Original article / research
|
|||||||||||||||||||||||||||||||||||||||
Characterisation of Candida in Vulvovaginitis Patients with Special Reference to Non albicans from a Tertiary Care Hospital in Mumbai, India |
|||||||||||||||||||||||||||||||||||||||
Nazneen I Malak, Nishat Khan, Vasant Baradkar, Jayanthi S Shastri 1. Senior Resident, Department of Microbiology, Government Medical College, Akola, Maharashtra, India. 2. Assistant Professor, Department of Microbiology, Topiwala National Medical College, Mumbai, Maharashtra, India. 3. Associate Professor, Department of Microbiology, Topiwala National Medical College, Mumbai, Maharashtra, India. 4. Professor and Head, Department of Microbiology, Topiwala National Medical College, Mumbai, Maharashtra, India. |
|||||||||||||||||||||||||||||||||||||||
Correspondence
Address : Dr. Nishat Khan, Assistant Professor, Department of Microbiology, Topiwala National Medical College, Mumbai-400034, Maharashtra, India. E-mail: khannishat.2009@gmail.com |
|||||||||||||||||||||||||||||||||||||||
ABSTRACT | |||||||||||||||||||||||||||||||||||||||
: Vulvovaginal Candidiasis (VVC) is one of the commonest vaginal infections caused by Candida spp. affecting women of reproductive age group. Though Candida spp. is of endogenous origin several host related and behavioural factors can contribute to the development of infection. Candida albicans is the commonest spp. responsible for infection. However, an increasing emergence of Non-albicans Candida (NAC) has led to the development of recurrent infections, treatment failure and complications. Aim: To characterise Candida spp. isolated from clinically suspected cases of VVC. Materials and Methods: It was an observational prospective study done during the period of May 2017 to Oct 2018. A total of 150 vaginal isolates from samples of vaginal discharge were included in the study. Candida spp identification was done by various methods like gram stain, germ tube test, culture on Sabouraud Dextrose Agar (SDA), Dalmau culture on corn meal agar, colour differentiation on CHROMagar (Chromogenic agar) and sugar assimilation tests. Statistical Package for Social Science (SPSS) was used for statistical analysis. Results: Women of age group 26-35 years were most commonly affected population. Candida albicans (49.3%) and NAC (50.7%) both were present in almost equal number. The commonest isolate found was Candida albicans (49.3%) followed by Candida glabrata (29.3%) and Candida tropicalis (21.4%). Conclusion: Highest infection rate (54%) was seen in the women of age group 26-35 years. Candida albicans being the commonest spp. As NAC are emerging rapidly, speciation will play a vital role in appropriate selection of antifungal agents for the treatment of fungal infections prior to the initiation of therapy. | |||||||||||||||||||||||||||||||||||||||
Keywords : Chromogenic agar, Fungal infections, Speciation, Vaginal candidiasis | |||||||||||||||||||||||||||||||||||||||
INTRODUCTION | |||||||||||||||||||||||||||||||||||||||
The VVC is the second most common vaginal infection affecting millions of women of reproductive age every year (1). VVC is defined as signs and symptoms of inflammation in the presence of Candida spp. and in the absence of other infectious aetiology (2). Candida spp. can be isolated from genital tract in upto 25% of asymptomatic healthy women of child bearing age (3). Nearly 70-75% of women over 25 years of age report to have atleast one episode of VVC during lifetime. The recurrence rate is 40-50% and 5-8% have Recurrent VVC (RVVC) which is characterised by four or more episodes of the disease over a period of one year (4). Certain physiological changes in the body like pregnancy, hormones, use of oral contraceptives, intra-uterine devices may lead to Candida vaginal colonisation. Use of immunosuppresants, glucocorticoids, can also lead to Candida infection (5). VVC is diagnosed clinically in a large proportion of women in reproductive age group presenting with complaints of curdy white vaginal discharge accompanied by vulvovaginal pruritis, dyspareunia and red swollen vulva and vaginal mucosa. However, accurate diagnosis can be made by microscopic examination and culture (6). The morbidity associated with VVC causes mental distress, altered self-esteem, anxiety, impairing work performance and interfering with sexual relations (7). Candida albicans is the most common pathogen in 80-90% of cases