Introduction
Vulvovaginal Candida infection which is caused by yeast-like Candida species affects the lower genital tract of women, particularly the vulva and the vagina. Candida albicans, Candida glabrata, Candida tropicalis, Candida kusei, Candida dubliniensis, Candida parapsilosis, Candida guilliermondii, and Candida famata are the species of Candida responsible for the infection [1]. Candida species when existing under certain changing conditions of the vaginal have the potential to cause vulvovaginitis, which occurs as a result of altered microflora by pathogens or pH change in the vaginal environment [2]. Vaginitis is the most common infection in women, and negatively affects the quality of life, is the cause of millions of hospital consultations yearly [3]. Apart from C. albicans being the main cause of Candida vulvovaginitis, other species have also been incriminated in the occurrence of the disease [4]. Vulvovaginal infection due to Candida is the second most prevalent, 20%–25% [2] after bacterial vaginosis.
Symptomatic and asymptomatic cases of vulvovaginal candidiasis (VVC) have been shown by some studies [5]. Symptoms include itching and redness in and around the vagina and vulva, burning sensation during micturition, vaginal discharges, and sexual pains [6], which most times get aggravated before the onset of menstrual period [7].
Some studies conducted on women of reproductive age, who presented signs and symptoms and were all sexually active, have shown that VVC is significantly prevalent [8]. In another study carried out in the coastal area of Cameroon on drug sensitivity testing against fungal pathogens and possible predisposing factors to vaginal Candida infection, C. albicans gave a prevalence of 65.3% [9].
Host-related risk factors responsible for increasing the prevalence and incidence of VVC have been given by some authors [5–7,9]. Host-related risk factors and behavioral factors include pregnancy [10–13], hormone replacement [14], glucocorticoids use and genetic predispositions [7], and indiscriminate use of antibiotics used as a treatment for vaginal candidiasis, which has led to drug resistance [15,16]. The development of resistance is also explained due to the use of drugs bought without appropriate medical procedures to treat these infections [6].
In Cameroon, specifically in the South West region, where Buea Regional Hospital is located, the paucity of epidemiological data on the burden of vaginal candidiasis and its associated risk factors of females within reproductive age, and with reports on the development of drug resistance, it is necessary to carry out this study. Performing prompt diagnostic confirmation and implementing adequate treatment may augment the clinical conditions [17]. The use of CHROM agar, a differential medium for Candida species [18], which is rapid, simple, and cost-effective [19], has led to efficient treatment and management of VVC. This study was, therefore, to determine the prevalence of VVC among women of childbearing age and predisposing factors for the development of VVC, which could be used by stakeholders to effectively carry out measures to curb its incidence and prevalence.
Materials and Methods
Study design
A quantitative descriptive study was carried out during the period from February to May 2023, at the Buea Regional Hospital, where vaginal swabs were collected at the microbiology laboratory for culture and microscopy, and a survey was used to obtain complementary data.
Data and sample collection procedure
All patients who came to the hospital to consult were given questionnaires, or read out to respondents after signing the consent form, and complementary data were obtained from it.
A total of 190 participants were sampled, where participants were randomly recruited into the study based on their accessibility to the researcher and acceptance to participate. Participants included in the study were women aged between 15 and 45 years who answered the questions administered in the questionnaire, showed one or more symptoms of vaginitis, and were not in their period of menstruation.
Sample collection and processing
Vaginal samples were obtained from the walls of the vaginal and endocervix of the volunteers with symptoms, by a trained laboratory scientist volunteers using cotton swabs and speculum, which had been sterilized. Sample collection was done following the standard protocol described previously [6]. After collection, the samples were transported without delay to the Buea Regional Hospital laboratory for culture, gram staining, and microscopy.
Isolation of Candida species
Culture procedure and microscopy
Fungi and yeast cells were isolated on the Sabouraud Dextrose Agar (SDA) agar (bioMerieux, France) which was modified according to standard methods to prevent the growth of bacteria. The SDA plates were inoculated by streaking the sample with a sterile wire loop. The plates were incubated aerobically for 24 hours at 37°C and colonies that were creamy to white were presumed to be yeast cells, and restreaked on SDA to obtain pure colonies. Gram staining and wet mount preparations were done according to standard assay methods described previously [9]. Gram-positive oval and budding isolates were selected as presumptive Candida species and stored on SDA agar slants at 4°C for further investigations.
