Vaginal candidosis: epidemiological and etiological factors

A review is presented of the emerging problem of candidal colonization regarding epidemiological and etiological factors. In recent years a change in epidemiological trends has been observed. Vaginal candidosis seems to show a higher frequency to recur and a significant increase in infections caused by non albicans species of candidas has been stated. The three stage mechanisms of adhesion, blastopore germination and epithelium invasion are emphasized. There is a balance between candidal organisms and vaginal defense factors (lactobacilli, cellular and humoral immunity) controlling and limiting fungal growth. Vaginitis appears because of an increased number or an enhanced virulence of candidas. In some other patients, a decreased vaginal defense mechanism is a determinant factor. There are still a number of factors involved in clinical candidal vulvovaginitis that need to be clarified.

[Vaginal candidiasis: frequency of occurrence and risk factors]

OBJECTIVE

Our purpose was to determine the incidence, risk factors and pregnancy outcome among women with vaginal growth of Candida species.

MATERIALS AND METHODS

In the period from January 1, 1994 to December 31, 1997 inoculation results have been assessed of vaginal secretions collected on a standard Sabouraud base and demographic data has been collected of 10,825 pregnant women delivering in single and full-term pregnancy in the Municipal Hospital in Bydgoszcz.

RESULTS AND CONCLUSIONS

Positive inoculation results for Candida sp. has been noted by 2248 women, which constitutes 20.77% from the delivering women meeting the above mentioned conditions. Properties correlated with positive inoculation results were: living in the country (23.55%), age--below 20 years (24.56%), civil status--widow or divorced (23.88%), vocation (22.66%) or primary education (22.44%), unemployment (22.82%), third or further birth (21.26%) and earlier pregnancy complications (22.46%). An analysis of two simultaneously occurring factors has disclosed a very high percentage of positive inoculation results--in the group of women attending school and residing in the country (37.50%) and women below 20 years of age that have had earlier pregnancy complications (42.31%).

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.

Sexual behaviors and other risk factors for Candida vulvovaginitis

Sexual behaviors are associated with many genital infections, but the role of sexual variables as risk factors for Candida vulvovaginitis has not been clearly determined. To assess the association between sexual behaviors and other risk factors with the presence of Candida vulvovaginitis, we performed a case-control study comparing these potential risk factors in women with and without culture-documented Candida vulvovaginitis in two Midwestern community-based medical offices. Participants included 156 women with Candida vulvovaginitis and 92 controls, ages 18-60. Risk factors for Candida vulvovaginitis, including sexual and partnership behaviors, demographic data, past genital infections, exposures, and diet, were investigated using logistic regression. The presence of Candida vulvovaginitis was positively associated with recent cunnilingus (odds ratio [OR] = 2.22 for five times a month compared with no times, 95% confidence interval [CI] 1.36, 3.84), but was less likely in women who masturbated with saliva in the previous month (OR = 0.30 if masturbated five times vs. no times, 95% CI 0.09, 0.99). Other independent risk factors included knowing the sexual partner a shorter period of time (OR = 1.56 for 1 year vs. 5 years, 95% CI 1.16, 2.13) and lower milk ingestion (OR = 3.57 for no servings vs. two servings per day, 95% CI 2.00, 6.67). Increased number of sexual partners, early age at first intercourse, and increased frequency of intercourse are not related to risk.

Treatment of recurrent vulvovaginal candidiasis

Vulvovaginal candidiasis is considered recurrent when at least four specific episodes occur in one year or at least three episodes unrelated to antibiotic therapy occur within one year. Although greater than 50 percent of women more than 25 years of age develop vulvovaginal candidiasis at some time, fewer than 5 percent of these women experience recurrences. Clinical evaluation of recurrent episodes is essential. Patients who self-diagnose may miss other causes or concurrent infections. Known etiologies of recurrent vulvovaginal candidiasis include treatment-resistant Candida species other than Candida albicans, frequent antibiotic therapy, contraceptive use, compromise of the immune system, sexual activity and hyperglycemia. If microscopic examination of vaginal secretions in a potassium hydroxide preparation is negative but clinical suspicion is high, fungal cultures should be obtained. After the acute episode has been treated, subsequent prophylaxis (maintenance therapy) is important. Because many patients experience recurrences once prophylaxis is discontinued, long-term therapy may be warranted. Patients are more likely to comply when antifungal therapy is administered orally, but oral treatment carries a greater potential for systemic toxicity and drug interactions.

