Prevalence of Candida spp. in cervical-vaginal samples and the in vitro susceptibility of isolates

Tchana Martinez Brandolt Gabriel Baracy Klafke Carla Vitola Gonçalves Laura Riffel Bitencourt Ana Maria Barral de Martinez Josiara Furtado Mendes Mário Carlos Araújo Meireles Melissa Orzechowski Xavier About the authors

Abstract

Vulvovaginal candidiasis (VVC) is an infection of the genital mucosa caused by different species of the genus Candida. Considering the lack of data on this topic in the south of Brazil, this study aimed to assess the prevalence of Candida spp. in the cervical-vaginal mucosa of patients treated at a university hospital in southern Rio Grande do Sul, as well as the etiology and the susceptibility of the isolates against fluconazole, itraconazole, miconazole and nystatin. Samples were collected at the gynecology clinic of the Federal Hospital of the University of Rio Grande, and the isolates were identified using phenotypic and biochemical tests. The susceptibility analysis was performed according to the CLSI M27-A2 protocol. Of the 263 patients included, Candida spp. was isolated in 27%, corresponding to a prevalence of approximately 15% for both VVC and colonization. More than 60% of the isolates were identified as Candida albicans; C. non-albicans was isolated at a rate of 8.6% in symptomatic patients and 14.3% in asymptomatic patients. The prevalence of resistance against fluconazole and itraconazole was 42% and 48%, respectively; the minimal inhibitory concentration of miconazole ranged from 0.031 to 8 µg/mL, and that of nystatin ranged from 2 to >16 µg/mL. The high rate of resistance to triazoles observed in our study suggests the necessity of the association of laboratory exams to clinical diagnosis to minimize the practice of empirical treatments that can contribute to the development of resistance in the isolates.

Keywords:
Vulvovaginal candidiasis; Antifungal; Susceptibility; Resistance

Introduction

Vulvovaginal candidiasis (VVC) is characterized by an infection of the genital mucosa by Candida yeasts, which mainly undertakes the vulva and the vagina. The disease occurs endogenously due to predisposing factors that favor yeast multiplication. Signs and symptoms such as itching, burning, cracking, erythema and vulvar edema, leukorrhea and the presence of whitish plaques on the vaginal mucosa are common.11 Andrioli JL. Frequência de leveduras em fluido vaginal de mulheres com e sem suspeita clínica de candidíase vulvovaginal. Rev Bras Ginecol Obstet. 2009;31(6):300-304. VVC is considered the second most common cause of genital infection in women of reproductive age, and although it represents a problem of global importance in public health, its exact incidence is unknown.22 Rodrigues MT, Simões LZ, Diniz CG. Clinical, microbiological and therapeutic aspects of vulvovaginal candidiasis and recurrent vulvovaginal candidiasis: importance of regional surveys. HU Rev. 2009;35(3):175-181.,33 WORD HEALTH ORGANIZATION (WHO). Laboratory diagnosis of sexually transmitted infections, including human immunodeficiency virus; 2013.

Risk factors for vulvovaginitis include pregnancy, use of oral contraceptives, genetic predisposition, and previous antibiotic therapy, among others. The incidence of infection, as well as the increase in colonization of the mucosa by the yeast, is also higher in women with diabetes due to their higher glycogen levels and in those with HIV due to immune suppression.44 Álvares CA, Svidzinski TIE, Consolaro MEL. Candidíase vulvovaginal: fatores predisponentes do hospedeiro e virulência das leveduras. J Bras Patol Med Lab. 2007;43(5):319-327.,55 Maccallum DM. Hosting infection: experimental models to assay Candida virulence. Int J Microbiol. 2012;2012:.

Studies show that 70-75% of all women of reproductive age develop at least one case of VVC during their lifetime.66 Sobel JD. Vulvovaginal candidosis. Lancet. 2007;369:1961-1971.,77 Dias LB, Melhem MSC, Szeszs MW, Filho JM, Hahn RC. Vulvovaginal candidiasis in Mato Grosso, Brazil: pregnancy status, causative species and drugs tests. Braz J Microbiol. 2011;42:1300-1307. The recurrence rate is 40-50%, and approximately 5-8% develop recurrent vulvovaginal candidiasis (RVVC), which is characterized by four or more episodes of disease over a period of twelve months.66 Sobel JD. Vulvovaginal candidosis. Lancet. 2007;369:1961-1971.

7 Dias LB, Melhem MSC, Szeszs MW, Filho JM, Hahn RC. Vulvovaginal candidiasis in Mato Grosso, Brazil: pregnancy status, causative species and drugs tests. Braz J Microbiol. 2011;42:1300-1307.
-88 Beikert FC, Le MT, Koeninger A, Technau K, Clad A. Recurrent vulvovaginal candidosis: focus on the vulva. Mycoses. 2011;54:807-810.

The main etiologic agent is Candida albicans, accounting for 70-90% of VVC cases.77 Dias LB, Melhem MSC, Szeszs MW, Filho JM, Hahn RC. Vulvovaginal candidiasis in Mato Grosso, Brazil: pregnancy status, causative species and drugs tests. Braz J Microbiol. 2011;42:1300-1307.,88 Beikert FC, Le MT, Koeninger A, Technau K, Clad A. Recurrent vulvovaginal candidosis: focus on the vulva. Mycoses. 2011;54:807-810. Among the non-albicans species C. glabrata is highlighted77 Dias LB, Melhem MSC, Szeszs MW, Filho JM, Hahn RC. Vulvovaginal candidiasis in Mato Grosso, Brazil: pregnancy status, causative species and drugs tests. Braz J Microbiol. 2011;42:1300-1307.

8 Beikert FC, Le MT, Koeninger A, Technau K, Clad A. Recurrent vulvovaginal candidosis: focus on the vulva. Mycoses. 2011;54:807-810.
-99 Colombo AL, Guimarães T, Camargo LFA, et al. Brazilian guidelines for the management of candidiasis - a joint meeting reporto of three medical societies: Sociedade Brasileira de Infectologia, Sociedade Paulista de Infectologia and Sociedade Brasileira de Medicina Tropical. Braz J Infect Dis. 2013;17(3):283-312. due to its prevalence and resistance to azoles.1010 Richter SS, Galask RP, Messer SA, Hollis RJ, Diekema DJ, Pfaller MA. Antifungal susceptibilities of Candida species causing vulvovaginitis and epidemiology of recurrent cases. J Clin Microbiol. 2005;43:2155-2162.,1111 Fan SR, e Liu XP. In vitro fluconazole and nystatin susceptibility and clinical outcome in complicated vulvovaginal candidosis. Mycoses. 2010;54:501-505.

