Prevalence and Species Distribution of Candida Clinical Isolates in a Tertiary Care Hospital in Ecuador Tested from January 2019 to February 2020
, Rubén Armas-González 3,4, María José Cáceres-Valdiviezo 2, Juan Carlos Fernández-Cadena 5,* and Derly Andrade-Molina 2,*Round 1
Reviewer 1 Report
My initial thoughts on this manuscript are that the authors have tried to do too much in one study with insufficient context given or discussion to justify much of it. Why was the seasonality analysis performed and what new information does it contribute?
The authors should be aware that there has been extensive revision of the nomenclature of Candida species in recent years, but this isn't mentioned and the current names for species are not used. At a minimum, the issue of nomenclature should be discussed briefly in the introduction, the species should be introduced by their current name with their previous name in parentheses e.g. Nakaseomyces glabratus (formerly Candida glabrata). There have been several reviews of fungal nomenclature changes published in the last 5 years that can be referred to for more information.
Methods:
From the description of sample collection, it is unclear if this means 250 prospective clinical samples that were positive for yeast were included, or something else. How many samples in total were tested in this time period? Did these all represent different episodes from different patients? Or did some come from the same patient? More information required. A dataset comprising only blood culture isolates or only confirmed invasive candidiasis isolates would have more value in highlighting the burden of different yeast species in life-threatening infections. Additionally, it may not be possible given the resource-limited setting, but susceptibility testing (by the Vitek2 yeast AST system?) might add more useful data.
It is unclear if the Candida chromagar was the primary isolation medium from clinical samples or if this was used to subculture the yeasts at a later date. If used for primary isolation, do the authors consider that Candida chromagar and only 48 hours incubation suitable for all sample types? Primary isolation details should be given, including total incubation time, incubation temperature(s), time to positivity, and details of direct microscopic examination. How many of the yeast isolates were associated with positive microscopy (i.e. likely to be clinically significant versus colonisers).
The Vitek 2 database version should be mentioned.
While the sequence/BLAST analysis is important for the purposes of identifying the yeast isolates, I am not really sure why a phylogenetic tree was created or what outcome might have been expected that might be different to the hundreds of phylogenetic studies of Candida species that have been performed previously. It doesn't contribute anything to the study and I suggest omitting.
Results:
I am not convinced that all of these clinical specimens represent infection, and in fact many represent colonization. For example, I find it difficult to believe that 22% of the isolates (BAL/TA) and 2.8% (sputum) were associated with pulmonary candidiasis, and more likely these represent normal respiratory flora. Almost 5% have no source information. I question the value of these data.
The fact that Candida auris was not identified is interesting, and worthy of mention. Can the authors be confident that Candida auris has not been missed given how difficult it can be to identify?
The reason for performing a seasonality analysis of species is not given and its results are not discussed. Given that we know nothing about how many unique episodes/patients these isolates were obtained from, the clinical significance of the isolates, or even if there may be incidences of nosocomial spread accounting for some fluctuations in certain species - I would suggest that this information contributes very little.
line 73: What is meant by axenically in this situation? A different word may be more suitable.
line 108: "Amplification of the ITS-1 and ITS-4 regions...". I think the authors mean ITS1 and ITS2 regions, since there is no ITS4 region. It would be better to say 'Amplification of the Internal Transcribed Spacer (ITS) regions...'.
line 171-172 "Initially, four isolates that were firstly recognized as C. parapsilosis by VITEK 2 were identified as C. parapsilosis using ITS sequencing." Is the second mention of C. parapsilosis in this sentence meant to read as C. orthopsilosis?
Table 2 can be removed, it provides no information that isn't already stated in a single sentence of the text.
Author Response
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Responses to reviewer 1
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1. Summary |
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We thank the referee for the time and attention invested on our paper. We trust any remaining concerns are properly addressed in this revised version.
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2. Questions for General Evaluation
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Reviewer’s Evaluation |
Response and Revisions |
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Does the title describe the article's topic with sufficient precision?
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No
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Title was changed |
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Does the introduction provide sufficient background and include all relevant references?
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Yes |
We re-wrote part of the introduction and add fungal name changes |
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Is the research design appropriate and are the methods adequately described?
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No |
We re-wrote part of methods with pertinent changes |
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Are the results presented clearly and in sufficient detail, are the conclusions supported by the results and are they put into context within the existing literature?
