Original Paper Urol Int 1992;49:163-166

Department of Urology. School of Medicine. Kanazawa University. Kanazawa, Japan

KeyWords Candida antigen CAND-TEC™ Candiduria patients Candida albicans Candida tropicalis Pyelonephritis Urinary tract infection

Candida Antigen Detection by a Latex Agglutination Test in Candiduria Patients

Abstract We evaluated a latex agglutination test commercially available in kit form for the identification of Candida pyelonephritis in candiduria patients. Tests were performed on sera from 11 patients with fever and candiduria plus other positive candidal sites (group A), 12 patients with fever and candiduria alone (group B), 17 afebrile patients with candiduria alone (group C), and 27 afe­ brile patients without documented candiduria or bacteriuria (group D). Posi­ tive antigenemia with a titer of 1:4 or greater was detected in 9 candiduria patients with fever: 7 (63.6%) in group A and 2 (16.7%) in group B. The inci­ dence of group B, in which Candida pyelonephritis was strongly suspected, was significantly less than that of group A and did not significantly differ from that of groups C and D. These results suggest that this test has little value in the diagnosis of Candida pyelonephritis without disseminated candidiasis.

Introduction Latex agglutination immunoassay is used to detect a circulating candidal antigen in patients with disseminated candidiasis including candidemia. Using this method, a commercial test, the Candida Detection System (CANDTEC™; Ramco Laboratories, Inc., Houston. Tex., USA), has been developed and since this test is relatively cheap, requires little time and is simple to use several investiga­ tors have examined its usefulness in patients with vari­ ous forms of Candida infection [1-7] including candid­ uria [8], Candida pyelonephritis is strongly suspected in some patients due to the presence of candiduria and fever alone. Since the development of pyelonephritis may be life-threatening in certain groups of patients (such as immunocompromised), the prompt diagnosis of this con­ dition is very important. However, since there are no uni­

Received: November 4, 1991 Accepted: January 31. 1992

versally accepted diagnostic criteria for Candida pyelone­ phritis, whether anticandidal treatment should be admin­ istered is a common clinical dilemma. In this paper, we evaluated the diagnostic value of this test, CAND-TEC, in patients suspected of having Candida pyelonephritis without disseminated candidiasis.

Patients and Methods Patients The study group comprised 40 candiduria patients who had no evidence of bacterial infection with significant urinary Candida col­ ony counts of 10,000/ml or more based on a previous report [9] and 27 control patients without documented candiduria or bacteriuria. The 40 candiduria patients were divided into 3 groups based on the presence of fever which was defined as an oral temperature of 38 °C or greater and microbiological evidence of Candida spp. in speci­ mens other than urine: 11 febrile patients with candiduria plus other

S. Tokunaga Department of Urology. School o f Medicine Kanazawa University Takaramachi 13-1. Kanazawa 920 (Japan)

© 1992 S. Kargcr AG, Basel 0042-1138/92/0493-0163 $2.75/0

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S. Tokunaga M. Ohkawa T. Nakashima H. Hisazumi

Table 1. Clinical characteristics of patients

Febrile ( > 38 °C) patients with candiduria plus other positive alone candidal sites ( n - 11) (n - 12) A Group 66.2 (39-76) Mean age, years (range) Men/womcn 8/3 5 Urologic surgery 5 Malignancy 2 Diabetes mellitus Renal insufficiency3 5* Candida spp. isolated from urine specimens 11 C. albicans 0 C. tropicalis

B 66.9 (46-84) 8/4 5 9

Afebrile ( < 38 °C) patients with candiduria alone ( n - 17)

Patients without candiduria or bacteriuria (n = 27)

C 64.1 (28-85) 11/6

D 60.4(20-86) 23/4 17 16 3 3








14 3




a Serum creatinine (> 2.0 mg/dl). * p < 0.05, significantly different from groups C and D.

positive candidal culture sites (5 in the blood, 3 in deep wound fluid discharge, 2 in ascites and 1 each in the sputum, pleural effusion and gastric juice), in whom disseminated candidiasis including candidemia was suspected (group A), 12 febrile patients with candiduria alone, in whom Candida pyelonephritis was strongly suspected (group B), and 17 afebrile patients with candiduria alone (group C). Group D was composed of control patients. All the 67 patients had urologie disorders such as malignancies, neurogenic bladder or benign prostatic hypertrophy. Sera were obtained simultaneously with microbiological evidence of infection. Additional serum sam­ ples were obtained from 12 febrile patients (groups A and B) after treatment with flucytosine at a total dose of 21 to 182 g (mean: 64) for 7-21 days (mean: 13).

Table 2. Serum candidal antigen titers Group


Patients with antigen titer of < 1:2





2 6 15 27

2 4 2 0

6 1 0 0

1 1 0 0

0 0 0 0

Patients with titer of > 1:4 7(63.6%)' 2(16.7%) 0 0

* p < 0.05, 0.01, 0.01, significantly different from groups B, C and D, respectively.