An increasing number of Candida spp. clinical isolates are resistant to antifungal agents routinely used for the treatment of VVC. In addition, studies in different regions of Brazil suggest that geographical factors interfere in the prevalence of Candida species as well as in the sensitivity of isolates to antifungals.11 Andrioli JL. Frequência de leveduras em fluido vaginal de mulheres com e sem suspeita clínica de candidíase vulvovaginal. Rev Bras Ginecol Obstet. 2009;31(6):300-304.,1111 Fan SR, e Liu XP. In vitro fluconazole and nystatin susceptibility and clinical outcome in complicated vulvovaginal candidosis. Mycoses. 2010;54:501-505.

12 Ferrazza MHSH, Maluf MLF, Consolaro MEL, Shinobu CS, Svidzinski TIE, Batista MR. Caracterização de leveduras isoladas da vagina e sua associação com candidíase vulvovaginal em duas cidades do sul do Brasil. Rev Bras Ginecol Obstet. 2005;27(2):58-63.
-1313 Dota KFD, Consolaro MEL, Svidzinski TIE, Bruschi ML. Antifungal activity of Brazilian propolis microparticles against yeasts isolated from vulvovaginal candidiasis. Evid Based Complement Altern Med. 2011;2011:1-8. Considering this and the lack of data on this topic in Rio Grande do Sul, this study aimed to identify the prevalence of Candida spp. isolated from the vaginal mucosa of patients with and without vulvovaginitis treated at a university hospital in extreme southern Brazil, as well as the susceptibility of these isolates to four antifungals used in gynecological routines.

Materials and methods

The study included 263 patients attended on from April 2013 to October 2014 at the gynecology clinic of the University Hospital of the Federal University of Rio Grande (FURG) - Rio Grande do Sul - Brazil. The women agreed to participate by signing the Clarified Informed Consent form. The sample size, calculated using Epi Info 6.0 and considering a prevalence of 30%, a confidence level of 99%, maximum permissible error of 20% and losses of 10%, was estimated to be a sample of 249 patients.

During the gynecological exam, a sample of cervical-vaginal mucosa was collected using a sterile brush, which was stored in sterile tubes containing PBS and kept refrigerated until processing. The sample was sent to the Mycology Laboratory of the Medicine Faculty from FURG, where it was processed within 12 h. The cultures were processed in Sabouraud agar with chloramphenicol 0.01% (SCl) and incubated at 37 °C for seven days with daily assessment of growth. The yeasts were identified using phenotypic tests such as micromorphology, chromogenic medium (CHROM Agar Candida®), germ tube test, and microculture in agar cornmeal and were confirmed by biochemical automated method (VITEK® 2). Each isolate was maintained on potato dextrose agar (PDA) in the mycology collection at room temperature under freezing at −20 °C in saline with 30% glycerol for subsequent susceptibility testing.

The variables evaluated in the study were obtained by self-administered pre-coded questionnaire and included age, skin color, educational level, marital status, family income, HIV infection status, pregnancy, contraception and vaginal pH at the time of sample collection. Signs and symptoms assessed during the gynecological exam were used to consider women as colonized or presenting VVC, the latter being those that had leukorrhea, pruritus, edema and/or vulvovaginal erythema associated with the presence of whitish plaques in the mucosa and the isolation of Candida spp. in mycological cultivation.

The in vitro susceptibility analysis of clinical isolates was performed by broth microdilution using the M27-A2 standard protocol CLSI (2002).1414 CLINICAL AND LABORATORY STANDARDS INSTITUTE (CLSI). Reference method for broth dilution antifungal susceptibility testing of yeasts, Approved Standard M27-A2. 2nd ed; 2002. For the standardization of fungal inoculum, isolates were subcultured on PDA for 24 h at 37 °C, young colonies were homogenized in sterile saline, and the turbidity was adjusted to 0.5 on the McFarland scale by spectrophotometry (530 nm) to obtain a concentration of 1-5 × 106 CFU/mL. Then, a dilution was performed at 1:100 and 1:20 in RPMI 1640, resulting in a concentration of 5 × 102 to 2.5 × 103 CFU/mL. The inoculum concentration was confirmed using the Pour-plate technique. The susceptibility test was performed at concentrations of 64 µg/mL to 0.125 µg/mL for fluconazole and at concentrations ranging from 16 µg/mL to 0.031 µg/mL for itraconazole, miconazole and nystatin.

The 96-well microplates were filled with 100 µL of the antifungal concentrations and 100 µL of inoculum and were incubated at 37 °C for 48 h along with growth and sterility controls. Each isolate was tested in duplicate, and the results were visually evaluated by turbidity, comparing the fungal growth in the well with the growth control. The minimum inhibitory concentration (MIC) of fluconazole, itraconazole and miconazole was one that inhibited 80% of yeast growth, and the MIC of nystatin inhibited 100% of growth.

According to the MIC result for fluconazole and itraconazole, the isolates were classified as S for sensitive, SDD for sensitive dose-dependent and R for resistant, as established by the cutoff point protocol M27-A2. For miconazole and nystatin, the MIC50 and MIC90 were calculated corresponding to the antifungal concentration capable of inhibiting the growth of 50% and 90%, respectively, of the isolates tested. After reading the results of MIC, 10 µL of the solutions from the wells related to concentrations higher than and equal to the MIC were plated on a Petri dish containing agar SCl and were incubated at 37 °C for 48 h to determine the fungicide minimum concentration (FMC).

The study was conducted according to ethical principles and was approved by the Research Ethics Committee of the Federal University of Rio Grande (65/2012). The results were compiled by conducting descriptive analysis of the data and chi-square tests for categorical variables using SPSS 19.0® software. p-values below 0.05 were considered statistically significant.

Results

The study population consisted mostly of women who had partners (64.5%), had white skin color (65.3%), were pregnant (60.3%) and were HIV-negative (72.9%). The mean age was 28.5 years and ranged from 12 and 68 years, with more than 65% of the women under 31 years of age (n = 176) and 54.7% (n = 135) using hormonal contraception (Table 1).

Table 1
Descriptive analysis of the study population ( n = 263) and the influence of the variables studied (chi-square test) in the development of vulvovaginal candidiasis (VVC) ( n = 35).

Of the 263 patients, Candida spp. was isolated in the mycological culture from cervical-vaginal samples in 27% (n = 71). Of these, vulvovaginal candidiasis was diagnosed in 49.3% (n = 35), resulting in a prevalence in the population of 13.3%. The remaining 50.7% (n = 36) that had no signs or symptoms of vulvovaginitis were classified as colonization cases.

The predominant species was Candida albicans in both groups, corresponding to 62.9% (n = 22) of isolates originating from the group of women colonized and 74.3% (n = 26) from the women with VVC. The other species identified colonizing the vaginal mucosa of healthy women were C. glabrata in 14.3% (n = 5), followed by C. sphaerica in 8.6% (n = 3) and C. parapsilosis complex in 2.9% (n = 1). Among cases of VVC by C. non-albicans (n = 5), 8.6% (n = 3) were due to C. glabrata, 2.9% (n = 1) were due to C. parapsilosis complex, and 2.9% (n = 1) were due to C. tropicalis. In addition, 11.4% (n = 4) of the isolates from colonization, and 11.4% (n = 4) of the etiologic agents of VVC were identified only in general, being classified as Candida spp.

