Antifungal Susceptibility of Candida Strains Isolated from Patients with Vaginal Candidiasis at the Centre University Hospitalist of Brazzaville

Sekangue Obili G; Potokoue Mpia NSB; Buambo G; Ossibi Ibara BR; Djendja Ingoba I; Gackosso G; Ossere RR; Onanga Koumou Lendongo; Itoua C

Antifungal Susceptibility of Candida Strains Isolated from Patients with Vaginal Candidiasis at the Centre University Hospitalist of Brazzaville

Sekangue Obili G*, Potokoue Mpia NSB, Buambo G, Ossibi Ibara BR, Djendja Ingoba I, Gackosso G, Ossere RR, Onanga Koumou Lendongo, Itoua C

Published Date: 2025-01-29

Sekangue Obili G¹^,4*, Potokoue Mpia NSB^2,⁴, Buambo G^2,⁴, Ossibi Ibara BR³^,⁴, Djendja Ingoba I¹, Gackosso G¹, Ossere RR¹, Onanga Koumou Lendongo⁴, Itoua C^2,⁴

¹Department of Parasitology Mycology and Parasitic Immunology, University Hospital Center of Brazzaville, Brazzaville, Republic of the Congo

²Department of Obstetrics and Gynecology, University Hospital Center of Brazzaville, Brazzaville, Republic of the Congo

³Department of Infectious Diseases, Brazzaville University Hospital, Brazzaville, Republic of the Congo

⁴Department of Health Sciences, Marien Ngouabi University, Brazzaville, Republic of the Congo

*Corresponding Author:: Sekangue Obili G
Department of Parasitology Mycology and Parasitic Immunology,
University Hospital Center of Brazzaville,
Brazzaville,
Republic of the Congo
E-mail: sekanguegeril@gmail.com

Received: December 06, 2024, Manuscript No. IPMMO-24-20268; Editor assigned: December 11, 2024, PreQC No. IPMMO-24-20268 (PQ); Reviewed: December 24, 2024, QC No. IPMMO-24-20268; Revised: January 01, 2025, Manuscript No. IPMMO-24-20268 (R); Published: January 29, 2025, DOI: 10.36648/2471-8521.10.1.070

Citation: Obili GS, Potokoue Mpia NSB, Ossibi Ibara BR, Itoua C, Djendja Ingoba I, et al. (2025) Antifungal Susceptibility of Candida Strains Isolated from Patients with Vaginal Candidiasis at the Centre University Hospitalist of Brazzaville. Med Mycol Open Access Vol.10 No.1: 70.

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Abstract

Objective: To study the sensitivity to antifungal agents of Candida strains isolated from vaginal candidiasis at the Brazzaville University hospital.

Materials and methods: This was a descriptive cross-sectional study conducted from 8 July to 8 October 2019 in the parasitology mycology department of the Brazzaville University Hospital centre. Candida strains isolated from vaginal samples were subjected to an in vitro sensitivity study using the Sabouraud disc diffusion method. The sensitivity of Candida to antifungal agents and their activity on Candida strains were assessed.

Results: The median age was 32 years (q1: 24 and q3:40 years). The most common age group was (25-35 years): 30.9%. C. non-albicans was present in 64.7% (22/34) of cases. Candida albicans was found in 35.3% of cases (12/34). Sensitivity to antifungal agents varied according to species. Econazole had a sensitivity of 70.6%, miconazole 38.2% and ketoconazole 64.7%. Itraconazole and fluconazole were resistant to 79.4% and 58.8% respectively. All Candida strains were sensitive to econazole. They had good sensitivity to miconazole.

Conclusion: The sensitivity of Candida strains to antifungal agents was reduced overall. Econazole remains the antifungal still active on all Candida strains.

