---
title: "Epidemiology and species-level susceptibility of Candida infections in a Tolima tertiary hospital"
id: "plos-one-4-clinical-and-microbiological-epidemiology-of-candida-infections-in-a-high"
canonical_url: "https://medichelpline.com/clinical-feed/plos-one-4-clinical-and-microbiological-epidemiology-of-candida-infections-in-a-high"
content_type: "clinical_feed_article"
specialty: "Infectious Disease"
source_name: "PLOS ONE (Medicine)"
source_url: "https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0354684"
published_at: "2026-07-24T14:00:00.000Z"
evidence_level: "Journal Feed"
license: "CC-BY-NC-4.0 / Informational Use"
---
# Epidemiology and species-level susceptibility of Candida infections in a Tolima tertiary hospital
## Provenance & Clinical Metadata
- **Canonical URL:** https://medichelpline.com/clinical-feed/plos-one-4-clinical-and-microbiological-epidemiology-of-candida-infections-in-a-high
- **Specialty:** [Infectious Disease](https://medichelpline.com/clinical-feed/infectious-disease.md)
- **Primary Source:** PLOS ONE (Medicine)
- **Source URL:** [Original Journal Publication](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0354684)
- **Published At:** 2026-07-24T14:00:00.000Z
- **Evidence Rating:** Journal Feed
## Executive GIST (TL;DR)
- This retrospective observational study integrated clinical/administrative and microbiology laboratory (WHONET) data from a high-complexity hospital in Ibagué, Tolima, Colombia, covering 2014–2024. The aim was to describe the clinical burden, species distribution, and antifungal susceptibility of **Candida spp.** isolated in routine care, and to explore factors associated with candidemia and invasive disease. - Study sources comprised two separate institutional workflows: (A) a clinical/administrative database of recorded candidiasis episodes (n = 987) and (B) a laboratory database of fungal/yeast isolate records (n = 776), of which 314 were confirmed **Candida** isolates. Databases were not linked record by record. - Clinically recorded candidiasis represented 0.41% of institutional care records (987/243,013; 4.06 per 1,000 records) with annual rates ranging 0.22–0.61% and a peak in 2018. Cumulative confirmed Candida isolates increased over time. - The clinical spectrum was dominated by mucocutaneous disease: vulvovaginal candidiasis (50.7%) and oropharyngeal candidiasis (24.3%). Deep-seated non-candidemic invasive candidiasis and candidemia accounted for 8.2% and 2.0% of episodes, respectively. - Patient demographics: 77.8% of episodes occurred in women (driven by vulvovaginal cases). Median age overall was 29 years (IQR 22–53); invasive forms had higher median ages. Length of stay was longer for candidemia and deep-seated invasive infections and was associated with ICU and general ward care. - Among microbiology isolates (n = 314), **Candida albicans** predominated (58.9%). Non-**albicans** species comprised 41.1%, including C. parapsilosis (16.6%), C. tropicalis (12.1%), and Nakaseomyces glabratus (6.4%). A single C. auris isolate was detected. - Specimen sources concentrated in superficial tissues (36.6%) and urine (33.4%); blood isolates represented 7.3% (n = 23). Bloodstream etiology was heterogeneous, with C. albicans and C. parapsilosis leading. - MIC-based susceptibility data were available for 196/314 isolates (62.4%) for the 2022–2024 period with VITEK 2. **Echinocandin** activity remained high; **azole** susceptibility was more variable. 5-flucytosine (5-FC) was analyzed by EUCAST ECOFF and reported separately. - Exploratory multivariable analyses (clinical/administrative data) found recorded candidemia associated with invasive devices (OR 5.54, 95% CI 2.01–15.64), recent surgery (OR 7.11, 95% CI 1.20–30.88), and tumor (OR 19.88, 95% CI 3.14–97.51). MCA separated invasive presentations from mucocutaneous forms. - Authors conclude there is a sustained burden of candidiasis with substantial non-**albicans** diversity, supporting ongoing local surveillance, species-level identification, and isolate-level susceptibility testing. De-identified datasets and analysis code are publicly available in Zenodo and GitHub as reported by the authors.
