Impact of Obesity on Cesarean Delivery Outcomes

BACKGROUND

The rate of cesarean delivery has increased over the last 2 decades. Obesity is a risk factor for complications during pregnancy and cesarean procedures. The objective of this study was to evaluate cesarean delivery outcomes in patients with vs without obesity, and determine the impact of obesity on complications.

METHODS

The medical records of patients who underwent a cesarean delivery from 2010 to 2014 were reviewed. Patients were grouped by body mass index (BMI) into obese (≥30kg/m²) and non-obese (<30kg/m²) cohorts for comparison.

RESULTS

Nine hundred seventy-one patients were included; 432 whom had obesity, and 539 did not have obesity. The rate of gestational diabetes was increased among patients with vs without obesity (15.3% vs 5.8%; P<0.001). Obesity was associated with an increased incidence of surgical site infections (8.1% vs 2.4%; P<0.001), yeast infection (2.8% vs 0.2%; P<0.001), and seroma (2.8% vs 0.4%; P=0.002). Obesity was an independent risk factor for surgical site infections, regardless of wound closure technique (adjusted odds ratio=3.24, 95% CI, 1.66-6.32; P<0.001).

CONCLUSIONS

Obesity is a risk factor for wound infections after a cesarean delivery. As obesity rates increase, it is important to be aware of these risks after performing a cesarean delivery.

Highlights Regarding Host Predisposing Factors to Recurrent Vulvovaginal Candidiasis: Chronic Stress and Reduced Antioxidant Capacity

We studied host factors that could predispose women to develop recurrent vulvovaginal candidiasis (RVVC), including glycemia, insulin resistance, chronic stress, antioxidant capacity, overall immune status, local inflammation and vaginal microbiota. The presence of yeasts in vaginal culture was screened in 277 women, with or without signs and symptoms of VVC and RVVC. The presence of an inflammatory process and microbiota were analyzed through vaginal bacterioscopy and cervical-vaginal cytology, respectively. Fasting-blood samples were collected by standard venipuncture for biochemical analyses. Flow cytometry was employed to obtain the T helper/T cytotoxic lymphocyte ratio, and insulin resistance was assessed by the HOMA index (HI). Yeasts were isolated from 71 (26%) women: 23 (32.4%) with a positive culture but without symptoms (COL), 22 (31%) in an acute episode (VVC), and 26 (36.6%) with RVVC. C. albicans was the main yeast isolated in all clinical profiles. The control group (negative culture) comprised 206 women. Diabetes mellitus and insulin resistance were more associated with the positive-culture groups (COL, VVC and RVVC) than with negative ones. The RVVC group showed lower mean levels of cortisol than the control group and lower antioxidant capacity than all other groups. The T Helper/T cytotoxic lymphocyte ratio was similar in all groups. The RVVC group showed a similar level of vaginal inflammation to the control group, and lower than in the COL and VVC groups. Only the CVV group showed a reduction in vaginal lactobacillus microbiota. Our data suggest that both chronic stress (decreased early-morning cortisol levels) and reduced antioxidant capacity can be host predisposing factors to RVVC.

Armed Forces Health Surveillance Center (AFHSC). Vaginal yeast infections while deployed in Southwest/Central Asia, active component females, U.S. Armed Forces, 2008-2013

In field settings, female service members may not have adequate access to bathrooms, showers, laundry, or sanitary products necessary to maintain adequate feminine hygiene; therefore, service women may be at risk for vaginal yeast infections while deployed. During the 6-year surveillance period, nearly 3,000 U.S. military service women were diagnosed with at least one clinically significant yeast infection while supporting combat operations in Southwest/Central Asia. The crude overall incidence rate was 35.1 per 1,000 person-years (p-yrs). Overall incidence rates were higher among black, non-Hispanic service women, and among those in the Army and Air Force, in enlisted grades, and in communications/intelligence and motor transport occupations. The yearly rate of yeast infections was relatively stable from 2008 through 2010, then decreased in 2011 through 2013. Prior to deploying to austere operational settings, female service members should be provided practical and useful information, realistic training, and material support to decrease the risk of acquiring and increase the effectiveness of treating clinically and military operationally significant yeast infections.

[Is diabetes mellitus a risk factor in genital yeast infections?]

OBJECTIVE

To analyze experimental and clinical data on diabetes mellitus (DM) related to infections with focus on vaginal mycosis. To evaluate a role of DM in the epidemiology of vulvovaginal candidiasis.

DESIGN

Review.

SETTING

Department of Clinical Microbiology, Department of Biological and Medical Sciences, Faculty of Pharmacy, Department of Obstetrics and Gynecology, Charles University in Prague, Faculty of Medicine and University Hospital Hradec Kralove.

METHODS

Review of literature data.

RESULTS

DM is a risk factor for fungal infections caused by yeasts (Candida albicans), members of Mucorales fungi, some dimorphic fungi (Coccidioides) and agents of onychomycosis. DM is usually associated only with increased colonization of the anatomical sites (oral cavity, vagina), and/ or with an intensified symptomatology of infection (onychomycosis, mucormycosis). Diabetic patients with oropharyngeal and vulvovaginal candidiasis have frequently changed etiology spectrum. The patients with VVC and DM, especially of older age or with prone to relapses, have tendency to shift of the spectrum to non-albicans species, mainly C. glabrata. Treatment of VVC in diabetic patients can be complicated owing to unfavourable antifungal susceptibility profile (C. glabrata) and/ or adverse interactions between some azole antifungals and sulfonylurea-based antidiabetics.

CONCLUSION

Diabetes mellitus is often cited as a risk factor, although in many cases there is a lack of reliable and clinically relevant information. This does not mean that this disease can be underestimated. On the contrary, it is necessary to get the DM as soon as possible under control and thus prevent complications when infection develops. Individual approach should be applied to the diabetic patients at risk of an infection. Yeast colonization and development of vaginal infection is complex process primarily dependent on sexual hormones, indigenous microbiota and finely tuned mechanisms of local immunity. Role of DM consists in the fact that it is one of the important co-factors that can change the setup of the vaginal environment in favour of yeasts and thus promote or facilitate the development of VVC.

Vaginal infections update

Vaginal symptoms are one of the leading reasons that women visit their health care providers. Women often self-diagnose and may treat themselves inappropriately. This article describes the etiology, risk factors, symptoms, diagnosis, and treatment of the 3 most common vaginal infections: bacterial vaginosis, trichomoniasis, and vulvovaginal candidiasis.

Evaluation of vulvovaginal symptoms and Candida colonization in women with type 2 diabetes mellitus treated with canagliflozin, a sodium glucose co-transporter 2 inhibitor

BACKGROUND/OBJECTIVE

Women with type 2 diabetes mellitus (T2DM) are at increased risk for vaginal Candida colonization, perhaps because of glucosuria. Sodium glucose co-transporter 2 (SGLT2) inhibitors, in development for the treatment of T2DM, improve glycemic control by increasing urinary glucose excretion. Vaginal Candida colonization and symptomatic vulvovaginal adverse events (VVAE) were assessed in females with T2DM treated with canagliflozin, a SGLT2 inhibitor.

