Characterisation of Candida africana among pregnant women with vaginitis

Abstract

Candida africana, an emerging variant within the Candida albicans complex, has a global intra-albicans complex prevalence of 1.67% and varies between 0% and 8.4% depending on the region. It mainly causes vulvovaginal candidiasis, a condition more common in pregnant women. In Uganda, 60% of pregnant women suffer from Vulvovaginal Candidiasis (VVC), mainly attributed to Candida albicans species. Due to its low frequency and similar phenotypic characteristics to C. albicans, there is a risk of misidentifying C. africana in clinical settings. Consequently, data of its impact on public health in Uganda are lacking. To address this issue, this study aimed at utilizing culture and Matrix Assisted Laser Desorption/Ionization Time of Flight (MALDI-TOF) to determine the prevalence of C. africana vaginitis, antifungal susceptibility, and host risk factors for vulvovaginal candidiasis in pregnant women at selected hospitals in Kampala, Uganda. A cross-sectional descriptive study design was used. Data were collected from pregnant women presenting to prenatal clinics at Mulago Specialized Women and Neonatal Hospital (MSWNH), Kawempe National Referral Hospital (KNRH), and Sebbi Hospital (SH), all located in the capital city of Uganda; Kampala. The study’s independent variables included frequency of drinking sweet beverages, frequency of wearing tights, history of curettage, and frequency of intravaginal douching. The main dependent variable was the diagnosis with Candida africana vaginitis. The study utilized phenotypic methods including 10% KOH wet preparation and examination, direct gram staining and examination, plating clinical specimens on Saboroud Dextrose Agar (SDA), Germ Tube test, Chlamydospores production test, species identification using Chromagar candida, and an a molecular method; MALDI-TOF mass spectrometry. Of the 154 high vaginal secretion specimens collected between March and June 2023, C. albicans was the most prevalent species (54.55%), followed by Candida glabrata (9.09%), and Pichia kudriavzevii (1.30%). Candida tropicalis, Candida parapsilosis, and Cyberlindnera jadinii each had a prevalence of 0.65%. There prevalence of C. africana was zero, and 33.03% of the clinical samples showed no fungal growth on SDA. The most common combination of symptoms among pregnant women was vaginal itching and discharge, reported by 36% of expectant mothers. Vaginal discharge was the most prevalent standalone symptom, observed in 28% of mothers. Other clinical presentations included sex and vaginal burning, which alone or in various combinations with vaginal itching and discharge were reported in 36% of expectant mothers. Pregnant women who regularly or rarely drank sweet, sugary drinks (OR = 2.9825, 95% CI = 0.5761, 6.9664) and wore tight pants (OR = 1.76, 95% CI = 0, 5470, 2.9845), had a higher risk of developing VVC than those who did not. The odds were lower for those who regularly or rarely used vaginal douching (OR = 0.6994, 95% CI = 0.4635, 1.7018) and for those who were previously exposed to the dilation and curettage procedure (OR = 0 .7925, 95% CI =). 0.4856, 1.7667). The odds of diagnosed with VVC were 1.75 times higher in pregnant women with a gestation period of 5 to 9 months than in women with a gestation period of 0 to 4 months (OR = 1.7531, 95% CI = 0.5905, 2.5848). Conclusion: The prevalence of C. africana was zero. However, the isolation of non-albicans species and uncommon yeasts highlights the need for clinicians to consider a broader range of organisms in the diagnosis and treatment of suspected vulvovaginal infections. Gestation age of 5 – 9 months, regular or infrequent wearing tight pants, consumption of sweet and sugary drinks, and exposure to Dilation and Curettage (D and C) procedure, were associated with an increased risk of VVC, and clinical symptoms alone are not sufficient for the accurate diagnosis of vulvovaginal candidiasis.