Microbiota in vaginal health and pathogenesis of recurrent vulvovaginal infections: a critical review.

Recurrent vulvovaginal infections (RVVI) has not only become an epidemiological and clinical problem but also include large social and psychological consequences. Understanding the mechanisms of both commensalism and pathogenesis are necessary for the development of efficient diagnosis and treatment strategies for these enigmatic vaginal infections. Through this review, an attempt has been made to analyze vaginal microbiota (VMB) from scratch and to provide an update on its current understanding in relation to health and common RVVI i.e. bacterial vaginosis, vulvovaginal candidiaisis and Trichomoniasis, making the present review first of its kind. For this, potentially relevant studies were retrieved from data sources and critical analysis of the literature was made. Though, culture-independent methods have greatly unfolded the mystery regarding vaginal bacterial microbiome, there are only a few studies regarding the composition and diversity of vaginal mycobiome and different Trichomonas vaginalis strains. This scenario suggests a need of further studies based on comparative genomics of RVVI pathogens to improve our perceptive of RVVI pathogenesis that is still not clear (Fig. 5). Besides this, the review details the rationale for Lactobacilli dominance and changes that occur in healthy VMB throughout a women's life. Moreover, the list of possible agents continues to expand and new species recognised in both health and VVI are updated in this review. The review concludes with the controversies challenging the widely accepted dogma i.e. "VMB dominated with Lactobacilli is healthier than a diverse VMB". These controversies, over the past decade, have complicated the definition of vaginal health and vaginal infections with no definite conclusion. Thus, further studies on newly recognised microbial agents may reveal answers to these controversies. Conversely, VMB of women could be an answer but it is not enough to just look at the microbiology. We have to look at the woman itself, as VMB which is fine for one woman may be troublesome for others. These differences in women's response to the same VMB may be determined by a permutation of behavioural, cultural, genetic and various other anonymous factors, exploration of which may lead to proper definition of vaginal health and disease.

Is multiple-site colonization with Candida spp. related to inadequate response to individualized fluconazole maintenance therapy in women with recurrent Candida vulvovaginitis?

OBJECTIVE: Although most women on fluconazole maintenance therapy for recurrent vulvovaginal candidosis experience a substantial improvement in quality of life, some do not respond to therapy. Is candidal colonization of extragenital sites related to suboptimal response to maintenance therapy? PATIENTS AND METHODS: Women included in a multicenter follow-up study (ReCiDiF) were evaluated for clinical signs and presence of yeasts in nose, mouth, anus, perineum, and urine. Candida was diagnosed by positive microscopy, confirmed by positive culture or polymerase chain reaction. After treatment, women were divided into groups according to their response to a fluconazole maintenance regimen (optimal, suboptimal, and nonresponders). RESULTS: The most frequent extravaginal Candida spp. were detected in urine (79.5%), perineum (78.6%), and anus (56.4%). Carriers of Candida in the mouth were more likely to have it in the anus (OR 3.2; 95% CI 1.4-7.7). Colonization in anus (OR 3.3; 95% CI 1.3-8.1) or in multiple extravaginal sites (OR 3.0; CI95% 1.2-7.4) was related to nonresponse to therapy. Candidal carriage in the anus did not increase anal and perianal symptoms. CONCLUSION: Women with anal carriage and multiple-site candidal colonization are less likely to respond to individualized decreasing dose fluconazole therapy.

Vulvovaginal Candidiasis in Pregnant Women and its Importance for Candida Colonization of Newborns.