METHODS

In a double-blind study, subjects with T2DM and inadequate glycemic control on metformin were randomized to placebo; canagliflozin 50, 100, 200, 300 mg daily or 300 mg twice daily; or sitagliptin 100 mg daily for 12 weeks. Vaginal swabs for Candida culture were collected from 198 female subjects at baseline and week 12, and during the trial if symptoms consistent with vulvovaginal candidiasis occurred.

RESULTS

At baseline, 23/198 (12%) females had vaginal cultures positive for Candida (C. glabrata: 14; C. albicans: 5; other: 4), with age ≤55 years associated with increased risk (odds ratio [OR], 3.5; 95% confidence interval [CI], 1.1-10.7). Of those with negative cultures at baseline, 31% of canagliflozin and 14% of placebo/sitagliptin subjects converted to positive at week 12 (OR, 2.8; 95% CI, 1.0-7.3 for canagliflozin vs. placebo/sitagliptin). Two placebo/sitagliptin (3%) and 16 canagliflozin subjects (10%) experienced VVAE. Positive vaginal culture for Candida species at baseline was a risk factor for VVAE (OR, 9.1; 95% CI, 2.4-34.0). All 9/9 subjects in the canagliflozin group with a vaginal culture taken at the time of the VVAE were positive for Candida species. Most VVAE were treated with antifungal therapy and resolved without study drug interruption; none led to discontinuation. Study limitations include small population, short duration, and not obtaining cultures in all women with VVAE.

CONCLUSION

Canagliflozin treatment was associated with an increase in vaginal colonization with Candida species and in VVAE in women with T2DM.

Recurrent infections in children with nickel allergic contact dermatitis

Some patients with nickel (Ni) allergic contact dermatitis (ACD) suffer from systemic symptoms after ingestion of Ni-rich foods, a condition termed Systemic Nickel Allergy Syndrome (SNAS). The aim of this study is to investigate in children the relationship between Ni ACD and lymphocyte subsets or susceptibility to infections. Nineteen children with Ni ACD and 18 controls matched for sex and age were enrolled. All participants underwent patch test, skin prick test and clinical assessment. Serum immunoglobulins and flow cytometry for lymphocyte subset study were also evaluated. In children with Ni ACD a higher incidence of recurrent upper respiratory tract infections and recurrent otitis media were detected. Serum levels of immunoglobulins and lymphocyte subsets did not show significant changes (p>0.05) between the two groups studied. We can hypothesize that in children with Ni ACD the risk of recurrent infections is increased. Although the clinical manifestations of SNAS are still controversial, we can suppose that recurrent infections may be considered a clinical symptom of this syndrome.

Chronic granulomatous disease presenting with hypogammaglobulinemia

Chronic granulomatous disease (CGD) is a primary immunodeficiency disorder caused by inherited defects in the nicotinamide adenine dinucleotide phosphate oxidase complex. The neutrophils of patient with CGD can ingest bacteria normally, but the oxidative processes that lead to superoxide anion formation, hydrogen peroxide production, nonoxidative pathway activation, and bacterial killing are impaired. Serious infections result from microorganisms that produce catalase. Immunoglobulin levels of patients with CGD are usually normal or elevated. We describe a patient with CGD associated with hypogammaglobulinemia, an unusual co-occurrence.

Distribution of Candida species in women with vulvovaginal symptoms and their association with different ages and contraceptive methods

The aim of this study was to determine the frequency and distribution of Candida spp. within different age groups and different contraceptive methods users in women with vulvovaginal symptoms. The study included 569 female outpatients who had visited the Education and Research Hospital of Mustafa Kemal University, Turkey, between Jaunary 2004 and June 2005. Among 569 women with symptoms of vulvovaginitis, 240 (42.2%) were positive for Candida spp., of which 106 (44.2%) were C. albicans and 134 (55.8%) were non-albicans spp. The age group 26-30 y had the highest frequency of Candida spp. (23.7%). Candida spp. were isolated from 44.2% of contraceptive method users, and 37.9% of non-contraceptive users (p>0.05). The isolation rate of C. albicans was higher among oral-contraceptive users (57.5%) than IUCD users (38.5%), coitus interruptus (48.5%) and condom users (42.8%). These results indicate that factors associated with age and contraceptive method used may influence the occurrence and distribution of Candida spp. in women with vulvovaginal symptoms.

[Genital candidiasis]

Genital candidiasis occurs mainly in women referred as vulvovaginal candidiasis (VVC), and occasionally occurs in men as to be called balanitis. VVC is one of the most common causes of infectious vaginitis. Approximately three-quarters of women will experience an episode of VVC at least once in their life and 5-8% of them will have more than four attacks within a year; this condition has been designated as recurrent VVC (RVVC). Causative agent in majority of VVC is Candida albicans, but occasionally VVC is caused by other Candida spp. VVC is not traditionally considered a sexually transmitted disease. On occasion sexual transmission of Candida can occur during vaginal intercourse. Particularly Candida transmission and sexual behaviors are linked to RVVC. Epidemiological evidence suggests that anogenital and, especially, orogenital contact transmits Candida.

Are glucocorticoids a consistent risk factor for infections in rheumatoid arthritis patients under treatment with methotrexate and etanercept?

OBJECTIVE

To evaluate the incidence of infections in subjects with rheumatoid arthritis (RA), treated with an anti-TNFalpha blocker during one year follow-up. The aim of the study was focused to evaluate the number of infectious episodes in two groups of patients treated with etanercept (ETN) plus methotrexate (MTX) or ETN plus MTX and glucocorticoid drugs (GCs/prednisone) for a 12 months period.

MATERIALS AND METHODS

Sixty-nine out of 122 RA patients treated with an anti-TNFalpha drug (ETN) were included in an outpatient control system within the Immunology Department Sapienza-University of Rome-II; School of Medicine. RA patients were studied during the first year after ETN introduction. Particularly 20 RA patients have been included in a subgroup. For these 20 patients infections have been monitored for 2 years: 12 months before and 12 months after ETN treatment starting.

RESULTS

According to drugs administration protocols, after a careful screening aiming to exclude latent tuberculosis infection, 20 patients have been treated with ETN (10 of them received treatment in association to MTX, while 10 were given a GCs therapy plus MTX). During the one-year ETN treatment period, 7 infections have been described in the group treated with ETN, MTX and GCs and no infection in the group treated with ETN and MTX. After analysing the infection number in the two groups of patients, in the year preceding biological treatment no significant change arose.

CONCLUSIONS

The risk of infections in subjects treated with the biological drug ETN is well known. Our data show that after one year therapy the [ETN+MTX+GCs] group is marked by a greater frequency of infectious episodes compared to the subjects treated with ETN plus MTX. Therefore, the additional infectious risk appears to be related to steroid therapy itself, though infections were not serious.