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No |
We have added relevant information that enriches the article.
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Are all the cited references relevant to the research?
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Yes |
Updated to changes |
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Does this article provide a relevant contribution to the scientific discussion of this topic?
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No |
Disagree, see point-by-point response below |
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English language and style |
Moderate editing of English language required |
The document was re-written and reviewed by a native English speaker |
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3. Point-by-point response to Comments and Suggestions for Authors |
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Comments 1: The article isn't really about the fungal infections so much as the isolated Candida species. I was expecting an article about Candida from eye specimens based on the title, but in fact there was wide diversity of specimen types included. |
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Response 1: We agree with this comment. We have changed the title to: “Prevalence and species distribution of Candida clinical isolates in a Tertiary care hospital in Ecuador tested from January 2019 to February 2020.”
Comments 2: From the description of sample collection, it is unclear if this means 250 prospective clinical samples that were positive for yeast were included, or something else. How many samples in total were tested in this time? It is unclear if the Candida chromagar was the primary isolation medium from clinical samples or if this was used to subculture the yeasts at a later date. If used for primary isolation, do the authors consider that Candida chromagar and only 48 hours incubation suitable for all sample types? Primary isolation details should be given, including total incubation time, incubation temperature(s), time to positivity, and details of direct microscopic examination. How many of the yeast isolates were associated with positive microscopy (i.e. likely to be clinically significant versus colonisers). While the sequence/BLAST analysis is important, for the purposes of identifying the yeast isolates, I am not really sure why a phylogenetic tree was created or what outcome was expected that might be different to the hundreds of phylogenetic studies of Candida species that have been performed previously. The purpose of the species seasonality analysis is unclear and given the diversity of clinical samples (including a significant number of colonisers) from which the yeasts were obtained, I suggest this also contributes very little. Response 2: Thanks for your comment. We have made the pertinent changes: L79-L89 “A total of 250 clinical fungal isolates were obtained according to the standard microbiological protocols of the laboratory of microbiology at Hospital Dr. Teodoro Maldonado Carbo (Guayaquil, Ecuador) from January of 2019 to February of 2020. Biological samples were examined in fresh to evaluate cell morphology and the Gram-stain appearance. Yeast-like colonies were purified onto Sabouraud Dextrose Agar (SDA-Oxoid, ThermoScientific), supplemented with chloramphenicol (0.05 g/l) and incubated to 37 °C for 24/48 hrs. Identification was done through subculture on a HardyCHROM™ Candida (CRITERION®, Hardy Diagnostics, Santa Maria, CA, USA) and incubated at 37°C for 48 hrs. To confirm Candida species, the YS card and the VITEK 2 system (bioMérieux, IncHazelwood, MO) were used following the manufacturer’s instructions.. In brief, ,…” Regarding your comment "I am not really sure why a phylogenetic tree was created or what outcome was expected that might be different to the hundreds of phylogenetic studies of Candida species that have been performed previously" We initially included the phylogenetic tree to provide taxonomic context for our analysis in Candida species considering that this is the first study of its kind of Candida clinical isolates in the country. However, upon reflection and considering your comment, we recognize that this aspect does not add novel information. With the results of the blast analysis, we were able to corroborate the taxonomic identity, for this reason this part has been removed in this version. Regarding the comment "The purpose of the species seasonality analysis is unclear and given the diversity of clinical samples (including a significant number of colonisers) from which the yeasts were obtained, I suggest this also contributes very little". We understand your concern regarding the apparent disconnect between the diversity of clinical samples and the purpose of the seasonality analysis. In response, we want to emphasize that our analysis seeks not only to showcase a general distribution of clinical isolates but also to highlight the dominance of C. albicans and C. tropicalis throughout the year and the emergence of atypical Candida species. We believe that these findings provide important results of the dynamics of Candida infections in a major hospital context. For this, we have expanded our discussion and explained how the diversity of clinical samples supports distribution during the study period in the hospital departments and how it could impact in the epidemiology of Candida in our local context, so the figure 2 data was replaced and in this version in which we showed prevalence among clinical isolates from hospitalized and non-hospitalized patients, alongside an additional figure detailing the distribution of Candida across various departments, now represented as the new Figure 1.
Comments 3: Are the results presented clearly and in sufficient detail, are the conclusions supported by the results and are they put into context within the existing literature? Detail on results is minimal, conclusions not supported. See my major comments below. Response 3: Thank you for your assistance and guidance, we have made major changes reorganizing results and modifications to the discussion to complement the suggestions made by the reviewer.