UNLABELLED: Vulvovaginal candidiasis is the second most common cause of vaginitis worldwide (after bacterial candidiasis). Maternal vulvovaginal candidiasis is a major risk factor for Candida colonization and infection of the infant where prognosis depends on different predisposing factors. The aim of this study was to determine the incidence and the etiological structure of vulvovaginal candidiasis in pregnant women and its impact on Candida colonization of newborns. MATERIALS AND METHODS: Samples of vaginal secretions from 80 healthy pregnant women who were clinically suspicious for Candida vaginitis were collected within 48 hours before delivery. Samples for probable Candida colonization from the oral mucosa and feces were collected from their newborns within 47-72 hours after birth. Samples were plated on Sabouraud agar, followed by species identification by API Candida yeast assay. RESULTS: Twenty-three (28.75 ± 5.06%) of the evaluated pregnant women were positive for Candida spp. Positive samples for Candida colonization were found in 18 (22.22 ± 4.62%) of the examined 81 newborns (one pair of twins) from mothers who were clinically suspicious for vaginal candidiasis. Isolates of the newborns were 100% identical to those of the mothers' vaginal secretion. Candida albicans was the predominant species identified in the pregnant women (91.67 ± 0.06%) and in the neonates (83.33±8.78%).

Skin infections in pregnancy.

A wide array of infectious diseases can occur in pregnancy. Their acquisition, clinical presentation, and course during gestation may be altered due to an impairment of the maternal cellular immunity. Some infectious diseases can lead to serious consequences for the mother or the offspring, including congenital malformations. This review describes in detail the clinical presentation, course, management, and associated maternal and fetal risks of selected viral (varicella-zoster virus infections, condylomata acuminata), fungal (candida vulvovaginitis), bacterial (Lyme borreliosis), and parasitic (scabies) infections. The treatment options are critically reviewed. First-line therapies include acyclovir and varicella-zoster virus immunoglobulin for varicella-zoster virus infections, surgical modalities for genital warts, topical clotrimazole and oral fluconazole for Candida vulvovaginitis, amoxicillin and cefuroxime for Lyme borreliosis, and permethrin for scabies. A synopsis of maternal and fetal risks of other important infections is also included.

Detection of Candida spp. in the vagina of a cohort of nulliparous pregnant women by culture and molecular methods: Is there an association between maternal vaginal and infant oral colonisation?

BACKGROUND: Most studies describing vaginal Candida spp. in pregnancy focus on symptomatic vaginitis, rather than asymptomatic colonisation, and solely utilise microbiological culture. The extent to which asymptomatic vaginal carriage may represent a reservoir for infant oral colonisation has been highly debated. MATERIALS AND METHODS: This study formed part of the Candida and Staphylococcus Transmission Longitudinal Evaluation (CASTLE) study, in Melbourne, Australia, from 2009 to 2011 and used culture and molecular methods to examine vaginal swabs collected late in the third trimester of pregnancy for Candida spp. Oral swabs from infants were also examined using culture methods. RESULTS: Overall, 80 of 356 (22%) women were positive for Candida spp; the majority being Candida albicans (83%). Candida glabrata and other Candida spp. were also identified, but in much lower numbers. Molecular analysis identified numerous positive samples not detected by culture, including 13 cases of C. albicans. In addition, some positive samples only recorded to genus level by culture were accurately identified as either C. albicans or C. glabrata following molecular analyses. Eighteen infants recorded positive Candida spp. cultures, predominantly C. albicans. However, there were only four (25%) mother/infant dyads where C. albicans was detected. CONCLUSIONS: This study provides valuable data on asymptomatic colonisation rates of Candida spp. within an asymptomatic population of women late in pregnancy. The utilisation of molecular methods improved the rate of detection and provided a more accurate means for identification of non-albicans Candida spp. The low mother/infant colonisation rate suggests that non-maternal sources are likely involved in determining infant oral colonisation status.