Susceptibility to vaginal candidiasis under different conditions in mice

In order to study the susceptibility of murine vaginal mucosa to Candida albicans under different conditions, vaginal lavage fluid and vaginal tissue of mice were observed and compared between murine models with normal immune system (estrogen-treated mice) and immunosuppressed murine model, and between primary infection model of vaginal candidiasis and secondary infection one. The average level of colony forming unit (CFU) from the immuosuppressed group was higher than that from estrogen-treated group at each time point and the peak time was delayed. The differences between the two groups were statistically significant (P < 0.05) from the fourth day after inoculation. A significant difference existed in the average level of CFU between the control group and the estrogen-treated group (P < 0.05), and between the control group and the immuosuppressed group (P < 0.01). It was concluded that the vaginal mucosa from the immunosuppressed mice is more susceptible to Candida albicans and no difference is found in susceptibility between mice with primary infection and secondary infection.

Prolonged (3-month) mycological cure rate after boric acid suppositories in diabetic women with vulvovaginal candidiasis

OBJECTIVE

Patients with diabetes mellitus (DM) are at increased risk of vulvovaginal candidiasis (VVC) due to C. glabrata. In our previous study we had shown that patients with diabetes mellitus and VVC show an overall superior mycological cure rate (74% versus 51%) with boric acid therapy at 15th day as compared to fluconazole. Present study was carried out to assess long term response to boric acid in diabetic women with VVC.

MATERIAL AND METHODS

Subjects included 40 consecutive diabetic women (type 2 DM=26 and type 1 DM=14) who had achieved mycological cure (high vaginal swab culture negativity) on day 15 of therapy following single-dose oral-150 mg fluconazole (n=21) or 600 mg of boric acid suppositories given daily for 14 days (n=19). At third month of follow up, patients were assessed for signs and symptoms of VVC and a repeat HVS was collected for fungal culture. HbA1c was measured to assess glycaemic control.

RESULTS

The mean age, BMI, HBA1c and frequency of various Candida species isolated at initial diagnosis were comparable in the fluconazole and boric acid treatment groups. Fifteen of 21 (71.4%) and 12 of 19 (63.1%) women who achieved mycological cure at 15 day remain cured at three months in the fluconazole and boric acid treated groups, respectively (P=0.83). With 74% mycological cure at 15th day, this would indicate that on an average only 46.6% of diabetic women with VVC would remain cured at 3 months after a course of 14 days boric acid therapy. Most of the patients relapsed with no change in Candida species. The demographic profile and mean HbA1c (8.6+/-2.2 versus 8.8+/-2.4%, P=0.83) were comparable in patients with (n=27) and without mycological cure (n=13).

CONCLUSION

The results of the current study indicating comparable mycological cure rate at 3 months between fluconazole and boric acid treated patients would support use of boric acid in the acute management of VVC in view of its superior short term response in diabetic women with C. glabrata infections. However, there is need to explore other therapeutic regimens which are effective in achieving long term mycological cure in diabetic women with VVC.

Safety and acceptability of 6% cellulose sulfate vaginal gel applied four times per day for 14 days

BACKGROUND

Six percent cellulose sulfate (CS) is a vaginal gel that has been in development as a microbicide.

STUDY DESIGN

This was a single-center, multi-dose, Phase I, placebo-controlled, randomized, fully masked study conducted in Yaoundé, Cameroon, and involving sexually active women at low risk for sexually transmitted infections (STIs).

METHODS

The study assessed the effect of CS and K-Y Jelly applied vaginally four times per day, for 14 consecutive days, on genital epithelial disruption, candidiasis and bacterial vaginosis (BV). Acceptability of the products was also assessed. Twenty-seven women were enrolled in each treatment group.

RESULTS

Two (7.4%) of the women in each group developed genital epithelial disruption. One (3.7%) of the women in each group developed candidiasis, and one (3.7%) of the K-Y users developed BV. One (3.7%) of the CS users said she would not buy her product for pregnancy prevention but would for STI prevention. All the remaining women indicated they would buy their product for both indications.

CONCLUSION

The results suggest that the safety and acceptability of 6% CS gel are comparable to that of K-Y Jelly.

Vulvovaginal candidosis

Despite therapeutic advances, vulvovaginal candidosis remains a common problem worldwide, affecting all strata of society. Understanding of anti-candida host defence mechanisms in the vagina has developed slowly and, despite a growing list of recognised risk factors, a fundamental grasp of pathogenic mechanisms continues to elude us. The absence of rapid, simple, and inexpensive diagnostic tests continues to result in both overdiagnosis and underdiagnosis of vulvovaginal candidosis. I review the epidemiology and pathogenesis of this infection, and also discuss management strategies.

Do panty liners promote vulvovaginal candidiasis or urinary tract infections? A review of the scientific evidence

Panty liners are used to absorb light menstrual flow, vaginal discharge, or urine leakage, or to maintain a clean, dry feeling. Allegations that panty liners may trap heat and moisture to promote vulvovaginal candidiasis (VVC) or promote colonization by microbes that contribute to urinary tract infections appear to be unfounded. As reviewed herein, measurements of the impact of panty liners on skin temperature and skin surface moisture had no clinically meaningful effect on cell densities of genital microflora. Epidemiological investigations of a potential link to VVC were either negative or were inconclusive because of confounding factors. Although enteric microbes reside on the vulva and perineum, no evidence exists that panty liner use promotes urethral colonization by enteric microbes. Moreover, a series of 13 randomized prospective trials of panty liners or ultra-thin pads demonstrated no clinically significant adverse effects either on the skin or on isolation frequencies or cell densities of representative genital microflora. Post-market surveillance systems suggest a low incidence of complaints. Evidence from vulvar clinic patients reveals no significant contribution of these products to persistent vulvar symptoms. Taken together, the scientific evidence supports the conclusion that panty liners are safe when used as intended and do not promote VVC or urinary tract infections.

Stress as a cause of chronic recurrent vulvovaginal candidosis and the effectiveness of the conventional antimycotic therapy

Chronic Candida vulvovaginitis cannot, at present, be treated effectively with local or oral antimycotic medication. Göttlicher & Meyer [Vulvovaginalmykose. Klinische Ergebnisse einer epidemiologischen Langzeitstudie, Thieme, Stuttgart (1998); Mycoses41 (1998) 49] formulated a hypothesis to explain this fact. They say that stress is the main cause of vulvovaginal mycosis, and that frequently cited predisposing somatic risk factors are not causing the illness. Two research projects were carried out to test this hypothesis. The first project was conceived to provide direct evidence for two empirical statements derived from the Göttlicher-Meyer hypothesis: (i) stress as a predictor of vulvovaginitis is least valid as the commonly assumed somatic factors and (ii) combinations of factors that reliably discriminate index women from symptom-free women point to aspects of psychosocial development, particularly stress, and not to somatic factors. Between March and November 1999, 309 successive patients were randomly chosen from those successively treated in one in-patient and two out-patient settings. Of those chosen, 117 had had at least one episode of vaginal candidosis within the 2 years prior to enlistment in the study. The remaining 192 patients had experienced no such illness. For the 117 index patients both of the above empirical statements were confirmed by statistical analyses. The second project was designed to test predictions concerning the ineffectiveness of traditional antimycotic treatment derived from the Göttlicher-Meyer hypothesis. Three different empirical statements were derived from the hypothesis--each based on the assumption of a Poisson distribution of relapses that remains uninfluenced by treatment attempts. Each of the statements was tested and confirmed in independent samples--the first in the sample used in project one, the second in a sample of 206 women insured by public Healths Management Organizations (HMOs) and the third in a sample of 179 women insured by private HMOs. Each patient had evidenced Candida albicans vulvovaginitis at least once in the time interval between 1996 and 2000. Statistical analyses confirmed each of the empirical statements, thereby substantiating the Göttlicher-Meyer hypothesis. The authors conclude that (i) psychosocial factors, particularly stress, are the primary causes of Candida albicans vulvovaginitis. Accompanying somatic factors are of little statistical significance in explaining occurrence and relapse. (ii) Traditional antimycotic treatment influences only the symptoms of the illness, not its causes, and has no effect on the probability of a relapse. Increased treatment effectiveness can be achieved only at the cost of a complete re-orientation concerning the causes of vaginal mycosis. Interventions designed to strengthen the patients' immune response are among the most promising.