Regarding the variables analyzed, 82.4% (n = 28) of patients diagnosed with VVC belonged to the group of women aged 30 years or younger (p = 0.047). For the other variables such as skin color, marital status, educational level, family income, contraception, pregnancy and HIV infection, there was no significant difference between the group of women with and without VVC (Table 1). The same occurred with the vaginal pH at the time of collection, in which 133 patients had pH ≤ 4.5, but only 14.3% (n = 19) of them were diagnosed with VVC (p = 0.948).

Of the 71 clinical isolates of Candida spp., 50 were subjected to in vitro susceptibility testing, 25 from healthy women and 25 from women with VVC. Considering all the isolates, regardless of species, the MIC to miconazole ranged from 0.031 to 8 µg/mL, with MIC50 = 0.5 µg/mL and MIC90 = 4 µg/mL, and the MIC to nystatin ranged from 2 to >16 µg/mL, with a MIC50 = 4 µg/mL and MIC90 = 8 µg/mL. Concerning fluconazole and itraconazole, resistance was observed in 42% and 48%, respectively, of the isolates (Table 2). No significant difference in MIC values was observed between clinical isolates of VVC and colonization. Concerning fluconazole, 100% of the isolates of C. albicans and C. glabrata showed an FMC > 64 µg/mL, and for itraconazole, 100% of C. glabrata and 97% of C. albicans showed an FMC > 16 µg/mL (Table 3).

Table 2
Results of the in vitro susceptibility test of Candida spp. from colonized and/or VVC patients against four antifungal agents. S-sensitive, SDD-sensitive dose-dependent and R-resistant.
Table 3
Fungicide Minimum Concentration (FMC) results of the four antifungals tested against Candida spp. isolated from colonized and/or VVC patients.

Discussion

The present study provides data about Candida spp. isolation from the vulvovaginal mucosa of women in southern Rio Grande do Sul, Brazil. We detected the yeast in 27% of the study population, corresponding to a prevalence of approximately 13% both for colonization and for vulvovaginal candidiasis. Similar and lower rates of fungal isolation in women with and without vulvovaginitis have been described in other studies of the southern region: 11 and 24.7% in patients in the state of Paraná,1212 Ferrazza MHSH, Maluf MLF, Consolaro MEL, Shinobu CS, Svidzinski TIE, Batista MR. Caracterização de leveduras isoladas da vagina e sua associação com candidíase vulvovaginal em duas cidades do sul do Brasil. Rev Bras Ginecol Obstet. 2005;27(2):58-63.

13 Dota KFD, Consolaro MEL, Svidzinski TIE, Bruschi ML. Antifungal activity of Brazilian propolis microparticles against yeasts isolated from vulvovaginal candidiasis. Evid Based Complement Altern Med. 2011;2011:1-8.

14 CLINICAL AND LABORATORY STANDARDS INSTITUTE (CLSI). Reference method for broth dilution antifungal susceptibility testing of yeasts, Approved Standard M27-A2. 2nd ed; 2002.
-1515 Gunther LSA, Martins HPR, Gimenes F, Abreu ALP, Consolaro MEL, Svidzinski TIE. Prevalence of Candida albicans and non-albicans isolates from vaginal secretions: comparative evaluation of colonization, vaginal candidiasis and recurrent vaginal candidiasis in diabetic and non-diabetic women. São Paulo Med J. 2014;132(2):116-120. 23.8% in patients in the state of Santa Catarina1212 Ferrazza MHSH, Maluf MLF, Consolaro MEL, Shinobu CS, Svidzinski TIE, Batista MR. Caracterização de leveduras isoladas da vagina e sua associação com candidíase vulvovaginal em duas cidades do sul do Brasil. Rev Bras Ginecol Obstet. 2005;27(2):58-63. and 18.2% in the city of Santo Ângelo-RS,1616 Camargo FP, Alves IA, Parlow MS, Goulart LS. Isolamento de Candida sp. da mucosa vaginal de mulheres atendidas em um serviço de ginecologia do município de Santo Ângelo-RS. NewsLab87; 2008. the latter being the only study held in Rio Grande do Sul. These differences in the isolation of Candida spp. from vaginal mucosa can be explained by cultural habits of different regions, especially in regard to hygiene practices, as this factor is directly related to self-contamination because the yeast belongs to the normal gastrointestinal tract microbiota.33 WORD HEALTH ORGANIZATION (WHO). Laboratory diagnosis of sexually transmitted infections, including human immunodeficiency virus; 2013.,1717 Holanda AAR, Fernandes ACS, Bezerra CM, et al. Candidíase vulvovaginal: sintomatologia, fatores de risco e colonização anal concomitante. Rev Bras Ginecol Obstet. 2007;29(1):3-9.,1818 Watson CJ, Fairley CK, Grando D, Garland SM, Myers SP, Pirotta M. Associations with asymptomatic colonization with Candida in women reporting past vaginal candidiasis: an observational study. Eur J Obstet Gynecol Reprod Biol. 2013;169:376-379. On the other hand, similar studies in northeastern Brazil show fungal isolation in women with and without vulvovaginitis of up to 46%.11 Andrioli JL. Frequência de leveduras em fluido vaginal de mulheres com e sem suspeita clínica de candidíase vulvovaginal. Rev Bras Ginecol Obstet. 2009;31(6):300-304.,1717 Holanda AAR, Fernandes ACS, Bezerra CM, et al. Candidíase vulvovaginal: sintomatologia, fatores de risco e colonização anal concomitante. Rev Bras Ginecol Obstet. 2007;29(1):3-9.,1919 Mascarenhas REM, Machado MSC, Silva BFBC, et al. Prevalence and risk factors for bacterial vaginosis and other vulvovaginitis in a population of sexually active adolescents from Salvador, Bahia, Brazil. Infect Dis Obstet Gynecol. 2012;:2012.,2020 Sá MCN, Sousa HR, Amaro CSO, Pinheiro DN, Oliveira MMM, Pinheiro MCN. Isolamento de Candida no esfregaço cérvico-vaginal de mulheres não gestantes residentes em area rebeirinha do Estado do Maranhão, Brasil, 2012. Rev Pan-Amazônica Saúde. 2014;5(1):25-34. It is assumed that other factors besides those mentioned above may explain the high prevalence of Candida spp. in this region, such as weather conditions and social and environmental factors that are favorable to the reproduction of yeast.2020 Sá MCN, Sousa HR, Amaro CSO, Pinheiro DN, Oliveira MMM, Pinheiro MCN. Isolamento de Candida no esfregaço cérvico-vaginal de mulheres não gestantes residentes em area rebeirinha do Estado do Maranhão, Brasil, 2012. Rev Pan-Amazônica Saúde. 2014;5(1):25-34.

