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UDC 618.16-002:616.34:616.992
COMBINATION OF VULVOVAGINAL AND INTESTINAL CANDIDIASIS: SUBSTANTINATION OF RATIONAL APPROACH TO THERAPY
Irkutsk State Medical University, Irkutsk I.O. Malova, Yu.A. Kuznetsova
On the grounds of the examination and treatment of 100 patients with chronic recurrent vulvovaginal candidiasis (CRVVC) and 50 patients with a combination of CRVVC and candidal intestinal dysbiosis (CID), the article analyzes the features of clinical manifestations of the disease, the species composition and sensitivity of cultures of the Candida genus isolated from the vagina and intestine to antimycotics, as well as the results of therapy proposed on the basis of the above studies.
Key words: chronic recurrent vulvovaginal candidiasis, candidal intestinal dysbiosis, fungi of the genus Candida, natamycin.
Chronic recurrent vulvovaginal candidiasis (CRVVC) is an important problem of modern medicine. The frequency of its occurrence, according to various authors, constitutes from 5 to 20% [1, 2].
The topicality of CRVVC problem is explained by frequent recurrence of the inflammatory process, development of complications, formation resistance of Candida fungi to antimycotic agents. Moreover, chronic recurrent development of VVC often complicates the course of pregnancy and can lead to early discharge of amniotic fluid, preterm delivery, development of candida infection in new-borns, development of ascending urogenital infection in mothers [3].
Chronic recurrent course of VVC can be favored by numerous factors, such as endocrinopa-thy (diabetes mellitus, underactive thyroid gland), pregnancy, long-term uncontrolled administration of broad-spectrum antibiotics, HIV infection and intake of immunosuppressors, administration of oral contraceptives and use of intrauterine devices, frequent syringing, wearing of tight synthetic under-clothes and use of daily pantyshields [3, 4, 5, 6, 7, 8]. As a rule, CRVVC is developed by combination of several factors.
According to one of the pathogenetic hypotheses, recurrence of VVC can be cause by the presence of Candida fungi in the intestine [1, 9, 10]. National and foreign literature do not cover the issues of combined candidal vaginal and intestinal disease fully enough.
Research objective: to analyze the relation of vaginal candidiasis (VC) and candidal intestinal dysbiosis (CID), to determine clinical peculiarities of the stated combined pathology, to study the species composition and sensitivity of Candida fungi isolated from the vagina and intestine to antimy-cotics, to determine the ways of rational approach to the therapy of such patients.
Materials and methods
The current research was conducted on the basis of the Center of urogenital infections of SBEI HPE Irkutsk State Medical University of the Ministry of Health of the Russian Federation in accordance with the World Medical Association Declaration of Helsinki on Biomedical Technologies, reviewed and approved by the Ethics Committee of SBEI HPE Irkutsk State Medical University of the Ministry of Health of the Russian Federation on 24.12.2012. There were obtained voluntary informed consents of patients to the study and treatment.
There were observed 150 women of reproductive age with diagnosed CRVVC with recurrence rate 4 and more per year. The age of women constituted from 16 to 50 years, the main age group were female patients from 20 to 40 years - 114 patients (the average age 30,5 ±3,5 years).
The study did not include pregnant women, patients with other urogenital infections, HIV-in-fected, patients receiving immunotherapy, women with severe somatic pathology.
All women were examined at the moment of disease exacerbation.
By the history taking there were considered complaints of patients connected with the urogenital and intestinal systems.
The material for laboratory research was gathered from the posterolateral vaginal fornix, fecal matter was also examined.
The culture of fungi was obtained by means of inoculation of Sabouraud's medium (made in Russia, Obolensk), the species of fungi was identified by means of chromogenic culture media HiMedia (India), the antimycotic sensitivity was determined by disk diffusion test to six drugs -nystatin, clotrimazole, fluconazole, amphotericin, itraconasole, ketoconazole.
