Vulvovaginal Candidosis (Excluding Mucocutaneous Candidosis): Guideline of the German (DGGG), Austrian (OEGGG) and Swiss (SGGG) Society of Gynecology and Obstetrics (S2k-Level, AWMF Registry Number 015/072, September 2020)

Treatment of vaginitis caused by non-albicans Candida species

INTRODUCTION

In the face of increased frequency of non-albicans Candida vulvovaginitis (VVC) reported worldwide, there is a paucity of effective oral and topical antifungal drugs available. Drug selection is further handicapped by an absence of data of clinical efficacy of available antifungal drugs for these infections.

AREAS COVERED

In this review, attention is directed at the cause of drug shortage as well as increased frequency of non-albicans Candida (NAC) vulvovaginitis. There is widespread recognition of reduced in vitro azole drug susceptibility in NAC species. Moreover, antifungal susceptibility tests have not been standardized or validated for NAC isolates, hence clinicians rely on an element of empiricism especially given the absence of randomized controlled comparative studies targeting NAC species. Clinical spectrum of NAC species isolates is highly variable with ongoing difficulty in determining a causal role in symptomatic patients.

EXPERT OPINION

We have entered the era of demand for Candida species-specific therapy and although consensus treatment guidelines are emerging, new antifungal agents that target these multiple-azole resistant or relatively resistant vaginal NAC species are urgently needed.

Recurrent Vulvovaginal Candidiasis: Assessing the relationship between feminine/vaginal washes and other factors among Ghanaian women

INTRODUCTION

Vulvovaginal Candidiasis (VVC) is a public health problem, with approximately 30-50% of women affected at least once during their lifetime. Recurrent Vulvovaginal Candidiasis (RVVC) is diagnosed following three or four repeated episodes of VVC in a calendar year. This condition poses health concerns with significant impacts on the quality of life of women. This cross-sectional study estimated the prevalence of RVVC and assessed the relationship between feminine/vaginal washes and other factors on RVVC among Ghanaian women in the Sekondi/Takoradi Metropolis.

METHODOLOGY

A cross-sectional study was employed to gather data from 304 women. Data were collected using a pretested questionnaire. Bivariate and multivariate analyses, including chi-square/Fisher's exact test and logistic regression, were performed using Jamovi (R Core Team 2021) software. Proportions were calculated, and odds ratios and their corresponding 95% confidence intervals were computed with the level of significance set at 0.05.

RESULTS

The prevalence of RVVC was estimated as 48.4% (95% CI 42.6%, 54.1%). Feminine Vaginal wash use (aOR = 3.86; 95% CI = 2.18, 6.84); age 36-45 years (aOR = 0.36; 95% CI = 0.17, 0.76) marital status (aOR = 2.37; 95% CI = 1.17, 4.79) and Sexual activity (aOR:0.43: 95%CI = 0.21, 0.88) were significantly associated with RVVC with p < 0.005.

CONCLUSION

RVVC is prevalent among women in the Sekondi/Takoradi Metropolis of Ghana. Feminine/Vaginal washes could be cautiously linked to the development of RVVC.

Management of recurrent vulvovaginal candidosis: Narrative review of the literature and European expert panel opinion

Recurrent vulvovaginal candidosis (RVVC) is a chronic, difficult to treat vaginal infection, caused by Candida species, which affects women of all ages and ethnic and social background. A long-term prophylactic maintenance regimen with antifungals is often necessary. In most clinical practice guidelines, oral fluconazole is recommended as the first-line treatment. Although clinical resistance to antifungal agents remains rare, overexposure to azoles may increase the development of fluconazole-resistant C. albicans strains. In addition, non-albicans Candida species are frequently dose-dependent susceptible or resistant to fluconazole and other azoles, and their prevalence is rising. Available therapeutic options to treat such fluconazole-resistant C. albicans and low susceptibility non-albicans strains are limited. Ten experts from different European countries discussed problematic issues of current RVVC diagnosis and treatment in two audiotaped online sessions and two electronic follow-up rounds. A total of 340 statements were transcribed, summarized, and compared with published evidence. The profile of patients with RVVC, their care pathways, current therapeutic needs, and potential value of novel drugs were addressed. Correct diagnosis, right treatment choice, and patient education to obtain adherence to therapy regimens are crucial for successful RVVC treatment. As therapeutic options are limited, innovative strategies are required. Well- tolerated and effective new drugs with an optimized mechanism of action are desirable and are discussed. Research into the impact of RVVC and treatments on health-related quality of life and sex life is also needed.

Antifungal activity of linalool against fluconazole-resistant clinical strains of vulvovaginal Candida albicans and its predictive mechanism of action

Candida albicans is the most frequently isolated opportunistic pathogen in the female genital tract, with 92.3% of cases in Brazil associated with vulvovaginal candidiasis (VVC). Linalool is a monoterpene compound from plants of the genera Cinnamomum, Coriandrum, Lavandula, and Citrus that has demonstrated a fungicidal effect on strains of Candida spp., but its mechanism of action is still unknown. For this purpose, broth microdilution techniques were applied, as well as molecular docking in a predictive manner for this mechanism. The main results of this study indicated that the C. albicans strains analyzed were resistant to fluconazole and sensitive to linalool at a dose of 256 µg/mL. Furthermore, the increase in the minimum inhibitory concentration (MIC) of linalool in the presence of sorbitol and ergosterol indicated that this molecule possibly affects the cell wall and plasma membrane integrity of C. albicans. Molecular docking of linalool with proteins that are key in the biosynthesis and maintenance of the cell wall and the fungal plasma membrane integrity demonstrated the possibility of linalool interacting with three important enzymes: 1,3-β-glucan synthase, lanosterol 14α-demethylase, and Δ 14-sterol reductase. In silico analysis showed that this monoterpene has theoretical but significant oral bioavailability, low toxic potential, and high similarity to pharmaceuticals. Therefore, the findings of this study indicated that linalool probably causes damage to the cell wall and plasma membrane of C. albicans, possibly by interaction with important enzymes involved in the biosynthesis of these fungal structures, in addition to presenting low in silico toxic potential.