<h4>Keywords</h4>
Sensitivity; Antifungals; Antifungal chart; Vaginal
candidiasis; Brazzaville University hospital centre
<h4>Introduction</h4>
Vaginal candidiasis is an infection caused by a fungus of the
genus Candida. This genus includes more than 200 species, around ten of which are involved in a pathological process in
humans.
 The worldwide incidence of vaginal candidiasis has increased
in recent years, with Candida albicans being the most common
species. At the same time, there has been a growing
involvement of non-albicans Candida, often isolated in recurrent
candidiasis.
 Vaginal candidiasis is second only to bacterial vaginosis.
Worldwide, more than 75% of women develop Candida vaginitis
during their period of genital activity.
 A study carried out in Gabon showed that Candida albicans was the main causative agent of vaginal candidiasis in 68.2% of
cases. Another study conducted in the Congo reported a
predominance of the same species in 32.3% of cases of vaginal
mycosis.
 Treatment of candidiasis is essentially based on the use of
antifungal agents. However, treatment failures are sometimes
observed. This is most often due to a problem in identifying the Candida species involved, especially as the incidence of non-albicans Candida is increasing daily. In addition, resistance to
antimicrobials, including antifungals, is implicated in these
failures. Some Candida species have natural resistance. Primary
resistance of Candida krusei to fluconazole and possible
resistance of Candida glabrata to fluconazole via an efflux
mechanism have been demonstrated. These resistances are not
only natural, but are mainly due to selection pressure associated
with certain therapeutic practices, such as the probabilistic
administration of antifungal agents or self-medication.
 In the Republic of Congo, Candida vaginitis is a frequent
reason for consultations in health facilities. Antifungal tests are
not routinely carried out. This explains the paucity of data on
resistance to antifungal agents, even though antifungal
treatment is usually prescribed. In order to improve patient care,
it is necessary to identify Candida species and assess their sensitivity profile. It was against this background that we
conducted this study, the aim of which was to investigate the
sensitivity to antifungal agents of Candida strains isolated during
vaginal candidiasis at the Brazzaville University hospital [<a href="#1" title="1">1</a>].
<h4> Materials and Methods</h4>
 This was a descriptive cross-sectional study that took place
from 8 July to 30 October 2019 at the parasitology mycology
laboratory of the Brazzaville University hospital center. All
women seen at the laboratory for vaginal swab analysis with or
without clinical signs, who had not received any antifungal
treatment and who had given informed consent were included.
Women with genital bleeding were excluded. For each patient
included in the study, sociodemographic, clinical and mycological
data were collected using a survey form. After inclusion, samples
were taken by swabbing (using 2 sterile swabs) of the vaginal
mucosa after the speculum had been removed.
 For each sample, the vaginal pH was assessed using a pH strip.
A direct examination and culture, on Sabouraud-Chloramphenicol and Sabouraud-Chloramphenicol-Actidione
media, was performed and incubated at 37°C for 24 hours. All
positive cultures were subjected to a filamentation test using a
yeast suspension mixed with 1 ml of fresh human serum. The
preparation was incubated at 37°C for 3 hours. Candida species
were identified using Biomerieux's API Candida gallery.
 All the Candida species identified were subjected to an in vitro antifungal susceptibility study using the Sabouraud agar disc