Colonización vaginal/rectal por Streptococcus agalactiae en gestantes de Melena del Sur, Cuba / Vaginal and rectal Streptococcus agalactiae colonization in pregnant women from Melena del Sur municipality in Cuba

Introducción: en Cuba se desconoce el peso de la colonización vaginal o rectal por Streptococcus agalactiae o estreptococo ß-hemolítico grupo B (SGB) como factor de riesgo para el desarrollo de sepsis neonatal precoz. Objetivo: determinar la prevalencia de colonización vaginal/rectal por SGB entre la población de gestantes del municipio Melena del Sur, Mayabeque. Métodos: se realizó un estudio observacional de corte transversal entre febrero-agosto 2011, en el que se incluyeron 120 gestantes (35-37 semanas). Se obtuvieron muestras vaginales y rectales que se cultivaron en caldo Todd Hewitt y medio Granada y se calculó la sensibilidad y especificidad de ambos medios de cultivo para la recuperación de SGB. Se hizo seguimiento de las embarazadas hasta el momento del parto para conocer acerca de la aparición de factores de riesgo para el desarrollo de sepsis neonatal, sobre la imposición de profilaxis antibiótica intraparto y si se produjeron casos de sepsis neonatal (tipo y evolución). Resultados: la especificidad lograda con el medio Granada para el aislamiento de SGB fue superior (94,57 %) pero la sensibilidad fue de solo 60,71 %; la combinación de su empleo y el caldo Todd Hewitt permitió la demostración de colonización por SGB en el 27,5 % de las gestantes. Se constató la administración de tratamiento profiláctico a las embarazas colonizadas en las que se presentaron factores de riesgo en el momento del parto y se produjeron solo cuatro casos de sepsis neonatales, lo que realza el valor de esta estrategia en la intercepción de la transmisión vertical.

Introduction: the impact of vaginal or rectal colonization by Streptococcus agalactiae or group B hemolytic streptococcus as risk factor for the development of early neonatal sepsis is still unknown in Cuba. Objective: to determine the prevalence of group B hemolytic streptococcus colonization of the vagina and the rectum among the pregnant women of the Melena del Sur municipality in Mayabeque province, Cuba. Methods: observational and cross-sectional study conducted from February to August 2011, which covered 120 pregnant women (35 to 37 weeks of gestation). Vaginal and rectal samples were taken to be cultured in ToodHewitt broth and grenade medium and the sensitivity and specificity of both culturing media were then calculated for recovery of Group B hemolytic streptococcus. The pregnant women were followed-up up to the delivery time so as to learn about the occurrence of risk factors for developing neonatal sepsis, the application of antibiotic prophylaxis intrapartum and the occurrence of cases of neonatal sepsis (type and progress). Results: the specificity of the grenade medium for Group B streptococcus was higher (94.57 %), but sensitivity was just 60.71 %. The combination of grenade medium plus Todd Hewitt broth allowed showing the Group B hemolytic streptococcus colonization in 27.5 % of pregnant women. It was then confirmed that prophylactic treatment was given to colonized pregnant women who presented with risk factors at the time of delivery and that there were just four neonatal sepsis cases, which stressed the value of this strategy in halting the vertical transmission.

Lack of evidence for sexual transmission of genital Candida species among women who have sex with women: a mixed methods study.

OBJECTIVE: The contribution of sexual transmission to genital Candida infection remains unclear. This study sought to investigate whether sexual behaviours were associated with the presence of genital Candida species among a cohort of women who have sex with women (WSW) in addition to determining the genetic concordance of genital Candida spp. among WSW in sexual partnerships. METHODS: WSW ≥18 years of age presenting to the Mississippi State Department of Health STD Clinic during 2009-2010 completed a sexual behaviour survey. Culture of vaginal fluid was performed for Candida spp. identification; associations with participant characteristics were determined using logistic regression analysis. Random amplified polymorphic DNA (RAPD) PCR was performed on DNA extracted from yeast cultures of WSW in sexual partnerships in which both partners had isolates of Candida spp. identified and among a set of age/sexual behaviour matched controls. RAPD genetic fingerprints were evaluated by hierarchical cluster analysis for concordance. RESULTS: Genital Candida spp. were isolated in 105/196 (53.6%) of women: 13/105 (12.4%) had symptomatic vulvovaginal candidiasis while 92/105 (87.6%) had asymptomatic vaginal colonisation. Bisexual identity, sex with women and men during the past 12 months and numbers of male sexual partners during the past 12 months were the only significant predictors of genital Candida spp. in bivariate analysis. 13 pairs of WSW in sexual partnerships in which both partners had genital Candida spp. and 11 WSW with genital Candida spp. not in sexual partnerships were identified. Candida spp. RAPD banding patterns were discordant for all isolates among WSW within partnerships and in controls. CONCLUSIONS: This study found no evidence supporting sexual transmission of genital Candida spp. between women.

