for infection [13]. A
correlation has to be made between clinical characteristics
of candidiasis and mycological tests such as direct
investigation and cultures. Colonisation of mucous mem-
branes is common in the normal population and, according
to literature, amounts to 1.969% on oral mucosa and for
15% (for men) and 20% (for women) in the genital area/
mucosa [1418]. Colonisation increases with age [1416].
The colonisation rate in our control group corresponds with
the published data; 51% of healthy subjects had a positive
culture for Candida spp. and 15% from genital swabs, with
a higher rate in women (20%) than in male controls (11%),
which is also in accordance to literature [17, 19].
The relevance of the isolation of Candida spp. from oral
or genital mucosa has to be judged in connection with
clinical symptoms and the proof of hyphae on direct
examination, which is a pathogenetic form of yeasts [18,
20]. In our population of transplant patients, direct
examination of a fresh sample was positive for pseudohy-
phae or pseudomycelia in 44% from oral mucosa and in
14% from the genital area/mucosa of the patients. Taking
into account the different symptom groups we had defined,
the proof of fungi in the wet mount preparation was
indicative for symptomatic candidiasis or facultative symp-
tomatic patients. Of those with positive cultures from the
oral mucosa site who met the criteria of symptomatic
candidiasis, 72% had concomitant positive smear results.
From the genital site, it was 81%. The sensitivity of a wet
mount preparation for the diagnosis of symptomatic
candidiasis is therefore comparable to what is reported in
literature [21]. Due to the fact that C. glabrata lacks the
ability of producing pseudohyphae, there could have been a
bias with reg ard to the ide ntification of facultative
symptomatic patients by wet mount preparation in our
analysis. However, C. glabrata comprised only 9% of all
isolated strains in OTR, and even less in the colonized
patients, of whom a minimal proportion could therefore
have been missed to be counted as facultative symptomatic.
Fig. 4 Box plots of daily im-
munosuppressive therapies (in
mg/d) in the three different
posttransplantation periods
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There are only a few pro- or retrospective studies on
candidal colonisation or infection in transplant patients;
only two of them deal with genital candidasis [5, 12]. In a
small sample of renal transplant patients, Glec and
coworkers found symptomatic oral candidiasis in 26% of
the patients [11]. This percentage corresponds to the rate of
patients with symptomatic oropharyngeal candidiasis in our
transplant population and to the rate observed in the
subgroups of the kidney and heart transplant recipients,
namely, 22%. In comparison, 17% of the liver- and 23% of
the lung-transplant recipients had oropharyngeal candidia-
sis. Liver transplant patients had the lowest prevalence
compared to the other OTR, but the difference was not
statistically significant. This is in contrast to what is known
for invasive candidiasis, which affects liver transplant
recipients more significantly, indicating an association of
this condition with a particular organ transplanted, i.e. the
particular associated surgical procedure. Apart from that,
invasion occurs more likely in rejection periods, which
require higher dosages of IS-therapy, and mainly in the
early posttransplantation period [2, 22, 23].
Because of our classification of four different clinical
groups a comparison of our results to published data on the
prevalence of asymptomatic Candida colonisation of the
oral mucosa in transplant patients is difficult. However, we
can summarize the number of our asymptomatic OTR who
are culture-positive, i.e. colonised, and those who fulfil
the criteria of facultative symptomatic patients, i.e. who
have positive cultures and/or smears but lack clinical
symptoms. These numbers set in contrast with the preva-
lence of colonisation reported in literature show that our
data are within the same range. In a report of Baidee and
coworkers, 35% of 120 kidney transplant patients and 78%
of 50 liver transplant patients had oral colonisation with
Candida spp. in the early posttransplantation period (the
first 6 months), indicating a significant difference for these
two transplant groups [5]. In our study population analysed
for the same posttransplantation period, 37% of the kidney
transplant and 60% of liver transplant patients were
colonised orally. However, the difference was not statisti-
cally significant, which most likely is due to the small
sample size of liver transplant patients in this period.
Kurnatowska and co-workers stated a genital colonisation
rate of 25% in a small sample of 32 kidney transplant
patients; for comparison, it was 23% in our population [12].
The observed age-effect in the controls, i.e. the increase of
colonisation with age, could not be observed in the
transplant population and was more or less overruled by
other more relevant factors.