Vaginal colonization with Candida spp. in human immunodeficiency virus-infected women: a cohort study

We have conducted a longitudinal study on factors associated with candidal vaginal colonization, a precursor of vaginitis, in a cohort of HIV-infected women in Italy. All consecutive women attending a single, tertiary care clinical site were offered free screening for sexually transmitted infections and genital disorders every 6-12 months. Candidal vaginal colonization was defined as a positive culture for Candida spp. in an asymptomatic woman. From January 1998 to July 2002 we analysed 214 women. The baseline prevalence of candidal vaginal colonization was 16.8%. In the logistic regression analysis, the time since HIV infection > or =36 months (odds ratio [OR] = 0.18, 95% confidence interval [CI] 0.016-0.53, P = 0.002) and a plasma viral load > or =10,000 copies/mL (OR = 3.9, 95% CI 1.03-14.9, P = 0.045) were independently associated with candidal colonization. Among 130 women who were followed for a mean period of 24 months, the incidence of vaginal colonization was 10.7/100 women-years. In the Cox regression analysis, a CD4(+) T-lymphocytes count <100 cells/microL during the follow-up was associated with an increased risk of candidal vaginal colonization (OR = 4.45, C.I. = 1.20-16.81, P = 0.03). Risk of candidal vaginal colonization episodes in HIV-infected women significantly increase when CD4(+) T-lymphocytes are less than 100.

Prevalence and risk factors for vaginal candidiasis among women seeking primary care for genital infections in Dar es Salaam, Tanzania

OBJECTIVE

To determine the prevalence and risk factors for vaginal candidiasis (VC) among women seeking primary care for genital infections.

DESIGN

Cross-sectional study.

SETTING

Ilala Municipal Hospital in Dar es Salaam, Tanzania.

SUBJECTS

Four hundred and sixty four women presenting with complaints of genital infections.

RESULTS

Of the 464 women examined, 177 (38.1%) had abnormal vaginal discharge, 68(14.7%) had genital ulcers, 272 (58.6%) had genital pruritus, 18 (3.9%) had genital warts and 58 (12.5%) had chancre. The prevalencies of VC, bacterial vaginosis, HIV, T vaginalis, N. gonorrhoeae and syphilis were 45%, 48.4%, 22%, 93%, 1.5% and 4.3%, respectively. The occurrence of VC was positively associated with HIV, (OR = 1.81, 95% CI (1.0-2.67), bacterial vaginosis; (OR = 2.6, 95% CI (1.7-3.9), genital pruritus; (OR = 1.8 1, 95% CI (1.2-2.7) genital discharge; (OR = 1.867, 95% (1.28-2.73) and negatively with T. vaginalis (OR = 0.27, 95% CI (0.12 - 0.6), occupation (OR = 0.65, 95% CI (0.35-0.86)) and with education (OR = 0.43, 95% CI (0.11-0.73). There were increased but non-significant odds for VC in patients with syphilis (OR = 1.6 95% CI (0.6-4.3) and venereal warts (OR = 2.5 95% CI (0.92-6.8) VC was not associated with N. gonorrhoeae, genital ulcers, age at first intercourse, number of sexual partners, marital status or antibiotic usage.

CONCLUSION

The high prevalence of vaginal candidiasis among women with genital infections should be taken into account when updating policies concerning syndromic management of sexually transmitted diseases. More gender specific approach to syndromic management of sexually transmitted infections in females should be considered.

An intravaginal live Candida challenge in humans leads to new hypotheses for the immunopathogenesis of vulvovaginal candidiasis

Acute and recurrent vulvovaginal candidiasis (VVC) remains a significant problem in women of childbearing age. While clinical studies of women with recurrent VVC (RVVC) and animal models have provided important data about a limited protective role of adaptive immunity, there remains a paucity of information on the protective mechanisms or factors associated with susceptibility to infection. In the present study, an intravaginal live Candida challenge in healthy adult women showed a differential susceptibility to symptomatic VVC, where 3 (15%) of 19 women with no history of VVC acquired a symptomatic infection compared to 6 (55%) of 11 women with an infrequent history of VVC. Furthermore, these studies revealed that protection against infection is noninflammatory while symptomatic infection correlates with a vaginal infiltration of polymorphonuclear neutrophils (PMNs) and a high vaginal fungal burden. Thus, the presence of symptomatic infection appears more dependent on host factors than on properties of the organism. Finally, vaginal lavage fluid from women with a symptomatic infection, but not those asymptomatically colonized, promoted the chemotaxis of PMNs. These results suggest that rather than RVVC/VVC being caused by an aberrant adaptive immune response, symptoms that define infection appear to be due to an aggressive innate response by PMNs.

Predictive value of the clinical diagnosis of lower genital tract infection in women

OBJECTIVE

We hypothesized that diagnostic approaches to lower genital tract infections are inaccurate and proposed this study to evaluate typical approaches.

STUDY DESIGN

Clinical diagnoses were made with symptoms, direct observation, wet mount, vaginal pH, and amines in 598 women with genital complaints. Laboratory testing for N gonorrhoeae, yeast, T vaginalis, C trachomatis, and bacterial vaginosis by Gram stain.

RESULTS

The most frequent symptoms were vaginal discharge (64%), change in discharge (53%), malodor (48%), and pruritus (32%). The infection rates were 46% bacterial vaginosis, 29% yeast, 12% trichomoniasis, 11% chlamydia or gonorrhea; 21% of the patients had no infection. The symptoms did not predict laboratory diagnosis. Clinical signs and symptoms with office-based tests and microscopy improved the accuracy of diagnoses. Amsel's clinical diagnosis of bacterial vaginosis was the most sensitive at 92%. The sensitivity of wet mount diagnosis of trichomoniasis was 62%, of yeast by microscopy was 22%, and of mucopus for the prediction of gonorrhea and/or chlamydia was 30%.

CONCLUSION

Symptoms alone should not be used to direct treatment in instances in which resources permit more complete evaluation with office-based testing that includes microscopy. Treatment failures or diagnostic uncertainty should prompt specific laboratory testing.