## Clinical Analysis & Structured Key Points
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Ramírez-Trujillo, Roles Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Software, Validation, Visualization, Writing – original draft, Writing – review & editing Affiliation Basic and Applied Microbiology Research Group (MICROBA), School of Microbiology, Universidad de Antioquia, Medellin, Colombia ⨯ * Paula Carvajal-Hernández, Roles Data curation, Formal analysis, Project administration, Resources, Validation, Writing – original draft, Writing – review & editing Affiliation Sub-directorate of Health Services, Clinica Tolima, Ibagué, Colombia ⨯ * Ángel González Roles Conceptualization, Formal analysis, Investigation, Methodology, Project administration, Resources, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing * E-mail: angel.gonzalez@udea.edu.co Affiliation Basic and Applied Microbiology Research Group (MICROBA), School of Microbiology, Universidad de Antioquia, Medellin, Colombia [ ![ORCID logo](https://journals.plos.org/resource/img/orcid_16x16.png) https://orcid.org/0000-0002-7052-7938 ](https://orcid.org/0000-0002-7052-7938 "ORCID Registry") ⨯ # Clinical and microbiological epidemiology of _Candida_ infections in a high-complexity hospital in Tolima, Colombia (2014–2024) * Rafael A. Ramírez-Trujillo, * Paula Carvajal-Hernández, * Ángel González ![PLOS](https://journals.plos.org/resource/img/logo-plos-full-color.svg) x * Published: July 24, 2026 * * [Article](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0354684) * [Authors](https://journals.plos.org/plosone/article/authors?id=10.1371/journal.pone.0354684) * [Metrics](https://journals.plos.org/plosone/article/metrics?id=10.1371/journal.pone.0354684) * [Comments](https://journals.plos.org/plosone/article/comments?id=10.1371/journal.pone.0354684) * [Media Coverage](http://plos.altmetric.com/details/doi/10.1371/journal.pone.0354684) * [Peer Review](https://journals.plos.org/plosone/article/peerReview?id=10.1371/journal.pone.0354684) * [Abstract](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0354684#abstract0) * [Introduction](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0354684#sec005) * [Methodology](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0354684#sec006) * [Results](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0354684#sec012) * [Discussion](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0354684#sec018) * [Supporting information](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0354684#sec020) * [Acknowledgments](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0354684#ack) * [References](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0354684#references) * [Reader Comments](https://journals.plos.org/plosone/article/comments?id=10.1371/journal.pone.0354684) * [Figures](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0354684) ## Abstract ### Background _Candida_ spp. infections are an increasing challenge in high-complexity hospitals, yet epidemiological data remain scarce in underrepresented in Colombian regions such as Tolima. ### Methods We conducted a retrospective observational study in a high-complexity hospital in Ibagué (Tolima, Colombia) from 2014 to 2024, integrating two institutional data sources: administrative/clinical records and the microbiology laboratory database (WHONET). Species identification relied on culture and VITEK, and antifungal susceptibility was interpreted using criteria from the Clinical and Laboratory Standards Institute (CLSI) and the European Committee on Antimicrobial Susceptibility Testing (EUCAST). We summarized data using frequencies/proportions and medians (IQR), explored patterns with multiple correspondence analysis (MCA), and estimated associations with candidemia using penalized multivariable logistic regression due to low event frequency. ### Results We identified 987 candidiasis episodes and 776 fungal isolates, of which 314 were _Candida_ (40.46%). Mucocutaneous disease predominated (vulvovaginal 50.7%; oropharyngeal 24.3%), while candidemia represented 2.0% of episodes. Among isolates, _Candida albicans_ was most frequent (58.9%), followed by _C. parapsilosis_ (16.6%), _C. tropicalis_ (12.1%), and _Nakaseomyces glabratus_ (6.4%); _Candida auris_ was detected once. In exploratory clinical/administrative models, clinically recorded candidemia showed associations with invasive devices (OR 5.54, 95% CI 2.01–15.64), recent surgery (OR 7.11, 95% CI 1.20–30.88) and tumor (OR 19.88, 95% CI 3.14–97.51). Susceptibility data were available for 196/314 isolates (62.4%); echinocandin activity was high, whereas azole susceptibility was more variable. ### Conclusions Candidiasis showed a sustained recorded burden and substantial non-_albicans_ diversity, supporting local surveillance, species-level identification, and isolate-level susceptibility testing. ## Figures ![Table 2](https://journals.plos.org/plosone/article/figure/image?size=inline&id=10.1371/journal.pone.0354684.t002) ![Table 3](https://journals.plos.org/plosone/article/figure/image?size=inline&id=10.1371/journal.pone.0354684.t003) ![Fig 1](https://journals.plos.org/plosone/article/figure/image?size=inline&id=10.1371/journal.pone.0354684.g001) ![Fig 2](https://journals.plos.org/plosone/article/figure/image?size=inline&id=10.1371/journal.pone.0354684.g002) ![Table 1](https://journals.plos.org/plosone/article/figure/image?size=inline&id=10.1371/journal.pone.0354684.t001) ![Fig 3](https://journals.plos.org/plosone/article/figure/image?size=inline&id=10.1371/journal.pone.0354684.g003) ![Fig 4](https://journals.plos.org/plosone/article/figure/image?size=inline&id=10.1371/journal.pone.0354684.g004) ![Fig 