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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 19  |  Issue : 1  |  Page : 79-83

Prevalence and antifungal susceptibility of Candida species isolated from HIV seropositive women attending gynecological clinic in Kaduna, Nigeria


1 Department of Obstetrics and Gynaecology, Kaduna State University, Nigeria
2 Department of Medical Microbiology, Kaduna State University, Nigeria

Date of Submission21-Apr-2021
Date of Decision19-Oct-2021
Date of Acceptance01-Mar-2022
Date of Web Publication12-Jul-2022

Correspondence Address:
Dr. Matthew C Taingson
Department of Obstetrics and Gynaecology, Kaduna State University
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njbcs.njbcs_21_21

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  Abstract 

Context: Candidal vulvovaginitis causes discomfort and increased HIV infectivity because viral shedding is increased among these women. Aim: To determine the prevalence of Candida infections among HIV seropositive women in the special treatment (STC) and the gynecological clinics of Barau Dikko Teaching Hospital and the antifungal susceptibility patterns of the isolates. Study Design: We conducted a cross-sectional study among HIV-positive women accessing care in our hospital. Methods and Materials: A total of 312 high vaginal swabs (HVS) were collected from HIV seropositive women with clinical features of vulvovaginitis between February and July 2019. Wet mount preparations in potassium hydroxide (KOH) and Gram stained smears were performed directly on specimens. Cultures for Candida species were performed using Sabouraud dextrose agar (SDA) (Oxoid, UK) at room temperature (28°C) and in the incubator at 37 °C. Antifungal susceptibility of the Candida species to amphotericin B, clotrimazole, fluconazole, and miconazole was assessed using the ATB FUNGUS 4 test kits (bioMerieux, Marcy l'Etoile, France). Statistical Analysis Used: Data collected were analyzed using SPSS, Version 23. Results: Out of the 312 HVS cultured, 40 yielded Candida species giving a point prevalence of 12.8% in the study population. Candida species isolated from HVS specimens were Candida tropicalis (n = 14, 4.5%), Candida glabrata (n = 13, 4.2%), Candida krusei (n = 11, 3.5%), Candida dubliniensis (n = 1, 0.3%), and others C. glabrata/C. tropicalis (n = 1, 0.3%). Susceptibility of the isolates to antifungal agents ranged from 27.5% to 52.5%. Amphotericin B was the best performing antifungal agent with a sensitivity of 52.5%. Conclusion: The prevalence from our study was low compared to other studies among HIV seropositive women.

Keywords: Antifungal susceptibility, candida species, HIV, vulvovaginitis


How to cite this article:
Taingson MC, Ige O, Adze J, Bature S, Durosinlorun AM, Mohammed C, Abubakar A, Airede L R. Prevalence and antifungal susceptibility of Candida species isolated from HIV seropositive women attending gynecological clinic in Kaduna, Nigeria. Niger J Basic Clin Sci 2022;19:79-83

How to cite this URL:
Taingson MC, Ige O, Adze J, Bature S, Durosinlorun AM, Mohammed C, Abubakar A, Airede L R. Prevalence and antifungal susceptibility of Candida species isolated from HIV seropositive women attending gynecological clinic in Kaduna, Nigeria. Niger J Basic Clin Sci [serial online] 2022 [cited 2022 Nov 29];19:79-83. Available from: https://www.njbcs.net/text.asp?2022/19/1/79/350711


  Introduction Top


Globally, an estimated 37.7 (30.2–45.1) million people were living with HIV in 2020, with southern sub-Saharan Africa having 60% of these cases.[1]

Mucocutaneous fungal infections such as vulvovaginal candidiasis are common opportunistic infections in HIV-positive individuals, and the management of such common and recurring infections remains a challenge for clinicians worldwide.[2] Although most cases of recurrent vulvovaginal candidiasis (VVC) have no known predisposing factors, its burden is more in women with HIV infection.[2] Studies have reported that vaginal candidiasis among HIV-positive women occurs frequently,[3] and is due primarily to Non-Candida Albicans.[3],[4] Depressed T-cell function due to drugs, the immunological or systemic disease is a well-recognized factor predisposing to either local or diffuse mucosal candidiasis.[4] Cell-mediated immunity depression has been shown to correlate with the occurrence of local or systemic candidal infection.[5] The prevalence of the infection has been related to the immune status of HIV-infected women,[6] and most authors have found some increase in the prevalence of colonization and disease, particularly among those whose CD4 counts are at the lower extremes.[5] Furthermore, genital tract infection with no ulceration as in VVC also can lead to increased HIV infectivity because viral shedding is increased.[7] Also, pruritus and scratching leading to abrasions could increase the risk of HIV acquisition and transmission.[8] There are conflicting reports on the prevalence of vulvovaginal candidiasis in HIV seropositive women and a progressively increased colonization with non–C. albicans strains with declining susceptibility to fluconazole.[2] We currently do not know the common microbiological isolates of vulvovaginal candidiasis and the sensitivity pattern in our population. This study was conceptualized to determine the prevalence of vulvovaginal candidiasis among HIV seropositive women attending Barau Dikko Teaching Hospital in Kaduna and the antifungal susceptibility patterns of the Candida species isolated from these women.