Diagnosing species of Candida
The germ tube test was employed to presumptively identify C. albicans, whereby a sterile wire loop was used to obtain a colony from slants. After inoculation of the colony in human serum and incubation for 2–3 hours at 37°C, about 50 ul of the inoculum was put on a glass slide and covered with a slip. Candida albicans was confirmed present by a short, slender, tube-like budding structure (Table 1), observed under the microscope using 10× and 40× objectives [9].
Candida species were screened and differentiated on chromogenic Candida agar medium (CHROMagar Candida, Paris France) by a change in color and morphology. After incubation, green colonies were presumptively considered to be C. albicans (Table 1).
Analysis of data
The statistical package SPSS version 22.0 was employed for analysis. Relationships among variables were determined by the chi-square test and odd ratios, and it was significant when p < 0.05.
Results
Isolation and overall burden of vulvovaginal C. albicans infection among study participants
Out of a total of 190 samples obtained, 102 tested positive for C. albicans giving an overall significant prevalence of 54% (p < 0.05), while 88 (46%) tested negative for Candida species (Fig. 1).
Prevalence of VVC among participants with respect to age
Among the 190 participants, those in the age range between 15 and 25 years had a prevalence of 47.6% with C. albicans infection, 26–35 years had 54.5% of positive cases, while those >35 years had 77.8% for Candidiasis due to C. albicans (p=0.03) (Fig. 2). The mean age of the participants was 30 years, calculated from the data obtained. The prevalence of Candida with respect to age was highest in the age group >35 years and lowest in 15–25 years.
Prevalence of VVC among study participants with respect to socio-economic information
In this study, participants who were married gave a prevalence of VVC of 39.5%, while those who were single recorded 63.2% (p < 0.05). Furthermore, 177 participants were Christians with a prevalence of 56.5%, while 13 participants were Muslims with a prevalence of 15.4% (p < 0.05) (Table 2). Participants who were students had a prevalence of 67.5%, while unemployed had a prevalence of 32.1%.
Prevalence of VVC with respect to clinical presentations
Out of 52 participants with a burning sensation while urinating, 24 had a positive culture for C. albicans, giving a prevalence of 46.1%. Out of those having itches (113), 61 had a positive culture for VVC, with a prevalence of 53.9%. Participants who had abnormal discharge with itching, gave prevalences for C. albicans of 66.7%, although there was no significant difference (p > 0.05) (Table 3).
Figure 1.
Pie chart showing overall prevalence (percentage) of VCC due to C. albicans.
Table 1.
| Species | Germ tube test | Gram staining and microscopy | Test on CROME differential agar |
|---|---|---|---|
| Candida albicans | Slender, budding yeast cells | Gram-positive, smooth convex | Light green colonies |
| Non-C. albicans species | / | Gram-positive, (convex for C. glabrata and flat for C. krusei) | Cream for C. glabrata, blue cobalt for C. tropicalis, and purple for C. krusei. |
Determination of predisposing factors to VVC
From a total of 190 participants, 75 who used antiseptic soap during douching, had a prevalence of 78.7% for VVC (Table 4). The use of antiseptic soap while douching significantly predicted VVC (p < 0.05) (OR=3.71; 95%; CI: 1.2–14.01).
Furthermore, 60 participants who had sexually transmitted infections (STIs) in the past registered a higher prevalence of 58.3% for C. albicans, than those who did not have STIs in the past (Table 4). There was no significant association between having STI in the past and VVC (p > 0.05).
Of all the antimicrobial drugs, participants who took antibiotics had the highest prevalence of VVC (75%), although the association (OR:1.86, 95%; CI: 0.78–4.01) was not significant (p > 0.05) (Table 4).
Sexually active participants gave a prevalence of 55.8% with a significant association for VVC (p < 0.05) (OR: 2.87, 95%; CI: 1.3–12.46) (Table 4).