diffusion method based on an inoculum of 0.3 Mac Farlan. The
antifungal discs tested were Econazole (10 μg), Fluconazole (100
μg), Ketoconazole (10 μg), Itraconazole (50μg) and Miconazole
(10 μg). The diameter of inhibition formed around the disc was
used to determine the Sensitive (S), Intermediate (I) or Resistant
(R) characteristics of each antifungal agent, taking into account
the interpretation criteria given by the manufacturer [<a href="#2" title="2">2</a>].
 The data collected were analyzed using EPi-info7.2.2.6
software and calculations were made using frequencies for
qualitative variables and central tendency and dispersion
parameters for quantitative variables.
<h4> Results</h4>
 Gynecological and obstetric sociodemographic
characteristics
 A total of 152 patients were selected. The median age of the
patients was 32 years, with q1: 24 years to q3:40 years.
 Species isolated from vaginal swabs
 Non-albicans Candida species were the most commonly
isolated. C. glabrata represented for 36.4% of non-albicans Candida species. It was followed by Candida albicans.
<div class="well well-sm">
<div class="row">
<div class="col-xs-12 col-md-2"><a onclick="openimage('https://www.imedpub.com/articles-images-2025/Medical-Mycology-Candida-20268-g001.png','','scrollbars=yes,resizable=yes,width=500,height=330')"class="thumbnail"><img src="https://www.imedpub.com/articles-images-2025/Medical-Mycology-Candida-20268-g001.png" class="img-responsive" alt="Medical-Mycology" title="Medical-Mycology" /></a></div>
<div class="col-xs-12 col-md-10">
Figure 1: Distribution of different non-albicans Candida species.
</div>
</div>
</div>
Sensitivity to antifungal agents
 The overall sensitivity of the antifungal agents tested was
100% for Econazole, 94.1% for miconazole, 91.2% for
ketoconazole, 41.2% for fluconazole and 17.8% for itraconazole. Table 1 shows the detailed sensitivity of each antifungal agent to Candida strains isolated from vaginal swabs. Econazole showed a
decrease in sensitivity to Candida strains, with an intermediate
sensitivity of 29.4% and a sensitivity of 76.6%. No Candida strains were found to be resistant to econazole. On the other
hand, for itraconazole, there was a decrease in the sensitivity of Candida strains to this compound, with an intermediate
sensitivity rate of 17.6% and a higher resistance rate than for all
the other compounds (79.4%) [<a href="#3" title="3">3</a>-<a href="#6" title="6">6</a>].
<div class="table-responsive">
<table class="table table-bordered">
<thead>
<tr>
<th>Antifungals</th>
<th>Results interpreters</th>
<th>Diameter in mm</th>
<th>Diamaters thresholds</th>
<th>Speciality</th>
</tr>
</thead>
<tbody>
<tr>
<td rowspan="3">Econazole </td>
<td>R </td>
<td><10 </td>
<td rowspan="3">10-20 </td>
<td rowspan="3">Pevaryl </td>
</tr>
<tr>
<td>S </td>
<td>>20 </td>
</tr>
<tr>
<td>I </td>
<td>10-20 </td>
</tr>
<tr>
<td rowspan="3">Fluconazole </td>
<td>R </td>
<td><10 </td>
<td rowspan="3">10-20 </td>
<td rowspan="3">Trifucan </td>
</tr>
<tr>
<td>S </td>
<td>>20 </td>
</tr>
<tr>
<td>I </td>
<td>10-20 </td>
</tr>
<tr>
<td rowspan="3">Itraconazole </td>
<td>R </td>
<td><10 </td>
<td rowspan="3">10-20 </td>
<td rowspan="3">Sporanox </td>
</tr>
<tr>
<td>S </td>
<td>>20 </td>
</tr>
<tr>
<td>I </td>
<td>10-20 </td>
</tr>
<tr>
<td rowspan="3">Ketaconazole </td>
<td>R </td>
<td><10 </td>
<td rowspan="3">10-20 </td>
<td rowspan="3">Nizoral </td>
</tr>
<tr>
<td>S </td>
<td>>20 </td>
</tr>
<tr>
<td>I </td>
<td>10-20 </td>
</tr>
<tr>
<td rowspan="3">Miconazole </td>
<td>R </td>
<td><10 </td>
<td rowspan="3">10-20 </td>
<td rowspan="3">Daktarin </td>
