INTRODUCTION:

Vulvovaginal Candidiasis (VVC) represents a spectrum of disease. Although it is the second most common vaginal infection, VVC is a non notifiable disease and has been excluded from the ranks of sexually transmitted diseases. For many years patients with vaginal candida were categorized into two groups : Asymptomatic carriers of Candida (colonization) and Symptomatic disease (Vaginal Candidiasis) .More recently, the concept of “VVC” has replaced these distinct categories and the “vulvar”, often dominant component of symptomatic infection^[32,33].

The presence of Candida in the vagina, in the absence of immunosuppression or damaged mucosa, is usually not associated with any signs of disease and is thus referred to as colonization. In contrast to asymptomatic colonization, VVC is defined as signs and symptoms of inflammation in the presence of Candida spp. and in the absence of other infectious etiology^[12]. Over a decade ago, VVC was classified into uncomplicated and complicated cases, a classification that has been internationally accepted and adapted ^{[1, 2, 3]} .Uncomplicated VVC is characterized by sporadic or infrequent occurrence of mild to moderate disease caused by C. albicans in immunocompetent women. Complicated VVC includes cases of severe VVC, VVC caused by non-C. albicans species.^[17,34,35]

The vaginal pH is often measured to exclude other infections such as bacterial vaginosis or trichomoniasis in which it is high (>4.5), while it is normal (4.0 to 4.5) in VVC. Vaginal culture is the most accurate method for the diagnosis of VVC and is indicated if microscopy is negative but VVC is suspected or in cases of high risk for non-C. albicans VVC. Among the various culture methods, there appears to be no difference between Sabouraud agar, CHROM agar Candida is a selective fungal medium that includes chromogenic substances allowing for quick identification of several different Candida spp. based on their color, which also facilitates the detection of mixed infections with more than one species of Candida^[ ^{4, 5].}Antigen detection or serologic tests as well PCR-based diagnosis are either not yet reliable or not clinically useful because they are too sensitive^[6,13].Candidal vulvovaginitis or vaginal thrush is an infection of the vagina’s mucous membrane by Candida albicans^[7].Up to 75% of women will have this infection at some point in their lives, and approximately 5% will have recurring episodes.^{[8, 14]} It is the second most common cause of vaginal inflammation after bacterial vaginosis.^[9]

It is most commonly caused by a type of fungus known as Candida albicans. The Candida species of fungus is found naturally in the vagina, and is usually harmless. However, if the conditions in the vagina change, Candida albicans can cause the symptoms of thrush^{[18, 19]}. Symptoms of thrush can also be caused by Candida glabrata, Candida krusei, Candida parapsilosis, and Candida tropicalis. Non-albican Candida is commonly found in complicated cases of vaginal thrush such that first line treatment is ineffective^{[20, 21, 22]}. These cases are more likely in immunocompromised patients.^{[10, 24, 25]}

As well as the above symptoms of thrush, vulvovaginal inflammation can also be present. The signs of vulvovaginal inflammation include erythema (redness) of the vagina and vulva, vagina fissuring (cracked skin), edema (swelling from a build-up of fluid), also in severe cases, satellite lesions (sores in the surrounding area)^[27-30]. This is rare, but may indicate the presence of another fungal condition, or the herpes simplex virus (the virus that causes genital herpes).^[11,15,16]In the present study, the prevalence of Vaginal Candidiasis among symptomatic patients coming to the Obstetrics and Gynecology department of SRM hospital has been investigated.

MATERIALS AND METHODS:

A prospective study was carried out from May 2010 to February 2011 to study the prevalence of vaginal candidiasis among symptomatic patients coming to the OG department of SRM hospital, a 1200 bedded tertiary care centre. Written informed consent was obtained from each patient. The perform included patients name, age , sex, date of admission, ward, a brief clinical history, the frequency of menstrual cycle, underlying diseases, antibiotic therapy, presence of any risk factors, steroid intake , pregnancy , diabetes mellitus , use of contraceptives and other symptoms suggestive of vaginal candidiasis like itching , color and odor of vaginal discharge etc.[Performa enclosed in annexure-1].High vaginal swabs were collected aseptically from the patients by standard techniques^[31]. A detailed clinical history was taken and recorded from the patients.

SPECIMEN PROCESSING:

A direct smear for assessment of the cellularity and presence of organism was carried out in all cases. The media for the study were procured from Himedia [Mumbai].The media and the biochemical reagents were prepared following standard procedures[ Textbook of Medical Microbiology, Jagdish Chander, 3^rd edition] [Annexure-2]^[23].Each batch of media and biochemical were tested with suitable controls and was utilized only if it was satisfactory.

The primary isolation of the specimen was done on Sabouraud Dextrose Agar (SDA) with and without antibiotics (Gentamicin) and incubated overnight at 37ºC.The isolates produced cream colored and smooth colonies on SDA^[26]. The isolates were subjected to gram stain which showed gram positive budding yeast cells. A preliminary identification of the isolates was done by performing the germ tube test and inoculating on Corn Meal Agar (CMA) which differentiated Candida albicans from Candida non albicans.