[Generalized cutaneous candidiasis in newborn at term]. / Candidiasis cutánea generalizada en recién nacido a término.

INTRODUCTION: Cutaneous candidiasis is a disease that affects children as well as adults. The presentation may be localized or systemic, and with multiple etiological agents. The most prevalent infecting species in children differs from that of the adult. OBJECTIVE: A case is presented where a congenital cutaneous candidiasis was transmitted to the child during birth. MATERIALS AND METHODS: A full term newborn was exposed to a subclinical vaginal candidiasis infection, and 24 hr after birth, developed congenital cutaneous candidiasis. The etiological agent was Candida albicans, and was associated with sepsis and respiratory distress. Blood cultures, cutaneous biopsy of vesicular lesions, blood tests and lumbar puncture were performed. RESULTS: Biochemistry and blood count showed a CRP of 5.7 mg/dl, leukocytosis with left shift and mild anemia. After 24 hr, the blood analyses showed an increase in a CRP (7.8 mg/dl) and increased progressively for three days; consequently, a lumbar puncture was performed. Blood culture was positive for Staphylococcus aureus. Cutaneous biopsy confirmed the cutaneous candidiasis. CONCLUSIONS: The early diagnosis is essential to prevent complications derived by the Candida albicans in newborns.

Candidiasis cutánea generalizada en recién nacido a término / Generalized cutaneous candidiasis in newborn at term

Introducción. La candidiasis cutánea es una enfermedad que afecta tanto a población infantil como adulta. Las forma de presentación puede ser localizada o sistémica y el agente etiológico múltiple, siendo las especies infecciosas de Candida albicans más prevalentes en niños. Objetivo. Presentar un caso de candidiasis cutánea congénita cuya causa aparente fue la transmisión vertical durante el parto. Material y metodología. Se describe el caso de un recién nacido a término expuesto a una candidiasis vaginal subclínica, que desarrolló una candidiasis cutánea congénita por C. albicans asociada a sepsis y dificultad respiratoria en las primeras 24 horas de vida. Se practicaron hemocultivos, biopsia cutánea de las lesiones pápulopústulo-vesiculosas, análisis de sangre y punción lumbar. Resultados. En la bioquímica y el hemograma se encontró una proteína C reactiva de 5,7 mg/dl, leucocitosis con desviación a la izquierda y anemia leve. A las 24 horas, en el control se encontró una proteína C reactiva (7,82 mg/dl) que fue en aumento progresivo durante tres días, por lo que se practicó punción lumbar. El hemocultivo fue positivo para Staphylococcus aureus. La biopsia cutánea dio como resultado histológico la candidiasis cutánea. Conclusiones. El diagnóstico precoz es fundamental para prevenir complicaciones derivadas del cuadro producido por C. albicans en neonatos.

Introduction. Cutaneous candidiasis is a disease that affects children as well as adults. The presentation may be localized or systemic, and with multiple etiological agents. The most prevalent infecting species in children differs from that of the adult. Objective. A case is presented where a congenital cutaneous candidiasis was transmitted to the child during birth. Materials and methods. A full term newborn was exposed to a subclinical vaginal candidiasis infection, and 24 hr after birth, developed congenital cutaneous candidiasis. The etiological agent was Candida albicans, and was associated with sepsis and respiratory distress. Blood cultures, cutaneous biopsy of vesicular lesions, blood tests and lumbar puncture were performed. Results. Biochemistry and blood count showed a CRP of 5.7 mg/dl, leukocytosis with left shift and mild anemia. After 24 hr, the blood analyses showed an increase in a CRP (7.8 mg/dl) and increased progressively for three days; consequently, a lumbar puncture was performed. Blood culture was positive for Staphylococcus aureus. Cutaneous biopsy confirmed the cutaneous candidiasis. Conclusions. The early diagnosis is essential to prevent complications derived by the Candida albicans in newborns.