Chronic vaginal candidiasis. Management in the postmenopausal patient

Vulvovaginal candidiasis (VVC) is a cause of significant morbidity in many women of a childbearing age worldwide. There is a paucity of literature on the prevalence of this condition in postmenopausal women, although it is believed to be uncommon because of the estrogen dependence of VVC. Postmenopausal women who have underlying risk factors for VVC (e.g. hormone replacement therapy, uncontrolled diabetes mellitus, immunosuppression caused by medication or disease) may be at risk of chronic or recurrent VVC. However, as in younger women, it is likely that, even after exhaustive investigations, no cause will be found in a significant number of patients. The investigation and treatment of VVC in older women should be the same as that undertaken in younger women. Both topical and oral preparations are available, but oral regimens are perhaps more acceptable because of the ease of administration and avoidance of potentially messy creams and suppositories. Ketoconazole at a dosage of 400 mg daily for 14 days can be used to achieve clinical remission of symptoms and negative fungal cultures. Induction treatment should be followed by maintenance therapy for 6 months with ketoconazole 100 mg daily, itraconazole 50 to 100 mg daily or fluconazole 100 mg weekly or 150 mg monthly. Short courses of topical therapy, e.g. 500 mg clotrimazole pessaries as a single weekly dose for 6 months or 100mg miconazole pessaries twice weekly for 3 months, followed by once weekly for 3 months may also be used.

Effects of reproductive hormones on experimental vaginal candidiasis

Vulvovaginal candidiasis (VVC) is an opportunistic mucosal infection caused by Candida albicans that affects large numbers of otherwise healthy women of childbearing age. Acute episodes of VVC often occur during pregnancy and during the luteal phase of the menstrual cycle, when levels of progesterone and estrogen are elevated. Although estrogen-dependent experimental rodent models of C. albicans vaginal infection are used for many applications, the role of reproductive hormones and/or their limits in the acquisition of vaginal candidiasis remain unclear. This study examined the effects of estrogen and progesterone on several aspects of an experimental infection together with relative cell-mediated immune responses. Results showed that while decreasing estrogen concentrations eventually influenced infection-induced vaginal titers of C. albicans and rates of infection in inoculated animals, the experimental infection could not be achieved in mice treated with various concentrations of progesterone alone. Furthermore, progesterone had no effect on (i) the induction and persistence of the infection in the presence of estrogen, (ii) delayed-type hypersensitivity in primary-infected mice, or (iii) the partial protection from a secondary vaginal infection under pseudoestrus conditions. Other results with estrogen showed that a persistent infection could be established with a wide range of C. albicans inocula under supraphysiologic and near-physiologic (at estrus) concentrations of estrogen and that vaginal fungus titers or rates of infection were similar if pseudoestrus was initiated several days before or after inoculation. However, the pseudoestrus state had to be maintained for the infection to persist. Finally, estrogen was found to reduce the ability of vaginal epithelial cells to inhibit the growth of C. albicans. These results suggest that estrogen, but not progesterone, is an important factor in hormone-associated susceptibility to C. albicans vaginitis.

Determinants of incident vulvovaginal candidiasis in human immunodeficiency virus-positive women

OBJECTIVE

Mucosal infections including vulvovaginal candidiasis are a common problem for women with human immunodeficiency virus (HIV) infection. Our objective was to determine which factors predict the development of symptomatic disease among HIV-infected women.

MATERIALS AND METHODS

In a prospective study from 1991 to 1995, 205 HIV-positive women were evaluated every 6 months for occurrences of vulvovaginal candidiasis. Included in the study were all initially asymptomatic women, whether they were fungal-culture-positive or -negative at baseline. Excluded from the study were all women with symptomatic vulvovaginal candidiasis at the initial visit, those who developed trichomonas vaginitis at any visit, and those who used any antifungal agents.

RESULTS

The risk of the development of vulvovaginal candidiasis did not differ between women who were asymptomatically colonized at baseline and those who were fungal-culture-negative. However, the risk of developing vulvovaginal candidiasis was increased 6.8 times for women with CD4 counts less than 200 cells/mm3 at baseline.

CONCLUSIONS

Fungal culture is not predictive of the development of symptomatic vulvovaginal candidiasis. Women infected with HIV who have CD4 counts below 200 cells/mm3 should be monitored more carefully for vulvovaginal candidiasis.