The rate of colonization of 13.7% observed in our study is consistent with the literature,33 WORD HEALTH ORGANIZATION (WHO). Laboratory diagnosis of sexually transmitted infections, including human immunodeficiency virus; 2013.,99 Colombo AL, Guimarães T, Camargo LFA, et al. Brazilian guidelines for the management of candidiasis - a joint meeting reporto of three medical societies: Sociedade Brasileira de Infectologia, Sociedade Paulista de Infectologia and Sociedade Brasileira de Medicina Tropical. Braz J Infect Dis. 2013;17(3):283-312. which describes that Candida spp. is part of the genital microbiota of up to 30% of healthy women.11 Andrioli JL. Frequência de leveduras em fluido vaginal de mulheres com e sem suspeita clínica de candidíase vulvovaginal. Rev Bras Ginecol Obstet. 2009;31(6):300-304.,1818 Watson CJ, Fairley CK, Grando D, Garland SM, Myers SP, Pirotta M. Associations with asymptomatic colonization with Candida in women reporting past vaginal candidiasis: an observational study. Eur J Obstet Gynecol Reprod Biol. 2013;169:376-379. Whereas the disease occurs endogenously, is important to differentiate between the colonization and infection of the vaginal mucosa.33 WORD HEALTH ORGANIZATION (WHO). Laboratory diagnosis of sexually transmitted infections, including human immunodeficiency virus; 2013.,1818 Watson CJ, Fairley CK, Grando D, Garland SM, Myers SP, Pirotta M. Associations with asymptomatic colonization with Candida in women reporting past vaginal candidiasis: an observational study. Eur J Obstet Gynecol Reprod Biol. 2013;169:376-379.

Ferrazza and co-workers1212 Ferrazza MHSH, Maluf MLF, Consolaro MEL, Shinobu CS, Svidzinski TIE, Batista MR. Caracterização de leveduras isoladas da vagina e sua associação com candidíase vulvovaginal em duas cidades do sul do Brasil. Rev Bras Ginecol Obstet. 2005;27(2):58-63. found a VVC prevalence of 19.2% in Santa Catarina and of 9.3% in Paraná; these data are similar to the prevalence of VVC found in our study.1212 Ferrazza MHSH, Maluf MLF, Consolaro MEL, Shinobu CS, Svidzinski TIE, Batista MR. Caracterização de leveduras isoladas da vagina e sua associação com candidíase vulvovaginal em duas cidades do sul do Brasil. Rev Bras Ginecol Obstet. 2005;27(2):58-63. However, it is below the 69% found by Holanda and co-workers1717 Holanda AAR, Fernandes ACS, Bezerra CM, et al. Candidíase vulvovaginal: sintomatologia, fatores de risco e colonização anal concomitante. Rev Bras Ginecol Obstet. 2007;29(1):3-9. in a study conducted in Natal, the 47.9% found by Andrioli and co-workers11 Andrioli JL. Frequência de leveduras em fluido vaginal de mulheres com e sem suspeita clínica de candidíase vulvovaginal. Rev Bras Ginecol Obstet. 2009;31(6):300-304. in Bahia, the 42.7% described by Sá and co-workers2020 Sá MCN, Sousa HR, Amaro CSO, Pinheiro DN, Oliveira MMM, Pinheiro MCN. Isolamento de Candida no esfregaço cérvico-vaginal de mulheres não gestantes residentes em area rebeirinha do Estado do Maranhão, Brasil, 2012. Rev Pan-Amazônica Saúde. 2014;5(1):25-34. in Maranhão and the 39.6% found by Dias and co-workers77 Dias LB, Melhem MSC, Szeszs MW, Filho JM, Hahn RC. Vulvovaginal candidiasis in Mato Grosso, Brazil: pregnancy status, causative species and drugs tests. Braz J Microbiol. 2011;42:1300-1307. in Mato Grosso. Considering that this disease is opportunistic, this discrepancy may be related to several factors related to the etiologic agent, the species distribution and/or virulence of the strains, the immune status of the host, or the environment, which influences the maintenance of temperature and humidity conducive to fungal proliferation.11 Andrioli JL. Frequência de leveduras em fluido vaginal de mulheres com e sem suspeita clínica de candidíase vulvovaginal. Rev Bras Ginecol Obstet. 2009;31(6):300-304.,1212 Ferrazza MHSH, Maluf MLF, Consolaro MEL, Shinobu CS, Svidzinski TIE, Batista MR. Caracterização de leveduras isoladas da vagina e sua associação com candidíase vulvovaginal em duas cidades do sul do Brasil. Rev Bras Ginecol Obstet. 2005;27(2):58-63.,2020 Sá MCN, Sousa HR, Amaro CSO, Pinheiro DN, Oliveira MMM, Pinheiro MCN. Isolamento de Candida no esfregaço cérvico-vaginal de mulheres não gestantes residentes em area rebeirinha do Estado do Maranhão, Brasil, 2012. Rev Pan-Amazônica Saúde. 2014;5(1):25-34.,2121 Tobudic S, Kratzer C, Presterl E. Azole-resistant Candida spp.- emerging pathogens?. Mycoses. 2012;55:24-32.