Vulvovaginal candidiasis in women who have sex with women.

OBJECTIVES: To determine whether vulvovaginal candidiasis (VVC) is associated with sexual activity between women. STUDY DESIGN: Cross-sectional survey of 708 new patients attending 2 sexual health clinics for lesbians and bisexual women in London, UK. Questionnaire for demographic variables, sexual history, symptoms, and sexual practice data linked with the results of Gram stain and/or culture of vaginal preparations for identification of Candida species. RESULTS: VVC (either symptomatic or asymptomatic) was common in this sample of women who have sex with women (18.4%). Logistic regression showed that VVC was significantly associated with larger numbers of female sexual partners in the previous year [OR 2.18 (CI 1.35-3.53) for 2 female partners compared with 0 or 1] but not with specific sexual practices, numbers of male partners, use of lubricants or vaginal douching. CONCLUSIONS: The increasing odds of candidiasis with greater numbers of female sexual partners raises the possibility that Candida species could be sexually transmitted between women.

Higher-risk behavioral practices associated with bacterial vaginosis compared with vaginal candidiasis.

OBJECTIVE: Bacterial vaginosis has been associated with hormonal factors and sexual practices; however, the cause is unclear, and the notion that bacterial vaginosis is a sexually transmitted infection is still debated. To investigate whether bacterial vaginosis is associated with specific sexual practices or instead has features in common with a sexually transmitted infection, we compared behavioral associations in women with bacterial vaginosis to women with vaginal candidiasis. METHODS: Women with symptoms of abnormal vaginal discharge or odor who attended Melbourne Sexual Health Centre between July 2003 and August 2004 were eligible for enrollment in the study. Information on demographics and behavioral and contraceptive practices were collected by self-completed questionnaire. Participants were tested for bacterial vaginosis, Candida spp (microscopy and culture), and sexually transmitted infections. Statistical comparisons were made between women with and without bacterial vaginosis and women with and without candidiasis, using univariate and multivariate analysis. RESULTS: A total of 342 women were enrolled in the study; 157 were diagnosed with bacterial vaginosis, 51 had candidiasis by microscopy, and 95 had candidiasis by culture. Bacterial vaginosis was associated with indicators of high-risk sexual behavior such as a new sexual partner and greater number of male partners in the last year, increased number of lifetime sexual partners, less than 13 years of education, a past history of pregnancy, and smoking (P < .05). Candidiasis was not associated with these risk behaviors and was instead related to practices such as receptive anal and oral sex and douching. CONCLUSION: The association between bacterial vaginosis and practices that are associated with sexually transmitted infections, in contrast to those observed with candidiasis, suggests a possible sexually transmitted cause. LEVEL OF EVIDENCE: II-2.

[Diagnosis of major sexually transmitted infections in the doctor's office: ectoparasites and yeasts]. / Diagnostik sexuell übertragener Krankheiten: Ektoparasiten und Pilze. Laus und Milbe finden den Weg zum nächsten Wirt auch ohne Sex.

Ectoparasites, such as lice and itch mites (scabies) as well as yeasts, may be transmitted not only by sexual contact, but also by less intimate skin contact. The nits of the louse are visible to the naked eye, while Candida albicans is detected under the microscope or by culture.

[Host-yeast interactions in relation to the urogenital tract, vulvovaginal candidiasis and urologic aspects of mycotic diseases]. / Interakce kvasinek s hostitelem ve vztahu k urogenitálnímu traktu, vulvovaginální kandidóza, urologické aspekty mykotických onemocnení.