Comments 4: I don't think there is much here that contributes to the literature on this topic. Please see my major comments below. Response 4: The prevalence of Candida species in a major hospital during January 2019 to February 2020 holds significant importance in understanding the dynamics of fungal infections in the region. By analyzing the distribution of Candida species during this specific timeframe, healthcare professionals and researchers can gain insights into the epidemiology, risk factors, and potential interventions for these infections, thereby improving patient care outcomes and public health strategies. This assessment allows examination of prevalence rates, species diversity, and potential variations in Candida infections within the Ecuadorian healthcare system. Guiding future research and clinical practices in this context will aid in the development of targeted prevention and treatment strategies, ultimately leading towards advancing our knowledge in the field of fungal infections and facilitating evidence-based decision-making for healthcare providers and policymakers. We also added the limitations of the study considering the suggestions made by the reviewer.
Comments 5: The fact that Candida auris was not identified is interesting, and worthy of mention. Can the authors be confident that Candida auris has not been missed given how difficult it can be to identify? Response 5: Agree. We did not discuss this issue, which we think is important as the reviewer mentions. In discussion we have added information about it: “We found no evidence of Candida auris presence in this hospital, contrasting with its reported in other Latin American countries. The accurate identification of C. auris presents challenges as it is often misidentified as closely related species such as C. haemulonii using conventional diagnostic approaches. To address this issue, the complete genome of C. haemulonii isolated in this study was sequenced by Whole Genome Sequencing and its identity was confirmed. Up to now, C. auris has not been documented in hospital environments or in the Resistance Antimicrobial Monitoring (RAM) system overseen by the Ecuadorian Government.” |
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4. Response to Comments on the Quality of English Language |
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Point 1: Moderate editing of English language required. |
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Response 4: Agree. The document was re-written and subsequently reviewed by native English speaker.
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5. Additional clarifications |
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Major comments
- My initial thoughts on this manuscript are that the authors have tried to do too much in one study with insufficient context given or discussion to justify much of it. Why was the seasonality analysis performed and what new information does it contribute?
The authors should be aware that there has been extensive revision of the nomenclature of Candida species in recent years, but this isn't mentioned and the current names for species are not used. At a minimum, the issue of nomenclature should be discussed briefly in the introduction, the species should be introduced by their current name with their previous name in parentheses e.g. Nakaseomyces glabratus (formerly Candida glabrata). There have been several reviews of fungal nomenclature changes published in the last 5 years that can be referred to for more information.
Response: Thanks for your comments. We made modifications to the discussion to complement the suggestions made by the reviewer and we also included the new nomenclature of fungal species.
- Methods:
From the description of sample collection, it is unclear if this means 250 prospective clinical samples that were positive for yeast were included, or something else. How many samples in total were tested in this time period? Did these all represent different episodes from different patients? Or did some come from the same patient? More information required. A dataset comprising only blood culture isolates or only confirmed invasive candidiasis isolates would have more value in highlighting the burden of different yeast species in life-threatening infections. Additionally, it may not be possible given the resource-limited setting, but susceptibility testing (by the Vitek2 yeast AST system?) might add more useful data.
It is unclear if the Candida chromagar was the primary isolation medium from clinical samples or if this was used to subculture the yeasts at a later date. If used for primary isolation, do the authors consider that Candida chromagar and only 48 hours incubation suitable for all sample types?
Primary isolation details should be given, including total incubation time, incubation temperature(s), time to positivity, and details of direct microscopic examination. How many of the yeast isolates were associated with positive microscopy (i.e. likely to be clinically significant versus colonisers).
The Vitek 2 database version should be mentioned.While the sequence/BLAST analysis is important for the purposes of identifying the yeast isolates, I am not really sure why a phylogenetic tree was created or what outcome might have been expected that might be different to the hundreds of phylogenetic studies of Candida species that have been performed previously. It doesn't contribute anything to the study and I suggest omitting.
Response: Thanks for your comments. We made important changes considering the reviewer's suggestions, we focused these analyzes on the clinical part, managing to distinguish the source of the isolates from hospitalized or non-hospitalized individuals. We were not able to delve into the patients' medical history in detail due to ethical permissions and additionally, this information was no longer stored in the hospital. However, these results show in this research a general overview of the epidemiology of Candida in this health center and will serve in the future to collect and highlight the importance of showing information on current fungal outbreaks at the local level. Thus, we also added more detailed information about the suggestions in methodology.