The PAV trial: does lactobacillus prevent post-antibiotic vulvovaginal candidiasis? Protocol of a randomised controlled trial [ISRCTN24141277]

Background

Complementary and alternative medicines are used by many consumers, and increasingly are being incorporated into the general practitioner's armamentarium. Despite widespread usage, the evidence base for most complementary therapies is weak or non-existent. Post-antibiotic vulvovaginitis is a common problem in general practice, for which complementary therapies are often used. A recent study in Melbourne, Australia, found that 40% of women with a past history of vulvovaginitis had used probiotic Lactobacillus species to prevent or treat post-antibiotic vulvovaginitis. There is no evidence that this therapy is effective. This study aims to test whether oral or vaginal lactobacillus is effective in the prevention of post-antibiotic vulvovaginitis.

Methods/design

A randomised placebo-controlled blinded 2 × 2 factorial design is being used. General practitioners or pharmacists approach non-pregnant women, aged 18–50 years, who present with a non-genital infection requiring a short course of oral antibiotics, to participate in the study. Participants are randomised in a four group factorial design either to oral lactobacillus powder or placebo and either vaginal lactobacillus pessaries or placebo. These interventions are taken while on antibiotics and for four days afterwards or until symptoms of vaginitis develop. Women self collect a vaginal swab for culture of Candida species and complete a survey at baseline and again four days after completing their study medications. The sample size (a total of 496 – 124 in each factorial group) is calculated to identify a reduction of half in post-antibiotic vulvovaginitis from 23%, while allowing for a 25% drop-out. An independent Data Monitoring Committee is supervising the trial. Analysis will be intention-to-treat, with two pre-specified main comparisons: (i) oral lactobacillus versus placebo and (ii) vaginal lactobacillus versus placebo.

Vulvovaginal candidiasis

VVC represents a spectrum of disease. Although there is a clear need for better use of diagnostic modalities and development of better treatment alternatives, most patients with VVC, even the complicated cases, at least have the perspective of achieving adequate control of their symptoms. Future advances, particularly in the area of home diagnostics, may help to optimize use of currently available medicines.

[Endogenous reinfection as a cause of recurrent genital candidiasis on women]

The cause of primary, recurrent genital candidosis (RGC), that 5% of the female population was afflicted with, is still unknown. It is not clear whether RGC is a result of reinfection or infection recidive caused by Candida sp. The goal of the study is to examine Candida presence in women's genital and intestinal tract; by resistotypization of the same isolated species of Candida fungi to prove their identity as well as the validity of the stated thesis that endogenous reinfection may be one of the possible causes of RGC. The study included 70 women (T-group) afflicted with primary RGC who, at the moment of the examination, were in the phase of manifest infection. In the control group there were 70 women (C-group) not afflicted with RGC. The microbiological test consisted of the microscopic and culture examination of women's genital and intestinal material. The Candida species were differentiated according to the gemination test and the biochemical activity measured by commercial Candi-Fast-test (Mycoplasma International, France) and Vitec-AMS-system (bioMerieux, France). Candi-Fast test examined the sensitivity of Candida species to antimicotics and determined the resistotypes of isolated species. The study did not show statistically significant difference between examined groups in terms of the Candida presence in intestinal tract. The Candida colonization of intestinal mucosa was proved in 24 women (34.28%) with RGC. Eighteen women (25.71%) of the control group, had Candida sp. in intestinal tract. The most frequent RGC agent, as well as most frequent coloniser of intestinal mucosa is Candida albicans (C. albicans--RGC--84.28%; T-group--intestinal tract--C. albicans--87.50%; C-group--intestinal tract--C. albicans--94.44%). In 20 women with RGC there was a presence of identical resistotypes of isolated Candida sp. Identical resistotypes of C. albicans was found in 19 women of the test group, in their genital and intestinal tract. Only in one patient it was recorded the same resistance types of C. trapicalis. In four patients Candida species isolated from genital and intestinal material were not identical. In two women with RGC C. albicans on vaginal mucosa was accompanied by C. glabrata in intestinal tract, while in two more women the presence of various resistotypes C. albicans was identified in genital and intestinal tract.

Relative risk of vaginal candidiasis after use of antibiotics compared with antidepressants in women: postmarketing surveillance data in England

BACKGROUND

Vaginal candidiasis is a common infection in women. The microflora of the vagina are influenced by a number of factors, including pregnancy, oral contraceptive use, menses and diabetes mellitus. Previous antibiotic use is generally accepted to be a risk factor for vaginal candidiasis but the published evidence to support this is limited.

AIM

To determine the relative risk of vaginal candidiasis following the use of antibiotics compared with antidepressants in prescription-event monitoring (PEM) studies.

METHODS

Using data from postmarketing surveillance studies of six antibiotics and six antidepressants, conducted using the observational cohort technique of PEM, the number of reports of vaginal candidiasis was determined in women aged > or =16 years, in each of the first 7 weeks following a prescription for one of these drugs. The relative risks for vaginal candidiasis following the use of these antibiotics and for each of the individual antibiotics compared with antidepressants were calculated for each week and for the overall 7-week period. Women treated with antidepressants were the most suitable comparator group from the PEM database, as they were of a similar age range and the studies were conducted at a similar time period to those of the antibiotics. Also, there was no pharmacological plausibility for vaginal candidiasis being associated with antidepressants.

RESULTS

There were 188 reports of vaginal candidiasis in 31 588 women, aged > or =16 years, treated with antibiotics and 70 in the 45 492 treated with antidepressants. The relative risk for vaginal candidiasis (antibiotic/antidepressants), was highest in the second week, 10.70 (95% CI 4.86-23.55) but was also significantly greater in the first and third weeks after the start of treatment. The risk was also higher in each of the 3 weeks after starting the course for five of the antibiotics, compared individually to the group treated with antidepressants, the exception being fosfomycin, which had a much smaller cohort.

CONCLUSION

This study shows a significant increase in the risk of developing vaginal candidiasis following the use of the antibiotics studied (ciprofloxacin, ofloxacin, norfloxacin, cefixime, azithromycin and fosfomycin) compared with that after taking the antidepressants fluvoxamine, fluoxetine, paroxetine, sertraline, venlafaxine and nefazodine in these PEM studies.

Management of patients with recurrent vulvovaginal candidiasis

Recurrent vulvovaginal candidiasis (RVVC) is by no means uncommon and is a source of considerable physical discomfort in addition to serving as a major therapeutic challenge. The syndrome is multifactorial in aetiology and hence management strategies must recognise the complex aetiological pathways. Many women receiving the misplaced diagnosis of RVVC have a variety of other infectious and non-infectious entities presenting with identical symptoms. Hence the first step in management is confirming the diagnosis of RVVC including microbial confirmation and species identification. Efforts should be made to identify and correct a causal mechanism. Maintenance suppressive azole antifungal regimens are highly effective in controlling symptoms, although cure is less common. Further advances in achieving higher cure rates await the availability of non-azole fungicidal agents.

