Candida albicans causing vulvovaginitis and their clinical response to antifungal therapy

ABSTRACT

The purpose of the present study was to determine the prevalence of Candida albicans causing vulvovaginitis, also to evaluate the utility of the E-test in determining their antifungal susceptibility to some azoles and to determine if failure of recurrent Candida albicans vulvovaginitis to respond clinically to fluconazole is related to in vitro mycologic resistance. Vaginal swabs were collected from 60 women suspected clinically to suffer from vulvovaginal candidiasis. Each was examined microscopically by Gram's stain and was inoculated on the surface of plates of Sabouraud dextrose agar. All isolates proved to be Candida species by culture and microscopy were subjected to the following tests Germ tube test, Chlamydospore production and Sucrose assimilation. Antifungal Susceptibility testing was done using E-test [AB BIODISK]. The results of this study showed that Total number of Candida species isolated were 33/60 of which 26[86.6%] were C.albicans. The range of antifungal susceptibility to the three azoles were as follows 0.125 - >/=256 for fluconazole, 0.008 - >/=32 for itraconazole and 0.008 - 4 for ketoconazole. Fourteen cases were non -recurrent vulvovaginitis and they responded well to fluconazole treatment and were clinically well on next visit to the clinic. While 12 cases had history of recurrent vulvovaginitis, only 8 of them were available for follow up. The most important risk factors for recurrent cases include receiving antibiotics for prolonged duration, hormone-replacement therapy, combined Oral contraceptive pills and Diabetes mellitus. Three of the 12 cases with recurrent vulvovaginal candidiasis [RVVC] were resistant to fluconazole, one of them was also resistant to ketoconazole and another case was also resistant to itraconazole. And 4 cases were susceptible dose dependant to fluconazole. All of the 12 patients were culture positive for C.albicans and 9 of them had previously responded to fluconazole [single dose] but subsequently failed. Three of the12 patients who were fluconazole resistant were given itraconazole or ketoconazole according to the results of in-vitro susceptibility tests while the other patients were treated with fluconazole plus local antimycotic.Clinical and mycological outcomes corresponded to each other. As all patients became clinically well and mycologically free [-ve culture] after therapy except one patient who refused to take maintenance dose of fluconazole for 3 weeks and so she had recurrent signs and symptoms and positive culture for C.albicans.While 4 of the 12 patients were not available for follow up. In Conclusion: The high frequency with which C.albicans was recovered in this study and its azole susceptibility support the continued use of azole agents for empirical therapy of candidal vulvovaginitis even those with RVVC. Antifungal susceptibility tests using E-test may be an important aid in treatment and the monitoring of outcome of vulvovaginal candidiasis