The minimal concentration of the drug inhibiting the growth of Candida spp. fungi was determined by means of serial dilutions in solid media
according to the methodological recommendations "Determination of microorganism sensitivity to antibacterial preparations" [11]. The current research was performed in reference to two antimy-cptic-macrolides: natamycin and nystatin extracted from vaginal suppositories by means of successive exhaustive extraction of active substances from water solution by organic solvents. Further, there were used solutions for nystatin and natamycin at a dilution of 1:8 which corresponds to the amount
of active substance of one suppository. The initial concentration of active substances constituted: 125 mg/ml for nystatin, 100 mg/ml for natamycin [12, 13, 14]. Afterwards, there were prepared double serial dilutions of the drug from 1:10000 to 1: 320000, then there were introduced 1 ml of every dilution into the Petri dishes containing 4 ml of Sabouraud. The concentration of active substances in dilutions is presented in Table 1.
Table 1
Concentration of nystatin and natamycin in serial dilutions (mg/ml)
Medication 1 dilution 2 dilution 3 dilution 4 dilution 5 dilution 6 dilution
nystatin 125,00 62,50 31,25 15,63 7,81 3,90
natamycin 100,00 50,00 25,00 12,50 6,25 3,13
The procedure was conducted with one loop transmitting the medication from lesser concentration to bigger, dishes were left till the gelation of agar. Then the agar was inoculated by the studied culture and incubated at the temperature of 370C during 48 hours, after that there was determined the minimal concentration of medication inhibiting the growth of cultures by the lack of growth on dishes.
All patients were divided into two groups:
- first group, main, with combined CRVVC and candidal intestinal dysbiosis (CRVVC + CID), - 50 women with Candida fungi revealed in high titers (> 104 cfu/ml) from vagina and intestine;
- second group, comparison (CRVVC) - 100 women with Candida fungi revealed in high titers (> 104 cfu/ml) only from vagina, the titer of Candida fungi in the intestine corresponded to normal values - 104 cfu/ml and lower.
The results of examination of Candida spp. sensitivity to antimycotics became the basis for the development of rational treatment of CRVVC patients.
To reverse CRVVC exacerbation in patients of both groups there was used the polyene antimy-cotic - natamycin in the form of vaginal suppositories 100 mg (1 suppository) 1 time a day during 6 days.
The treatment of CID in patients of the 1 group included natamycin in the form of gastroresistant tablets 100 mg 91 pill) 4 times a day per os during 10 days.
Upon the end of treatment for CRVVC exacerbation there was prescribed the course of maintenance therapy continuing for 6 months.
Patients of the 1st group and 50 patients of the 2nd group (group 2a) received natamycin in the form of vaginal suppositories 100 mg 1 time a day during 3 days before the expected exacerbation monthly.
25 patients of the 2nd group (group 2b) received fluconazole 150 mg orally once a week.
25 patients of the 2nd group (group 2c) received clotrimazole in the form of vaginal tablet 500 mg once a week.
The statistical processing of the obtained results was performed by means of package of computer programs Primer of Biostatistics [15]. Differences of compared parameters were considered significant by p<0,05. The evaluation of statistical significance of differences of clinically compared groups was conducted by means of non-parametric MannWhitney U test, differences between the parameters were considered significant by p<0,05; Z-cri-terion, differences between the parameters were considered significant by p<0,05. Frequencies (%) for qualitative parameters were determined on the basis of contingency tables.
Results and discussion
The majority of patients of the 1st group were characterized by congestive hyperemia of external genital organs, moderate or expressed infiltration, numerous genital fissures. The inflammation was accompanied by moderate itching and burning. In patients of the 2nd group there were more often marked intense edematous hyperemia, excoriation, "crumbly" fur accompanied by intensive itching and burning (Table 2).
Anamnestic data of patients on the state of gastro-intestinal tract are presented in Table 3.