of VVC (8). However, there is an alarming increase of NAC species over last decade. Emperical use of antibiotics, over the counter use of antifungals, immunosuppressive conditions like Human Immunodeficiency Virus (HIV), autoimmune conditions or other severe illness may be responsible for the growing NAC (9). The prevalence of NAC has been found to be 10-30% in patients with VVC (10). Most commonly implicated NAC species include Candida glabrata, Candida tropicalis, Candida krusei and Candida parapsilosis (11). VVC can be classified into uncomplicated and complicated cases. Uncomplicated VVC is characterised by sporadic or infrequent VVC with mild to moderate severity caused by Candida albicans in apparently healthy non-immunocompromised women. Complicated VVC include episodes due to NAC species or severe cases caused by any Candida spp. Moreover, both RVVC which is characterised by four or more episodes of the disease over a period of one year and VVC are classified as complicated when associated with recognised risk factors like diabetes, immunocompromised conditions like HIV or immunosuppressive therapy like corticosteroids (12). Azoles are the most frequent class of antifungals used to treat Candida infections. Since fluconazole is also used in the syndromic management of Reproductive Tract/Sexually Transmitted Infections (RTI/STI) program, in the kit for vaginal discharge, this may be a cause of recurrent infections and treatment failure by NAC. Further, if VVC is not treated on time, many complications occur, such as pelvic inflammatory disease, infertility, ectopic pregnancy, pelvic abscess, spontaneous abortion and menstrual disorders. Prevention, early diagnosis and prompt treatment of VVC are therefore essential to avert the complications (10). Since, VVC is frequently encountered in women visiting the gynaecology clinic, this study was initiated to characterise Candida spp. isolated from clinically suspected cases of VVC. Early speciation would help the clinician in selecting proper antifungal drug and thereby reducing the emerging resistance. Hence this study was carried out. | |||||||||||||||||||||||||||||||||||||||
MATERIAL AND METHODS | |||||||||||||||||||||||||||||||||||||||
The present study was an observational prospective study which was carried out in the microbiology laboratory of Topiwala National Medical College, Mumbai, Maharashtra, India from May 2017 to October 2018 after approval from the institutional ethics committee, ECARP/2017/02. A total of 150 vaginal Candida isolates from samples of vaginal discharge received during this period were included in the study. As the study was carried on laboratory isolates, there was no patient history/neither informed consent was needed. Patients who had any other fungal infection and were on antifungals were excluded from the study. The isolates received were processed by standard mycological tests (13). Age of all the patients whose sample were received was recorded to know the common occurrence. Gram smear was performed on all the isolates for the presence of gram positive budding yeast cells (Table/Fig 1). The isolates were subcultured on Sabouraud Dextrose Agar (SDA) with antibiotics to observe different morphologies of Candida spp. as shown in (Table/Fig 2). To differentiate between Candida albicans and NAC germ tube test was performed (Table/Fig 3) (14). Further speciation of NAC spp was done by Dalmau culture method on corn meal agar. The production of chlamydospore, arrangement of blastospores and pseudohyphae were observed extensively by this method (Table/Fig 4). CHROMagar was used to identify species on the basis of colour (14). Sugar assimilation test was performed with Maltose, Sucrose, Lactose, Cellobiose, Trehalose and Dulcitol sugars, presence of growth around the disc indicating a positive test (14). STATISTICAL ANALYSIS SPSS version 25.0 was used to analyse the data. Data was entered and percentages were calculated. | |||||||||||||||||||||||||||||||||||||||
RESULTS | |||||||||||||||||||||||||||||||||||||||
