Background. Vulvovaginal candidiasis is characterized by curd-like vaginal discharge and itching, and is associated with considerable health and economic costs. Materials and Methods. We examined the incidence, prevalence, and risk factors for vulvovaginal candidiasis among a cohort of 898 women in south India. Participants completed three study visits over six months, comprised of a structured interview and a pelvic examination. Results. The positive predictive values for diagnosis of vulvovaginal candidiasis using individual signs or symptoms were low (<19%). We did not find strong evidence for associations between sociodemographic characteristics and the prevalence of vulvovaginal candidiasis. Women clinically diagnosed with bacterial vaginosis had a higher prevalence of vulvovaginal candidiasis (Prevalence 12%, 95% CI 8.2, 15.8) compared to women assessed to be negative for bacterial vaginosis (Prevalence 6.5%, 95% 5.3, 7.6); however, differences in the prevalence of vulvovaginal candidiasis were not observed by the presence or absence of laboratory-confirmed bacterial vaginosis. Conclusions. For correct diagnosis of vulvovaginal candidiasis, laboratory confirmation of infection with Candida is necessary as well as assessment of whether the discharge has been caused by bacterial vaginosis. Studies are needed of women infected with Candida yeast species to determine the risk factors for yeast’s overgrowth. 1. Introduction Vulvovaginal candidiasis is caused by overgrowth of Candida yeast species in the vagina and is characterized by curd-like vaginal discharge, itching, and erythema [1]. Vulvovaginal candidiasis has been associated with considerable direct and indirect economic costs [2], enhanced susceptibility to HIV infection [3], and is being investigated for a potential relationship with preterm birth [4]. Treatment of vulvovaginal candidiasis is warranted when a woman presenting with a complaint of symptoms consistent with vulvovaginal candidiasis also has laboratory confirmation of the presence of Candida from a vaginal specimen. Short-course azole-based treatment regimens are considered effective and safe [5] and are accessible and affordable in most settings. Much of the epidemiologic literature concerning vulvovaginal candidiasis reports on studies in which women were queried on their self-reported history of vulvovaginal candidiasis [6], but without laboratory-confirmation of infection by Candida. Other studies, in which investigators only measure the presence of Candida infection of the vagina [1], are not able to identify women with
References
[1]
J. M. Achkar and B. C. Fries, “Candida infections of the genitourinary tract,” Clinical Microbiology Reviews, vol. 23, no. 2, pp. 253–273, 2010.
[2]
B. Foxman, R. Barlow, H. D'Arcy, B. Gillespie, and J. D. Sobel, “Candida vaginitis: self-reported incidence and associated costs,” Sexually Transmitted Diseases, vol. 27, no. 4, pp. 230–235, 2000.
[3]
J. A. R？ttingen, W. D. Cameron, and G. P. Garnett, “A systematic review of the epidemiologic interactions between classic sexually transmitted diseases and HIV: how much really is known?” Sexually Transmitted Diseases, vol. 28, no. 10, pp. 579–597, 2001.
[4]
C. L. Roberts, J. M. Morris, K. R. Rickard et al., “Protocol for a randomised controlled trial of treatment of asymptomatic candidiasis for the prevention of preterm birth [ACTRN12610000607077],” BMC Pregnancy and Childbirth, vol. 11, article 19, 2011.
[5]
J. D. Sobel, “Vulvovaginal candidosis,” Lancet, vol. 369, no. 9577, pp. 1961–1971, 2007.
[6]
A. M. Geiger, B. Foxman, and B. W. Gillespie, “The epidemiology of vulvovaginal candidiasis among university students,” American Journal of Public Health, vol. 85, no. 8, pp. 1146–1148, 1995.
[7]
H. L. Kent, “Epidemiology of vaginitis,” American Journal of Obstetrics & Gynecology, vol. 165, no. 4, pp. 1168–1176, 1991.
[8]
J. Marrazzo, “Vulvovaginal candidiasis,” British Medical Journal, vol. 326, no. 7397, pp. 993–994, 2003.
[9]
J. H. Prasad, S. Abraham, K. M. Kurz et al., “Reproductive tract infections among young married women in Tamil Nadu, India,” International Family Planning Perspectives, vol. 31, no. 2, pp. 73–82, 2005.
[10]
R. A. Bang, M. Baitule, S. Sarmukaddam, A. T. Bang, Y. Choudhary, and O. Tale, “High prevalence of gynaecological diseases in rural Indian women,” Lancet, vol. 1, no. 8629, pp. 85–88, 1989.
[11]
S. Hawkes and K. G. Santhya, “Diverse realities: sexually transmitted infections and HIV in India,” Sexually Transmitted Infections, vol. 78, no. 1, supplement, pp. i31–i39, 2002.
[12]
R. Stephenson, M. A. Koenig, and S. Ahmed, “Domestic violence and symptoms of gynecologic morbidity among women in North India.,” International Family Planning Perspectives, vol. 32, no. 4, pp. 201–208, 2006.