Increased severity of Candida vaginitis in BALB/c nu/nu mice versus the parent strain is not abrogated by adoptive transfer of T cell enriched lymphocytes

The role of the host immune system in combating candidal infections in the vagina is poorly understood. A murine model of Candida vaginitis was used to elucidate the role of T cells in a candidal infection. Athymic BALB/c nu/nu mice or normal BALB/c mice were induced into estrus and then infected with 1 x 10(6) Candida albicans intravaginally. The infection was monitored over 1 week. Samples from blood, small intestine, tongue, kidney, spleen, liver, uterus and vagina were tested for recoverable C. albicans. Histology of the vagina was assessed for both inflammation and extent of infection. Results indicated that the BALB/c nu/nu mice had similar levels of vaginal yeast load to the normal BALB/c mice. In 25-30% of nude mice Candida was also recovered from extra vaginal sites (kidney, liver, small intestine), however, extra vaginal dissemination was not observed in any normal BALB/c animals. Histologically, both the nu/nu and control BALB/c had similar levels of vaginal inflammation; however, the nu/nu mice had more florid fungal growth in the vaginal epithelium. Adoptive transfer of either immune or non-immune BALB/c T cells into nude mice had no affect on either infection or vaginal inflammation. Immunohistochemical staining of vaginal tissues from normal BALB/c mice or nude mice adoptively transferred with either immune or non-immune T cells with anti-CD3 monoclonal antibody revealed no significant difference between groups in the numbers of CD3+ vaginal T cells. However, in mice receiving either immune or non-immune T cells no yeast was recovered from any tissues except the vagina. These data show that T cells have a limited role in protecting the vagina from C. albicans infection.

Biotyping and virulence properties of skin isolates of Candida parapsilosis

The biotype and virulence of skin isolates of Candida parapsilosis were compared with blood isolates of the same fungus. Morphotype, resistotype, and electrophoretic karyotype determinations did not reveal any special cluster with a unique or dominant pathogenic feature among all of the isolates, regardless of their source. However, all cutaneous isolates had uniformly elevated secretory aspartyl-protease (Sap) activity, more than four times higher than the enzyme activity of the blood isolates. They were also highly vaginopathic in a rat vaginitis model, being significantly more virulent than blood isolates in this infection model. In contrast, skin isolates were nonpathogenic in systemic infection of cyclophosphamide-immunodepressed mice, while some blood isolates were, in this model, highly pathogenic (median survival time, 2 days, with internal organ invasion at autopsy). Finally, skin isolates did not differ, as a whole, from blood isolates in their adherence to plastic. This property was associated with a morphotype, as defined by a colony with continuous fringe, which was present among both skin and blood isolates. While confirming the genetic heterogenicity of C. parapsilosis, our data strongly suggest that the potential of this fungus to cause mucosal disease is associated with Sap production and is substantially distinct from that of systemic invasion.

Women and HIV: when to test?

The devastating effects of HIV infection in women can be altered dramatically with new therapies. Certain clinical syndromes, including oral thrush, diffuse lymphadenopathy, wasting, unexplained fevers, or oral hairy leukoplakia, clearly indicate a need for HIV testing. This article reviews other clinical syndromes, both gender-specific and non-gender-specific, that may prompt the practitioner to consider HIV testing.

[Chronic and recurrent vulvovaginal candidiasis]

Approximately 15 % of non-pregnant women and 30 % of pregnant women yield positive cultures of Candida species in the vaginal specimens. A diagnosis of vulvovaginal candidiasis (VVC) should only be made when Candida spp. are isolated from the vulvovaginal area, together with the presence of signs and symptoms. In Japan several topical drugs for vaginal candidiasis are available, but oral azoles has not been approved. According to our studies, treatment with topical drugs resulted in symptomatic cure and negative culture conversion in 80 %-90 % of patients at the end of initial treatment (6-14 days or high-dose one day treatment according to the drug used). However Candida spp. reappeared in the vagina after several weeks in 7-34 % (according to the drug used) of initially cured cases, and some of them were again symptomatic. A small proportion of women experienced three or more episodes of symptomatic VVC annually. Repeated reinfection from a gastrointestinal reservoir or sexual transmission, subclinical presence of yeasts in the vagina, impaired host defense mechanisms, enhanced Candida virulence have been discussed as factors relating to recurrent vulvovaginal candidiasis (RVVC). Oral ketoconazole give the best result in treating RVVC, however it is not used because of possible side effects. Several studies have evaluated oral therapy for RVVC with fluconazole and itraconazole that have less side effects. However, several reports have documented the emergence of fluconazole-resistant candidiasis in long-term treatment of mycotic diseases other than VVC. The optimal treatment for RVVC remains difficult to establish.