Laboratory Study Circulating Candida antigens were detected in serum using the CAND-TEC test described above. We considered a titer of 1:4 or greater as significant although controversy exists regarding the crite­ ria for positive antigenemia [5],

Results The clinical characteristics and isolates of Candida spp. obtained from urine specimens of the study groups are shown in table 1. No significant differences were


found among the 4 patient groups with respect to age, sex or history of urologic surgery, malignancy or diabetes mellitus. Renal insufficiency with a serum creatinine of 2.0 mg/ml or greater was found in 5 patients of group A. which was significantly different compared to groups C and D (p < 0.05). The species isolated from urine sam­ ples were Candida albicans in 37 (92.5%) and C. tropicalis in 3 (7.5%). The species isolated from the positive culture sites other than urine samples were identical to those from urine in each patient. The distribution of candidal antigen titers is shown in table 2. Positive candidal antigenemia with a titer of 1:4 or greater was detected in 9 of 40 candiduria patients.


Candida Antigen Detection in Candiduria Patients

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Blood Culture Blood culture was performed by the Culture Bottle System (Hoffman-La Roche, Basel, Switzerland). Candida species were identified by the API 20C System (API System SA. Montalicu, Vercieu, France), and the production of germ tubes and chlamydosporcs was examined using standard techniques [10]. Statistical analysis was performed by the x2 test or Fisher's exact probability test.

Discussion Although candiduria is not an infrequent finding, its clinical significance is unclear [11], Thus, there are no universally accepted diagnostic criteria to differentiate whether the presence of candiduria signifies benign sapro­ phytic colonization or true Candida urinary tract infec­ tion including Candida pyelonephritis. Several methods to serologically diagnose significant Candida infection have been investigated. Concerning Candida pyelone­ phritis, a positive serum precipitin test was reported as a diagnostic aid with a sensitivity of 83% [9]. However, since almost everyone encounters Candida species be­ cause of their saprophytic nature, antibodies to the organ­ isms are always present in human sera [12, 13]. In addi­ tion, the detection of a significant antibody response after the onset of fever takes at least 2 weeks [14], Therefore, serum antibody titers have been regarded as being of little value in the prompt and accurate diagnosis of this condi­ tion. Recently, several methods to detect Candida antigens or metabolites in patient sera have been developed [1-8, 14, 15], We previously reported that using an enzymatic fluorometric assay, serum ZJ-arabinitol. a major candidal metabolite, is a useful parameter in the prompt diagnosis of Candida pyelonephritis in candiduria patients [16], However, the measurement kit is only limitedly available in Japan and, in addition, some other methods such as

enzyme-linked immunosorbent, gas-liquid chromato­ graphic or spectrofluorometric assays are complicated, time-consuming and, in part, expensive. On the other hand, since the CAND-TEC assay has the advantages described above, its usefulness in patients with various Candida infections has been investigated [1-8], This assay which detects candidal protein antigen, not mannans [1], is apparently specific for the fungal antigen which circulates in the sera of patients with infections caused by C. albicans, C. tropicalis or C. parapsilosis [2], This test was recently reported to be unreliable [5-7] because the antigen detected by this assay has not been identified [ 1,3], while the positive threshold has not been decided [3]. In addition, renal function, as well as the presence of rheumatoid factor [2], leads to a false-positive elevation of the titer [5, 6], although this was not found in our study. To our knowledge, there is only the single paper by Suits et al. [8] concerning candiduria patients. They eval­ uated this test using a positive threshold titer of 1:8 or greater in sera from 41 debilitated patients who had per­ sistent C. albicans with urinary Candida colony counts greater than 10,000/ml. Positive antigenemia was found in 13 (87%) of 15 patients with candiduria plus other can­ didal positive sites and 8 (31 %) of 26 patients with candi­ duria alone; this difference was significant. In addition, the mortality rate in the former 13 patients with positive antigenemia was 100% which is significantly higher than that of 63% in the latter 8 patients with positive anti­ genemia. From these results, it was suggested that candi­ dal antigenemia could become a prognostic determinant in debilitated patients with candiduria, although the au­ thors did not analyze the diagnostic value of Candida uri­ nary tract infection. In the present study, using a positive threshold titer of 1:4 or greater, the incidence in patients suspected of having Candida pyelonephritis was only 16.7%. On the other hand, the incidence in patients with suspected disseminated candidiasis (group A) was 63.6%, and a significant difference was found as compared to that in patients with candiduria alone (groups B and C) or in patients without documented candiduria or bacteriuria (group D). These results indicate that this test is of value in the diagnosis of disseminated candidiasis but not of Candida urinary tract infection, particularly isolated Can­ dida pyelonephritis. Some investigators have suggested that monitoring the dynamic evolution of the titer is important [3, 5], We monitored the titer before and after treatment with flucy­ tosine in 3 patients with suspected disseminated candidi­ asis and 1 with suspected Candida pyelonephritis. Since