Altogether, 245 Candida strains could be isolated from
the oral cavity and 72 isolates from the genital area of the
400 transplant patients. Similarly, in the controls, 213
isolates were found orally and 59 genitally. In the OTR, the
early posttransplantation period was clearly associated with
a significantly higher numbers of positive cultures from the
oral and genital site compared to patients in the late
posttransplantation period or to controls. This applied for
all types of OTR. Six controls and six OTR had double
colonisation on the oral site, primarily with C. albicans and
C. glabrata. Sixty-two of the patients were culture-positive
concomitantly on the oral and genital sites, a condition
mainly observed in the early period after transplantation.
However, this effect was without statistical significance
when the different posttransplantation periods were com-
pared. A significant difference in the concordance of
cultures was found between the early and late posttrans-
plantation period with significantly more discordant cul-
tures in the late phase.
Recent literature reports an increase of non-albicans
strains and the emergence of resistant strains in certain risk
groups, particularly in patients who are immunosuppressed
or require recurrent systemic antifungal therapy [8, 2426].
In our study population, when all patients were analysed
together, there was no proportional difference with regard
to C. albicans and non-albicans Candida species isolated
from patients and controls from both sites. However, when
the different posttransplantation periods were analysed
separately, there was a statistically significant increase of
non-albicans Candida species with time after transplanta-
tion (after 18 months) in comparison to the early post-
transplantation period (the first 6 months) in the genital and
oral sites. When the early period was compared to the
control group, this increase was only significant for the
genital site.
A possible explanation could be that most of the patients
receive systemic antifungal therapy within their posttrans-
plant lives [1, 27, 28], but we have no explanation for this
distribution in the control group.
From the various known risk factors for oropharyngeal
and genital candidiasis and colonisation [1, 2, 4, 22, 23,
2931], there was a trend of increasing symptomatic
oropharyngeal candidiasis and genital colonisation in the
patients with antibiotic intake or antibiotic prophylaxis in
the preceding 3 weeks; however, in the multivariable
analysis this effect was not statistically significant. Patients
wearing dentures had a nearby two-fold increased risk for
having a positive culture result on the oral site. Genital
colonisation was more than two-fold increased in patients
with diabetes mellitus compared to those without; this was
true for all patient groups and all posttransplantation
periods. All other risk factors, i.e. CMV infection or
neutropenia, were not evaluated due to small numbers.
Another relevant factor turned out to be gender; female
organ transplant recipients had a three-fold risk for a
positive culture result from a genital swab and a almost
two-fold risk for oral swab.
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Immunosuppressive drug-combinations and dosages
differ significantly in the different types of transplanted
organs and posttransplantation phases. Higher dosages of
CsA, tacrolimus and steroids were administrated in the first
6 months after transplantation, and liver transplant recipi-
ents have significantly more often a mono or dual therapy.
A direct association between positive cultures and immu-
nosuppressive therapy could therefore only be observed for
higher dosages of tacrolimus and corticosteroids.
With this prospective study we were able to get additional
information about candidal colonisation and infection of the
mucous membranes in a large group of different transplant
patients with particular focus on immunusppressive regimens
and different periods in the posttransplantation phase.
References
1. Patterson JE (1999) Epidemiology of fungal infections in solidorgan transplant patients. Transpl Infect Dis 1(4):229236.
doi:10.1034/j.1399-3062.1999.010402.x
2. Fishman JA, Rubin RH (1998) Infection in organ-transplant
recipients. N Engl J Med 338(24):17411751. doi:10.1056/
NEJM199806113382407
3. Hogewoning AA, Goettsch W, van Loveren H, de Fijter JW,
Vermeer BJ, Bouwes Bavinck JN (2001) Skin infections in renal
transplant recipients. Clin Transplant 15(1):3238. doi:10.1034/
j.1399-0012.2001.150106.x
4. Tsambaos D, Badavanis G (2001) Skin manifestations in solid
organ transplant recipients. Skin Pharmacol Appl Skin Physiol 14
(5):332343. doi:10.1159/000056364
5. Badiee P, Kordbacheh P, Alborzi A, Zeini F, Mirhendy H,
Mahmoody M (2005) Fungal infections in solid organ recipients.
Exp Clin Transplant 3(2):385
3896. Harrell FE (2001) Regression modeling strategies with applica-
tions to linear models logistic regression and survival analysis.