5](https://journals.plos.org/plosone/article/figure/image?size=inline&id=10.1371/journal.pone.0354684.g005) ![Table 2](https://journals.plos.org/plosone/article/figure/image?size=inline&id=10.1371/journal.pone.0354684.t002) ![Table 3](https://journals.plos.org/plosone/article/figure/image?size=inline&id=10.1371/journal.pone.0354684.t003) ![Fig 1](https://journals.plos.org/plosone/article/figure/image?size=inline&id=10.1371/journal.pone.0354684.g001) ![Fig 2](https://journals.plos.org/plosone/article/figure/image?size=inline&id=10.1371/journal.pone.0354684.g002) ![Table 1](https://journals.plos.org/plosone/article/figure/image?size=inline&id=10.1371/journal.pone.0354684.t001) **Citation:** Ramírez-Trujillo RA, Carvajal-Hernández P, González Á (2026) Clinical and microbiological epidemiology of _Candida_ infections in a high-complexity hospital in Tolima, Colombia (2014–2024). PLoS One 21(7): e0354684. https://doi.org/10.1371/journal.pone.0354684 **Editor:** Theerapong Krajaejun, Ramathibodi Hospital, Mahidol University, THAILAND **Received:** April 16, 2026; **Accepted:** July 12, 2026; **Published:** July 24, 2026 **Copyright:** © 2026 Ramírez-Trujillo et al. This is an open access article distributed under the terms of the [Creative Commons Attribution License](http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. **Data Availability:** De-identified clinical and microbiological datasets used to reproduce the main analyses have been deposited in Zenodo DOI ( ), together with the analysis code, R scripts, and supporting workbooks used to generate Tables 1–3 and Figs 1–5. The code is also publicly available without restrictions at GitHub ( ). **Funding:** The author(s) received no specific funding for this work. **Competing interests:** The authors have declared that no competing interests exist. ## Introduction Fungal infections (FIs) are an increasing public health problem, causing 1.5 million deaths annually, a burden comparable to tuberculosis or malaria [[1](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0354684#pone.0354684.ref001)]. This rise reflects expanding vulnerable populations (e.g., diabetes, untreated HIV, cancer, transplantation, immunosuppressive therapies) and healthcare exposures in critically ill patients, including broad-spectrum antibiotics and invasive devices [[2](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0354684#pone.0354684.ref002)]. _Candida_ spp., commensal yeasts, can act opportunistically, producing disease from superficial mucocutaneous infection to invasive candidiasis and candidemia, a frequent cause of hospital-acquired sepsis, particularly in intensive care units (ICUs) [[3](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0354684#pone.0354684.ref003),[4](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0354684#pone.0354684.ref004)]. Globally, a shift toward non-_albicans_ species and variable antifungal susceptibility complicates empiric therapy and may worsen outcomes [[5](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0354684#pone.0354684.ref005)]. In 2022, the World Health Organization (WHO) issued its first list of priority fungal pathogens, highlighting _C. auris_ and _C. albicans_ as critical and _Nakaseomyces glabratus_ , _C. tropicalis_ , and _C. parapsilosis_ as high-priority pathogens. Despite surveillance initiatives in several regions, data in Latin America and especially Colombia, remain limited and fragmented, with underreporting exacerbated by the absence of mandatory notification for most fungal diseases [[2](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0354684#pone.0354684.ref002),[6](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0354684#pone.0354684.ref006)]. Recent actions led by the Colombian National Institute of Health (INS), including the incorporation of _C. auris_ into Colombia’s National Public Health Surveillance System (SIVIGILA, for its Spanish acronym), the updating of national guidelines, and laboratory surveillance criteria for _Candida_ spp. isolates recovered from healthcare-associated infections (HAIs; IAAS in Spanish) or showing antifungal resistance profiles, represent important progress in fungal disease surveillance; however, implementation and data availability remain incomplete [[7](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0354684#pone.0354684.ref007)]. In Tolima, evidence on local prevalence, species distribution, and resistance patterns of _Candida_ spp. is scarce relative to other Colombian regions [[2](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0354684#pone.0354684.ref002),[8](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0354684#pone.0354684.ref008)], limiting data-driven decisions and detection of temporal changes or intrahospital events [[9](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0354684#pone.0354684.ref009),[10](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0354684#pone.0354684.ref010)]. Therefore, this single-center study aimed to evaluate the epidemiology, species distribution, exploratory associated factors, and antifungal susceptibility profiles of _Candida_ infections at a high-complexity referral hospital in Ibagué, Tolima, Colombia, spanning a ten-year period (2014–2024). ## Methodology ### Design and setting An observational, retrospective descriptive-analytical study was conducted in a high-complexity hospital in Ibagué, Tolima, Colombia, between 2014 and 2024. Two institutional data sources from the same participating hospital were used: (A) a clinical/administrative database derived from hospital administrative and clinical records, and (B) a microbiological database derived from Microbiology Laboratory records. Although