BIOCHEMICAL REACTIONS:

Once presumptively identified as belonging to the genus Candida, the organism was subjected to further identification upon species level based on characteristic biochemical tests which includes Sugar fermentation test, Sugar assimilation test, Pellicle formation in Sabouraud Dextrose Broth (SDB), Urease test and CHROM Agar.

RESULTS AND DISCUSSION:

The present study was carried out from May 2010 to February 2011 in the Obstetrics and Gynecology department of SRM Medical College Hospital which is a tertiary care centre. A total of 68 samples were collected from symptomatic patients attending the outpatient department of Obstetrics and Gynecology.

The demographic profile of the study subjects is shown in Figure 1.The age distribution shows that symptomatic patients were common in the reproductive age group and least among the adolescent and premenopausal age group.

Among the total (n=68), majority of the patients (n=51) were between 21 to 40 years of age.

The distribution of Candida species is depicted in Figure 2.

Of the total (n=68) number of samples collected, Candida albicans constitute only 29% (n=7) compared to Candida non albicans which was 71% (n=17).

Figure 2:

The distribution among pregnant and non pregnant women is given in Figure 3.

Among the pregnant women (n=25) Candida albicans were isolated from 4 samples and Candida non albicans from 6 samples.

Likewise in non pregnant women (n=43) only 3 samples grew Candida albicans and Candida non albicans was isolated from 11 samples.

Figure 3:

Figure 4 depicts the distribution of species among Candida non albicans.

Among the Candida non albicans (n=17), Candida parapsilosis was the commonest isolate 41% (n=7), followed by Candida krusei 23% (n=4), Candida glabrata 18% (n=3), Candida kefyr12% (n=2) and Candida tropicalis 6% (n=1).

Figure4:

Depicts the percentage of diabetic and non diabetic patients

Among the total of 68 symptomatic patients who attended the obstetrics and gynecology department of SRM hospital 1.5 %( n=1) was diabetic whereas 98.5 %( n=67) were no diabetic patients.

Figure 5:

Figure 6 depicts the percentage of antibiotic user and nonuser.

Among the total of 68 symptomatic patients who attended the obstetrics and gynecology department of SRM hospital 6% (n=4) were antibiotic users whereas 94% (n=64) were antibiotic nonusers.

Candida albicans (n=7) assimilated all sugars except dulcitol, whereas Candida parapsilosis (n=7) did not assimilate lactose and dulcitol. Glucose and xylose were assimilated by Candida krusei (n=4) and Candida glabrata (n=3) assimilated glucose, xylose and dulcitol. Candida kefyr (n=2) did not assimilate sucrose and dulcitol; likewise dulcitol and lactose were not assimilated by Candida tropicalis (n=1).

Table 1 shows the distribution of isolates based on sugar fermentation.

ISOLATE	TOTAL	GLUCOSE	MALTOSE	SUCROSE	LACTOSE
C. albicans	+++	+++	+++	-	-
C. parapsilosis	+++	+++	-	-	-
C. krusei	++	++	-	-	-
C. glabrata	++	++	-	-	-
C. kefyr	+	+	+	+	-
C. tropicalis	+	+	+	1+	-

+++ shows high growth, ++ shows moderate growth, + shows less growth

Table 2: DISTRIBUTION OF ISOLATES BASED ON SUGAR

*ISOLATE*	*GLU*	*MAL*	*SUC*	*LAC*	*XYL*	DUL
C. albicans	+	+	+	+	+	-
C. parapsilosis	+	+	+	-	+	-
C. krusei	+	-	-	-	+	-
C. glabrata	+	-	-	-	+	+
C. kefyr	+	-	+	+	+	-
C.tropicalis	+	+	+	-	+	-

+ shows the presence of growth, _ shows the absence of growth.

SUMMARY AND CONCLUDING:

As outlined in this research, genitourinary candidiasis is exceedingly common. Although C. albicans remains the main responsible species, non-C. albicans species are emerging, highlighting the importance of improved and reliable culture techniques. The different disease manifestations are distinct from each other and affect different risk groups, and thus treatment regimens and indications differ also. Despite its high incidence and clinical relevance, genitourinary candidiasis is understudied. From this work we were concluded that Vaginal Candidiasis affects about 50 to 72% of women, 40 to 50% having recurrent episodes. The majority of episodes of VVC are uncomplicated many women in whom recurrent yeast infections are diagnosed have been misdiagnosed. However, further work is required to identify the Recurrent episodes require clinical examination, culture of swabs, and consideration of underlying disease.

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Received on 12.07.2013 Modified on 02.08.2013

Research J. Pharm. and Tech. 6(10): October 2013; Page 1111-1115

Candida Infections of the Genitourinary Tract