A total of 150 isolates were received. The women in the study were divided into different age groups. Highest infection rate of 54% was seen in age group of 26-35 years as shown in (Table/Fig 5). Of the total number of isolates (n=150), Candida albicans (49.3%) and NAC (50.7%) were in almost equal number. Different colony morphology were seen on Corn meal agar as described in (Table/Fig 6), (Table/Fig 7), (Table/Fig 8). On CHROMagar medium, light green colour was shown by all the Candida albicans isolates (49.3%) whereas all the isolates of Candida glabrata (29.3%) and Candida tropicalis (21.4%) showed pink and blue purple colour respectively. (Table/Fig 9) shows sugar assimilation results given by different Candida spp. All the isolates of Candida glabrata were positive for dulcitol whereas Candida albicans and Candida tropicalis were differentiated by lactose sugar. Hence, on the basis of the above mentioned tests, NAC isolated were Candida glabrata and Candida tropicalis. Amongst the total NAC spp (n=76), Candida glabrata (n=44) (57.9%) was commonest followed by Candida tropicalis (n=32) (42.1%). Among the total isolated Candida spp (n=150), Candida albicans (n=74) was the predominant species followed by Candida glabrata (n=44) and Candida tropicalis (n=32) (Table/Fig 10). | |||||||||||||||||||||||||||||||||||||||
DISCUSSION | |||||||||||||||||||||||||||||||||||||||
The VVC affects females of reproductive age group causing abnormal vaginal discharge. Changes in vaginal flora, acidity of vaginal fluid, hormonal variation and various host related and behavioural factors cause Candida spp to induce pathological changes and thereby cause infection in the vagina (2). Although Candida albicans is responsible for the largest number of symptomatic episodes of vaginal discharge, the occurence of NAC species is increasing. NAC spp cause various complications like pelvic inflammatory disease, infertility, ectopic pregnancy, spontaneous abortion and menstrual disorders (6). Thus, to avoid such complications and recurrence and to give an effective therapy to patients it is necessary to speciate Candida. In this study, the common age group affected was 26-35 years followed by 36-45 years. This suggests that women in reproductive age group were more vulnerable to vaginal candidiasis. Similar findings were reported by Lakshmi N et al., who showed 45% infection rate in 26-35 years age group followed by 25% in 36-45 years age group (11). Also, Babin D et al., reported 49.58% as the highest infection rate in the age group 26-35 years (15). The spp isolation in different studies is shown in (Table/Fig 11) (11),(15),(16),(17),(18). The above studies show a preponderance of NAC, however in present study both had an equal isolation. NAC were further speciated by colony morphology on corn meal agar, colour differentiation on CHROMagar and sugar assimilation tests. The NAC species found in this study were Candida glabrata that predominated with 57.9% followed by Candida tropicalis (42.1%).This finding correlated with the report of Gandhi TN et al., (17) in which Candida glabrata (15.65%) was the commonest NAC spp followed by 9.85% Candida tropicalis. Also, Muthusamy S and Elangovan S, reported 22.91% Candida glabrata as the commonest NAC species (16). Distribution of Candida isolates in this study included Candida albicans (49.3%) followed by Candida glabrata (29.3%) and Candida tropicalis (21.4%). Similar findings were reported by Gandhi TN et al., showing 66.4% Candida albicans followed by 15.65% Candida glabrata and 9.85% Candida tropicalis (17). Muthusamy S and Elangovan S, reported Candida albicans (45.8%) as the predominant species followed by 22.91% of Candida glabrata followed by 14.58% Candida parapsilosis and 8.33% Candida tropicalis (16). However, Candida parapsilosis was not reported in this study. Thus, in this study, both Candida albicans and non-albicans spp were isolated. Limitation(s) As the study was carried out on laboratory isolates, clinical history of the patients was not taken and hence clinical parameters were not included in this study. | |||||||||||||||||||||||||||||||||||||||
CONCLUSION | |||||||||||||||||||||||||||||||||||||||
This study showed highest infection rate in females of reproductive age group. The findings of the study suggest that the albicans and non-albicans species of Candida are both associated with vaginal infections. Speciation of Candida will help the clinicians in advising proper antifungal therapy as NAC infections do not respond to the commonly used drugs. This will prevent recurrent infections in patients and also prevent resistance in the organisms due to improper use of antifungals. | |||||||||||||||||||||||||||||||||||||||
|
|||||||||||||||||||||||||||||||||||||||
TABLES AND FIGURES | |||||||||||||||||||||||||||||||||||||||