- Results:
I am not convinced that all of these clinical specimens represent infection, and in fact many represent colonization. For example, I find it difficult to believe that 22% of the isolates (BAL/TA) and 2.8% (sputum) were associated with pulmonary candidiasis, and more likely these represent normal respiratory flora. Almost 5% have no source information. I question the value of these data.
The fact that Candida auris was not identified is interesting, and worthy of mention. Can the authors be confident that Candida auris has not been missed given how difficult it can be to identify?
The reason for performing a seasonality analysis of species is not given and its results are not discussed. Given that we know nothing about how many unique episodes/patients these isolates were obtained from, the clinical significance of the isolates, or even if there may be incidences of nosocomial spread accounting for some fluctuations in certain species - I would suggest that this information contributes very little.
Response: We successfully determined whether each sample originated from individuals who were hospitalized or not. Utilizing this distinction, we identified that samples derived from blood and CFN are indicative of candidemia. Conversely, samples from other sources were analyzed under the presumption of colonization.
In the context of C. auris, in the hospital 186 samples were isolated and analyzed, of which 168 were identified by ITS sequencing during the specified timeframe. Of that 90.3% tested, we did not find microbiological or molecular evidence of the presence of C. auris. Moreover, species categorized under rare NCA were subjected to whole-genome sequencing to confirm their identities.
It is worth noting that, to date, the presence of C. auris has not been reported within hospital settings or in the Resistance Antimicrobial Monitoring (RAM) system administered by the Ecuadorian Government. This finding underscores the significance of our study and highlights the critical need for ongoing surveillance and genomic analysis to better understand the distribution and characteristics of Candida in our country.
With respect to the last point mentioned, we believe that this distribution result presented on a quarterly basis allows us to see a general distribution of clinical isolates but also to highlight the dominance of C. albicans and C. tropicalis throughout the year and the emergence of atypical Candida species.
Detail comments
line 73: What is meant by axenically in this situation? A different word may be more suitable.
Response: We agree. This Line was re-written.
line 108: "Amplification of the ITS-1 and ITS-4 regions...". I think the authors mean ITS1 and ITS2 regions, since there is no ITS4 region. It would be better to say 'Amplification of the Internal Transcribed Spacer (ITS) regions...'.
Response: We agree. This Line was re-written.
line 171-172 "Initially, four isolates that were firstly recognized as C. parapsilosis by VITEK 2 were identified as C. parapsilosis using ITS sequencing." Is the second mention of C. parapsilosis in this sentence meant to read as C. orthopsilosis?
Response: We agree. This Line was re-written.
Table 2 can be removed, it provides no information that isn't already stated in a single sentence of the text.
Response: We agree. Table 2 was eliminated, and the results were described in a paragraph.
Reviewer 2 Report
The authors describe the spread of Candida spp from a microbiological point of view. The topic might be of interest since it offers an overview of distribution of Candida spp in a representative Hospital in Ecuador. However the main limitation is that we do not have clinical information at all. Are the patients immunosuppressed, how many of them are from ICU? Which typology of patients are admitted to this Hospital? The different typology of Hospital Departments might influence the distribution of Candida spp. (for example the presence of patients with indwelling devices). Excluding clinical information we should consider the paper only from a microbiological and molecular point of view, Such aspects are well described in the methods and in the results. The discussion is well structured,
Results: line 133: as already underlined, the sentence " clinical isolates were obtained from patients..." lacks of clinical information. At least the characteristics of the Hospital might be reported, which could give an idea of the clinical setting. In table 1 the blood source should be taken apart from the others. According to the organization of the paper the source of the specimen add information that cannot bring to any conclusion. Anyway Candidemia is a serious event, which could be related to a particular type of patients and a particular type of Candida spp.
Discussion line 237-239: this sentence is not clear ; line 259-260: is not clear, moreover it is not correct to compare the prevalence of C, glabrata fro different sources to bloodstream infection as reported in the following lines. The sentence of the 267-269 is not a correct conclusion coming from the previous phrases.
Author Response
Responses to reviewer 2
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1. Summary |
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We thank the referee for the time and attention invested on our paper. We trust any remaining concerns are properly addressed in this revised version.
