Cancer patients are highly vulnerable to fungal infections due to immunosuppression from underlying malignancies and treatments (Shelke et al., 2024). Candida species are the most commonly reported fungi in cancer patients. They can colonize various body sites, including mucosal membranes, the gastrointestinal tract, and the urogenital tract. This colonization is exacerbated in cancer patients due to immunosuppression, mucosal disruption, and the use of antimicrobials. Colonization, especially at multiple body sites, significantly increases the risk of invasive candidiasis, which may develop within approximately 7 days. Risk factors influencing this transformation include underlying comorbidities, use of indwelling devices, exposure to broad-spectrum antimicrobials, and surgical or invasive procedures (Alenazy et al., 2021; Lass-Flörl et al., 2024). Each year, around 2.5 million people are reported to develop invasive candidiasis, with a mortality rate ranging from 25 to 50% (Bilal et al., 2023).

Historically, Candida albicans has been predominantly isolated in cases of candidiasis worldwide. However, recent studies show a shift toward non-albicans Candida (NAC) species (Meneghello et al., 2024). This trend is largely attributed to the widespread use of antifungals such as fluconazole and caspofungin. This has led to selective pressure favoring NAC species, which are often less susceptible to azoles and echinocandins.(Lass-Flörl et al., 2024; Lee et al., 2023). The specific distribution of NAC species varies by region and patient population, likely influenced by the use of antifungals and healthcare practices (Bilal et al., 2023; Meneghello et al., 2024; Ngamchokwathana et al., 2021).

In China, antifungal susceptibility patterns vary across regions, and recent studies have noted a decline in susceptibility compared to developed countries (Bilal et al., 2022). Antifungal susceptibility testing often requires a long time. Therefore, guidelines such as those from the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) and the Infectious Diseases Society of America (IDSA) recommend tailoring empirical antifungal therapy based on local species distribution, risk factors, prior antifungal use, and susceptibility data (Pappas et al., 2009; Pappas et al., 2015; Ullmann et al., 2012). In this study, we aimed to analyze the distribution of Candida species in various cancer types, along with their associated risk factors and antifungal susceptibility profiles. We also examined the correlation between the consumption of commonly used antifungal drugs and both species distribution and the proportion of non-susceptible isolates in Jiangxi, China, over the past 7 years.

Candida infection is common in cancer patients due to their immunocompromised status, requiring timely management. However, studies focusing on Candida isolates from cancer patients in China are limited (Sharifi et al., 2023). This study comprehensively analyzed the species distribution, risk factors, and antifungal susceptibilities of Candida isolates from cancer patients in Jiangxi, China. Overall, C. albicans remains dominant in our study; however, the year-wise trend showed a decreasing incidence of C. albicans and an increasing trend of NAC. This shifting epidemiological landscape aligns with the previously published literature from China (Khan et al., 2025). Among the NAC group, C. tropicalis was the most frequently reported, followed by N. glabrata and C. parapsilosis. The high proportion of C. tropicalis in our study aligns with previous findings, contrasting with Europe and the United States, where N. glabrata is more common (Ricotta et al., 2020; Wang et al., 2021; Wolfgruber et al., 2024). The variation in species distribution might be due to differences in healthcare practice, patients’ demographics, and regional latitudes (Bilal et al., 2022; Khan et al., 2025). Among the sample types, sputum and throat swabs were the most frequent in our study. This is due to the high proportion of lung and nasopharyngeal cancer cases, for which sputum and throat swab collection is a less invasive and more patient-friendly method to obtain biological specimens (Lucaciu et al., 2024; Sharifi et al., 2023). C. parapsilosis was predominantly found in blood samples, consistent with its known role in candidemia, due to its affinity for intravascular catheters and ability to form biofilms (Franconi et al., 2023).