[13]
M. Koenig, S. Jejeebhoy, S. Singh, and S. Sridhar, “Investigating gynaecological morbidity in India: not just another KAP survey,” Reproductive Health Matters, vol. 6, no. 11, pp. 84–97, 1998.
[14]
S. Garg, N. Sharma, P. Bhalla et al., “Reproductive morbidity in an Indian urban slum: need for health action,” Sexually Transmitted Infections, vol. 78, no. 1, pp. 68–69, 2002.
[15]
V. K. Desai, J. K. Kosambiya, H. G. Thakor, D. D. Umrigar, B. R. Khandwala, and K. K. Bhuyan, “Prevalence of sexually transmitted infections and performance of STI syndromes against aetiological diagnosis, in female sex workers of red light area in Surat, India,” Sexually Transmitted Infections, vol. 79, no. 2, pp. 111–115, 2003.
[16]
P. Madhivanan, K. Krupp, V. Chandrasekaran et al., “The epidemiology of herpes simplex virus type-2 infection among married women in Mysore, India,” Sexually Transmitted Diseases, vol. 34, no. 11, pp. 935–937, 2007.
[17]
P. Madhivanan, K. Krupp, V. Chandrasekaran et al., “Prevalence and correlates of bacterial vaginosis among young women of reproductive age in Mysore, India,” Indian Journal of Medical Microbiology, vol. 26, no. 2, pp. 132–137, 2008.
[18]
K. Krupp, P. Madhivanan, C. Karat et al., “Novel recruitment strategies to increase participation of women in reproductive health research in India,” Global Public Health, vol. 2, no. 4, pp. 395–403, 2007.
[19]
Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines. US Department of Health and Human Services, 2006.
[20]
P. Madhivanan, K. Krupp, J. Hardin, C. Karat, J. D. Klausner, and A. L. Reingold, “Simple and inexpensive point-of-care tests improve diagnosis of vaginal infections in resource constrained settings,” Tropical Medicine and International Health, vol. 14, no. 6, pp. 703–708, 2009.
[21]
R. P. Nugent, M. A. Krohn, and S. L. Hillier, “Reliability of diagnosing bacterial vaginosis is improved by a standardized method of gram stain interpretation,” Journal of Clinical Microbiology, vol. 29, no. 2, pp. 297–301, 1991.
[22]
R. Amsel, P. A. Totten, and C. A. Spiegel, “Nonspecific vaginitis. Diagnostic criteria and microbial and epidemiologic associations,” American Journal of Medicine, vol. 74, no. 1, pp. 14–22, 1983.
[23]
S. Vyas and L. Kumaranayake, “Constructing socio-economic status indices: how to use principal components analysis,” Health Policy and Planning, vol. 21, no. 6, pp. 459–468, 2006.
[24]
S. E. Hawes, S. L. Hillier, J. Benedetti et al., “Hydrogen peroxide-producing lactobacilli and acquisition of vaginal infections,” Journal of Infectious Diseases, vol. 174, no. 5, pp. 1058–1063, 1996.
[25]
S. Vishwanath, V. Talwar, R. Prasad, K. Coyaji, C. J. Elias, and I. De Zoysa, “Syndromic management of vaginal discharge among women in a reproductive health clinic in India,” Sexually Transmitted Infections, vol. 76, no. 4, pp. 303–306, 2000.
[26]
S. Hawkes, L. Morison, S. Foster et al., “Reproductive-tract infections in women in low-income, low-prevalence situations: assessment of syndromic management in Matlab, Bangladesh,” Lancet, vol. 354, no. 9192, pp. 1776–1781, 1999.
[27]
S. Rahman, J. Bogaerts, R. Motiur, R. Razzak, K. Nessa, and M. Reza, “Validity assessment of flowcharts for syndromic management of vaginal discharge,” Working Paper 158, ICDDR, B, Centre for Health and Population Research, Dhaka, Bangladesh, 2003.
[28]
M. Romoren, M. Velauthapillai, M. Rahman, J. Sundby, E. Klouman, and P. Hjortdahl, “Trichomoniasis and bacterial vaginosis in pregnancy: inadequately managed with the syndromic approach,” Bulletin of the World Health Organization, vol. 85, no. 4, pp. 297–304, 2007.
[29]
S. Mohanty, I. Xess, F. Hasan, A. Kapil, S. Mittal, and J. E. Tolosa, “Prevalence & susceptibility to fluconazole of Candida species causing vulvovaginitis,” Indian Journal of Medical Research, vol. 126, no. 3, pp. 216–219, 2007.
[30]
K. Puri, A. Madan, and K. Bajaj, “Incidence of various causes of vaginal discharge among sexually active females in age group 20-40 years,” Indian Journal of Dermatology, Venereology and Leprology, vol. 69, no. 2, pp. 122–125, 2003.