</tr>
<tr>
<td>S </td>
<td>>20 </td>
</tr>
<tr>
<td>I </td>
<td>10-20 </td>
</tr>
<tr>
<td nowrap="nowrap" colspan="5" valign="bottom">Note: I: Intermediate; R: Resistance; S: Sensitive</td>
</tr>
</tbody>
</table>
</div>
Table 1: Interpretation of antifungal inhibition zones.
For the ketoconazole and miconazole molecules, the strains
were more sensitive to antifungal agents than resistant.
However, for fluconazole, the resistance rate (58.8%) was slightly
higher than the sensitivity rate (41.2%) (Table 2) [<a href="#7" title="7">7</a>-<a href="#10" title="10">10</a>].
<div class="table-responsive">
<table class="table table-bordered">
<thead>
<tr>
<th>Variables </th>
<th>Number (n) </th>
<th>Percentage (%)</th>
</tr>
</thead>
<tbody>
<tr>
<td colspan="3">Econazole</td>
</tr>
<tr>
<td>Sensitive </td>
<td>24 </td>
<td>70.6 </td>
</tr>
<tr>
<td>Intermediate </td>
<td>10 </td>
<td>29.4 </td>
</tr>
<tr>
<td>Resistant </td>
<td>0 </td>
<td>0.0 </td>
</tr>
<tr>
<td colspan="3">Fluconazole</td>
</tr>
<tr>
<td>Sensitive </td>
<td>5 </td>
<td>14.7 </td>
</tr>
<tr>
<td>Intermediate </td>
<td>9 </td>
<td>26.5 </td>
</tr>
<tr>
<td>Resistant </td>
<td>20 </td>
<td>58.8 </td>
</tr>
<tr>
<td colspan="3">Ketoconazole</td>
</tr>
<tr>
<td>Sensitive </td>
<td>22 </td>
<td>64.7 </td>
</tr>
<tr>
<td>Intermediate </td>
<td>9 </td>
<td>26.5 </td>
</tr>
<tr>
<td>Resistant </td>
<td>3 </td>
<td>8.8 </td>
</tr>
<tr>
<td colspan="3">Itraconazole</td>
</tr>
<tr>
<td>Sensitive </td>
<td>1 </td>
<td>0.2 </td>
</tr>
<tr>
<td>Intermediate </td>
<td>6 </td>
<td>17.6 </td>
</tr>
<tr>
<td>Resistant </td>
<td>27 </td>
<td>79.4 </td>
</tr>
<tr>
<td colspan="3">Miconazole</td>
</tr>
<tr>
<td>Sensitive </td>
<td>13 </td>
<td>38.2 </td>
</tr>
<tr>
<td>Intermediate </td>
<td>19 </td>
<td>55.9 </td>
</tr>
<tr>
<td>Resistant </td>
<td>2 </td>
<td>5.9 </td>
</tr>
</tbody>
</table>
</div>
Table 2: Sensitivity of different antifungal agents to Candida strains.s
Table 3 shows the percentage sensitivity of Candida species to
the antifungal agents tested in vitro. All strains of C. albicans and
C. non-albicans were sensitive to Econazole. However, strains of C. glabrata, C. krusei and C. tropicalis showed total resistance
(100%) to itraconazole. For the ketoconazole molecule, all non-albicans
C. strains except C. tropicalis were fully susceptible
(100%) [<a href="#11" title="11">11</a>-<a href="#15" title="15">15</a>].
<div class="table-responsive">
<table class="table table-bordered">
<thead>
<tr>
<th> </th>
<th>Econazole (%)</th>
<th>Fluconazole (%)</th>
<th>Ketoconazole (%)</th>
<th>Itraconazole (%)</th>
<th>Miconazole (%)</th>
</tr>
</thead>
<tbody>
<tr>
<td colspan="6">C. albicans</td>
</tr>
<tr>
<td>Sensitivity </td>
<td>100.0 </td>
<td>41.7 </td>
<td>83.3 </td>
<td>25.0 </td>
<td>91.7 </td>
</tr>
<tr>
<td>Resistance </td>
<td>0 </td>
<td>58.3 </td>
<td>16.7 </td>
<td>75.0 </td>
<td>8.3 </td>
</tr>
<tr>
<td colspan="6">C. glabrata</td>
</tr>
<tr>
<td>Sensitivity </td>
<td>100 </td>
<td>50.00 </td>
<td>100 </td>
<td>0 </td>
<td>100 </td>
</tr>
<tr>
<td>Resistance </td>
<td>0 </td>
<td>50.00 </td>
<td>0 </td>
<td>100 </td>
<td>0 </td>
</tr>
<tr>
<td colspan="6">C. krusei</td>
</tr>
<tr>
<td>Sensitivity </td>
<td>100 </td>
<td>50.00 </td>
<td>100 </td>
<td>0 </td>
<td>100 </td>
</tr>
<tr>
<td>Resistance </td>
<td>0 </td>
<td>50.00 </td>
<td>0 </td>
<td>100 </td>
<td>0 </td>
</tr>
<tr>
<td colspan="6">C. famata</td>
</tr>
<tr>
<td>Sensitivity </td>
<td>100 </td>
<td>33.33 </td>
<td>100 </td>
<td>66.67 </td>
<td>100 </td>
</tr>
<tr>
<td>Resistance </td>
<td>0 </td>
<td>66.67 </td>
<td>0 </td>
<td>33.33 </td>
<td>0 </td>
</tr>
<tr>
<td colspan="6">C. parapsilosis</td>