Among the cancer types, Candida species were most commonly isolated from patients with lung and nasopharyngeal malignancies. This may be due to their anatomical site, as the respiratory and upper aerodigestive tracts are exposed to the external environment, which poses a high risk of colonization and infection (Liu et al., 2025). Furthermore, radiotherapies in these cancers can cause salivary gland dysfunction, mucositis, and alterations in oral flora, which facilitate Candida colonization and infection (Bhumitrakul et al., 2024). NAC was significantly predominant in gastric, colon, and urogenital cancers, while C. albicans was significantly more prevalent in lung and nasopharyngeal cancers. The unique mucosal environment and frequent exposure to broad-spectrum antimicrobials might selectively favor the colonization of NAC in gastrointestinal and urogenital cancer (Sun et al., 2025). Conversely, the commensal nature of C. albicans in the oropharyngeal tract and its adaptability to an oxygen-rich environment might promote its colonization in infection among lung and nasopharyngeal cancer patients (Debta et al., 2022).

Regarding risk factor analysis, inappropriate empirical therapies were significantly associated with the NAC group. This may be due to the lower susceptibility of NAC species to commonly used empirical treatments, leading to delayed infection clearance and enabling their proliferation (Katsipoulaki et al., 2024). Furthermore, correlation analysis was performed with caspofungin and fluconazole consumption, with the distribution of Candida species, and the proportion of non-susceptibility. Notably, a negative correlation was observed between caspofungin consumption and C. albicans distribution, and positive correlations were observed with N. glabrata and C. tropicalis. Similarly, a positive correlation was found between fluconazole consumption and C. parapsilosis. This finding reinforces our previous observation of the epidemiological shift of C. albicans to NAC, as well as the significant association between inappropriate therapies and the NAC group. The C. albicans are comparatively more susceptible to antifungal drugs and are mostly cleared with empirical treatments. This selective pressure promotes the emergence of less susceptible NAC species (Dawoud et al., 2024). Besides this, hypoproteinemia, anemia, UTI, and indwelling catheter use were observed as independent risk factors for the NAC group. The low serum protein level and anemia indicate impaired immune function and oxygen delivery, favoring the proliferation of NAC species (Jørgensen, 2024). Similarly, UTI disrupts the normal urogenital flora, providing a conducive environment for NAC species colonization and infection. Catheterization is a well-documented risk factor for NAC, as C. parapsilosis and C. tropicalis form biofilms on its surface, facilitating candidiasis (Wijaya et al., 2023; Yamin et al., 2021). Radiotherapy, targeted therapy, glucocorticoid use, chest tube insertion, and parenteral nutrition were independent risk factors for the C. albicans group. Studies have shown that radiotherapy and glucocorticoid use impair mucosal immunity, promoting the adhesion and invasiveness of C. albicans (Pasman et al., 2022). Targeted therapy contributes to immunosuppression, promoting the pathogenic transformation of commensal C. albicans (Feng et al., 2024). Similarly, chest tubes and parenteral nutrition provide direct access to a nutritionally rich environment for the proliferation of C. albicans species (Cinti et al., 2024; Nagar et al., 2023).

Regarding the antifungal susceptibility profiles, amphotericin B was the most susceptible drug against all Candida species, reaffirming its status as a potent broad-spectrum antifungal agent. C. albicans isolates were susceptible primarily to the tested antifungal agents, except for itraconazole and 5-flucytosine, for which 6.67 and 3.52% of the tested isolates were non-wild types. These findings align with prior studies, which report generally high but not absolute susceptibility to tested antifungal agents (Bilal et al., 2022). The occasional resistance may be linked to mutations in genes involved in ergosterol biosynthesis, efflux pump regulation, cytosine permease function, and deaminase activity (Huang et al., 2025). Among the NAC, the azole drugs were less susceptible compared to other antifungal agents. Specifically, the C. tropicalis isolates showed high resistance to all azole drugs, with rates of 40.9, 51.32, 74.45, and 64.98% against fluconazole, voriconazole, itraconazole, and posaconazole, respectively. A previously published systematic analysis of data from the past 10 years in China reported high resistance rates, with 22.05% of C. tropicalis isolates being non-susceptible to fluconazole and 16.9% to itraconazole (Bilal et al., 2022). This high resistance to azole drugs reflects emerging regional resistant trends due to its widespread use. Previous literature attributes such resistance to mechanisms such as ERG11 mutation and efflux pump overexpression (Siqueira et al., 2025). The echinocandins showed a comparatively less resistant rate (<5%) against all NAC species. However, careful administration of echinocandin drugs is required, as some recent studies have reported the emergence of resistance due to mutations in the hotspot region of the FKS1 and FKS2 genes (ElFeky et al., 2025; Huang et al., 2025). Notably, 22.06% of P. kudriavzevii isolates were non-wild-types against 5-flucytosine. The resistance has been linked in previous reports to mutations in cytosine permease (FCY2) and deficient cytosine deaminase activity, which impair 5-flucytosine uptake and metabolism (Czajka et al., 2023). These mutations are reportedly more prevalent in P. kudriavzevii than in other NAC species (Jamiu et al., 2020). Therefore, based on the current literature, monotherapy with 5-flucytosine for P. kudriavzevii is often unsuitable and may require combination therapy with other antifungal agents such as echinocandins or amphotericin B (Nguyen et al., 2024).