The differences in geographical location should be considered among the epidemiologic factors that also interfere in the prevalence of Candida spp. isolated from vaginal mucosa.1212 Ferrazza MHSH, Maluf MLF, Consolaro MEL, Shinobu CS, Svidzinski TIE, Batista MR. Caracterização de leveduras isoladas da vagina e sua associação com candidíase vulvovaginal em duas cidades do sul do Brasil. Rev Bras Ginecol Obstet. 2005;27(2):58-63. In this study, C. albicans was predominant, accounting for over 60% of the isolates both in colonized patients and in those with VVC. In fact, this species is the most pathogenic of the gender, being related to most cases of VVC described, and generally represents more than half of the isolates identified in other studies.77 Dias LB, Melhem MSC, Szeszs MW, Filho JM, Hahn RC. Vulvovaginal candidiasis in Mato Grosso, Brazil: pregnancy status, causative species and drugs tests. Braz J Microbiol. 2011;42:1300-1307.,1515 Gunther LSA, Martins HPR, Gimenes F, Abreu ALP, Consolaro MEL, Svidzinski TIE. Prevalence of Candida albicans and non-albicans isolates from vaginal secretions: comparative evaluation of colonization, vaginal candidiasis and recurrent vaginal candidiasis in diabetic and non-diabetic women. São Paulo Med J. 2014;132(2):116-120.,1616 Camargo FP, Alves IA, Parlow MS, Goulart LS. Isolamento de Candida sp. da mucosa vaginal de mulheres atendidas em um serviço de ginecologia do município de Santo Ângelo-RS. NewsLab87; 2008.,2222 Dalazen D, Zanrosso D, Wanderley L, Silva NL, Fuentefria AM. Comparação do perfil de suscetibilidade entre isolados clínicos de Candida spp. orais e vulvovaginais no Sul do Brasil. J Bras Patol Med Lab. 2011;47(1):33-38. Ferraza and co-workers1212 Ferrazza MHSH, Maluf MLF, Consolaro MEL, Shinobu CS, Svidzinski TIE, Batista MR. Caracterização de leveduras isoladas da vagina e sua associação com candidíase vulvovaginal em duas cidades do sul do Brasil. Rev Bras Ginecol Obstet. 2005;27(2):58-63. described the identification of this species in Santa Catarina in 100% and 72% of isolates from the asymptomatic and symptomatic patients, respectively, and in 66.7% of patients with VVC in state of Paraná. Similarly, Camargo and co-workers1616 Camargo FP, Alves IA, Parlow MS, Goulart LS. Isolamento de Candida sp. da mucosa vaginal de mulheres atendidas em um serviço de ginecologia do município de Santo Ângelo-RS. NewsLab87; 2008. identified C. albicans in more than 80% of the isolates from patients with and without VVC in Santo Ângelo-RS.

Approximately 25% of cases of VVC were caused by non-albicans species in our study. Among these, C. glabrata, described as the second most important species in cases of VVC due to its frequency1010 Richter SS, Galask RP, Messer SA, Hollis RJ, Diekema DJ, Pfaller MA. Antifungal susceptibilities of Candida species causing vulvovaginitis and epidemiology of recurrent cases. J Clin Microbiol. 2005;43:2155-2162.,1212 Ferrazza MHSH, Maluf MLF, Consolaro MEL, Shinobu CS, Svidzinski TIE, Batista MR. Caracterização de leveduras isoladas da vagina e sua associação com candidíase vulvovaginal em duas cidades do sul do Brasil. Rev Bras Ginecol Obstet. 2005;27(2):58-63.,1515 Gunther LSA, Martins HPR, Gimenes F, Abreu ALP, Consolaro MEL, Svidzinski TIE. Prevalence of Candida albicans and non-albicans isolates from vaginal secretions: comparative evaluation of colonization, vaginal candidiasis and recurrent vaginal candidiasis in diabetic and non-diabetic women. São Paulo Med J. 2014;132(2):116-120.,1818 Watson CJ, Fairley CK, Grando D, Garland SM, Myers SP, Pirotta M. Associations with asymptomatic colonization with Candida in women reporting past vaginal candidiasis: an observational study. Eur J Obstet Gynecol Reprod Biol. 2013;169:376-379.,2323 Rodrigues MT, Gonçalves AC, Alvim MCT, et al. Associação entre cultura de secreção vaginal, características sociodemográficas e manifestações clínicas de pacientes com diagnóstico de candidíase vulvovaginal. Rev Bras Ginecol Obstet. 2013;35(12):554-561. and greater resistance to antifungals1010 Richter SS, Galask RP, Messer SA, Hollis RJ, Diekema DJ, Pfaller MA. Antifungal susceptibilities of Candida species causing vulvovaginitis and epidemiology of recurrent cases. J Clin Microbiol. 2005;43:2155-2162.,2222 Dalazen D, Zanrosso D, Wanderley L, Silva NL, Fuentefria AM. Comparação do perfil de suscetibilidade entre isolados clínicos de Candida spp. orais e vulvovaginais no Sul do Brasil. J Bras Patol Med Lab. 2011;47(1):33-38.,2424 Oliveira PM, Mascarenhas RE, Lacroix C, et al. Candida species isolated from the vaginal mucosa of HIV-infected women in Salvador, Bahia, Brazil. Braz J Infect Dis. 2011;15(3):239-244. was found in 8.6% of symptomatic patients and in 14.3% of colonized patients in our study, which highlights the importance of laboratory tests for correct identification of the etiologic agent, although the clinical diagnosis of the disease is easily performed and commonly applied.22 Rodrigues MT, Simões LZ, Diniz CG. Clinical, microbiological and therapeutic aspects of vulvovaginal candidiasis and recurrent vulvovaginal candidiasis: importance of regional surveys. HU Rev. 2009;35(3):175-181.,2525 Rathod SD, Klausner JD, Krupp K, Reingold AL, Madhivanan P. Epidemiologic features of vulvovaginal candidiasis among reproductive-age women in India. Infect Dis Obstet Gynecol. 2012;:2012.

Regarding the variables studied, the largest number of patients with VVC was from the group of women younger than 31 years, being within the reproductive age group,33 WORD HEALTH ORGANIZATION (WHO). Laboratory diagnosis of sexually transmitted infections, including human immunodeficiency virus; 2013. which is considered a risk factor for VVC due to sexual activity.88 Beikert FC, Le MT, Koeninger A, Technau K, Clad A. Recurrent vulvovaginal candidosis: focus on the vulva. Mycoses. 2011;54:807-810. However, this difference in age between the group of women with VVC and the otherwise healthy group was not detected by other authors.11 Andrioli JL. Frequência de leveduras em fluido vaginal de mulheres com e sem suspeita clínica de candidíase vulvovaginal. Rev Bras Ginecol Obstet. 2009;31(6):300-304.,1717 Holanda AAR, Fernandes ACS, Bezerra CM, et al. Candidíase vulvovaginal: sintomatologia, fatores de risco e colonização anal concomitante. Rev Bras Ginecol Obstet. 2007;29(1):3-9.,1919 Mascarenhas REM, Machado MSC, Silva BFBC, et al. Prevalence and risk factors for bacterial vaginosis and other vulvovaginitis in a population of sexually active adolescents from Salvador, Bahia, Brazil. Infect Dis Obstet Gynecol. 2012;:2012.,2323 Rodrigues MT, Gonçalves AC, Alvim MCT, et al. Associação entre cultura de secreção vaginal, características sociodemográficas e manifestações clínicas de pacientes com diagnóstico de candidíase vulvovaginal. Rev Bras Ginecol Obstet. 2013;35(12):554-561. Similarly, use of hormonal contraception or intrauterine devices, vaginal pH ≤ 4.5, pregnancy and HIV infection, which are considered as risk factors for the development of VVC33 WORD HEALTH ORGANIZATION (WHO). Laboratory diagnosis of sexually transmitted infections, including human immunodeficiency virus; 2013.,55 Maccallum DM. Hosting infection: experimental models to assay Candida virulence. Int J Microbiol. 2012;2012:.,2020 Sá MCN, Sousa HR, Amaro CSO, Pinheiro DN, Oliveira MMM, Pinheiro MCN. Isolamento de Candida no esfregaço cérvico-vaginal de mulheres não gestantes residentes em area rebeirinha do Estado do Maranhão, Brasil, 2012. Rev Pan-Amazônica Saúde. 2014;5(1):25-34.,2626 Auler ME, Morreira D, Rodrigues FFO, et al. Biofilm formation on intrauterine devices in patients with recurrent vulvovaginal candidiasis. Med Mycol. 2010;48:211-216. were not significantly associated with VVC infection in our study. This discrepancy may be due to the small number of women with VVC in our study (n = 35), which does not allow for a robust statistical analysis for risk factors for the disease.