[A twelve-year old girl with diabetes mellitus type 2]

A 12-year-old very obese girl was referred for hyperglycaemia. She had no complaints apart from a recent vaginal candidiasis. Non-insulin-dependent diabetes mellitus (type 2 diabetes) was diagnosed. She was started on a hypocaloric diet and on an oral hypoglycaemic agent (metformin 500 mg/day). This case illustrates the importance of awareness of the existence of type 2 diabetes in childhood and adolescence.

Vaginal candidiasis: review and role of local mucosal immunity

Vulvovaginal candidiasis is a common mucosal fungal infection in women of child-bearing ages. Despite the role for cell-mediated immunity and T cells in host protection against the majority of mucosal Candida albicans infections, there is controversy as to whether immunosuppression by HIV infection enhances susceptibility to vaginal candidiasis. To date, host defense against C. albicans vaginitis has been studied in women with recurrent vaginitis, in HIV-infected women, and in animal models of experimental vaginitis. Together, data suggest that local immunity is more important than that in the systemic circulation for host defense against vaginitis. Thus, current investigations have been focused specifically on innate and acquired immune responses against C. albicans at the vaginal mucosa. This review will discuss the current knowledge of host defenses against C. albicans vaginitis, both systemically and locally, and try to shed some light on several issues surrounding the efficiency of this seemingly compartmentalized immune response.

Managing patients with vulvovaginal candidiasis

Epidemiologic studies have demonstrated a continuing increase in the prevalence of vulvovaginal candidiasis. Although in the past most of these infections were caused by Candida albicans, an increasing percentage are caused by non-albicans Candida species that are less sensitive to the most frequently used antifungal agents. An accurate diagnosis of these infections and the subsequent choice of the most appropriate therapy can only be made after a thorough evaluation of the patient. Successful treatment of vulvovaginal candidiasis is dependent on compliance with therapy; thus, the treatment regimen chosen should fit the patient's daily lifestyle. Newer single-dose regimens offer the option of completing therapy with a single treatment for most patients with uncomplicated vaginal candidiasis. Use of topical agents avoids the potential systemic adverse effects and drug interactions that have been noted with oral antifungals. Patient education and support can also enhance satisfaction with the treatment plan and promote compliance.

Epidemiology and in vitro activity of antimycotics against candidal vaginal/skin/nail infections in Singapore

BACKGROUND

Candidal infections of the skin/nails and vagina are very common worldwide. Various in vitro test systems are available to help to determine the antifungal activity of drugs. The minimum inhibitory concentration (MIC) is a standard measure of the in vitro potency of drugs against yeasts.

METHODS

Vaginal smears and skin/nail scrapings of 50 consecutive patients with candidal vaginitis and 46 consecutive patients (28 women, 18 men) with cutaneous/nail candidosis were used in the study. Direct microscopy and culture from vaginal smears and skin scrapings were performed on all patients. The MICs were determined using the broth dilution method.

RESULTS

For vaginal candidosis, the mean age of the patients was 28.2 years (range, 9-49 years). Candida albicans accounted for 58% of the isolates, C. glabrata for 32%, C. tropicalis for 6%, and C. parasilosis for 4%. At the MIC of < or = 4 mg/L, 65-95% of C. albicans, 66-94% of C. glabrata, 33-100% of C. tropicalis, and 0-50% of C. parasilosis were susceptible to the drugs tested (ketoconazole, itraconazole, nystatin, amorolfine, clotrimazole, and miconazole). For cutaneous/nail candidosis, the mean age of the patients was 45 years (range, 19-82 years). C. albicans made up 59% of the isolates, C. parasilosis 20%, C. krusei 13%, C. glabrata 4%, and C. tropicalis 4%. At the MIC of < or = 4 mg/L, 59-96% of C. albicans, 100% of C. glabrata, 83-100% of C. krusei, 89-100% of C. parasilosis, and 100% of C. tropicalis were susceptible to the drugs tested (ketoconazole, itraconazole, nystatin, amorolfine, clotrimazole, and miconazole).

CONCLUSIONS

C. albicans is the most common Candida species causing cutaneous/nail and vaginal candidosis in Singapore. The in vitro antifungal activities of ketoconazole, itraconazole, nystatin, amorolfine, clotrimazole, and miconazole are similar against the various Candida species. C. parasilosis in vaginal candidosis appears to be less susceptible. Here, itraconazole and amorolfine may be more effective.