both sources came from the same physical institution, they were generated through separate institutional information workflows and were not linked record by record for this retrospective study. The primary scope of the study was the overall clinical and microbiological burden of _Candida_ infections, including mucocutaneous, localized, invasive, and bloodstream presentations, rather than candidemia alone. MIC-based susceptibility analyses were restricted to 2022–2024, the period with structured MIC exports in WHONET format. The clinical/administrative database was used to describe clinically recorded candidiasis episodes and to explore factors associated with candidemia and invasive candidiasis, whereas the microbiological database was used to describe _Candida_ spp. isolates, specimen sources, species distribution, antifungal susceptibility, and factors associated with non-_albicans_ isolation. Selection-stage counts and data access details are provided in ([S1 Text](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0354684#pone.0354684.s002)). Data were accessed for research purposes on 2 August 2025 for the clinical/administrative database and on 9 August 2025 for the microbiological database. This study is reported in accordance with the STROBE statement and the RECORD extension for routinely collected health data; completed checklists are available as Supporting Information ([S1 Checklist](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0354684#pone.0354684.s001)). ### Population, definitions, and selection Patients with a clinical diagnosis of candidiasis and/or microbiological identification of _Candida_ spp. were included. The unit of analysis was an infection episode/record in the hospital database and an isolate record in the laboratory database. Exact duplicates were removed within each database; no additional time-window deduplication was applied. Records without clinical or microbiological corroboration, contaminated samples, or missing key variables were excluded. Clinical forms were classified using the recorded clinical/administrative diagnosis and ICD-10 coding ([S1 Table](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0354684#pone.0354684.s005)). Cases were grouped as mucocutaneous/localized non-invasive candidiasis, candidemia, deep-seated non-candidemic invasive candidiasis, or other/unspecified candidiasis. Deep-seated non-candidemic invasive candidiasis included organ-specific invasive records without recorded candidemia, including CNS involvement/meningitis. Combined or disseminated candidiasis was not assigned as a separate category because it was not documented in the clinical/administrative diagnosis fields. For suspected invasive fungal infection, EORTC/MSG categories (proven/probable/possible) were applied when appropriate. ### Isolation, identification, and susceptibility Clinical samples were processed by the institution’s Microbiology Laboratory as part of routine care. _Candida_ spp. were identified using routine laboratory methods, including conventional culture and/or BD Phoenix during 2014–2021 and the VITEK 2 Compact system during 2022–2024. During the VITEK 2 Compact period, yeast identification was performed using the YST card, and antifungal susceptibility testing was performed using the AST-YS08 card. WHONET MIC data exports (µg/mL) included amphotericin B, fluconazole, voriconazole, caspofungin, micafungin, and flucytosine (5-FC). MICs were interpreted using current CLSI guidance (S/I/R) when breakpoints were available. Because clinical breakpoints are not available for 5-FC for several species, 5-FC was analyzed exclusively using EUCAST ECOFF classification and reported as wild-type (WT) or non-wild-type (NWT), as described in [[11](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0354684#pone.0354684.ref011)] ([S2 Table](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0354684#pone.0354684.s006), [S2 Text](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0354684#pone.0354684.s003)). To avoid overinterpretation, 5-FC results are reported separately in [S6 Table](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0354684#pone.0354684.s010). Isolates without MIC results for a given antifungal were excluded from that antifungal-specific analysis ([S3 Table](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0354684#pone.0354684.s007)). ### Statistical analysis Data were prepared, cleaned, coded, and managed in Microsoft Excel before statistical analysis. All statistical analyses were performed using R software, version 4.4.2. Categorical variables were summarized as n (%) and continuous variables as median (IQR). Group comparisons used χ² tests and non-parametric tests; two-sided _p value_ <0.05 was considered significant. Multiple correspondence analysis (MCA) was applied to selected categorical variables defined a priori. Logistic regression estimated odds ratios (ORs) and 95% confidence intervals (CIs); Firth-penalized logistic regression was used for candidemia (infrequent outcome), and standard logistic regression for invasive candidiasis and the non-albicans outcome. Age was categorized as <27 vs ≥ 27 years, and length of stay as 1–3, 4–10, and ≥11 days (reference: ≥ 11). Missing data were handled by reporting variable-specific denominators; regression models used complete-case analysis. Regression models were exploratory and data-source specific: candidemia and invasive candidiasis models used the clinical/administrative database, whereas the non-_albicans_ model used microbiological isolate records. Because the databases were not linked record by record, these models were not inte
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