From the clinical point of view, conspicuous is the state of urogenital tract in women with combined CRVVC and CID during the disease recurrence: it was not characterized by expressed acute inflammatory component in contrast to the compared group. In the majority of patients there prevailed infiltration, congestive vaginal mucous membrane hyperemia, fissures, "creamy" secretions, itching and burning were moderately expressed. Moreover, the number and intensity of subjective and objective intestinal symptoms differed significantly from the comparison group:
in 32% of patients - loss of appetite, in 68% - abdominal discomfort and meteorism, in 74% - expressed flatulence. None of the patients of the stated group were characterized by normal stool: in 52% of women it was characterized by the changed consistency and increase of frequency up to 3 times a day, 48% had complaints about regular constipations con-
tinuing from 2 to 5 days. Undoubtedly, gathering of anamnesis in patients with CRVVC in relation to the state of GlT can afford the practicing physician ground for suspecting a particular pathology and targeted planning of examination and further rational treatment.
Table 2
Objective symptoms in women with CRVVC
Clinical symptoms CRVVC+CID CRVVC
n= 50 % n=100 %
congestive hyperemia + moderate infiltration + fissure + «creamy» fur 22 44 18 18*
Genital changes intense edematous hyperemia + excoriation + "crumbly" fur 5 10 43 43*
moderate hyperemia + single excoriations 20 40 32 32
no evidence 4 8 2 2
itching moderate 35 70 41 41*
subjective symp- intense 11 22 57 57
toms no evidence 21 42 5 5
burning moderate 19 38 57 57*
intense 10 20 38 38*
* - value for Mann-Whitney U test (significance of differences by the comparison of groups P<0,05)
Table 3
Intestinal changes in women with CRVVC
Changes CRVVC+CID CRVVC
n=50 % n=100 %
Appetite normal 34 68 97 97
reduced 16 32 3 3*
Flatulence 37 74 51 51*
Abdominal discomfort, meteorism 34 68 47 47*
formed once a day - - 69 69*
stool type constipations from 2 to 5 days 24 48 28 28*
loose stool 2-3 times a day 26 52 3 3*
* - z-criterion (significance of differences by the comparison of groups P<0,05)
The vaginal culture examination of patients of the 1st group showed: C. albicans - in 38 patients (in 76%), C. krusei - in 10 (in 20%), C. glabrata -in 2 (in 10%). The intestinal examination revealed in the 1st group revealed: C. albicans - in 35 (70%), C. krusei - in 11 (22%), C. glabrata - in 3 (6%), C. tropicalis - in 1 (2%). Moreover, in 43 (86%) women of the 1st group the fungi cultures from vagina and intestine were identical: C. albicans - in 33 (66%) patients, C. krusei - in 8 (16%), C. glabrata - in 2 (4%).
In three patients there was determined the combination C. albicans (vagina) + C. krusei (intestine), in two - C. krusei (vagina) + C. albicans (intestine), in one - C. albicans (vagina) + C. tropicalis (intes-
tine), in one - C. albicans (vagina) + C. glabrata (intestine).
The study of Candida spp. sensitivity to antimy-cotics isolated from the vagina of patients of the 1st group showed that 100% of C. albicans cultures were sensitive to nystatin, 68,4% - to fluconazole, 65,8% - to clotrimazole and itraconasole, 60,5% -to ketoconazole, 47,4% - to amphotericin B.
The study of Candida spp. sensitivity to anti-mycotics isolated from the intestine of patients of the 1st group showed that 100% of C. albicans cultures were sensitive to nystatin, 68,6% - to clo-trimazole, 65,7% - to itraconasole, 62,9% - to fluco-nazole, 60% - to ketoconazole, 48,6% - to amphoter-icin (Figure 1).
Figure 1.
Sensitivity of C. albicans cultures isolated from vagina and intestine to antimycotics (disk diffusion test)
All 10 C.krusei cultures isolated from the vagina and intestine of patients of the 1st group were sensitive to nystatin and resistant to fluconazole. 7 C.krusei cultures were sensitive to clotrimazole, 5 - to ketoconazole, 4 - to itraconasole, 2 - to am-photericin B. One C.glabrata culture was resistant
to fluconazole, second - to fluconazole, clotrima-zole and amphotericin B (Figure 2).