  Materials and Methods Top


Study area

The study was carried out at Barau Dikko Teaching Hospital, a 240-bed tertiary hospital located in Kaduna town, which is the capital of Kaduna State, in the north-western region of Nigeria. Women enrolled for care at Special Treatment Clinic (STC), which is the HIV/AIDS treatment Centre, as well as the gynecology clinic situated within the hospital premises, were recruited into the study.

Study design

A hospital-based; cross-sectional study design was used to determine the prevalence of Candida spp causing vulvovaginitis among HIV seropositive women. A well-structured questionnaire was used to obtain bio-demographic data.

Study population

This study involved HIV-positive women accessing care at the special treatment clinic and presented to the gynecological clinic with symptoms of vulvovaginitis.

Inclusion and exclusion criteria

Consenting HIV-seropositive women participated in the study. Women with signs and symptoms suggestive of ulcerative lower genital tract infection were excluded.

Ethical consideration

Ethical clearance was obtained from the Ethics Committee of Barau Dikko Teaching Hospital Kaduna. Protocol number: 1800014-1. Nature aims and objectives of the study were explained to the subjects, and informed consent was obtained in writing before they were recruited into the study.

Sample collection

After voiding urine, each subject was placed in dorsal position, the vulva was inspected for abnormalities such as edema, macular rash, erythema, excoriation marks, and discharge, and an appropriate sized sterile Cusco bivalve speculum, rinsed with warm water, was gently inserted into the vagina to expose the external cervical os. The vaginal walls and the cervix were inspected for erythema, excoriation marks, and discharge. The colour, smell, and consistency of the discharge were noted. Two high vaginal Probtec swabs (Becton Dickinson, Sparks Maryland USA) were collected by touching the sidewall of the vagina midway between the introitus and the cervix. One was used for wet preparation while the other swab for culture to minimize contamination.

Sample processing

Direct examination

Specimens of vaginal swabs were examined by placing the specimen on a clean, dried, grease-free slide mounted with a drop of KOH 10%, and examined under both low (10×) and high (40×) power fields of the microscope for the presence of fungal elements. The details regarding the hyphae, spores, budding cells and pseudohyphae were noted.[9]

Culture and isolation

The high vaginal swab was directly streaked onto Sabouraud dextrose agar medium (SDA) and incubated for 48 hours at 37°C to obtain pure isolates. The fungal growths were preserved in screw-capped tubes containing 5 ml of SDA slants; they were tightly wrapped with parafilm and stored at 4°C in the refrigerator.

Germ tube test

The germ tube test is a presumptive test for the identification of Candida albicans. The procedure of Menza et al., 2013[10] was used to conduct the test. A loopful of the yeast cells was inoculated into 0.5 mL of human serum (negative for HBV, HCV, and HIV infections) and incubated at 37°C for three hours. A drop of the incubated serum was placed on a microscope slide and covered with a coverslip, and examined under the microscope using the x10 and x40 objective lenses for the presence of a germ tube. Germ tube is considered as a lateral tube without septum and has no constriction at initiating site.[11]

Cultivation on selective medium (CHROM agar)

Purified single colonies from SDA were inoculated on CHROM agar using an inoculating loop and incubated at 37oC for 48 hours. The method is based on the differential release of chromogenic breakdown products from various substrates by Candida species following differential exoenzyme activity.[12] Candida isolates were classified according to their colors on CHROM agar based on the manufacturer's protocol.

Antifungal susceptibility testing

The disc for the antifungal susceptibility testing included clotrimazole (10 ug), fluconazole (25 ug), amphotericin B (20 ug), and miconazole (10 ug) (MAST DIAGNOSTICS, Mast group LTD, Merseyside) The disc diffusion procedure of Clinical and Laboratory Standards Institute (CLSI) reference test similar to the standardized procedure was used for antibacterial agents.[13]

Statistical analysis

Data collected were analyzed using IBM-SPSS (Version 23). Descriptive statistics like frequencies, percentages, and mean were computed.