Overall, the mortality rate in our study (6–10%) was comparatively lower than that reported in other studies from China, which have documented rates ranging from 20 to 50% (Bilal et al., 2023; Dai et al., 2025; Zhang et al., 2019). Our lower mortality rate may be attributed to the inclusion of all Candida cases, rather than only those involving invasive or bloodstream infections, which are typically associated with a higher mortality rate (Kwon et al., 2021). When comparing survival probabilities between the C. albicans and NAC groups, the NAC group showed a lower survival probability and a 1.5-fold higher mortality risk. The finding of a high mortality risk in the NAC group aligns with previous results reported by other researchers. This higher mortality risk associated with NAC may be attributed to their antifungal resistance mechanisms, particularly against azole drugs, and delays in initiating appropriate empirical therapies (Chastain et al., 2024; Hoenigl et al., 2024).

The increasing prevalence of azole-resistant non-albicans Candida species in our oncology patients highlights the need to reconsider empirical antifungal therapy, favoring agents such as amphotericin B and echinocandins, which have shown higher susceptibility. This aligns with IDSA guidelines, which recommend echinocandins as first-line treatment in high-resistance settings (Pappas et al., 2015). Incorporating local resistance data into antifungal stewardship programs can promote targeted, timely therapy, reduce unnecessary azole use, and prevent the development of further resistance. Stewardship efforts, including ongoing surveillance, clinician education, and region-specific treatment protocols, are crucial in oncology care to optimize antifungal use, enhance patient outcomes, and preserve drug efficacy (Fisher et al., 2022).

The limitations of the present study include its retrospective nature, single-center design, and the unavailability of isolates for molecular analysis, such as genotyping and detection of resistance mechanisms, including ERG11 and FKS mutations. Additionally, clearly distinguishing between colonization and invasive candidiasis was impossible due to the absence of some clinical details, such as radiological and biomarker data. These factors may limit the external validity of the findings, though they remain clinically relevant within similar hospital settings. Nevertheless, we included all culture-positive cases in which physicians had a clinical suspicion of fungal infection, reflecting real-world diagnostic practices. Despite these limitations, our study remains distinctive in providing a thorough evaluation of Candida cases among cancer patients, a dataset that is rarely available. The findings from this work are expected to aid healthcare professionals in more effectively managing Candida infections in similar clinical settings.

This study retrospectively analyzed the species distribution, risk factors, and antifungal susceptibility patterns of Candida isolates among cancer patients in Jiangxi, China. While C. albicans remained the predominant species, a year-wise trend indicated a declining proportion of C. albicans and a rising incidence of NAC. Caspofungin consumption showed a negative correlation with C. albicans and positive correlations with N. glabrata and C. tropicalis distribution. A higher proportion of C. albicans isolates were recovered from lung and nasopharyngeal cancers, whereas NAC species were more frequently associated with gastric, colon, and urogenital cancers. Inappropriate empirical therapy, hypoproteinemia, anemia, and the use of indwelling catheters were identified as independent risk factors for NAC infections. In contrast, radiotherapy, targeted therapy, and glucocorticoid use were significantly associated with C. albicans. The NAC group exhibited a 1.5-fold higher mortality risk than the C. albicans group. Amphotericin B and echinocandins demonstrated good activity against Candida species, whereas lower susceptibility rates to azole drugs were observed, particularly among NAC isolates. Future large-scale, multicenter molecular studies are warranted to investigate emerging azole resistance mechanisms in NAC species.