Candida is a genus of yeasts and is the most common cause of fungal infections worldwide. Many species are harmless commensals or endosymbionts of hosts including humans; however, when mucosal barriers are disrupted or the immune system is compromised they can invade and cause diseases. Fungal pathogens are becoming increasingly important cause of either superficial mycotic infections or systemic infection which may be community-acquired and nosocomial infections; the genus Candida is the most pathogenic fungi. Although Candida is consisting of more than 200 species, only a few of them has been associated with human infection. Of these, C. albicans is the most important infectious agent and represents a serious public health challenge. But in recent years, non-albicans Candida species are also being implicated.
Overgrowth of several species including C. albicans can cause infections ranging from superficial, such as oropharyngeal candidiasis (thrush) or vulvovaginal candidiasis (vaginal candidiasis) and subpreputial candidiasis which may cause balanitis, to systemic, such as fungemia and invasive candidiasis. Oral candidiasis is common in elderly denture wearers. In otherwise healthy individuals, these infections can be cured with topical or systemic antifungal medications (commonly over-the-counter antifungal treatments like miconazole or clotrimazole).
Meyers et al. (1978) established that Candida are almost universal in low numbers on healthy adult skin and C. albicans is part of the normal flora of the mucous membranes of the respiratory, gastrointestinal and female genital tracts. While women are more susceptible to genital yeast infections, men can also be infected. Certain factors, such as prolonged antibiotic use, increase the risk for both men and women. People with diabetes or impaired immune systems, such as those with HIV, are more susceptible to yeast infections. A weakened or undeveloped immune system or metabolic illnesses are significant predisposing factors of candidiasis. Almost 15% of people with weakened immune systems develop a systemic illness caused by Candida species. Vaginal symptoms are one of the most common reasons for consulting gynaecologist with approximately 10 million visits each year.
In recent years, the number of vaginal yeast infections has been dramatically increasing. It is estimated that about 75% of all women infected by Candida spp. at least once during their reproductive years, and approximately between 40-50% during the childbearing years suffer from recurrent chronic infection. Candida vaginitis or Volvovaginal candidiasis (VVC) is a common fungal infection of the vagina attributed to an overgrowth of Candida species. It is one of the most common medical problems throughout the world affecting a large proportion of healthy women during their life time. Importantly, yeasts (mainly C. albicans) are the third leading cause of catheter-related infections, with the second highest colonization to infection rate and the overall highest crude mortality. Overgrowth of Candida in the vagina produces symptoms which include: vaginal and vulvar pruritus, itching, pain, sexual dysfunctions, dryness, cracks, and odorless thick, white vaginal discharge.
Candida albicans is indicated as the most common causative pathogen of Vulvovaginal candidiasis which represent about 80–95%. However, recently there are many reports from different countries indicated that about 10-30% of the patients infected with VVC are due to non-albicans Candida species as C. glabrata, C. parapsilosis, C. tropicalis and C. krusei. A number of resistant vaginal yeast pathogen has been dramatically increasing, and several reports indicated differences in the distribution of Candida spp. associated with VVC and their antifungal drug susceptibility patterns from different geographic locations and this was corroborated by this present study where C. glabrata is the most predominant. Mårdh et al. (2002) reported that up to 7.5% of vaginal Candida isolates have been resistant to one or more of the commonly used azoles. In addition, recently non-albicans species have shown resistance to the antifungals commonly used to treat Vulvovaginal candidiasis. The appearance of resistant Candida to certain antifungal may play a role in cases of recurrent vulvovaginal candidiasis. In a study conducted by Richter et al. (2005) fluconazole resistance was observed among 15.2% and 41.7% of vaginal isolates of C. glabrata and C. krusei, respectively.
Candida glabrata is a haploid yeast of the genus Candida, previously known as Torulopsis glabrata. This species of yeast is non-dimorphic and no mating activity has been observed. Until recently, C. glabrata was thought to be a primarily non-pathogenic organism. However, with the ever increasing population of immune-compromised individuals, trends have shown C. glabrata to be a highly opportunistic pathogen of the urogenital tract, and of the bloodstream (Candidemia). It is especially prevalent in the elderly and HIV positive people. There are many reasons for the emergence of resistances; prolonged exposure and increased use of antifungal for recurrent Vulvovaginitis candidiasis are the most common risk factors for resistance. Furthermore, the distribution of these infections may depend on numerous risk factors that have been associated with VVC such as, pregnancy, uncontrolled diabetes mellitus, obesity, poor personal hygiene, poor dietary habits, and use of contraceptives. Nelson et al. (2013) reported also that in pregnant women, vaginal candidiasis has been related to emotional stress and suppression of immune system. This high prevalence of vaginal candidiasis may lead to pregnancy complications like abortions, premature birth, low birth weight and other morbidities.
Another main factor of prevalence of VVC includes the misuse of antibiotics for treatment of such infections. This misuse of drugs results in resistance especially to the common antifungal agents. Although multidrug resistance is uncommon, increasing reports of multidrug resistance to the azoles, echinocandins, and polyenes have occurred in several Candida species, most notably Candida glabrata and more recently Candida auris. However, the use of antifungal and antibiotics has proven to be very effective in curtailing the spread of these infections either completely or partially, although the uncontrolled use of some antifungal and antibiotics results in resistance thus limiting their effectiveness and usability. Rajasekara et al. (2007) also opined that other draw backs are the high cost of these chemical substances and their undesirable side effects in the long run.
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