An epidemiological survey of vulvovaginal candidiasis in Italy

Eight Italian hospital or University gynecology clinics participated in a prospective survey of patients with culture-confirmed symptomatic vulvovaginal candidiasis (VVC) (October 1999 to March 2001). Of 1138 patients recruited in the study, 931 were evaluable. A recent history of VVC was documented in 43.5% patients (358/823) with a mean number of 2.9+/-2.7 episodes per patient (N=302). A total of 77 patients (10.0%) had a history of recurrent VVC (four and more episodes in a 12-month period). The most frequent associated factors were related to life style: synthetic fabric underwear, vaginal douching and bike, training bike and motorbike (about 1/3 each). Oral contraception was found in 20.8% patients, recent antibiotic use in 15.9% patients, current pregnancy concerned 10.3% patients while 3.4% patients were taking hormonal replacement therapy. Diabetes, corticosteroids or HIV were rarely encountered. Yeast was documented by direct microscopy in 78.3% patients (448/572). A positive culture was obtained in 98.3% patients (909/925). Candida albicans was the predominant species (77.1%), followed by Candida glabrata (14.6%) and Candida krusei (4.0%). With the exception of one center with a lower proportion of C. albicans, this latter represented between 75 and 85% of the isolates. Overall, this study confirmed the preponderant role played by C. albicans in either sporadic and recurrent VVC.

Follow-up of users of intrauterine device with and without bacterial vaginosis and other cervicovaginal infections

This study aimed to assess the prevalence of bacterial vaginosis (BV) and other cervicovaginal infections, as well as the incidence of complications among new users of IUD, 1 and 6 months after its insertion, in the City of Campinas, Brazil. A total of 223 women who had a TCu-380A IUD inserted from May through November 2001, were included in the study. After the IUD insertion all women were scheduled to two additional visits: after 1 month and after 6 months, when they were interviewed and a pelvic examination was performed, along with a collection of specimens from the vagina and the endocervix for laboratory testing. The Nugent's criterion was used for the BV diagnosis. They were also evaluated with regard to presence of complications possibly related to IUD insertion and use, i.e., abnormal bleeding, dysmenorrhea, expulsion and pelvic inflammatory disease. The prevalence of cervicovaginal infections was 29.1%, BV being the most frequent (19.7%). Dysmenorrhea was more frequent among women with BV than among women without BV (p = 0.03). A trend of abnormal bleeding being more frequent among women with BV was also found. In conclusion, BV after 1 month of IUD insertion was not associated with IUD complications, with the exception of dysmenorrhea.

"Not thrush again!" Women's experience of post-antibiotic vulvovaginitis

OBJECTIVES

To examine the frequency of post-antibiotic vulvovaginitis (PAV); describe how women prevent and treat PAV; and determine whether concern about PAV affects their decisions about taking antibiotics.

DESIGN

Cross-sectional survey using a written questionnaire.

SETTING AND PARTICIPANTS

Five general practice waiting rooms in north-western Melbourne, in February 2000. 1298 women aged 18-70 years were surveyed.

MAIN OUTCOME MEASURES

Self-reported symptoms and management of vulvovaginitis and PAV.

RESULTS

The response rate was 86%. Thirty-five per cent of women reported ever having PAV and 73% reported ever having symptoms suggestive of vulvovaginal candidiasis. Antifungal medications and lactobacillus products or yoghurt were most popular for both prevention (49%, 40%) and treatment (63%, 43%) of PAV. Other home remedies such as tea tree oil, vinegar, and dietary and clothing modification were infrequently used by the women surveyed. Twenty-three per cent of women who had taken antibiotics in the previous month had experienced symptoms of vulvovaginitis. Of women who had ever had vulvovaginitis, 35% were moderately to very concerned about developing PAV when prescribed antibiotics. Because of this concern, around a fifth of these women would not take prescribed antibiotics.

CONCLUSIONS

Concern about PAV affects women's decision-making regarding antibiotic use. Many women use unproven complementary therapies to prevent or treat PAV. When prescribing antibiotics, doctors should discuss the risks of PAV and its management with patients.

Military women's risk factors for and symptoms of genitourinary infections during deployment

Symptoms of vaginitis and urinary tract infections are miserable, distracting, and significantly affect women's quality of life. Among civilian women, these symptoms account for 10.5 million office visits per year. To examine the scope of the problem for military women during deployment situations, surveys were sent to randomly selected Army and Navy units. Of 841 women who completed the anonymous survey and had been deployed, vaginal infections were experienced by 30.1% and urinary tract infections by 18.4% of them during deployment. Vaginal symptoms were consistent with symptoms associated with the three most common vaginal infections (candida, bacterial, and trichomonas vaginitis). A variety of risk factors, both behavioral and situational, significantly differentiated women with and without infections. Urinary tract infections and vaginal infections are common during deployment situations where resources for self-care and appropriate primary health care for women are scarce or unavailable. One solution is a self-diagnosis and treatment kit for deployed military women.

The secreted aspartyl proteinases Sap1 and Sap2 cause tissue damage in an in vitro model of vaginal candidiasis based on reconstituted human vaginal epithelium

Secreted aspartyl proteinases (Saps) contribute to the ability of Candida albicans to cause mucosal and disseminated infections. A model of vaginal candidiasis based on reconstituted human vaginal epithelium (RHVE) was used to study the expression and role of these C. albicans proteinases during infection and tissue damage of vaginal epithelium. Colonization of the RHVE by C. albicans SC5314 did not cause any visible epithelial damage 6 h after inoculation, although expression of SAP2, SAP9, and SAP10 was detected by reverse transcriptase PCR. However, significant epithelial damage was observed after 12 h, concomitant with the additional expression of SAP1, SAP4, and SAP5. Additional transcripts of SAP6 and SAP7 were detected at a later stage of the artificial infection (24 h). Similar SAP expression profiles were observed in three samples isolated from human patients with vaginal candidiasis. In experimental infection, secretion of antigens Sap1 to Sap6 by C. albicans was confirmed at the ultrastructural level by using polyclonal antisera raised against Sap1 to Sap6. Addition of the aspartyl proteinase inhibitors pepstatin A and the human immunodeficiency virus proteinase inhibitors ritonavir and amprenavir strongly reduced the tissue damage of the vaginal epithelia by C. albicans cells. Furthermore, SAP null mutants lacking either SAP1 or SAP2 had a drastically reduced potential to cause tissue damage even though SAP3, SAP4, and SAP7 were up-regulated in these mutants. In contrast the vaginopathic potential of mutants lacking SAP3 or SAP4 to SAP6 was not reduced compared to wild-type cells. These data provide further evidence for a crucial role of Sap1 and Sap2 in C. albicans vaginal infections.

Prevention and treatment of vulvovaginal candidiasis using exogenous Lactobacillus

OBJECTIVE

To review literature examining exogenous Lactobacillus therapy for vulvovaginal candidiasis and to discuss recommendations for clinical practice and future research.

DATA SOURCES

Computerized searches on MEDLINE and CINAHL November 2000, September 2001, and March 2002, with search terms including Lactobacillus, acidophilus, Candida, and yeast infections.

STUDY SELECTION

Relevant English-language articles from the past 10 years. Unique or seminal studies included where pertinent.

DATA EXTRACTION AND SYNTHESIS

Data organized under the following headings: endogenous Lactobacillus, exogenous Lactobacillus, Candida, studies of intravaginal Lactobacillus therapy for vulvovaginal candidiasis, studies of oral Lactobacillus therapy for vulvovaginal candidiasis.