According to our study as well as that of Rodrigues and co-workers2323 Rodrigues MT, Gonçalves AC, Alvim MCT, et al. Associação entre cultura de secreção vaginal, características sociodemográficas e manifestações clínicas de pacientes com diagnóstico de candidíase vulvovaginal. Rev Bras Ginecol Obstet. 2013;35(12):554-561. the other variables such as marital status, educational level and skin color do not exert significant influence on the development of VVC. Moreover, Álvares and co-workers44 Álvares CA, Svidzinski TIE, Consolaro MEL. Candidíase vulvovaginal: fatores predisponentes do hospedeiro e virulência das leveduras. J Bras Patol Med Lab. 2007;43(5):319-327. state that the vaginal microbiota of black women has a lower incidence of bacterial species, and there would thus be a decrease in natural defenses against fungal growth, predisposing them to infection by Candida spp.44 Álvares CA, Svidzinski TIE, Consolaro MEL. Candidíase vulvovaginal: fatores predisponentes do hospedeiro e virulência das leveduras. J Bras Patol Med Lab. 2007;43(5):319-327.,2020 Sá MCN, Sousa HR, Amaro CSO, Pinheiro DN, Oliveira MMM, Pinheiro MCN. Isolamento de Candida no esfregaço cérvico-vaginal de mulheres não gestantes residentes em area rebeirinha do Estado do Maranhão, Brasil, 2012. Rev Pan-Amazônica Saúde. 2014;5(1):25-34.

In vitro studies have shown different resistance rates of Candida spp. from the vaginal mucosa to the azole drugs commonly used in the treatment and prophylaxis of VVC.77 Dias LB, Melhem MSC, Szeszs MW, Filho JM, Hahn RC. Vulvovaginal candidiasis in Mato Grosso, Brazil: pregnancy status, causative species and drugs tests. Braz J Microbiol. 2011;42:1300-1307.,88 Beikert FC, Le MT, Koeninger A, Technau K, Clad A. Recurrent vulvovaginal candidosis: focus on the vulva. Mycoses. 2011;54:807-810.,1010 Richter SS, Galask RP, Messer SA, Hollis RJ, Diekema DJ, Pfaller MA. Antifungal susceptibilities of Candida species causing vulvovaginitis and epidemiology of recurrent cases. J Clin Microbiol. 2005;43:2155-2162.,1111 Fan SR, e Liu XP. In vitro fluconazole and nystatin susceptibility and clinical outcome in complicated vulvovaginal candidosis. Mycoses. 2010;54:501-505.,1313 Dota KFD, Consolaro MEL, Svidzinski TIE, Bruschi ML. Antifungal activity of Brazilian propolis microparticles against yeasts isolated from vulvovaginal candidiasis. Evid Based Complement Altern Med. 2011;2011:1-8.,2222 Dalazen D, Zanrosso D, Wanderley L, Silva NL, Fuentefria AM. Comparação do perfil de suscetibilidade entre isolados clínicos de Candida spp. orais e vulvovaginais no Sul do Brasil. J Bras Patol Med Lab. 2011;47(1):33-38.,2424 Oliveira PM, Mascarenhas RE, Lacroix C, et al. Candida species isolated from the vaginal mucosa of HIV-infected women in Salvador, Bahia, Brazil. Braz J Infect Dis. 2011;15(3):239-244.,2727 Ge SH, Wan Z, Li J, Xu J, Li RY, Bai FY. Correlation between azole susceptibilities, genotypes, and ERG11 Mutations in Candida albicans isolates associated with vulvovaginal candidiasis in China. Antimicrob Agents Chemother. 2010;54(8):3126-3131.,2828 Nunes EB, Monteiro JCMS, Nunes NB, Paes ALV. Perfil de sensibilidade do gênero Candida a antifúngicos em um hospital de referência da Região Norte do Brasil. Rev Pan-Amazônica Saúde. 2011;2(4):23-30. Concerning fluconazole, the resistance rates range from 0.8% to 12.5%.77 Dias LB, Melhem MSC, Szeszs MW, Filho JM, Hahn RC. Vulvovaginal candidiasis in Mato Grosso, Brazil: pregnancy status, causative species and drugs tests. Braz J Microbiol. 2011;42:1300-1307.,1010 Richter SS, Galask RP, Messer SA, Hollis RJ, Diekema DJ, Pfaller MA. Antifungal susceptibilities of Candida species causing vulvovaginitis and epidemiology of recurrent cases. J Clin Microbiol. 2005;43:2155-2162.,1111 Fan SR, e Liu XP. In vitro fluconazole and nystatin susceptibility and clinical outcome in complicated vulvovaginal candidosis. Mycoses. 2010;54:501-505.,2424 Oliveira PM, Mascarenhas RE, Lacroix C, et al. Candida species isolated from the vaginal mucosa of HIV-infected women in Salvador, Bahia, Brazil. Braz J Infect Dis. 2011;15(3):239-244.,2828 Nunes EB, Monteiro JCMS, Nunes NB, Paes ALV. Perfil de sensibilidade do gênero Candida a antifúngicos em um hospital de referência da Região Norte do Brasil. Rev Pan-Amazônica Saúde. 2011;2(4):23-30. These values are considerably lower than the results found in our study, in which 42% of the isolates were resistant to fluconazole. However, Dalazen and co-workers2222 Dalazen D, Zanrosso D, Wanderley L, Silva NL, Fuentefria AM. Comparação do perfil de suscetibilidade entre isolados clínicos de Candida spp. orais e vulvovaginais no Sul do Brasil. J Bras Patol Med Lab. 2011;47(1):33-38. in a study conducted in Santa Catarina, found 100% of fluconazole resistance. With respect to itraconazole, resistance rates described in other studies range from 1.9 to 43%,1010 Richter SS, Galask RP, Messer SA, Hollis RJ, Diekema DJ, Pfaller MA. Antifungal susceptibilities of Candida species causing vulvovaginitis and epidemiology of recurrent cases. J Clin Microbiol. 2005;43:2155-2162.,1313 Dota KFD, Consolaro MEL, Svidzinski TIE, Bruschi ML. Antifungal activity of Brazilian propolis microparticles against yeasts isolated from vulvovaginal candidiasis. Evid Based Complement Altern Med. 2011;2011:1-8.,2727 Ge SH, Wan Z, Li J, Xu J, Li RY, Bai FY. Correlation between azole susceptibilities, genotypes, and ERG11 Mutations in Candida albicans isolates associated with vulvovaginal candidiasis in China. Antimicrob Agents Chemother. 2010;54(8):3126-3131.,2828 Nunes EB, Monteiro JCMS, Nunes NB, Paes ALV. Perfil de sensibilidade do gênero Candida a antifúngicos em um hospital de referência da Região Norte do Brasil. Rev Pan-Amazônica Saúde. 2011;2(4):23-30. also lower than the 48% found in our study. In addition to the high rate of resistance to fluconazole and itraconazole observed, the FMC of more than 90% of the isolates was greater than the maximum antifungal concentration tested. Therefore, there is a tendency to avoid the prophylactic use of low doses of antifungals in gynecological routines to prevent the emergence of drug-resistant isolates.22 Rodrigues MT, Simões LZ, Diniz CG. Clinical, microbiological and therapeutic aspects of vulvovaginal candidiasis and recurrent vulvovaginal candidiasis: importance of regional surveys. HU Rev. 2009;35(3):175-181.