Springer, New York, p 60
7. Costa CR, de Lemos JA, Passos XS, de Araujo CR, Cohen AJ,
Souza LK, Silva Mdo R (2006) Species distribution and
antifungal susceptibility profile of oral Candida isolates from
HIV-infected patients in the antiretroviral therapy era. Mycopa-
thologia 162(1):4550. doi:10.1007/s11046-006-0032-y
8. Erkose G, Erturan Z (2007) Oral Candida colonization of human
immunodeficiency virus infected subjects in Turkey and its
relation with viral load and CD4(+) T-lymphocyte count. Mycoses
50(6):485490. doi:10.1111/j.1439-0507.2007.01393.x
9. Chen YC, Chang SC, Tai HM, Hsueh PR, Luh KT (2001)
Molecular epidemiology of Candida colonizing critically ill
patients in intensive care units. J Formos Med Assoc (Taiwan yizhi) 100(12):791797
10. Silveira FP, Husain S (2007) Fungal infections in solid organ
transplantation. Med Mycol 45(4):305320. doi:10.1080/136937
80701200372
11. Gulec AT, Demirbilek M, Seckin D, Can F, Saray Y,
Sarifakioglu E, Haberal M (2003) Superficial fungal infec-
tions in 102 renal transplant recipients: a case-control study. J
Am Acad Dermatol 49(2):187192. doi:10.1067/S0190-9622
(03)00861-2
12. Kurnatowska I, Chrzanowski W, Kacprzyk F, Kurnatowska A
(2003) Multifocal fungal infections in patients after renal
transplantation undergoing immunosuppression. Pol Merkuriusz
Lek 15(88):388390
13. Bornstein J, Lakovsky Y, Lavi I, Bar-Am A, Abramovici H (2001)
The classic approach to diagnosis of vulvovaginitis: a critical
analysis. Infect Dis Obstet Gynecol 9(2):105111. doi:10.1155/
S1064744901000187
14. Zaremba ML, Daniluk T, Rozkiewicz D, Cylwik-Rokicka D,
Kierklo A, Tokajuk G, Dabrowska E, Pawinska M, Klimiuk A,
Stokowska W, Abdelrazek S (2006) Incidence rate of Candida
species in the oral cavity of middle-aged and elderly subjects. Adv
Med Sci 51(Suppl 1):233236
15. Grimoud AM, Marty N, Bocquet H, Andrieu S, Lodter JP,
Chabanon G (2003) Colonization of the oral cavity by Candida
species: risk factors in long-term geriatric care. J Oral Sci 45
(1):5155
16. Cannon RD, Chaffin WL (1999) Oral colonization by Candida
albicans. Crit Rev Oral Biol Med 10(3):359383. doi:10.1177/
10454411990100030701
17. David LM, Walzman M, Rajamanoharan S (1997) Genital
colonisation and infection with Candida in heterosexual and
homosexual males. Genitourin Med 73(5):394396
18. Ferrer J (2000) Vaginal candidosis: epidemiological and etiolog-
ical factors. Int J Gynaecol Obstet 71(Suppl 1):S21S27.
doi:10.1016/S0020-7292(00)00350-719. Pirotta MV, Garland SM (2006) Genital Candida species detected
in samples from women in Melbourne, Australia, before and after
treatment with antibiotics. J Clin Microbiol 44(9):32133217.
doi:10.1128/JCM.00218-06
20. Fidel PL Jr, Sobel JD (1996) Immunopathogenesis of recurrent
vulvovaginal candidiasis. Clin Microbiol Rev 9(3):335348
21. Buitrn Garca R BA, Amancio Chassin O, Basurto Kuba E,
Araiza J, Romero Cabello R (2007) Correlation between
clinical characteristics and mycological tests in the vulvovag-
initis by Candida. Ginecol Obstet Mex 2007 Feb;75(2):6872
22. Hagerty JA, Ortiz J, Reich D, Manzarbeitia C (2003) Fungal
infections in solid organ transplant patients. Surg Infect (Larchmt)
4(3):263271. doi:10.1089/109629603322419607
23. Marik PE (2006) Fungal infections in solid organ transplantation.
Expert Opin Pharmacother 7(3):297
305. doi:10.1517/14656566.7.3.297
24. Singh N (1998) Infections in solid organ transplant recipients.
Curr Opin Infect Dis 11(4):411417
25. Procop GW, Roberts GD (2004) Emerging fungal diseases: the
importance of the host. Clin Lab Med 24(3):691719. vi-vii.