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Seven and 2 of these 9 patients belonged to groups A and B, respectively. The incidence of patients with positive antigenemia in group A was 63.6%, which was signifi­ cantly higher than that of groups B. C and D (p < 0.05, p < 0.01 and p < 0.01, respectively). The incidence of 16.7% in group B was not significantly different from that of group C or D. The effect of renal function on antigen titer was studied in the 40 candiduria patients. Renal insufficiency was found in 3 (33.3%) of the 9 patients with positive antigenemia and 6 (19.4%) of the 31 patients without antigenemia; this difference was not statistically significant. Of 12 patients treated with flucytosine, the 4 (3 in group A and 1 in group B) in whom the treatment was effective, i.e., no Candida spp. isolated from any site and no clinical symptoms or signs including fever, leukocyto­ sis or flank pain found at the end of the treatment, had positive antigenemia before the administration. Positive antigenemia of all the 4 patients became negative between 6 and 16 days after initiation of the treatment.

the titers became negative in accordance with both the clinical symptoms and microbiological findings in these patients, this test may be of some help in judging the effi­ cacy of antifungal treatment of invasive candidiasis, inclung Candida pyelonephritis.

Acknowledgement This research was supported in part by grant B-02454369 from the Education Ministry of Japan.

1 Fung JC, Donta ST, Tilton R: Candida detec­ tion system (CAND-TEC) to differentiate be­ tween Candida albicans colonization and dis­ ease. J Clin Microbiol »986:24:542-547. 2 Gentry LO. Willkinson ID, Lea AS, Price MF: Latex agglutination test for detection of Can­ dida antigen in patients with disseminated dis­ ease. Fur J Clin Microbiol 1983:2:122-128. 3 Bailey JW. Sada E. Brass C, Bennett JE: Diag­ nosis of systemic candidiasis by latex agglutina­ tion for serum antigen. J Clin Microbiol 1985; 21:746-752. 4 DeLozier JB I I I , Stratton CW, Potts JR I I I : Rapid diagnosis of Candida sepsis in surgical patients. Am Surg 1987;53:600-602. 5 Ness MJ, Vaughan WP, Woods GL: Candida antigen latex test for detection of invasive can­ didiasis in immunocompromised patients. J Infect Dis 1989;159:495-502.

6 Bougnoux M-E. Hill C. Moissenet D. De Chauvin MF. Bonny M. Vicens-Sprauel I, Pietri F. McNeil M. Kaufman L, Dupouy-Camet J. Bohuon C, Andremont A: Comparison of anti­ body. antigen, and metabolite assay for hospi­ talized patients with disseminated or periph­ eral candidiasis. J Clin Microbiol 1990:28: 905-909. 7 Phillips P. Dowd A. Jewesson P. Radigan G. Tweeddale MG, Clarke A, Geere I, Kelly M: Nonvalue of antigen detection immunoassay for diagnosis of candidemia. J Clin Microbiol 1990;28:2320-2326. 8 Suits T, Wise GJ, Walters B: Candidal antigenemia: A prognostic determinant. J Urol 1989:141:1381-1384. 9 Kozinn PJ. Taschdjian CL, Goldberg PK, Toni EF, Seelig MS: Advances in the diagnosis of renal candidiasis. J Urol 1987:119:184-187. 10 Silvia-Hutner M, Cooper BH: Yeast of medical importance; in Lennette EH, Balows A, Hausler WJ Jr, Truant JP (eds): Manual of Clinical Microbiology, ed 3. Washington, American Society for Microbiology, 1980, pp 567-572.

11 Ohkawa M. Tokunaga S: Clinical significance of candiduria: An update. Int Urogynecol J. in press. 12 Müller H-L: Serologische Diagnostik der My­ kosen. Chemotherapy 1976;22:87-102. 13 Ohkaw'a M. Tokunaga S. Shoda R. Hisazumi H: Clinical significance of antibody-coated bacteria test in patients with candiduria. Br J Urol 1990:66:22-25. 14 Fujita S, Matsubara F, Matsuda T: Enzymelinked immunosorbent assay measurement of fluctuations in antibody titer and antigenemia in cancer patients with and without candidia­ sis. J Clin Microbiol 1986;23:568-575. 15 Greenfield RA, Troutt DL, Rickard RC, Altmiller DH: Comparison of antibody, antigen, and metabolite assays in rat models of systemic and gastrointestinal candidiasis. J Clin Micro­ biol 1988:26:409-417. 16 Tokunaga S. Ohkawa M. Takashima M. Hisa­ zumi H: Clinical significance of measurement of D-arabinitol levels in candiduria patients. Urol Int, in press.



Candida Antigen Detection in Candiduria Patients

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Candida antigen detection by a latex agglutination test in candiduria patients.

We evaluated a latex agglutination test commercially available in kit form for the identification of Candida pyelonephritis in candiduria patients. Te...
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