High burden of Candida blankii (syn.Tardiomyces blankii) bloodstream infections among neonates in an intensive care unit in Bangladesh

Invasive fungal infections (IFIs) remain underrecognized in low- and middle-income countries due to limited surveillance. This study aims to report the burden of Candida blankii infections detected through ongoing surveillance in the Neonatal Intensive Care Unit (NICU) of a tertiary hospital in Dhaka, Bangladesh. Since August 2022, IFI surveillance in a NICU in Bangladesh enrolled neonates with sepsis who met predefined clinical criteria. Blood samples were collected and processed using the BACT/ALERT 3D system, and fungal isolates were identified with automated identification system. Antifungal susceptibility testing (AFST) was performed on a subset of isolates using E-strip gradient diffusion. Whole-genome sequencing of nine representative C. blankii isolates, initially identified by VITEK MS, confirmed species identification by demonstrating 94% to 99% average nucleotide identity with reference sequences in the NCBI GenBank database. A total of 411 neonates were enrolled, with a mean age of 16 (± 7) days; 39% were male. More than half (225/411, 55%) had positive fungal blood cultures, among which C. blankii was the most common species (126/225, 31%). The isolates showed high MICs to fluconazole and voriconazole but lower MIC values against amphotericin B (AMP) and echinocandins. In-hospital mortality among C. blankii cases was significantly higher than in infections caused by other fungi. Findings indicate a substantial burden of C. blankii in the NICU and underscore the need for improved diagnostics, targeted treatment strategies, and strengthened infection control in resource-limited neonatal settings.