</tr>
<tr>
<td>Sensitivity </td>
<td>100 </td>
<td>50.00 </td>
<td>100 </td>
<td>50.00 </td>
<td>100 </td>
</tr>
<tr>
<td>Resistance </td>
<td>0 </td>
<td>50.00 </td>
<td>0 </td>
<td>50.00 </td>
<td>0 </td>
</tr>
<tr>
<td colspan="6">C. tropicalis</td>
</tr>
<tr>
<td>Sensitivity </td>
<td>100 </td>
<td>0 </td>
<td>33.33 </td>
<td>0 </td>
<td>66.67 </td>
</tr>
<tr>
<td>Resistance </td>
<td>0 </td>
<td>100 </td>
<td>66.67 </td>
<td>100 </td>
<td>33.33 </td>
</tr>
</tbody>
</table>
</div>
Table 3: Susceptibility of Candida species to the different antifungal agents tested.
<h4>Discussion</h4>
 Prevalence of vaginal candidiasis
 The prevalence of vaginal candidiasis in our study was 22.4%.
Our results are similar to those found by some authors in
Ouagadougou, Bob Dioulasso, Punjab and Casablanca. Others,
on the other hand, have obtained results higher than ours for
some and lower for others. We note a wide variability in the
prevalence of vaginal candidiasis in the literature. This variability
can be explained by the susceptibility of each woman to
different exposure to predisposing factors. These include factors
associated with behaviour, contraception, sexual contamination. Candida virulence and anti-candida immunity. This anti-candida
immunity is based on cell-mediated. humoral or innate
immunity [<a href="#16" title="16">16</a>-<a href="#18" title="18">18</a>]. Some authors link this to genetic
predisposition in certain populations.
 Different Candida species isolated from vaginal
candidiasis
 The mycological study of our patients' samples showed a
predominance of non-albicans Candida species over Candida
albicans. This trend has also been reported by some authors. In
general, a predominance of non-albicans species is observed in
recurrent candidiasis. However, in addition to recurrent vaginal
candidiasis, disruption of the vaginal ecosystem by the use of
certain antiseptics or the practice of certain hygiene habits may
also be responsible for this increase in non-albicans Candida
species. These results are in contrast to those obtained by
Mbou, et al., in the same town, who showed a predominance of Candida albicans. This is also what most of the literature reports
[<a href="#19" title="19">19</a>-<a href="#21" title="21">21</a>].
 The most common non-albicans Candida species were Candida glabatra, Candida tropicalis, Candida famata and Candida krusei. Saccharomyces cerevisiae was also identified. In
the literature, we note variability in the prevalence of non-albicans Candida species. Some authors have found C. glabrata, C. Kefir, C. tropicalis, C. glabatra, C. parapsilosis, C. tropicalis, S.
cerevisiae, C. famata, C. rugosa, C. parapsilosis, C. glabatra, C.
tropicalis, C. parapsilosis, C. glabatra, C. tropicalis, C. famata.
Despite this diversity of prevalence, it appears that C. glabrata is
the non-albicans Candida species most frequently found in
several studies. On the one hand, this could be explained by the
fact that C. glabrata is one of the species most frequently found
among the commensal Candida species of the digestive tract
and genitourinary tract. Secondly, its incidence has increased
due to the selection pressure exerted by the increasing use of
azoles in the treatment of vaginal candidiasis.
 The increase in the number of non-albicans Candida species
should raise fears that recurrent vaginal candidiasis is becoming
increasingly common. This is because these species are
becoming less and less resistant to antifungal agents, especially
in certain areas.
 Sensitivity of isolated Candida strains to antifungal
agents
 The antifungal agents we tested in this study were mainly
azoles, which are the molecules most commonly used in the