11 C.krusei cultures isolated from the intestine of patients of the 1st group were sensitive to ny-statin and resistant to fluconazole, 6 cultures were sensitive to clotrimazole, 3 - itraconasole, 5 - to ke-toconazole (Figure 2).
Figure 2.
Sensitivity of C. krusei cultures isolated from vagina and intestine to antimycotics (disk diffusion test)
C. tropicalis culture was sensitive to nystatin, clotrimazole, ketoconazole. One C. glabrata culture was resistant to fluconazole and ketoconazole, second - to fluconazole, ketoconazole, clotrimazole, third - to fluconazole, ketoconazole and amphotericin B.
The analysis of data presented in Figures 1 and 2 allows to state that the sensitivity of Candida fungi - both C.albicans and C.non-albicans, isolated from two locuses - vagina and intestine, is practically identical which gives the practicing physician
the opportunity to prescribe one antifungal drug for sanation of both locuses.
The fungi cultures isolated from the vagina of patients of the 2nd group were presented
in the following way: C. albicans - in 82 (82%) out of 100 patients, C. krusei - in 7 (7%), C. glabrata - in 11 (11%). Table 4 shows the results of study of Candida spp. fungi sensitivity.
Table 4
Sensitivity Candida spp. fungi isolated from the vagina of women of the 2nd group to antimycotics (abs./%)
Candida spp. nystatin fluconazole clotrimazole itraconasole ketoconazole amphotericin
C. albicans 82/100 54/65,9 63/: 76,8 51/62,2 49/59,8 47/57,3
C. krusei 7/100 - 6/8 5,7 2/28,6 2/28,6 6/85,7
C. glabrata 11/100 - 9/8 1,8 4/36,7 4/36,7 4/36,7
According to the study results, all Candida spp. fungi cultures isolated from women with CRVVC of both groups possessed the highest sensitivity to the polyene antimycotic - nystatin.
At the present time, there is available one more polyene drug - natamycin which is, according to the Federal Recommendations of RSDV 2013, recommended for VVC treatment.
The comparative analysis of minimal concentrations of nystatin and natamycin inhibiting the growth of Candida fungi (Tables 5, 6, 7) revealed that the majority of Candida spp. cultures isolated from vagina (65%) and intestine (80%) are mostly sensitive to the lowest concentrations of na-tamycin and 94, respectively, to high concentrations of nystatin.
Table 5
Minimal concentrations of nystatin and natamycin inhibiting the growth of Candida spp. isolated from the vagina of
women of the 1st group
Candida spp. (number of cultures) medication dilution (mg/ml)
1 dil. 2 dil. 3 d il. 4 dil. 5 dil. 6 dil.
nys. nat. nys. nat. nys. nat. nys. nat. nys. nat. nys. nat.
C. albicans (38) 22 - 13 - 1 6 2 16 1 14 - 2
C. krusei (10) 10 - - - - 5 - 3 - 1 - 1
C. glabrata (2) 1 - 1 - - 1 - 1 - - - -
Table 6
Minimal concentrations of nystatin and natamycin inhibiting the growth of Candida spp. isolated from the intestine of
women of the 1st group
Candida spp. (number of cultures) medication dilution (mg/ml)
1 dil. 2 dil. 3 dil 4 dil. 5 dil. 6 dil.
nys. nat. nys. nat. nys. nat. nys. nat. nys. nat. nys. nat.