Vulvovaginal candidiasis: epidemiologic, diagnostic, and therapeutic considerations

Although it is the second most common vaginal infection in North America, vulvovaginal candidiasis is a non-notifiable disease and has been excluded from the ranks of sexually transmitted diseases. Not surprisingly, vulvovaginal candidiasis has received scant attention by public health authorities, funding agencies, and researchers. Epidemiologic data on risk factors and pathogenic mechanisms remain inadequately studied. Most important, standards of care, including diagnosis and therapy, remain undefined. A conference was held in April 1996 to define and summarize what is known and supported by scientific data in the areas of epidemiology, diagnosis, and treatment of vulvovaginal candidiasis; but, more important, the conference aimed at defining what is not known, poorly studied, and controversial. Guidelines for the treatment and diagnosis of the different forms of vulvovaginal candidiasis are suggested.

[Mycotic vulvovaginitis]

Vulvovaginitis is the most common clinical manifestation of fungal infections causing human mycoses; the incidence occurs in 10% of women, during pregnancy the incidence achieves 30% of cases. Candida albicans has resulted to be the most commonly isolated agent in patients with fungemia. In fact, Candida appears to be the species recovered in as many as 90% of cases. They are mainly the sexual activity, hormonal contraception and several pathologies such as diabetes mellitus and thyroiditis responsible for the pathogenesis of infection. The first symptom of this infection is usually pruritus associated to leukorrhea, dyspareunia and vulvovaginal irritation. Antifungal therapy may be required in more severe cases of vulvovaginal candidiasis. Candida species can be identified on isolation culture media including agar and on direct examination. Diagnosis can also be made through san immunologic examination. However, the authors confirm that the risk factors together with a correct diagnosis of the Candida etiological agent in the different species (albicans, glabrata, tropicalis, krusei) should be accurately investigated in order to give the correct therapeutical approach.

Sex, thrush and bacterial vaginosis

Bacterial vaginosis (BV) is the most common cause of vaginal discharge in women of childbearing age. In some women it shows a relapsing and remitting course with apparently spontaneous onset and resolution. There are intermediate patterns of vaginal flora in which lactobacilli and other species co-exist. We asked women with recurrent BV to prepare vaginal smears daily, and to record symptoms, time of menstruation, sexual activity and use of douches or medication. We Gram-stained the smears and assigned a Nugent score for BV, and noted the presence of candida, pus cells, sperm and blood. Eighteen women collected daily vaginal smears for up to 10 months. Forty months of slides were collected in total. Bacterial vaginosis arose spontaneously on 23 occasions. We saw candida arise 11 times. Bacterial vaginosis appeared after candida on 9 of these 11 episodes. We saw BV regress spontaneously 13 times. Nine of these resolutions occurred within 48 h of unprotected sexual intercourse: BV only arose on one occasion within 48 h of unprotected intercourse. The intermediate pattern was seen for up to 10 days, and occurred as BV began or resolved in some women, and sometimes resolved without developing into BV. Bacterial vaginosis arose most often in the first 7 days of a menstrual cycle, and resolved spontaneously most often in mid-cycle. In women with recurrent BV, BV arises most often around the time of menstruation and resolves spontaneously in mid-cycle. Recurrences often follow an episode of candidiasis, and BV often regresses after unprotected sexual intercourse.

The impact of contraceptive methods on the onset of symptomatic vulvovaginal candidiasis within the menstrual cycle

OBJECTIVE

Vulvovaginal candidiasis is the second most common cause of vaginal discharge. Low-dose oral contraceptives are no longer thought to increase the absolute risk of episodic vulvovaginal candidiasis. This study investigates the possible impact that hormonal contraception may have on the timing of onset of symptoms within the menstrual cycle.

STUDY DESIGN

In a retrospective chart review of reproductive-aged women seen at the Women's Health Care Clinic at Harbor-University of California, Los Angeles, Medical Center, data from the records of 448 symptomatic women who had 507 episodes of vulvovaginal candidiasis were extracted and analyzed for timing of onset of symptoms within the menstrual cycle. Diagnosis was based on symptoms, physical findings, and microscopy. Onset was divided into five physiologic ranges within an idealized 28-day menstrual cycle. Comparisons among groups were made with use of chi 2 and p < 0.05 thresholds for statistical significance.

RESULTS

No differences were found in the onset of symptoms within the idealized menstrual cycle ranges between women using hormonal birth control methods and those using nonhormonal ones. The distribution was remarkably uniform throughout the cycle with the exception of the first few days (during menses).

CONCLUSION

The timing of onset of symptoms of vulvovaginal candidiasis within a woman's menstrual cycle is not affected by her method of birth control.