Another group of azole drugs used for topical treatment of VVC is miconazole.2222 Dalazen D, Zanrosso D, Wanderley L, Silva NL, Fuentefria AM. Comparação do perfil de suscetibilidade entre isolados clínicos de Candida spp. orais e vulvovaginais no Sul do Brasil. J Bras Patol Med Lab. 2011;47(1):33-38. In our study, the MIC for this drug ranged from 0.031 to 8 µg/mL. These data were similar to those found in a study by Choukri and co-workers2929 Choukri F, Benderdouche M, Sednaoui P. In vitro susceptibility profile of 200 recent clinical isolates of Candida spp. to topical antifungal treatments of vulvovaginal candidiasis, the imidazoles and nystatin agents. J Mycol Méd. 2014;24:303-307. in which the MIC to miconazole varied between 0.015 and 8 µg/mL and in a study by Richter and co-workers1010 Richter SS, Galask RP, Messer SA, Hollis RJ, Diekema DJ, Pfaller MA. Antifungal susceptibilities of Candida species causing vulvovaginitis and epidemiology of recurrent cases. J Clin Microbiol. 2005;43:2155-2162. in which the variation was between 0.007 and 4 µg/mL. Moreover, Dalazen and co-workers2222 Dalazen D, Zanrosso D, Wanderley L, Silva NL, Fuentefria AM. Comparação do perfil de suscetibilidade entre isolados clínicos de Candida spp. orais e vulvovaginais no Sul do Brasil. J Bras Patol Med Lab. 2011;47(1):33-38. found a variation in the MIC of miconazole of between 0.097 and ≥100 µg/mL. The different genotypes of the same species may be significantly different in their susceptibility to azoles.2727 Ge SH, Wan Z, Li J, Xu J, Li RY, Bai FY. Correlation between azole susceptibilities, genotypes, and ERG11 Mutations in Candida albicans isolates associated with vulvovaginal candidiasis in China. Antimicrob Agents Chemother. 2010;54(8):3126-3131.

The polyenic agents are another group of drugs used for the treatment of VVC; this group includes nystatin, which is the most used in Brazil and is freely available in the Unified Health System (SUS) in Brazil.3030 Martins HPR, Da Silva MC, Paiva LCF, Svidzinski TIE, Consolaro MEL. Efficacy of fluconazole and nystatin in the treatment of vaginal Candida species. Acta Dermato-Venereol. 2012;92:78-82. The MIC of nystatin found in our study ranged from 2 to >16 µg/mL; however, in a study by Choukri and co-workers,2929 Choukri F, Benderdouche M, Sednaoui P. In vitro susceptibility profile of 200 recent clinical isolates of Candida spp. to topical antifungal treatments of vulvovaginal candidiasis, the imidazoles and nystatin agents. J Mycol Méd. 2014;24:303-307. the MIC varied between 1 and 4 µg/mL, and in a study by Richter and co-workers,1010 Richter SS, Galask RP, Messer SA, Hollis RJ, Diekema DJ, Pfaller MA. Antifungal susceptibilities of Candida species causing vulvovaginitis and epidemiology of recurrent cases. J Clin Microbiol. 2005;43:2155-2162. the concentration ranged from 1 to 16 µg/mL. Knowledge of the patterns of susceptibility to typical drugs in isolates from different regions will allow for the rationalization of the empirical use of antifungal agents, thus contributing to the control of the isolated resistance to drugs.22 Rodrigues MT, Simões LZ, Diniz CG. Clinical, microbiological and therapeutic aspects of vulvovaginal candidiasis and recurrent vulvovaginal candidiasis: importance of regional surveys. HU Rev. 2009;35(3):175-181.

Our results will encourage the development of other studies related to the resistance mechanisms of these yeasts and also of clinical trials in the hospital to determine whether the high resistance to antifungals detected in vitro actually corresponds to therapeutic failure.

According to this data discrepancies and the lack of epidemiological data in the state of Rio Grande do Sul, the present study has been collaborating with local epidemiology, elucidating the etiological factors of VVC and warning of the high resistance rates found in vitro in Candida spp. isolates evaluated.