CONCLUSIONS

Vaginally administered or orally ingested Lactobacillus is able to colonize the vaginal ecosystem. Controlled intervention studies regarding the effect of such colonization on vulvovaginal candidiasis are promising but few. These studies had small numbers of participants, were inconsistent in the form of Lactobacillus used, and reported conflicting results. Further randomized controlled trials involving large numbers of women are imperative. In the meantime, health care providers should discuss potential benefits with affected patients while clarifying the current lack of conclusive evidence. Without further research into currently available sources and brands of Lactobacillus and without governmental regulation of supplements and their contents, however, it is difficult to make recommendations regarding appropriate product choice.

Incident and persistent vulvovaginal candidiasis among human immunodeficiency virus-infected women: Risk factors and severity

OBJECTIVE

To examine risk factors for vulvovaginal candidiasis among women with or at risk for human immunodeficiency virus (HIV) infection.

METHODS

Data were from 856 HIV-infected women and 421 at-risk uninfected women observed semiannually at four study sites from April 1993 through February 1999. At enrollment women were 15-55 years old and had no acquired immunodeficiency syndrome-defining conditions. Three definitions for vulvovaginal candidiasis of differing severity were constructed using data from vaginal Candida culture and Gram stains scored for yeast and three signs on pelvic examination (vulvovaginal edema, erythema, or discharge): 1) culture or Gram stain positivity plus at least one clinical sign, 2) culture or Gram stain positivity plus at least two clinical signs, and 3) visible yeast on Gram stain plus at least one clinical sign.

RESULTS

The prevalence and cumulative incidence of each definition of vulvovaginal candidiasis were greater among HIV-infected women than among women not infected with HIV (P <.01 for all comparisons). Stratified by status at the preceding visit, vulvovaginal candidiasis was most likely among women with prior vulvovaginal candidiasis, least likely among women without earlier Candida colonization, and intermediately likely among women with preceding subclinical Candida colonization. Among HIV-infected women, lower CD4 count and higher HIV viral load were associated with vulvovaginal candidiasis. Several other factors were independently associated with vulvovaginal candidiasis, with strong associations for diabetes mellitus and pregnancy in particular. Vulvovaginal candidiasis was not more severe among HIV-infected women.

CONCLUSION

Vulvovaginal candidiasis occurred with higher incidence and greater persistence, but not greater severity, among HIV-infected women.

[Vaginal candidiasis--treatment protocols using miconazole and fluconazole]

The incidence of fungal infections is growing in the last 20 years. The epidemiological studies show that 45% of all vaginal infections are caused by Candida albicans or other Candida species. 7 out of 10 women suffer from yeast infection at least once in a lifetime and 4 out of 10 have multiple recurrences. 20-55% of women have asyptomatic vaginal colonization with Candida species. It is strongly believed that fungal infection is not sexually transmitted disease. The route of transmission is oral and it is estrogene dependant. The diagnosis is based on macroscopic, microscopic examination (KOH preparation), culture and rarely Pap test. Treatment of vaginal candidiosis is based on two principles: elimination of predisposing factors antifungal treatment Local treatment is the first line of choice in cases of acute vaginal yeast infection with 84-90% success rate. There are a variety of local preparations on our market including Nizoral, Clotrimazole, Canesten, Gyno-Daktarine, Gyno-Pevaryl, Miconazole. Different groups of broad spectrum oral antimycotics are also used including Nystatine, Ketoconazole (Nizoral), Fluconazole (Diflucan, Fungolon, Mycosyst), itraconazole (Orungal). The treatment of chronic, recurrent and resistant forms of vaginal candidosis is carried out with prolonged local and/or systemic therapy for a period of at least 6 months. Different regimes of therapy are proposed. Fluconazole is an oral drug of choice for continuous treatment of vaginal yeast infection with the least toxicity.

Symptomatic vaginal candidiasis after pivmecillinam and norfloxacin treatment of acute uncomplicated lower urinary tract infection

The comparative incidence of symptomatic vaginal candidiasis associated with pivmecillinam and norfloxacin treatment in women with acute symptomatic uncomplicated UTI was determined in two randomised, double-blind, clinical trials. Adverse events reported following general enquiry were reviewed. Presence of Candida vaginitis was based upon the specification as such by investigators, the presence of specific symptoms such as genital pruritus and/or the prescription of specific anti Candida therapy. The incidences of Candida vaginitis were as follows; Study 1 pivmecillinam 200 mg tid for 7 days 13 (4.6%), pivmecillinam 200 mg bid for 7 days 7 (2.4%), pivmecillinam 400 mg bid for 3 days 6 (2.1%) and placebo 6 (2.1%), P=0.19. Study 2 pivmecillinam 400 mg bid for 3 days 7 (1.5%), norfloxacin 400 mg bid for 3 days 20 (4.3%), P=0.016. The incidence of Candida vaginitis in women with acute symptomatic uncomplicated UTI given 3 days treatment with pivmecillinam 400 mg bid is similar to that seen with placebo and is significantly less than the incidence with norfloxacin 400 mg bid for 3 days.

Candida-specific antibodies during experimental vaginal candidiasis in mice

Protective host defense mechanisms against vaginal Candida albicans infections are poorly understood. Although cell-mediated immunity (CMI) is the predominant host defense mechanism against most mucosal Candida infections, the role of CMI against vaginal candidiasis is uncertain, both in humans and in an experimental mouse model. The role of humoral immunity is equally unclear. While clinical observations suggest a minimal role for antibodies against vaginal candidiasis, an experimental rat model has provided evidence for a protective role for Candida-specific immunoglobulin A (IgA) antibodies. Additionally, Candida vaccination-induced IgM and IgG3 antibodies are protective in a mouse model of vaginitis. In the present study, the role of infection-induced humoral immunity in protection against experimental vaginal candidiasis was evaluated through the quantification of Candida-specific IgA, IgG, and IgM antibodies in serum and vaginal lavage fluids of mice with primary and secondary (partially protected) infection. In naïve mice, total, but not Candida-specific, antibodies were detected in serum and lavage fluids, consistent with lack of yeast colonization in mice. In infected mice, Candida-specific IgA and IgG antibodies were induced in serum with anamnestic responses to secondary infection. In lavage fluid, while Candida-specific antibodies were detectable, concentrations were extremely low with no anamnestic responses in mice with secondary infection. The incorporation of alternative protocols-including infections in a different strain of mice, prolongation of primary infection prior to secondary challenge, use of different enzyme-linked immunosorbent assay capture antigens, and concentration of lavage fluid-did not enhance local Candida-specific antibody production or detection. Additionally, antibodies were not removed from lavage fluids by being bound to Candida during infection. Together, these data suggest that antibodies are not readily present in vaginal secretions of infected mice and thus have a limited natural protective role against infection.

