Globally the leading cause of neonatal deaths is infection with 10% reported to be due to Candida spp.  . The mortality due to neonatal-candidiasis is estimated to range between 30% and 73%  . Candida colonization in neonates with low birth weight is reported to be the first step for invasive candidiasis  . Studies have shown 7% - 25% of low birth weight neonates are colonized by Candida spp. and are at high risk of developing invasive candidiasis  . Among neonates with very low birth weight admitted in intensive care unit, Candida spp. is reported to be the third leading causative agent of sepsis  .
Neonatal Candida spp. colonization is reported to commonly occur in the first weeks of life whereby up to 10% - 64% of neonates can be colonized . The neonatal Candida spp. colonization was reported in a study conducted in India to be significantly more in neonates with low birth weight < 1500 gram with prevalence of 33.3% compared to the prevalence of 10% among neonates with birth weight > 1500 gram .
Risk factors for Candida spp. colonization include: use of broad spectrum antibiotics, resuscitation after birth and per vaginal deliver with colonized mother  . Furthermore, Candida spp. colonization has been pronounced more in premature neonates regardless of their birth weight . Studies have documented 7% - 28.3% of Candida spp. colonized premature neonates developed blood candidiasis   . Invasive procedures like mechanical ventilation, cannulation, central catheterization and parenteral nutrition have been documented as factors associated with invasive Candida spp. infection among colonized neonates with low birth weight   .
Despite having 40% - 50% admissions of neonates with low birth weight at Bugando Medical Centre neonatal intensive care unit (BMC NICU), there is paucity of data on the magnitude and patterns of Candida spp. colonization in this and other centers in the developing countries. Here, we report the prevalence of Candida spp. and their distribution among recruited neonates from intensive care unit of the Bugando Medical Centre (BMC), Sekou Toure Regional Referral Hospital (SRRH) and Sengerema District Designated Hospital (SDDH).
2. Material and Methods
The descriptive cross sectional hospital based study was conducted from January 2019 to April 2019. The study recruited neonate with low birth weight below 2500 grams on their first day of life admitted in neonatal intensive care units and premature units of BMC, SRRH and SDDH. The neonatal admission per month at BMC ranges from 100 - 200 with about 40% - 50% having low birth weight. At SRRH and SDDH the admissions due to low birth weight range from 40 - 50 and 150 - 200, respectively. The study excluded all neonates with abdominal wall malformations such as gastroschisis, omphalocele and genital urinary tract like bladder exstrophy. The sample size was obtained by the use of Kish Leslie formula  using the prevalence of Candida spp. colonization obtained from a study conducted in Uganda .
Screening of the neonatal gestation age and maturity was done using Ballard score . Parents with neonates fulfilling inclusion criteria were interviewed to obtain social demographic and clinical data like age, sex, residence mode of delivery, serological HIV status and history of premature rupture of membrane (PROM). Clinical examination to assess temperature, respiratory rate, presence or absence of cyanosis, jaundice, umbilical redness, convulsions, reduced movements and inability to feed was done by qualified pediatrician. Oral and umbilical-rectal swabs were taken on day 1 and day 7. All swabs were transported to microbiology laboratory in the Stuart transport media (HiMedia-Mumbai, India) within two hours of collection for processing. All swabs were cultured on Sabouraud’s dextrose agar (SDA) supplemented with 50 µg/ml gentamicin and 50 µg/ml chloramphenicol (HiMedia-Mumbai, India) as previously described . Colonial morphology, germ tube test and reaction on the chromogenic agar (Brilliance Candida agar, Oxoid-UK) were used for identification of Candida spp.
Data were entered on excel spread sheet for consistent check and cleaning then transferred to STATA version 13 for analysis. Categorical data were summarized using proportions while continuous data were summarized using median and interquartile range. The protocol of this study was ethically approved by the joint CUHAS/BMC research ethics and review committee (CREC) with certificate number CREC /333/2019. Parents were informed about the purpose, procedures, risks and benefits of the participation, prior to obtain written informed consent.
3.1. Social Demographic and Clinical Data of 320 Studied Neonates
A total of 227 (70.8%), 57 (17.8) and 36 (11.4%) neonates were recruited from BMC, SRRH and SDDH, respectively. Their median body weight was 1600 [IQR 1000 - 2000] grams and median gestation age at delivery being 33 [30 - 35] weeks. Nearly half of neonates were admitted in the neonatal intensive care unit 165 (51.6%). The majority 208 (65.0%) of studied neonates were spontaneous vaginal delivery. A total 231 (72.2%) of parents resided in urban areas and the slightly majority of studied neonates were female 182 (56.8%) (Table 1).