Discussion
The study was done for the isolation, and identification of Candida species and to determine the burden and factors which predict the occurrence of VVC among patients attending Buea Regional Hospital. The methods used are efficient enough in the diagnosis of Candida isolates in a clinical setting [22]. Our study gave an overall prevalence of 54% for VVC (Fig. 1). This result differs from another study, which reported a prevalence of 16.5% [23]. This relatively high prevalence may be attributed to lack of knowledge, poverty, and inadequate hygienic conditions. Candida albicans, which causes vaginal candidiasis affects a reasonable number of healthy women of childbearing age [24] and more than half of all women suffer at least once during their lifetime. Budding oval yeast cells seen on direct microscopic examination of vaginal smear is suggestive of C. albicans [5]. Further identification methods such as culture on SDA and CHROMagar media are employed to identify and differentiate species of Candida.
In this study, participants’ average age was 30 years. The prevalence of Candida was significantly highest (p < 0.05) among the age group >35 years (77.8%) and lowest among 15–25 years (47.6%). This result is in agreement with a study reported [25,26], but contradicts another study [27]. This could be a result of a lack of adequate hygiene, and frequent sex among this age group. Most menopausal women are above 46 years of age with practically less sexual activity and, thus, are resistant to Candida infections [14].
Socio-economically, data showed a significantly high prevalence of single participants (63.2%) (p < 0.05), which correlates with that of Potokoué et al. [5]. Furthermore, Christians had a significantly higher prevalence (p < 0.05) of 56.5%, compared to Muslims (15.4%) (Table 2), which corroborates with the study from another author [6]. Participants who were students had a prevalence of 67.5%, which contradicts that of Waikhom et al. [6]. This high rate could be due to limited resources.
Clinically, participants with a burning sensation while urinating, gave a significant (p < 0.05) prevalence of VVC (46.1%), which is in agreement with a previous study [6]. Clinical presentations of VVC do not correlate sometimes with the presence of the Candida species. It will be right to confirm clinical findings with laboratory diagnosis of VVC. The prevalence of VVC among participants who had vaginal discharge was 66.7%, although there was no significant difference (p > 0.05) (Table 3), which does not corroborate with results obtained in another study [6]. Furthermore, participants who had itches only gave a significantly highest prevalence (53.9%), which contradicts Waikhom et al. [6]. This may be due to infections that reoccur and produce more detectable Candida spp. in their vagina, even when asymptomatic.
Table 2.
Prevalence of VVC with respect to socio-economic information of study participants.
| Parameter | Frequency (N=190) | Positive (N=102) | Percentage (%) | p-value |
|---|---|---|---|---|
| Marital status | ||||
| Married | 76 | 30 | 39.5 | 0.01 |
| Single | 114 | 72 | 63.2 | |
| Occupation | ||||
| Employed | 26 | 15 | 57.7 | 0.03 |
| Unemployed | 28 | 9 | 32.1 | |
| Self-employed | 56 | 24 | 42.9 | |
| Students | 80 | 54 | 67.5 | |
| Religion | ||||
| Christian | 177 | 100 | 56.5 | 0.001 |
| Muslims | 13 | 2 | 15.4 |
Data is presented as frequency and percentage. Positive represents women who were culture positive for VVC. Percentage is calculated considering the number of positive culture on the total number of participants for each parameter.
Table 3.
Distribution of clinical presentation amongst study participants with positive culture for VVC.
| Clinical parameter | Frequency (N=190) | Positive (N=102) | Percentage (%) | p-value |
|---|---|---|---|---|
| Having itches only | 113 | 61 | 53.9 | 0.021 |
| Abnormal discharge + itching | 15 | 10 | 66.7 | 0.126 |
| Abnormal discharge only | 10 | 7 | 70 | 0.195 |
| Burning sensation while urinating | 52 | 24 | 46.1 | 0.041 |
| No symptom | 0 | 0 | ||
Data is presented as frequency and percentage. Positive represents women who were culture positive for VVC. Percentage is calculated considering the number of positive culture on the total number of participants for each parameter.
Table 4.