Facts and myths on recurrent vulvovaginal candidosis--a review on epidemiology, clinical manifestations, diagnosis, pathogenesis and therapy

Approximately three-quarters of all women will experience an episode of vulvovaginal candidosis at least once in their life and 5-10% of them will have more than one attack. Women suffering from three to four attacks within 12 months will be diagnosed with recurrent vulvovaginal candidosis (RVVC). This review covers the large number of proposed aetiological factors for RVVC. The diagnosis of the condition made by conventional means by health providers is often false and is also often misdiagnosed by the affected woman herself. The review covers various methods of diagnosing RVVC and the current knowledge on potential pathogenetic mechanisms proposed for genital candida infections. Treatment of RVVC, including local and systemic antimicrobial therapy and behaviour modification to decrease the risk of recurrences, are discussed. Recent knowledge on drug resistance in candida is also included.

Spectrum and proteinase production of yeasts causing vaginitis in Saudi Arabian women

BACKGROUND

Yeast vaginitis is a common infection. Data on the identity and prevalence of the etiological species would serve both epidemiological and therapeutic ends. Proteinase secretion by the invading yeast has been implicated in facilitating infection. Hence a prospective study was conducted to determine the species causing vaginitis in women from Saudi Arabia and the yeast's ability to produce proteinase.

MATERIAL/METHODS

The subjects were patients with clinical signs of vaginitis. A high vaginal swab specimen from each patient was cultured, and only women yielding heavy yeast growth were enrolled. The isolated yeasts were identified by routine procedures, then evaluated for proteinase production in a medium containing bovine serum albumin.

RESULTS

A total of 500 patients were studied. Candida albicans was the major species to cause vaginitis (59%), followed by C. glabrata (31%), C. tropicalis (4%), C. krusei (3.2%), Saccharomyces cerevisiae (1.6%), C. parapsilosis (0.6%), and C. kefyr (0.6%). All isolates of C. albicans and C. parapsilosis and 95% of C. tropicalis produced proteinase, while isolates from the remaining species did not.

CONCLUSIONS

These results indicate that 59.6% of yeast vaginitis in women from Saudi Arabia is caused by C. albicans, and 31.6% by C. glabrata. Of relatively low prevalence were C. tropicalis and C. krusei. The study also revealed that both proteinase producers and non-producers were involved in causing vaginitis, indicating that proteinase secretion is not an essential factor in the pathogenesis of yeast vaginitis.

Persistent colonization and transient suppression of DTH responses in an estrogen-dependent vaginal candidosis murine model

Recurrence of vaginal candidosis in women of childbearing age has been attributed to several predisposing factors including the presence of significant amounts of estrogen in the reproductive tract. In this study, the effect of estrogen on the level of C. albicans colonization, persistence of infection and suppression of DTH responses was investigated in an estrogen-dependent vaginal candidosis murine model. Mice were first injected subcutaneously with 0.5 mg of estradiol valerate 72 hours prior to C. albicans intravaginal inoculation and at weekly intervals thereafter for a period of up to 4 weeks; the inoculum consisted of 2 x 10(7) stationary-phase C. albicans blastoconidia in a volume of 20 microl. C. albicans colonization was evaluated in the spleen, liver, kidney, small intestine and reproductive tract of estrogen-treated and control mice 72 hours following inoculation, DTH responses were evaluated 2 and 5 weeks following primary inoculation and persistence of infection was evaluated at days 2, 3, 4, 8, 12, 19 and 26 post inoculation. Estrogen-treated mice exhibited higher levels of C. albicans colonization compared with control mice; this was most evident in the small intestine and reproductive tract. Estrogen treatment resulted in pronounced suppression of C. albicans-specific DTH responses; in that average footpad swelling was 4.7 mm in untreated mice compared with 2.3 mm in estrogen-treated mice. Long-term estrogen treatment resulted in the persistence of infection; in contrast, C. albicans infection resolved by day 8 post inoculation in untreated mice. DTH responses assayed 5 weeks post primary inoculation in treated mice were on average 4.1 mm, this was similar to that observed in untreated mice tested for DTH response 2 and 5 weeks post primary inoculation. These results suggest that, on the one hand, estrogen has an enhancing effect on C. albicans colonization and persistence of infection. On the other, estrogen seems to suppress DTH responses within the first 2 weeks post infection; persistence of infection under the influence of estrogen, however, seems to coexist with detectable systemic cell-mediated immunity.

Growth inhibition of Candida albicans by human vaginal epithelial cells

Vulvovaginal candidiasis (VVC) is a common mucosal infection caused by Candida species in women of childbearing age. Although acute VVC affects a large number of women and is often precipitated by hormonal fluctuations involving high estrogen levels, recurrent VVC (RVVC) affects another 5%-10% of women without any known predisposing factors. We have recently reported that vaginal epithelial cells from nonhuman primates and mice inhibit the growth of Candida albicans in vitro, which may represent an innate host defense mechanism against C. albicans at the vaginal mucosa. In the present study, we show that vaginal epithelial cells collected from healthy women with no history of VVC also exhibit anti-Candida activity, with no differences in activity at various stages of the menstrual cycle. Women diagnosed with RVVC, on the other hand, have reduced epithelial cell anti-Candida activity. These results are further evidence that vaginal epithelial cells provide an innate host resistance mechanism against Candida and that reduced activity may contribute to RVVC.

Vaginal thrush: perceptions and experiences of women of south Asian descent

It is estimated that 75% of all women will, at some time in their lives, experience at least one episode of vaginal thrush. This paper reports the perceptions and experiences of women of South Asian descent living in England, who were suffering or had suffered from thrush. The paper draws upon data collected during 20 semi-structured interviews. The women reported that thrush sometimes had a considerable impact on their lives, making some of them feel 'dirty', embarrassed, depressed and stigmatized. Some women delayed seeking professional help even if they had access to a female General Practitioner. Access to professional care was sometimes hampered by language barriers, but more often by structural factors of gender and social class. Although almost all the women came originally from Gujarat (or had parents who were born in Gujarat), they reported a wide range of experiences. Since vaginal thrush causes much distress and since it is often preventable, the findings presented here have implications for clinical practice. The paper concludes with suggestions for future developments.

Candidiasis during pregnancy may result from isogenic commensal strains

OBJECTIVE

Our laboratory previously demonstrated that asymptomatic vaginal colonization during pregnancy is a factor predisposing patients to subsequent symptomatic vulvovaginal candidiasis. It is unknown whether symptoms result from strain replacement or a change in host relationship to the original colonizing strain. This study was undertaken to determine whether Candida albicans isolates from asymptomatic women could be responsible for subsequent symptomatic vaginitis.

METHODS

We retained isolates of C. albicans from women followed longitudinally through pregnancy, and identified six pairs of cultures from women who were colonized without symptoms and who later became symptomatic (average time 14 weeks). We used a random amplification of polymorphic DNA (RAPD) analysis to determine whether isolates from our study patients were genetically similar or dissimilar.

RESULTS

Analysis of these pairs of yeast strains by RAPD revealed that five of the six women had symptoms apparently due to the same yeast strain that was found initially as a commensal strain. To increase the power of these observations, we also performed RAPD analysis on six randomly selected yeast strains from other women in this study who had not become symptomatic to determine whether any of these unrelated strains matched strains from those women who became symptomatic.

CONCLUSION

Symptomatic yeast vaginitis is usually due to strains of C. albicans already carried in the lower genital tract, underscoring the need to understand regulation of growth and virulence of the organism in vivo.