Vulvovaginal in overuse of topical antifungal agents,

Vulvovaginal Candidiasis (VVC) mostly affects women of
childbearing age and it is the second most common form of vaginitis.1Approximately
75% of women have at least one episode of VVC and around 40–45% of women have
two or more episodes of VVC in their lifetime. Vulvo- vaginal yeast infection occurs due to overgrowth of Candida species. These yeast cells are normally
present in the vagina in small numbers ( Commensals). Risk of infection is
higher in women having diabetes mellitus, on oral contraceptives, Human
Immuno-deficiency Virus (HIV)/ Acquired Immuno-deficiency Syndrome (AIDS), using
broad spectrum anti-biotic therapy, pregnant women and women involved in
receptive oral sex. 2-4  Pregnant women have a
two-fold increase in the prevalence of vaginal colonization by Candida species
compared with non-pregnant women.5 Women having high sugar intake have higher risk of getting
VVC. VVC can be due to several different species of Candida, but C. albicans is considered as one of the
true vaginopathic agents. 6-7

According
to CDC, the diagnosis of Candida vaginitis is suggested by the presence of
the following symptoms: external dysuria and vulvar pruritus, pain, swelling,
and redness. Signs include vulvar edema, fissures, excoriations, and thick
curdy white vaginal discharge.

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Incorrect
diagnosis results in overuse of topical antifungal agents, with subsequent risk
of contact and irritant vulvar dermatitis. Studies done have shown that the
percentage of Candida albicans isolates showing susceptibility to azoles was
significantly lower in recurrent VVC than in VVC and recurrent VVC is mostly caused
by non albican species 8

There are several methods that are
being used for antifungal susceptibility testing like broth micro dilution and
disk diffusion method. Many commercial methods are being used in the developed
world for antifungal susceptibility testing.

 

OBJECTIVE

The aim of
the study is to:

·       
Identify
the species of Candida causing Vulvo- vaginal candidiasis(VVC)

·       
Identify
risk factors involved in
associated with VVC.

·       
To
perform anti fungal susceptibility of the fungal isolates.

 

METHODOLOGY

Collection
of Specimens:
 A swab from 100 clinically suspected cases of VVC will
be taken from outpatients and inpatients in the Gynaecology and Obstetrics
Department. Complete medical history of the patient will be recorded. Equal number of swabs from a
control group will be taken.

 

Following
procedures are to be done with the collected Sample:

 

Wet
Mount: The vaginal
discharge is mixed with a solution of 10% Potassium Hydroxide (KOH). The solution will be covered with a cover slip
and will be observed under low power and high power.

 

Gram
Staining: Gram’s stain will be performed and observed
microscopically for the presence of pus cells, budding yeast cell and
pseudohyphae.

 

Cultures:
The sample which will be emulsified in sterile saline and this suspension will
be inoculated on to the Sabouraud dextrose agar (SDA) and Blood Agar.

 

SDA and Blood
Agar plates will be incubated at 25°C for 48 hours.

 

Candida CHROMagar: Different species of Candida can be
identified by the growth on CHROMagar. Colour of the colonies will be recorded.

 

Germ
Tube Confirmatory Test: Germ tube test will be conducted from the growth on
SDA. Germ
tube test is a diagnostic
test in which loop full of
the colony is suspended in human serum and incubated at 37°C for 2
to 4 hours. Presence of any germ tube on direct microscopy confirms  Candida
albicans.

 

Anti
Fungal Susceptibility testing using Candifast:

Presence or absence of the growth of yeast
with various antifungal agents is the basic principle for the different anti
fungal susceptibility tests.

 

Candifast:
The Candifast kit is used for the identification of Candida species and testing
of their susceptibility to antifungal agents Amphotericine B, Nystatine,
Flucytosine, Econazole, Ketoconazole, Miconazole and Fluconazole.

The test will be performed using colonies
which are 24 to 48 hours old and isolated on SDA. The 20-well tray of Candifast
has all the required reagents and no additional reagent is need to be added to complete
the test.

 

Statistical
Analysis:

The recorded data will be analysed using
relevant statistical methods.

 

IMPLICATION

Fungi which
were considered as non-pathogenic or less virulent are now the primary cause of
morbidity and mortality in immune-compromised and severely ill patients. The predominant
causative agent of candidiasis has shifted from C. albicans to non-albicans species.xx

 Antifungal tests are needed because the VVC
infections are becoming complicated day by day due to the following reasons:

(i)               
the increase in number of patients with profound
immunosuppression and a related increase in incidence and mortality rates of
invasive fungal infections that affect these patients.11-12

(ii)             
the emergence and recognition of antifungal resistance.20

Various studies show that Non-albicans
Candida species have reduced susceptibility to commonly used antifungal
drugs. xx Thus, it is important to know which species of Candida is most
prevalent and also know the anti fungal susceptibility pattern, so that appropriate therapy can
be given.