References

  • 1
    Andrioli JL. Frequência de leveduras em fluido vaginal de mulheres com e sem suspeita clínica de candidíase vulvovaginal. Rev Bras Ginecol Obstet. 2009;31(6):300-304.
  • 2
    Rodrigues MT, Simões LZ, Diniz CG. Clinical, microbiological and therapeutic aspects of vulvovaginal candidiasis and recurrent vulvovaginal candidiasis: importance of regional surveys. HU Rev 2009;35(3):175-181.
  • 3
    WORD HEALTH ORGANIZATION (WHO). Laboratory diagnosis of sexually transmitted infections, including human immunodeficiency virus; 2013.
  • 4
    Álvares CA, Svidzinski TIE, Consolaro MEL. Candidíase vulvovaginal: fatores predisponentes do hospedeiro e virulência das leveduras. J Bras Patol Med Lab. 2007;43(5):319-327.
  • 5
    Maccallum DM. Hosting infection: experimental models to assay Candida virulence. Int J Microbiol 2012;2012:.
  • 6
    Sobel JD. Vulvovaginal candidosis. Lancet 2007;369:1961-1971.
  • 7
    Dias LB, Melhem MSC, Szeszs MW, Filho JM, Hahn RC. Vulvovaginal candidiasis in Mato Grosso, Brazil: pregnancy status, causative species and drugs tests. Braz J Microbiol 2011;42:1300-1307.
  • 8
    Beikert FC, Le MT, Koeninger A, Technau K, Clad A. Recurrent vulvovaginal candidosis: focus on the vulva. Mycoses 2011;54:807-810.
  • 9
    Colombo AL, Guimarães T, Camargo LFA, et al. Brazilian guidelines for the management of candidiasis - a joint meeting reporto of three medical societies: Sociedade Brasileira de Infectologia, Sociedade Paulista de Infectologia and Sociedade Brasileira de Medicina Tropical. Braz J Infect Dis 2013;17(3):283-312.
  • 10
    Richter SS, Galask RP, Messer SA, Hollis RJ, Diekema DJ, Pfaller MA. Antifungal susceptibilities of Candida species causing vulvovaginitis and epidemiology of recurrent cases. J Clin Microbiol. 2005;43:2155-2162.
  • 11
    Fan SR, e Liu XP. In vitro fluconazole and nystatin susceptibility and clinical outcome in complicated vulvovaginal candidosis. Mycoses 2010;54:501-505.
  • 12
    Ferrazza MHSH, Maluf MLF, Consolaro MEL, Shinobu CS, Svidzinski TIE, Batista MR. Caracterização de leveduras isoladas da vagina e sua associação com candidíase vulvovaginal em duas cidades do sul do Brasil. Rev Bras Ginecol Obstet. 2005;27(2):58-63.
  • 13
    Dota KFD, Consolaro MEL, Svidzinski TIE, Bruschi ML. Antifungal activity of Brazilian propolis microparticles against yeasts isolated from vulvovaginal candidiasis. Evid Based Complement Altern Med 2011;2011:1-8.
  • 14
    CLINICAL AND LABORATORY STANDARDS INSTITUTE (CLSI). Reference method for broth dilution antifungal susceptibility testing of yeasts, Approved Standard M27-A2 2nd ed; 2002.
  • 15
    Gunther LSA, Martins HPR, Gimenes F, Abreu ALP, Consolaro MEL, Svidzinski TIE. Prevalence of Candida albicans and non-albicans isolates from vaginal secretions: comparative evaluation of colonization, vaginal candidiasis and recurrent vaginal candidiasis in diabetic and non-diabetic women. São Paulo Med J 2014;132(2):116-120.
  • 16
    Camargo FP, Alves IA, Parlow MS, Goulart LS. Isolamento de Candida sp. da mucosa vaginal de mulheres atendidas em um serviço de ginecologia do município de Santo Ângelo-RS. NewsLab87; 2008.
  • 17
    Holanda AAR, Fernandes ACS, Bezerra CM, et al. Candidíase vulvovaginal: sintomatologia, fatores de risco e colonização anal concomitante. Rev Bras Ginecol Obstet 2007;29(1):3-9.
  • 18
    Watson CJ, Fairley CK, Grando D, Garland SM, Myers SP, Pirotta M. Associations with asymptomatic colonization with Candida in women reporting past vaginal candidiasis: an observational study. Eur J Obstet Gynecol Reprod Biol 2013;169:376-379.
  • 19
    Mascarenhas REM, Machado MSC, Silva BFBC, et al. Prevalence and risk factors for bacterial vaginosis and other vulvovaginitis in a population of sexually active adolescents from Salvador, Bahia, Brazil. Infect Dis Obstet Gynecol. 2012;:2012.
  • 20
    Sá MCN, Sousa HR, Amaro CSO, Pinheiro DN, Oliveira MMM, Pinheiro MCN. Isolamento de Candida no esfregaço cérvico-vaginal de mulheres não gestantes residentes em area rebeirinha do Estado do Maranhão, Brasil, 2012. Rev Pan-Amazônica Saúde. 2014;5(1):25-34.
  • 21
    Tobudic S, Kratzer C, Presterl E. Azole-resistant Candida spp.- emerging pathogens?. Mycoses 2012;55:24-32.
  • 22
    Dalazen D, Zanrosso D, Wanderley L, Silva NL, Fuentefria AM. Comparação do perfil de suscetibilidade entre isolados clínicos de Candida spp. orais e vulvovaginais no Sul do Brasil. J Bras Patol Med Lab 2011;47(1):33-38.
  • 23
    Rodrigues MT, Gonçalves AC, Alvim MCT, et al. Associação entre cultura de secreção vaginal, características sociodemográficas e manifestações clínicas de pacientes com diagnóstico de candidíase vulvovaginal. Rev Bras Ginecol Obstet. 2013;35(12):554-561.
  • 24
    Oliveira PM, Mascarenhas RE, Lacroix C, et al. Candida species isolated from the vaginal mucosa of HIV-infected women in Salvador, Bahia, Brazil. Braz J Infect Dis. 2011;15(3):239-244.
  • 25
    Rathod SD, Klausner JD, Krupp K, Reingold AL, Madhivanan P. Epidemiologic features of vulvovaginal candidiasis among reproductive-age women in India. Infect Dis Obstet Gynecol 2012;:2012.
  • 26
    Auler ME, Morreira D, Rodrigues FFO, et al. Biofilm formation on intrauterine devices in patients with recurrent vulvovaginal candidiasis. Med Mycol. 2010;48:211-216.
  • 27
    Ge SH, Wan Z, Li J, Xu J, Li RY, Bai FY. Correlation between azole susceptibilities, genotypes, and ERG11 Mutations in Candida albicans isolates associated with vulvovaginal candidiasis in China. Antimicrob Agents Chemother. 2010;54(8):3126-3131.
  • 28
    Nunes EB, Monteiro JCMS, Nunes NB, Paes ALV. Perfil de sensibilidade do gênero Candida a antifúngicos em um hospital de referência da Região Norte do Brasil. Rev Pan-Amazônica Saúde 2011;2(4):23-30.
  • 29
    Choukri F, Benderdouche M, Sednaoui P. In vitro susceptibility profile of 200 recent clinical isolates of Candida spp. to topical antifungal treatments of vulvovaginal candidiasis, the imidazoles and nystatin agents. J Mycol Méd 2014;24:303-307.
  • 30
    Martins HPR, Da Silva MC, Paiva LCF, Svidzinski TIE, Consolaro MEL. Efficacy of fluconazole and nystatin in the treatment of vaginal Candida species. Acta Dermato-Venereol. 2012;92:78-82.

Publication Dates

  • Publication in this collection
    Jan-Mar 2017

History

  • Received
    29 Apr 2015
  • Accepted
    30 May 2016
Sociedade Brasileira de Microbiologia USP - ICB III - Dep. de Microbiologia, Sociedade Brasileira de Microbiologia, Av. Prof. Lineu Prestes, 2415, Cidade Universitária, 05508-900 São Paulo, SP - Brasil, Ramal USP 7979, Tel. / Fax: (55 11) 3813-9647 ou 3037-7095 - São Paulo - SP - Brazil
E-mail: bjm@sbmicrobiologia.org.br