Risk factors associated with VVC amongst study participants.
| Parameter | Frequency N=190 | Positive total N=102 | Percentage (%) | OR(95% CI) | p-value | ||
|---|---|---|---|---|---|---|---|
| Antimicrobial drug taken and contraceptive pills | |||||||
| Nystatin | 35 | 21 | 60 | 1.86 (0.78–4.01) | 0.23 | ||
| Fluconazole | 120 | 56 | 46.7 | ||||
| Contraceptive pills | 19 | 13 | 68.4 | ||||
| Antibiotics | 16 | 12 | 75 | ||||
| Sexually active | 2.87 (1.3–12.46) | 0.04 | |||||
| Yes | 165 | 92 | 55.8 | ||||
| No | 25 | 10 | 40 | ||||
| Had STI in the past | 0.54 (0.05–3.91) | 0.41 | |||||
| Yes | 60 | 35 | 58.3 | ||||
| No | 130 | 67 | 51.5 | ||||
| Pregnant | |||||||
| Yes | 50 | 25 | 50.0 | 0.6 ( 0.17–1.15) | 0.51 | ||
| No | 140 | 77 | 55.0 | ||||
| Use antiseptic soap while douching | |||||||
| Yes | 75 | 59 | 78.7 | 3.71 (1.2–14.01) | 0.02 | ||
| No | 115 | 43 | 37.4 | ||||
| Iron pant before wearing | |||||||
| Yes | 82 | 47 | 57.3 | 2.3 (0.99–3.43) | 0.08 | ||
| No | 108 | 55 | 50.9 | ||||
OR=Odd Ratio; CI: Confidence Interval. Percentage is calculated considering the number of positive culture on the total number of participants for each parameter.
In this study, the use of antiseptic soap during douching had a significant (p < 0.05) prevalence of 78.7% and showed prediction for VVC (OR=3.71, 95%; CI: 1.2–14.01). This finding is contrary to other studies [28] which showed no relationship. Antiseptic soap tends to destroy the vaginal flora, which protects and keeps yeast cells under control, thus, distorting vaginal pH, making the yeast overgrow and causing VVC [9]. Furthermore, participants who had STIs in the past registered a higher prevalence of 58.3% for C. albicans, than those who did not have STIs in the past (Table 4). There was no significant association between having STI in the past and VVC (OR: 0.54, 95%; CI: 0.05–3.91) (p=0.41). This contradicts another study where previous episodes of vaginal infection were significantly (p=0.004) associated (OR: 2.79, 95%; CI: 1.38–5.64) with vaginal candidiasis [9].
Figure 2.
Prevalence of VCC among participants according to age group.
Participants who took antibiotics had the highest prevalence of VVC (75%), followed by the use of contraceptive pills, although no significant association (OR: 1.86; 95% CI: 0.78–4.01; p > 0.05) (Table 4), which is in line with prior studies [29,30], where antibiotics use and contraceptive pills were insignificantly correlated with vaginal candidiasis. The indiscriminate use of antibiotics has been shown to deplete normal bacteria flora leading to overgrowth of Candida. Contraceptive pills predicted high glycogen in the wall of the vagina, a requirement for the growth of C. albicans [29].
Results from this study have indicated that those who were sexually active, had a significant (p < 0.05) higher prevalence of 55.8%, with strong predictions for VVC (OR: 2.87 95% CI: 1.3–12.46), than those who were not sexually active had 40% (Table 4). There was a significant association between being sexually active with VVC. This study does not corroborate with that of Potokoué et al. [5], who gave a prevalence of 2.9% for participants with multiple sex partners. In women of childbearing age, VVC is one of the most occurring diseases during the period of vaginal activity [24].
Conclusion
Findings from this research work indicated an overall prevalence of 53.6% for VVC. Socio-demographic data showed that individuals greater than 35 years of age recorded a prevalence of 77.8% for VVC, which is more than what is recorded in the other age groups. Participants who were single, recorded the highest prevalence. Clinically, those who presented with abnormal discharge had significantly highest prevalence of VVC. Factors which predict vaginal candidiasis infection may differ with the study group under investigation. This study showed the association of VVC with some lifestyles such as antiseptic soap usage in douching, and being sexually active.