C. albicans (35) 23 - 9 - 1 8 2 18 - 8 - 1
C. krusei (11) 9 - 2 - - 6 - 5 - - - -
C. glabrata (3) 1 - 2 - - 1 - 2 - - - -
C. tropica- lis (1) - - 1 - - - - - - 1 - -
Table 7
Minimal concentrations of nystatin and natamycin inhibiting the growth of Candida spp. isolated from the vagina of women of the 2nd group
Candida spp. (number of cultures) medication dilution (mg/ml)
1 dil. 2 dil. 3 dil. 4 dil. 5 dil. 6 dil.
nys. nat. nys. nat. nys. nat. nys. nat. nys. nat. nys. nat.
С. albicans (82) 37 - 40 - 5 4 - 41 - 22 - 15
C. krusei (7) 6 - 1 - - 2 - 3 - 2 - -
C. glabrata (11) 8 - 3 - - 1 - 8 - 2 - -
The results of our microbiological study allowed us to choose natamycin as an etiotropic medication both for the treatment of CRVVC recurrence and long-term maintenance therapy.
After the course of CRVVC recurrence therapy the clinical recovery was observed in all (100%) patients of both groups. The culture study was performed in 10 days after the termination of therapy. According to its results, in 86% of patients the growth of fungi in the vagina was not registered, in 24% of women the titer of Candida fungi constituted less than 103 cfu/ml. According to the culture study of the intestinal material of 1st group patients receiving oral gastroresistant tablets in addition to vaginal suppositories of natamy-
Conclusion
Consequently, by combined candida disease of vagina and intestine in women with CRVVC, the microbiota of both locuses is prevailed by C.al-bicans fungi, respectively: 76% - in the vagina, 70% - in the intestine; C. non-albicans fungi - 24% - in the vagina, 30% - in the intestine. In 86% of patients Candida fungi cultures isolated from vagina and intestine were identical.
In our opinion, by history taking, the practicing physician should specificate possible changes in patients with CRVVC connected with intestine. The obtained data can considerably simplify the pathogenic diagnosis, and, thus, to improve the approach to CRVVC recurrence treatment.
Our microbiological researches showed the highest sensitivity of Candida fungi (albicans and non-albicans) to natamycin which became the ground for prescribing the given drug to patients with CRVVC recurrence with not only dam-
cin, the growth of fungi was not observed in 100% of patients.
After the course of maintenance therapy with natamycin, the CRVVC recurrence developed in 1 woman of the 1st group and 1 woman of the 2a group, which was determined by the noncompli-ance of drug therapy. The effectiveness of maintenance therapy with natamycin constituted 98%.
After the course of maintenance therapy, in 6 patients receiving fluconazole orally and 5 patients receiving clotrimazole intravaginally there developed the clinical picture of CRVVC recurrence, while the titer of fungi in the vagina was > 104 cfu/ ml. The natamycin treatment, in comparison to fluconazole (p = 0,008) and clotrimazole (p = 0,024) treatment, turned out to be more effective (Table 8).
aged urogenital tract (intravaginally), but also to patients with combined vaginal candidiasis with candidal intestinal dysbiosys (intravaginal-ly and orally), and also for maintenance 6-month therapy of CRVVC (intravaginally).
The effectiveness of the suggested approach to treatment of women with combined CRVVC and CID constituted: after the main therapy course - 100%, after the maintenance therapy course -98%. the suggested approach treatment of women with combined CRVVC and CID can be recommended for use by dermatovenerologists and obstetrician-gynaecologists.
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Table 8
The effectiveness of maintenance therapy by CRVVC in women
Medications 1st group natamycin (n=50) 2a group natamycin n=50 2b group fluconazole n=25 2c group clotrimazole n=25 Criterion P 1, 2а - 2b Criterion P 1, 2а - 2c
Rate of recovery 0,98 0,98 0,76 0,8 0,008 0,024
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Contacts:
Corresponding author - Malova Irina Olegov-na, Doctore of Medical Sciences, Professor, Head of the Department of dermatovenerology of the Advanced Training Faculty and teaching stuff of Irkutsk State Medical Universit, Irkutsk. 664025, Irkutsk, Rossiyskaya Ulitsa, 16. Tel.: (3952) 242313. Email: marinakartina@mail.ru
