Candida albicans is a fungal organism that can live as commensals in Humans. It can manifest in pathogenic state causing painful mucosal Infections as oral thrush, and vaginal infections, among many other clinical manifestations. On few occasions predisposes to life threatening systemic infections. The relation of humans to Candida is a dynamic process can change their status from commensals to an opportunistic state, and lead to Candidosis. Women are at higher risk of getting genital infections if the circumstances permit. The isolation rate of Candida from Vagina increases during pregnancy. The Vulvovaginal region remains a venerable point for Candidosis. Many genital infections of women in developing countries are ignored, due to lack awareness, poor genital hygiene, poverty, lack of medical care. The importance of infection lies with 5 - 8 % of the adult women continue to have recurrent vulvovingal Candidosis .Many women resort to empirical treatment, less often over the counter drugs. On many occasions mixed infections are missed the important one being bacterial vaginosis caused by Gardernella vaginalis, and other sexually transmitted diseases.
Microbiology of Candida spp
There are several species among the Candida, few have higher predisposition in causing Candidosis which include, C.albicans, C, glabrata. But majority of isolates are C.albicans and account for 85 - 95% of infections. C.glabrata can cause 10 -20 % of the infections. The importance of speciation is gaining importance as several anti candidal drugs are becoming drug resistant due to over the counter availability, failure to administer the optimal dosage and lead to recurrent infections. Future demands will rise for identification of species and antimycotic sensitivity testing.
Why Women are at Risk,
Sexual behavior is prime factor in recurrent vulvovaginitis. Many women ignore this as prime factor .Other contributing factors are frequency of intercourse, periodicity, receptive orogenital sex practices, and multiple sex partners. Does the tight and synthetic undergarments make difference is contraveriosual, but makes little difference. Men who have sex with women with Candidosis get colonized, and manifest with acute symptoms. Candida are isolated more in men with uncircumcised than those who were circumcised, Pregnant women are at higher risk. Oral contraceptives with higher estrogen content, enhances colonization and present with active infection. .Intrauterine contraceptive devices, protective devices as Diaphragms and condoms can increase the risk infections.
Diabetes mellitus predisposes to vaginal colonization; Women with type 2 Diabetes are more prone for colonization with C.glabrata infection. Genital hygiene and effective control of diabetes makes the true difference in recovery. Reduced consumption of refined food will help in reduction of Candida infections.
Use of Broad spectrum antibiotics cause imbalance in normal flora and predisposes to colonization in Intestinal and Vaginal regions. On usage of Antibiotics some women present with copious white colored vaginal discharge, Microscopy will demonstrate actively germinating yeast cells or few yeast cells needing culturing for appropriate Diagnosis and effective control measures.
How Women with Vulvovaginal Candidosis Present to Physician
Majority of women present with acute pruritus, and vaginal discharge which appear as white cheesy secretions, vaginal sore, vulval burning, dysuria, dyspareunia, many women present some of these features even one week before the onset of menses.
Self Diagnosis is deceptive, and use of over the counter medicines can lead to chronic Candidosis. Good physical examination is highly essential which can help to rule out other sexually related infections, apart from cervical cancer.
Need for Optimal Microbiology Diagnosis
Microscopic examination of the discharge by wet film, and KOH 10 % will reveal the presence of yeasts. Culturing of specimens on Sabouraud agar is more effective in diagnosing cases missed by direct Microscopy. Speciation among Candida is gaining importance for Epidemiological surveys and administration of appropriate antimycotic agents as some species are gaining importance, and becoming resistant to routinely used antifungal agents.
It is a concern to the Physician the presence of Candida is merely a colonizer or infectious, outcome of Diagnosis will remain with good clinical evaluation and appropriate clinical examination
Principles of treatment of Vaginal Candidosis
1. Every patient should be assessed on Individual basis, 2. Several Azole preparations are in use and produce prompt results with topical application. 3. Azoles can produce cure in 80 - 90 % of patients. 4. Oral Azole can produce higher cure rates. 5. But Azoles are poor in Effectiveness on C glabrata, it is necessary to culture the vaginal secretions in recurrent Candidosis. 6. Emerging Newer Medications Topical Miconozole suppositories, with oral antifungal Medications. Vaginal - Clotrimazole + oral Fluconozole.
7 During Pregnancy topical Azoles produce effective cure in 7 days. 8 Recurrent Vulvovaginitis Needs a good clinical examination Needs correction of the predisposing conditions. Culturing for species identification, if necessary antifungal Sensitivity testing. 9 Candidosis and HIV infections - Candidosis is included in category of AIDS defining illness, only women with risk factors should be screened for HIV status.
DrT.V.Rao MD, and Mrs Jisha Paul M.Sc,are Microbiology teachers in India.Interested with issues on Infectious diseases, and in particular Hospital acquired Infection Presently working on Candidal infection in patients attending a Teaching Hospital in India.