Limitations
Due to time constraints, the researchers enrolled a lesser number of participants in the study than initially anticipated and because of this, there was a paucity of some complementary data in the ante-natal clinic records. The need to use a more accurate method to better identify Candida species is necessary.
Acknowledgment
The authors thank the Director of Buea Regional Hospital, Dr. Martin Mokake, the general supervisor, Dr. Malika Esembese, who authorized the study to be conducted at Buea regional hospital, and for the support they gave to realize this piece of work. The authors are grateful to Ntemun Watard Emmanuela, who helped in the data collection. The authors express their gratitude to the Laboratory workers at the Buea Regional Hospital. Finally, they thank all those who took out time to participate in the study.
Authors’ contributions
Ekwi DN conceived and designed the study; Fabrice NA participated in data collection and laboratory work; Ekwi DN wrote and prepared the manuscript; and Fabrice NA was involved in data management and manuscript editing.
Ethics authorization
Authorization was obtained from the South West regional delegation for Public health, with protocol identification number, R11/MINSANTE/SWR/RDPH/PS/438/470. Participants signed an informed consent before taking part in the study. Confidentiality was upheld throughout the procedures. Authorities of the regional hospital Buea, and the South West regional delegation for public health, were provided the findings of this study for the adequate follow-up of patients.
Interest competition
The authors have no interest conflicts as far as this study is concerned.
References
1. Adane B, Yeshiwork A. Vulvovaginal candidiasis: species distribution of Candida and their antifungal susceptibility patter. BMC Women Health 2018; 18:94; doi: 10.1186/s12905-018-0607-z
2. Asticcioli S, Sacco L, Daturi R, Matti C, NucleoE, Zara F, et al. Trends in frequency and in vitro antifungal susceptibility patterns of Candida isolates from women attending the STD outpatients’ clinic of a tertiary care hospital in northern Italy during the years 2002–2007. New Microbiol 2009; 32:199–204.
3. Rathod SD, Klaysner JD, Hubdard A, Li T, Reingold AL, Madhivanan P. Logic regression-derived algorithms for syndromic management of vaginal infections. Infect Dis Obstet Gynecol 2015; 15:106.
4. Theill L, Duduik C, Morano S, Gamarra S, Nardin ME, Méndez E, et al. Prevalence of antifungal susceptibility of C. albicans and its related species isolated from vulvovaginal samples in a hospital Argentina. Rev Argent Microbiol 2016; 48(1):43–9.
5. Potokoué MNS, Sékangué OG, Ossibi IBR, Djendja I, Gackosso G, Buambo G, et al. Vaginal candidiasis in women of childbearing age at the University Hospital of Brazzaville: prevalence and associated factors. Microbiol Infect Dis 2021; 5(3):1–5.
6. Waikhom SD, Afeke I, Kwawu GS, Mbroh HK, Osei GY, Louis B, et al. Prevalence of vulvovaginal candidiasis among pregnant women in the Ho municipality, Ghana: species identification and antifungal susceptibility of Candida isolates. BMC Pregnancy Childb 2020; 20:266; doi: https://doi.org/10.1186/s12884-020-02963-3
7. Sobel JD. Vulvovaginal candidosis. Lancet 2007 Jun 9; 369(9577):1961–71.
8. Center for Disease Control and Prevention. Vulvovaginal candidiasis. Fungal Dis 2016; 42(6):905–27.
9. Ane-Anyangwe I, Meriki HD, Silum SP, Nsongomanyi FR, Zofou D. Antifungal susceptibility profiles and risk factors of vaginal candidiasis amongst female university students in southwest region, Cameroon. Afr J Clin Exper Microbiol 2015; 16(1):67–72.
10. Viguié-Vallanet C. Les mycoses génitales: Périnée de la femme: maladies de la peau et des muqueuses. Correspondances en pelvi-périnéologie 2005; 5(1):20–7.
11. Konate A, Yavo W, Kassi FK, Djohan V, Angora EK, Barro-Kiki PC, et al. Aetiologies and contributing factors of vulvovaginal candidisasis in Abidjan. J Mycmed 2013; 24:93–9.