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2. Questions for General Evaluation
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Reviewer’s Evaluation |
Response and Revisions |
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Does the title describe the article's topic with sufficient precision?
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No
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Title was changed |
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Does the introduction provide sufficient background and include all relevant references?
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Yes |
We re-wrote part of the introduction, and we add new fungal names |
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Is the research design appropriate and are the methods adequately described?
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Yes |
We re-wrote part of methods, detailing description of sample collection and eliminated phylogenetic analysis |
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Are the results presented clearly and in sufficient detail, are the conclusions supported by the results and are they put into context within the existing literature?
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Yes |
We have added relevant information that enriches the article, including clinical information.
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Are all the cited references relevant to the research?
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Yes |
Updated to changes |
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Does this article provide a relevant contribution to the scientific discussion of this topic?
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Yes |
Updated to changes |
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English language and style |
Moderate editing of English language required |
The document was re-written and reviewed by a native English speaker |
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- Point-by-point response to Comments and Suggestions for Authors
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Comments 1: The title sounds intriguing, but it is not supported by an explanatory comment in the paper. "There is more than meets the eye" is not justified reading the paper. Please provide a better explanation for this title. Moreover according to the paper, since clinical information are lacking, we do not know exactly wether Candida specimens refer to infection or colonization (see sputum, or urine since Candida might be present in mouth or genito-urinary tract as colonization). |
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Response 1: We agree with this comment. We have changed the title to: “Prevalence and species distribution of Candida clinical isolates in a Tertiary care hospital in Ecuador tested from January 2019 to February 2020.”
Response to Comments on the Quality of English Language Point 1: Moderate editing of English language required. Response 2: Agree. The document was re-written and subsequently reviewed by native English speaker.
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4. Response to Comments on the Quality of English Language |
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Point 1: Moderate editing of English language required. |
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Response 4: Agree. The document was re-written and subsequently reviewed by native English speaker.
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- Additional clarifications
Major comments
The authors describe the spread of Candida spp from a microbiological point of view. The topic might be of interest since it offers an overview of distribution of Candida spp in a representative Hospital in Ecuador. However the main limitation is that we do not have clinical information at all. Are the patients immunosuppressed, how many of them are from ICU? Which typology of patients are admitted to this Hospital? The different typology of Hospital Departments might influence the distribution of Candida spp. (for example the presence of patients with indwelling devices). Excluding clinical information we should consider the paper only from a microbiological and molecular point of view, Such aspects are well described in the methods and in the results. The discussion is well structured,
Response: Thanks for your comments. We made important changes considering the reviewer's suggestions, we focused these analyzes on the clinical part, managing to distinguish the source of the isolates from hospitalized or non-hospitalized individuals and the hospital department. We were not able to delve into the patients' medical history in detail due to ethical permissions and additionally, this information was no longer stored in the hospital. However, these results show in this research a general overview of the epidemiology of Candida in this health center and will serve in the future to collect and highlight the importance of showing information on current fungal outbreaks at the local level.
Detail comments
Results: line 133: as already underlined, the sentence " clinical isolates were obtained from patients..." lacks of clinical information. At least the characteristics of the Hospital might be reported, which could give an idea of the clinical setting. In table 1 the blood source should be taken apart from the others. According to the organization of the paper the source of the specimen add information that cannot bring to any conclusion. Anyway Candidemia is a serious event, which could be related to a particular type of patients and a particular type of Candida spp.
Response: Thanks for your comments. We have modified Table 1 to present data of the prevalence of Candida isolates sourced from both hospitalized and non-hospitalized patients (Figure 2). These results emphasize that isolates from blood and cerebrospinal fluid are indicative of candidemia and the rest of the isolates were classified as colonization. This distinction is important to understanding the epidemiological od candida infection within different conditions of patients.
Discussion:
line 237-239: this sentence is not clear ;
Response: Agree. The sentence was re-written.
line 259-260: is not clear, moreover it is not correct to compare the prevalence of C, glabrata from different sources to bloodstream infection as reported in the following lines. The sentence of the 267-269 is not a correct conclusion coming from the previous phrases.
Response: Agree. The whole paragraph was re-written.
Round 2
Reviewer 1 Report
The manuscript has been much improved.
The abbreviations NCA and NAC are both used throughout the manuscript for Non-albicans Candida/Non-Candida albicans. Please choose one. Similarly the abbreviations BAL/TAL and BAL/TA are used interchangeably. Please choose one.