[31]
J. Thulkar, A. Kriplani, and N. Agarwal, “Utility of pH test & Whiff test in syndromic approach of abnormal vaginal discharge,” Indian Journal of Medical Research, vol. 131, no. 3, pp. 445–448, 2010.
[32]
J. Bhatia and J. Cleland, “The contribution of reproductive ill-health to the overall burden of perceived illness among women in southern India,” Bulletin of the World Health Organization, vol. 79, no. 11, pp. 1065–1069, 2001.
[33]
A. Ahmad and A. U. Khan, “Prevalence of Candida species and potential risk factors for vulvovaginal candidiasis in Aligarh, India,” European Journal of Obstetrics Gynecology and Reproductive Biology, vol. 144, no. 1, pp. 68–71, 2009.
[34]
D. J. White and A. Vanthuyne, “Vulvovaginal candidiasis,” Sexually Transmitted Infections, vol. 82, no. 4, supplement, pp. iv28–iv30, 2006.
[35]
P. Nyirjesy, S. M. Seeney, M. H. T. Grody, C. A. Jordan, and H. R. Buckley, “Chronic fungal vaginitis: the value of cultures,” American Journal of Obstetrics and Gynecology, vol. 173, no. 3, pp. 820–823, 1995.
[36]
J. D. Sobel, S. Faro, R. W. Force et al., “Vulvovaginal candidiasis: epidemiologic, diagnostic, and therapeutic considerations,” American Journal of Obstetrics and Gynecology, vol. 178, no. 2, pp. 203–211, 1998.
[37]
V. Redondo-Lopez, C. Meriwether, C. Schmitt, M. Opitz, R. Cook, and J. D. Sobel, “Vulvovaginal candidiasis complicating recurrent bacterial vaginosis,” Sexually Transmitted Diseases, vol. 17, no. 1, pp. 51–53, 1990.
[38]
A. Schwiertz, D. Taras, K. Rusch, and V. Rusch, “Throwing the dice for the diagnosis of vaginal complaints?” Annals of Clinical Microbiology and Antimicrobials, vol. 5, no. 1, article 4, 2006.
[39]
R. S. McClelland, B. A. Richardson, W. M. Hassan et al., “Prospective study of vaginal bacteria flora and other risk factors for vulvovaginal candidiasis,” Journal of Infectious Diseases, vol. 199, no. 12, pp. 1883–1890, 2009.
[40]
S. L. Hillier, M. A. Krohn, R. P. Nugent et al., “Characteristics of three vaginal flora patterns assessed by Gram stain among pregnant women,” American Journal of Obstetrics and Gynecology, vol. 166, no. 3, pp. 938–944, 1992.
[41]
V. D. Mijac, S. V. Dukic, N. Z. Opavski, M. K. Dukic, and L. T. Ranin, “Hydrogen peroxide producing lactobacilli in women with vaginal infections,” Journal of Obstetrics & Gynecology and Reproductive Biology, vol. 129, no. 1, pp. 69–76.
[42]
P. Auger and J. Joly, “Microbial flora associated with Candida albicans vulvovaginitis,” Obstetrics and Gynecology, vol. 55, no. 3, pp. 397–401, 1980.
[43]
B. Zdolesk, D. Hellberg, G. Froman, S. Nilsson, and P. A. Mardh, “Vaginal microbiological flora and sexually transmitted diseases in women with recurrent or current vulvovaginal candidiasis,” Infection, vol. 23, no. 2, pp. 81–84, 1995.
[44]
R. C. R. Martinez, S. A. Franceschini, M. C. Patta et al., “Analysis of vaginal lactobacilli from healthy and infected Brazilian women,” Applied and Environmental Microbiology, vol. 74, no. 14, pp. 4539–4542, 2008.
[45]
J. Xu and J. D. Sobel, “Antibiotic-associated vulvovaginal candidiasis,” Current Infectious Disease Reports, vol. 5, no. 6, pp. 481–487, 2003.
[46]
L. O. Eckert, “Acute vulvovaginitis,” The New England Journal of Medicine, vol. 355, no. 12, pp. 1244–1252, 2006.
[47]
M. Pirotta, J. Gunn, P. Chondros et al., “Effect of lactobacillus in preventing post-antibiotic vulvovaginal candidiasis: a randomised controlled trial,” British Medical Journal, vol. 329, no. 7465, pp. 548–551, 2004.
[48]
T. E. Will, “Lactobacillus overgrowth for treatment of moniliary vulvovaginitis,” Lancet, vol. 2, no. 8140, p. 482, 1979.
[49]
P. A. M？rdh, A. G. Rodrigues, M. Gen？, N. Novikova, J. Martinez-De-Oliveira, and S. Guaschino, “Facts and myths on recurrent vulvovaginal candidosis - A review on epidemiology, clinical manifestations, diagnosis, pathogenesis and therapy,” International Journal of STD and AIDS, vol. 13, no. 8, pp. 522–539, 2002.