treatment of vaginal candidiasis. Overall, there was a reduction
in sensitivity for all the azoles we tested. But only econazole did
not show any development of resistance. Econazole was active
on all the Candida strains we isolated. This azole molecule can
therefore be used in all cases of vaginal candidiasis without the
need for an antifungigram. However, prescribing it as a first line
treatment can lead to the development of resistance, especially
if the bacteria have not been identified beforehand.
 Our results differ from those found in Ahvaz, where strains
isolated from vaginal candidiasis showed resistance to
econazole. This difference in results clearly shows that
resistance is not only region dependent but also depends on the
possibility of genetic transfer of resistance from one strain to
another.
 Fluconazole had a resistance rate of around 60% in our study.
This resistance rate is well above that reported by several
authors, who reported fluconazole sensitivity of over 60%. In
contrast, in Cameroon, 82% resistance was observed in strains
isolated from vaginal candidiasis. Although resistance to
fluconazole is increasingly being observed, there are still areas,
such as Addis Ababa, where fluconazole remains active against
all strains of Candida. This development of resistance to
fluconazole may be due to the fact that, as this compound is
more of a fungi static than a fungicide, its increased prescription
has led to the emergence of resistance mechanisms in Candida
strains. This phenomenon is all the more dangerous as
fluconazole has become the drug of first choice in the treatment
of certain fungal infections.
 Ketoconazole is a compound that remains active on Candida
isolated from vaginal candidiasis. However, our study shows an
increase in intermediate sensitivity with a low rate of resistance,
elements which should attract attention and increase vigilance
in the use of this molecule. The resistance rate we obtained is
lower than that reported in Cameroon, where resistance was
72% and in Ahvaz, Iran, where it was 37.3%. On the other hand,
100% sensitivity was reported in Abidjan.
 Itraconazole reached equally worrying proportions in our
study. This was not the case in China, where the rate of
resistance to itraconazole was 2.5% or in Ahvaz, Iran, where it
was 11.9%. As for miconazole, its use requires maximum doses
to ensure optimal therapeutic efficacy, as it showed an
intermediate sensitivity of almost 60%, whereas it has the
lowest degree of resistance of all the molecules in our study. Its
low resistance rate has been noted by several authors.
 The Candida strains we isolated showed a different profile
depending on the antifungal agent tested. All the Candida
strains in our study were totally sensitive to econazole, whereas
sensitivity to the other molecules varied according to species.
This disparate sensitivity profile of Candida strains is an
argument in favour of routine antifungal testing in our
environment.
<h4>Conclusion</h4>
 Vaginal candidiasis is highly prevalent at Brazzaville University
hospital. The fungal agents responsible are dominated by non-albicans Candida. Several molecules are currently showing a loss
of sensitivity and even total resistance to certain azole
antifungals. However, Econazole is still active on all the Candida strains that have been identified.
 Therefore, the fact that antifungals are not systematically
performed in cases of vaginal candidiasis at Brazzaville
University Hospital is an attitude that encourages the emergence
of antifungal resistance. Antifungal grams should therefore be
encouraged.
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