OBJECTIVE: A review of the role of yeasts in indigenous microbiota with the focus on urogenital tract. The yeast in vaginal environment and their relation to acute and recurrent form of vulvovaginal candidiasis. DESIGN: A review. SETTING: Department of Obstetrics and Gynecology, Department of Urology, Medical Faculty, Charles University, Hradec Králové. SUBJECT AND METHODS: Review of current literature data with the contribution on own experience. CONCLUSIONS: Vulvovaginal candidiasis is one of the most frequent complaints in patients attending gynecologist. Recurrent form of this disease is still an unsolved problem because the etiopathogenesis is unexplained and successful therapeutic management from the point of view of next attacks is very difficulty.

Candida transmission and sexual behaviors as risks for a repeat episode of Candida vulvovaginitis.

OBJECTIVE: To assess associations between female and male factors and the risk of recurring Candida vulvovaginitis. METHODS: A prospective cohort study of 148 women with Candida vulvovaginitis and 78 of their male sexual partners was conducted at two primary care practices in the Ann Arbor, Michigan, area. RESULTS: Thirty-three of 148 women developed at least one further episode of Candida albicans vulvovaginitis within 1 year of follow-up. Cultures of Candida species from various sites of the woman (tongue, feces, vulva, and vagina) and from her partner (tongue, feces, urine, and semen) did not predict recurrences. Female factors associated with recurrence included recent masturbating with saliva (hazard ratio 2.66 [95% CI 1.17-6.06]) or cunnilingus (hazard ratio 2.94 [95% CI 1.12-7.68]) and ingestion of two or more servings of bread per day (p

Vaginal infections in pregnant women in Jamaica: prevalence and risk factors.

Trichomoniasis, bacterial vaginosis (BV) and candidiasis are reproductive tract infections (RTIs) of the vagina. We conducted a cross-sectional study in 4 prenatal clinics in Kingston, Jamaica, to estimate the prevalence of these infections and the risk factors that may facilitate their transmission among pregnant women. Of the 269 women studied, 18.0% had culture-positive trichomoniasis, 44.1% had BV (Nugent score > or = 7) and 30.7% were positive for candidiasis by wet mount. A multiple logistic regression analysis showed that having a malodorous discharge was associated with trichomoniasis (odd ratios [OR]=3.9, confidence intervals [CI]=1.04-14.7) and BV (OR=3.4, CI=1.3-8.7). Women who took action to prevent HIV infection had lower BV prevalence (OR=0.34, CI=0.12-0.98). Women who were employed were less likely to have any of the infections (OR=0.61, CI=0.36-1.03). The strong association of a symptomatic presentation with trichomoniasis and BV suggests the merit of considering syndromic management of vaginitis in this population.

The value of treating the male partner in vaginal candidiasis.

OBJECTIVE: To determine whether treatment of the sexual partners of women with vulvo-vaginal candidiasis with oral Ketoconazole can affect the cure and recurrence rate of candida vaginitis. METHODS: A total number of 144 women with vaginal candidiasis were treated with Ketoconazole 400 mg daily for 7 days, and half the male partners were treated with Ketoconazole 400 mg daily for 7 days. All women had physical follow-up examination, and mycological cultures were obtained at one week and four weeks after the start of treatment. The incidence of predisposing factors or of a recurrence history did not differ between treatment groups. Chi-square test was used to determine the significance of difference between the two groups with or without simultaneous treatment of the male partners. RESULTS: In the control group (untreated partners) 53 of 72 patients were cured after one week, with a cure rate of 74%, compared to 57 of 72 patients (treated partners) with a cure rate of 79%. The recurrence rate in the control group (untreated partners) 4 weeks after the start of treatment was 28 of 53 (53%), compared to 35 of 57 (61%) in the (untreated partners) group. No significant statistical difference was found in the cure and recurrence rates for both groups. CONCLUSION: Simultaneous treatment of the male partners with Ketoconazole did not influence either cure rate or recurrence rate in women with vaginal candidiasis.