The majority of neonates were delivered in the health care facilities 302 (94.4%) and 192 (60.0%) were resuscitated at birth. A total of 210 (65%) neonates had poor feeding and 194 (65.6%) had IV cannulation. Antibiotics use was
Table 1. Socio-demographic distribution and other characteristics of 320 neonates with low birth weight.
GANBS is gestation age at delivery by new Ballard score, SVD is spontaneous vertex delivery.
recorded in about one third of the neonates 126 (39.4%). Fever (axillary temperature above 37.5˚C) was observed in 40 (12.5%) neonates.
3.2. Candida Spp. Colonization
A total of 52 (16.3%) neonates were colonized by Candida spp. on both day 1 and 7. A total of 34 (10.6%) and 41 (12.8%) neonates were colonized by Candida spp. on first day and seventh day of life, respectively. Of these, 28 (82.4%) were orally and 6 (17.6%) were colonized on the umbilicus/rectum. Of 34 neonates colonized on the first day of life, 23 (67.7%) were still being colonized on the seventh day. The majority of neonates were colonized by Candida albicans 38 (73.1%). Of 14 non-albicans Candida spp. detected 10 (19.2%) were Candida glabrata, Figure 1.
Of 28 orally colonized neonates, 20 (71.4%) had Candida albicans. For the second swab taken on day 7, a total of 41 neonates were colonized and of them 31 (75.6%) were orally colonized. Of 31 neonates colonized orally by Candida spp. 25 (80.6%) had Candida albicans.
Candida colonization in neonates has been documented as a major predisposing factor to invasive candidiasis   . In the current study the prevalence of neonatal candida colonization on either oral, umbilicus or rectum was found to be 16.3%. This prevalence is within the range of 12.4% - 18% previously reported in Jordanian, Brazil and India    . Horizontal transmission from the nursing mother, overcrowd and sharing of incubators are among risk factors which have previously documented to influence Candida spp. colonization among neonates with low birth weight      .
The prevalence reported in the current study is significantly lower (p = 0.022) than the prevalence reported from Uganda 23.3% . The study in Uganda recruited much younger neonates with low birth weight than the current study, age and birth weight have been found to increase risk of Candida spp. colonization . In the current study the median gestation age and birth weight was 33 [30 - 35] weeks and 1600 [100 - 200] grams, respectively.
Figure 1. Candida species colonizing low birth weight neonates.
As in previous studies,    Candida albicans was the predominant specie detected. The ability of C. albicans to maintain synergistic relationship with other bacteria flora of the skin and buccal cavity can explain the findings  . Non-albicans Candida spp. were detected to colonize 26.9% of colonized neonates with low birth weight. Candida colonization by non-albicans Candida spp. have also been observed in different population from our previous studies  . This has also been reported in other studies worldwide in the past decade   and is highly associated with increased rate of candida infections due to non-albicans Candida spp.
Candida glabrata has been noted as one of the leading non-albicans Candida spp. colonizing and causing infections in different population  . This has also been observed in the current study whereby Candida glabrata was the most frequently non-albicans Candida spp. isolated. The isolation of Candida glabrata is of public health concern due to its variable susceptibility to fluconazole the most frequently used antifungal agents . Candida glabrata has also been reported as emerging health threat causing neonatal sepsis .
The prevalence of candida colonization among neonates with low birth weight is within the reported range of other studies from Africa, and is mainly due to Candida albicans. Future studies are highly needed to explore the role of colonization and subsequent Candida spp. infections.
The patterns of Candida spp. colonizing these neonates might not reflect the true picture due to low discriminatory index of the techniques used to speciate the isolated Candida spp.
Authors would like to acknowledge the support provided by Department of Microbiology and Immunology of the Catholic University of Health and Allied Sciences, Mwanza, Tanzania.
Ethics Approval and Consent to Participate
The protocol of this study was ethically approved by the joint CUHAS/BMC research ethics and review committee (CREC) with certificate number CREC/333/2019. All parents of the neonates were requested to sign the written informed consent before recruitment was done. All data were treated as confidential
Consent for Publication
Availability of Data and Materials
The datasets used and/or analyzed during the current study available from the corresponding author on reasonable request.
WM and MFM designed the work. WM, FM & AH recruited patients, BM, VS and MFM performed laboratory investigations and results interpretations. MFM and WM analyzed and interpreted the data. MFM wrote the first draft of the manuscript which was critically reviewed by all authors. All authors read and approved the final version of the manuscript.
The authors declare no conflicts of interest regarding the publication of this paper.
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