doi:10.1016/j.cll.2004.05.004
26. Gupta AK, Ryder JE, Nicol K, Cooper EA (2003) Superficial
fungal infections: an update on pityriasis versicolor, seborrheic
dermatitis, tinea capitis, and onychomycosis. Clin Dermatol 21
(5):417425. doi:10.1016/j.clindermatol.2003.08.003
27. Nucci M, Marr KA (2005) Emerging fungal diseases. Clin Infect
Dis 41(4):521526. doi:10.1086/432060
28. Nguyen MH, Peacock JE Jr, Morris AJ, Tanner DC, Nguyen ML,
Snydman DR, Wagener MM, Rinaldi MG, Yu VL (1996) The
changing face of candidemia: emergence of non-Candida albicansspecies and antifungal resistance. Am J Med 100(6):617623.
doi:10.1016/S0002-9343(95)00010-0
29. Berg D, Otley CC (2002) Skin cancer in organ transplant
recipients: epidemiology, pathogenesis, and management. J Am
A cad D erm atol 47(1) :11 7. Q ui z 1 8 -2 0 . d o i:10.1067/
mjd.2002.125579
30. Lindelof B, Sigurgeirsson B, Gabel H, Stern RS (2000) Incidence
of skin cancer in 5356 patients following organ transplantation. Br
J Dermatol 143(3):513519
31. Patel R, Paya CV (1997) Infections in solid-organ transplant
recipients. Clin Microbiol Rev 10(1):86124
Eur J Clin Microbiol Infect Dis
http://dx.doi.org/10.1034/j.1399-3062.1999.010402.xhttp://dx.doi.org/10.1056/NEJM199806113382407http://dx.doi.org/10.1056/NEJM199806113382407http://dx.doi.org/10.1034/j.1399-0012.2001.150106.xhttp://dx.doi.org/10.1034/j.1399-0012.2001.150106.xhttp://dx.doi.org/10.1159/000056364http://dx.doi.org/10.1007/s11046-006-0032-yhttp://dx.doi.org/10.1111/j.1439-0507.2007.01393.xhttp://dx.doi.org/10.1080/13693780701200372http://dx.doi.org/10.1080/13693780701200372http://dx.doi.org/10.1067/S0190-9622(03)00861-2http://dx.doi.org/10.1067/S0190-9622(03)00861-2http://dx.doi.org/10.1155/S1064744901000187http://dx.doi.org/10.1155/S1064744901000187http://dx.doi.org/10.1177/10454411990100030701http://dx.doi.org/10.1177/10454411990100030701http://dx.doi.org/10.1016/S0020-7292(00)00350-7http://dx.doi.org/10.1128/JCM.00218-06http://dx.doi.org/10.1089/109629603322419607http://dx.doi.org/10.1517/14656566.7.3.297http://dx.doi.org/10.1517/14656566.7.3.297http://dx.doi.org/10.1016/j.cll.2004.05.004http://dx.doi.org/10.1016/j.clindermatol.2003.08.003http://dx.doi.org/10.1086/432060http://dx.doi.org/10.1016/S0002-9343(95)00010-0http://dx.doi.org/10.1067/mjd.2002.125579http://dx.doi.org/10.1067/mjd.2002.125579http://dx.doi.org/10.1067/mjd.2002.125579http://dx.doi.org/10.1067/mjd.2002.125579http://dx.doi.org/10.1016/S0002-9343(95)00010-0http://dx.doi.org/10.1086/432060http://dx.doi.org/10.1016/j.clindermatol.2003.08.003http://dx.doi.org/10.1016/j.cll.2004.05.004http://dx.doi.org/10.1517/14656566.7.3.297http://dx.doi.org/10.1517/14656566.7.3.297http://dx.doi.org/10.1089/109629603322419607http://dx.doi.org/10.1128/JCM.00218-06http://dx.doi.org/10.1016/S0020-7292(00)00350-7http://dx.doi.org/10.1177/10454411990100030701http://dx.doi.org/10.1177/10454411990100030701http://dx.doi.org/10.1155/S1064744901000187http://dx.doi.org/10.1155/S1064744901000187http://dx.doi.org/10.1067/S0190-9622(03)00861-2http://dx.doi.org/10.1067/S0190-9622(03)00861-2http://dx.doi.org/10.1080/13693780701200372http://dx.doi.org/10.1080/13693780701200372http://dx.doi.org/10.1111/j.1439-0507.2007.01393.xhttp://dx.doi.org/10.1007/s11046-006-0032-yhttp://dx.doi.org/10.1159/000056364http://dx.doi.org/10.1034/j.1399-0012.2001.150106.xhttp://dx.doi.org/10.1034/j.1399-0012.2001.150106.xhttp://dx.doi.org/10.1056/NEJM199806113382407http://dx.doi.org/10.1056/NEJM199806113382407http://dx.doi.org/10.1034/j.1399-3062.1999.010402.x