Sometimes species names are italicised and sometimes not, and sometimes only part of the names are italicised. Please ensure Candida has a capital C on every use.
Line 101: remove the extra "a" and unnecessary spacing.
Line 118: "SYBR green nucleic" should read 'SYBR green nucleic acid stain'.
Line 125: "intergenic spacers" should be "internal transcribed spacers" Intergenic spacers are different.
Line 226: "for a year period distribution" is awkward writing. Suggest rewording
Line 317 Please write in full what FPPL means.
Line 324 Write out NGS in full
Figure 2: "Upset plot" should be written as 'UpSet plot'
Author Response
Responses to reviewer 1
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1. Summary
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2. Questions for General Evaluation
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Reviewer’s Evaluation |
Response and Revisions |
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Does the title describe the article's topic with sufficient precision?
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Yes
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Does the introduction provide sufficient background and include all relevant references?
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Yes |
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Is the research design appropriate and are the methods adequately described?
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Yes |
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Are the results presented clearly and in sufficient detail, are the conclusions supported by the results and are they put into context within the existing literature?
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Yes |
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Are all the cited references relevant to the research?
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Yes |
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Does this article provide a relevant contribution to the scientific discussion of this topic?
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Yes |
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English language and style |
Minor editing of English language required |
The manuscript was modified. |
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Major comments Comments 1: The manuscript has been much improved. |
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Response: Thank you for your comment.
Detail comments Comments 1: The abbreviations NCA and NAC are both used throughout the manuscript for Non-albicans Candida/Non-Candida albicans. Please choose one. Similarly, the abbreviations BAL/TAL and BAL/TA are used interchangeably. Please choose one Response: We agree. The abbreviations were modified accordingly.
Comments 2: Sometimes species names are italicised and sometimes not, and sometimes only part of the names are italicised. Please ensure Candida has a capital C on every use. Response: We agree. Species names were italicized and the word Candida was capitalized in all instances.
Comments 3: Line 101: remove the extra "a" and unnecessary spacing. Response: We agree. The line was re-written.
Comments 4: Line 118: "SYBR green nucleic" should read 'SYBR green nucleic acid stain'. Response: We agree. The line was re-written.
Comments 5: Line 125: "intergenic spacers" should be "internal transcribed spacers" Intergenic spacers are different. Response: We agree. The line was modified accordingly.
Comments 6: Line 226: "for a year period distribution" is awkward writing. Suggest rewording. Response: We agree. The sentence was re-written.
Comments 7: Line 317 Please write in full what FPPL means. Response: We agree. The sentence was re-written.
Comments 8: Line 324 Write out NGS in full Response: We agree. The line was re-written
Comments 9: Figure 2: "Upset plot" should be written as 'UpSet plot' Response: We agree. The name of the plot was modified accordingly. |
- Point-by-point response to Comments and Suggestions for Authors
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4. Response to Comments on the Quality of English Language |
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Point 1: Minor editing of English language required. |
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Response: Agree. The document was re-written according to the suggestions.
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- Additional clarifications
Reviewer 2 Report
The paper is very technical, citing a variety of Candida ssp, albicans and not albicans. Reported information are wide and complete, on the other hand more difficult to read, I believe suitable for experts.
no further comment
Author Response
Responses to reviewer 2
We really appreciate your comments in all reviewer version, your feedback helps us to improve our paper.
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1. Summary
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2. Questions for General Evaluation
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Reviewer’s Evaluation |
Response and Revisions |
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Does the title describe the article's topic with sufficient precision?
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Yes
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Does the introduction provide sufficient background and include all relevant references?
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Yes |
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Is the research design appropriate and are the methods adequately described?
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Yes |
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Are the results presented clearly and in sufficient detail, are the conclusions supported by the results and are they put into context within the existing literature?
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Yes |
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Are all the cited references relevant to the research?
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Yes |
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Does this article provide a relevant contribution to the scientific discussion of this topic?
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Yes |
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English language and style |
English language fine. No issues detected |
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- Point-by-point response to Comments and Suggestions for Authors
Major Comments
Comments 1: The paper is very technical, citing a variety of Candida ssp, albicans and not albicans. Reported information are wide and complete, on the other hand more difficult to read, I believe suitable for experts.
Response: Thank you for your comments.
- Response to Comments on the Quality of English Language
- Additional clarifications.