12. Ogouyèmi-Hounto A, Adisso S, Djamal J, Sanni R, Amangbegnon R, Biokou-Bankole B, et al. Place des candidoses vulvovaginal au cours des infections génitales basses et facteurs de risque associés chez les femmes au Bénin. J Mycol Méd 2014; 24:100–5.
13. Alem T, Feleke M. Prevalence, risk factors and antifungal susceptibility pattern of Candida species among pregnant women at Debre Markos Referral Hospital, northwest Ethiopia. BMC Pregnancy Childb 2019; 19:527–34.
14. Nelson M, Wanjiru W, Margaret MW. Prevalence of vaginal candidiasis and determination of the occurrence of Candida species in pregnant women attending the antenatal clinic of Thika District Hospital, Kenya. Open J Med Microbiol 2013; 3:264–72.
15. Al-akeel RA, El-kersh TA, Al-Sheikh YA, Al-Ahmadey ZZ. Prevalence and comparison for detection methods of Candida species in vaginal specimens from pregnant and non pregnant Saudi women. Afr J Microbiol Res 2013; 7(1):56–65.
16. James GD, Essieen UC, Victoria MD. Prevalence and antifungal susceptibility profile of vulvovaginal candidiasis amongst women of reproductive age in Jos Metropolis, Nigeria. World J Pharmaceutical Life Sci 2017; 3(3):152–6.
17. Meizoso T, Rivera T, Fernández-Aceñero M, Mestre MJ, Garrido M, Garaulet C. Intrauterine candidiasis: report of four cases. Arch Gynecol Obstet 2008; 278(2):173–6.
18. Liguori G, Di Onofrio V, Lucariello A, Gallé F, Signoriello G, Colella G, et al. Oral candidiasis: a comparison between conventional methods and multiplex polymerase chain reaction for species identification. Oral Microbiol Immunol 2009; 24(1):76–8.
19. Baradkar V, Mathur M, Kumar S. Hichrom Candida agar for identification of Candida species. Indian J Pathol Microbiol 2010; 53(1):93.
20. Shettar SK, Patil AB, Nadagir SD, Shepur TA, Mythri BA, Gadadavar S. Evaluation of HiCrome differential agar for speciation of Candida. J Acad Med Sci 2012; 2(3):101.
21. HiMedia. HiCrome™ Candida differential agar. Paris, France: HiMedia Laboratories, 2018.
22. Howell SA, Hazen KC. Candida, Cryptococcus, and other yeasts of medical importance. Manual of clinical microbiology. 10th edition. Washington, DC: American Society of Microbiology Press, pp 1793–821, 2011.
23. Aring BJ, Mankodi PJ, Jasani JH. Incidence of vaginal candidiasis in leucorrhoea in women attending in OPD of gynecology and obstetrics department. Int J Biomed Adv Res 2012; (12):867–86.
24. Amouri I, Abbes S, Sellami H, Makni F, Sellami A, Ayadi A. La candidose vaginale: revue. J Mycol Med 2010; 20:108–15.
25. Willacy H, Jackson C. Vaginal and vulval candidiasis. Available via http://www.patient.co.uk/doctor/vaginal-and-vulval-candidiasis 2011 (Accessed 17 May 2015).
26. Akortha E, Chikwe O, Nwaugo O. Antifungal resistance among Candida species from patients with genitourinary tract infection isolated in Benin City, Edo estate, Nigeria. Afr J Microbiol Res 2013; 3(11):694–9.
27. Alo MN, Anyim C, Onyebuchi AK, Okonkwo EC. Prevalence of asymptomatic co-infection of candidiasis and vaginal trichomoniasis among pregnant women in Abakaliki, South-Eastern Nigeria. J Nat Sci Res 2014; 2(7):87–91.
28. Martino JL, Youngpairoj S, Vermund SH. Vaginal douching: personal practices and public policies. J Womens Health (Larchmt) 2004; 13(9):1048–65.
29. Faro S. Sexually transmitted diseases. Compr Ther 1998; 24(2):78–85.
30. Hazen KC. New and emerging yeast pathogens. Clin Microbiol Rev 1995; 8(4):462–78.
