VULVOVAGINAL CANDIDIASIS PREVALENCE AMONG PREGNANT WOMEN IN DIFFERENT HOSPITALS IN IBB, YEMEN

Background and aims: Candida species are opportunistic yeasts that affect the genital urinary tract that causes vulvovaginal candidiasis in the most females, particularly in developing countries. This work aims to find the prevalence of vulvovaginal candidiasis among pregnant women in Ibb, Yemen. Material and methods: Two hundred and eighteen samples of females attending outpatient obstetrics and gynecology clinics were chosen from several hospitals (Al-Thawra, Maternity and Childhood Center, Maternal Reproductive Health Center, and Nasser General Hospital) located in Ibb, from December 2019 to March 2020. The laboratory works were performed in the microbiology department of Al-Thawra Hospital, Ibb. Vaginal swabs were cultivated on Sabouraud dextrose agar, then the species of Candida identification and anti-fungal sensitivity tests were performed regarding the standard procedure of microbiology. Results: The findings revealed that out of 218 cases, 134 (61.5%) were infected with Candida species, and the rate of candidiasis was higher among women coming from rural areas than among women in urban areas; and in the age group 28-37 years. C. albicans (61.2%) were the most prevalent species followed by C. tropicalis (21.64%), C. glabrata (11.19%), and C. kefyr (5.97%). Susceptibility tests showed that the most isolated Candida species were sensitive to nystatin (94.8), fluconazole (91.04%), amphotericin B (88.80%), voriconazole (78.35%), clotrimazole (75.37%), ketoconazole (73.13%), and itraconazole (69.40%). Conclusion: It can be concluded that Candida vaginitis is very common among pregnant women, and the tested anti-fungal agents continue to be effective against all isolates of Candida species. In contrast, there was a slight increase resistant against itraconazole, ketoconazole, clotrimazole, and voriconazole which raises concern about a rise in Candida species that are resistant to these drugs.


INTRODUCTION
Candida vaginitis, also often called vulvovaginal candidiasis, is a pathogen of the vagina caused by diverse types of Candida species 1,2 . Vulvovaginal candidiasis (VVC) considers the second disease cause of symptomatic vaginal diseases after bacterial vaginitis 1, 3 and responsible for over 25% of infectious vaginitis 4, 5 . Almost 75% of women have VVC in their lifetime 3 . Also, it was documented that more than 40% of affected females will have two or more incidence of vulvovaginal candidiasis in the year 6,7 . The clinical manifestations of vulvovaginal candidiasis are representing on the itching, vaginal discomfort, an unpleasant burning feeling, and soreness that lead to whitish-yellowish vaginal discharge often with a curdlike appearance 8 . The frequency rates of Candida species among pregnant women with VVC various from the study area to another 9 . Some reports have documented that the C. albicans was ranged between 80-90% among women with acute VVC that caused by Candida sp., whereas other species of Candida are less frequently isolated 1,10, 11 . However, in the last 10

MATERIALS AND METHODS Study Design and Data Collection
Two hundred and eighteen (218) samples were sampled from pregnant women presenting Obstetrics and Gynecology outpatient clinics in several hospitals (AL-Thwrah, Maternity Center and Childhood, Reproductive Health Center for Mothers, Nasser General hospital) that situated in Ibb City, in the period from December 2019 to March 2020. All participated cases were interviewed and patient information was reported with intended questionnaires that include; demographic, age, medical history, and symptoms.

Sample Collection
The swab specimens were collected from female pregnant by the obstetrician. By using s sterile cotton swab, two wipes per patient, was carefully inserted into the upper part of the vagina. The samples were immediately transmitted to the diagnostic laboratory of the Microbiology Department of the AL-Thwrah Hospital for examination 3, 21 .

Examination of Specimen Microscopic Examination
One swab of each case was subjected to direct examination by the wet mount. One drop of normal saline was transferred to each sample and mixed well and microscopically examined under 10x and 40x 22 .

Culture Methods
The second swab was cultivated on the surface of Sabouraud Dextrose Agar (SDA) (Oxide, UK) with chloramphenicol (250mg/l). The plates were incubated for 48 h at 37°C. The morphological features for the colony were studied and confirmed by detecting the budding characterization with pseudo-hyphae by using the Gram tube test 23 .

Candida species Identification
The Candida species were identified according to morphological characterizations on the surface of culture medium, the formation of germ tube test, and carbohydrate assimilation as the following: Germ Tube Test A small part from a pure colony of Candida species was picked and transported into a sterile tube that contains 0.5ml serum of human, mixed well, and aerobic incubated for 2h at 37°C. Then, one drop of each serum was transported to a clean slide and scanned by a microscope with objective lenses (x40) to identify the existence of germ tubes that characterized with initially short hyphal 24 .

Sugar Assimilation Test
From the overnight of yeast suspension culture, one mL was transferred to the basal carbohydrate-free medium (II) of molten agar cooled to 45°C and poured to petri dish plates. Saturated discs with 1% with sugar were placed on the solidified surface of plates and incubated for five days at 37°C. The occurrence of growth around each disc implies the carbohydrate assimilation of tested sugar. The glucose, sucrose, Dgalactose, maltose, raffinose, lactose, trehalose, and xylose were used in the sugar assimilation test 25 .

RESULTS
A hundred and thirty-four samples (61.5%) found positive growth in culture and 84 specimens (38.5%) recorded negative growth ( Figure 1). Table 1 shows the prevalence of vulvovaginal candidiasis regarding patient's residents. It was observed that the women coming from the rural area had the highest rate (65%) while the patients coming from the urban area was 60.13%.   (Figure 2).

Figure 2: The first time and recurrent infection
In the present investigation, it was isolated four species of Candida from vaginal specimens and identified according to carbohydrate assimilation. C. albicans was (61.2%) the most predominant Candida species identified from specimens followed by an non-albicans species that are C. tropicalis 29(21.64%), C. glabrata 15(11.19%), and C. kefyr 8(5.97%) (Figure 3).  Table 3. In the current study, the women coming from rural areas had a higher rate (65%) of vaginitis than patients from the urban area. This finding in disagreement with Abdul-Aziz et al., 20 who revealed that 88.44% of vaginitis was among reproductivewomen residents in an urban area. The high occurrence of communicable vaginitis among rural women frequently refers to poor situations of healthcare, absence of health education, lower-income, and difficulty in medical treatment in time 29 . However, the education status plays a significant role in contributing to the improvement of personal hygiene which lacks in the rural area and that may explain the variance in the frequency of infection between the urban area and rural area 14

CONCLUSION
It can be concluded that vulvovaginal candidiasis is very common among pregnant women, and the tested anti-fungal agents continue to be effective against all isolates of Candida species. In contrast, there was a slight increase in resistance against itraconazole, ketoconazole, clotrimazole, and voriconazole which raises concern about a rise in Candida species that are resistant to these drugs.