  Results Top


Socio-demographic characteristics of study participants

A total of 312 HIV seropositive women were included in this study. The ages of the study participants ranged from 18 to 56 years, and the mean age was 37.7 ± 0.5. One hundred and thirty-nine (44.6%) had no formal education, 66 (21.2%) were widowed. The mean age at menarche was 15.0 ± 0.1, age at coitarche was 19.1 ± 0.2, and the average number of sexual partners was 2.2 ± 0.1 [Table 1].
Table 1: Socio-demographic characteristics of study participants at Barau Dikko Teaching Hospital, Kaduna Nigeria

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  Discussion Top


Our study was done to determine the prevalence of vulvovaginal candidiasis and the sensitivity of the isolates to common antifungal agents in the studied population. We found a prevalence of 12.8% for Candida sp from this study [Table 2]. This was about twice the prevalence of 6.8% reported in an Italian study,[14] but much lower than the 27.6% and 21.7% reported among HIV seropositive women in Lagos and Ogun state Nigeria, respectively.[3],[15] Another study in Brazil,[16] found a prevalence of 29.7%, while 34.11% and 37% were reported in Iran and the USA[2],[17] The lower prevalence recorded among our participants may be attributed to the suppressed viral load as all of them were on antiretroviral medication[2] and non-pregnant.[18]
Table 2: The distribution of different Candida species among the different age groups

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This study also showed that the 30–39-year age group had the highest frequency (n = 22, 55%) of Candida isolation from high vaginal swabs, followed by the 20–29-year age group (n = 13, 32.5%) [Table 2]. A similar finding was reported by Olowe et al.[19] where a high rate of Candidiasis among women between 30 and 35 years was detected. However, this contradicts that of Zeng et al.[20] who reported a fourfold risk in women who had first sexual intercourse at age 20 and below. They suggested in their study that there could be a link between the disease and sexual activity.[20]

The most frequent Candida species isolated from a high vaginal swab in this study was Candida tropicalis, followed closely by Candida glabrata [Table 3]. This finding compares favorably with an Indian study.[21] However, in the study conducted by Anorlu et al.[3] Candida brussei was the commonest yeast isolated from high vaginal specimens, followed by Candida glabrata. Another report from a population in Nigeria confirmed that Candida glabrata was the commonest yeast isolated from both urinary and high vaginal specimens, followed by Candida albicans and Candida tropicalis.[21] followed by Candida glabrata was the commonest isolates reported in Iran and the USA.[18],[22]
Table 3: Frequency of Candida species isolated from HIV Seropositive women at Barau Dikko Teaching Hospital, Kaduna Nigeria

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All species of Candida largely showed sensitivity to amphotericin B, clotrimazole, while some isolates were resistant to fluconazole and miconazole [Table 4]. This is similar to the findings previously reported.[23],[24],[25] The reason for a higher sensitivity of amphotericin-B compared to others may be as a result of it not being regularly prescribed and used extensively because of cost, difficulty with administration, and high toxicity[24] [Table 5]. High resistance to amphotericin B, however has been reported.[26] The resistance to fluconazole and miconazole was 42.5 and 47.5%, respectively, [Table 6], this is similar to the findings of Badiee et al.[27] This has been attributed to its wide use as a first-line antifungal agent, as well as its low toxicity and ease of administration.[27] There has been an increase in the incidence of vaginal candidiasis due to Candida species resistant to the commonly used antifungal agent and recurrent infections.[28] A similar finding of a high rate of multiple drug-resistant Candida species was noticed in this study and has also been reported.[28]
Table 4: Antifungal susceptibility pattern of Candida species isolated from HIV Sero-positive women at Barau Dikko Teaching Hospital Kaduna State Nigeria

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Table 5: Total susceptibility pattern of Candida species isolated from HIV sero-positive women at Barau Dikko Teaching hospital, Kaduna Nigeria

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Table 6: Multiple resistance patterns of Candida isolates among HIV Sero-positive women at Barau Dikko Teaching Hospital, Kaduna Nigeria

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  Conclusion Top


The prevalence of vulvovaginal candidiasis among HIV seropositive women attending the gynecological clinic at the Barau Dikko Teaching Hospital Kaduna was 12.8%. Candida tropicalis was the most frequent yeast isolated from high vaginal swabs, followed by Candida glabrata. Candida isolates in our study population were most sensitive to Amphotericin B with a susceptibility rate of 52.5%; however, multiple drug-resistant Candida species rate of 32.5% was also recorded. This necessitates more effective treatment programs to reduce the rate of this infection in HIV-infected women.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Funding for this research was received from TETFUND through Kaduna State University.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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