Title: Candidemia in neonatal Intensive care unit and its response to fluconazole treatment
Objectives:
 1. To determine the prevalence of Candidemia in neonates admitted to NICU
2. To identify the various species of Candida causing Candidemia in NICU
3. To determine the anti-fungal susceptibility pattern of the Candida isolates
4. To monitor the response to treatment by anti-fungal drugs
Methods:
Specimen collection: Blood samples collected for culture from neonates admitted to NICU were processed in BACTEC/BACT-Alert automated blood culture machine.
The bottles flagging positive in the automated blood culture machine were subcultured on Blood agar, Sabourad’s dextrose agar plate and Mac Conkey’s medium and incubated at 35-370c for 48 hours.
A preliminary gram’s stain was also done on the bottles flagging positive for growth.
Colonies resembling yeast were subjected to identification and speciation by Germ tube test, Slide culture by Delmau’s method and Sugar assimilation test by modified Wickerham and Burton method.
Antifungal susceptibility to fluconazole and voriconazole was determined by modified disk diffusion test using Muller Hinton agar supplemented with 5% glucose and methylene blue. 
Response to treatment was monitored by observation
Results:
A total of 258 blood samples from different neonates in NICU were collected for culture in the study period spanning 6 months. Average time of stay in NICU at the time of positive blood culture was 7.5 days. A total of 55 (21.3%) were positive for Candida spp. The species distribution was as follows: C. krusei 43 (78%), C. tropicalis 10 (18%), C. gulliermondii 01 (1.8%), C. albicans 01 (1.8%). Species wise antifungal susceptibility pattern is as follows: C. krusei ( Fluconazole 07 , voriconazole 43) , C. albicans ( Fluconazole 01, voriconazole 01), Candida gulleirmondii ( Fluconazole 01 , voriconazole 01 ) , C. tropicalis ( Fluconazole 10 , voriconazole 01 ). 
 A total of 55 Culture positive neonates received intravenous fluconazole treatment for an average period of one week. The treatment outcome was as follows: 
Improved: …. Dead: 06, Unimproved: 07, Improved:  42
Conclusion:
1. Prevalence of 21.3% cases of Candidemia in neonates was noted in the study
2. C. krusei, which is noted for its intrinsic resistance to fluconazole, was the predominant species (78%) causing Candidemia in the neonates in NICU
3. All Candida species were sensitive to fluconazole and voriconazole, except C. krusei, which was resistant to fluconazole in 87% of cases. 
4. A large proportion of cases recovered after receiving fluconazole treatment, including those who had C. krusei candidemia, indicating in-vivo sensitivity of C. krusei to fluconazole or the other hypothesis could be that the Candidemia was transient.  But nothing could be conclusively proved.
5. Voriconazole showed uniform sensitivity across all species and could be the drug of choice for empirical and specific treatment in cases of neonatal Candidemia in settings where echinocandins are not easily available

Candidemia in neonatal Intensive care unit and its response to fluconazole therapy