Journal of Medical and Dental Science Research

Volume 10~ Issue 12 (2023) pp: 09 - 16

ISSN(Online): 2394-076X ISSN (Print):2394-0751

Research Paper

Fluconazole Susceptibility pattern of Candida species among Pregnant

Women in a Tertiary Healthcare Centre in Southern Nigeria

*Okoli, D.C,1 Obunge O.K,1 Ogboma HAA,2 Wariso KT,1 Oboro IL3

1
Department of Medical Microbiology, University of Port Harcourt Teaching Hospital, Rivers State, Nigeria
2
Department of Obstetrics and Gynaecology, University of Port Harcourt Teaching Hospital, Rivers State, Nigeria
3
Department of Medical Microbiology, College of Health Sciences, Rivers State University, Rivers State, Nigeria
*corresponding author:docchizzy@yahoo.com
ABSTRACT
In recent years, the prevalence of fungal infections has been on the rise, particularly among vulnerable
populations such as pregnant women. Pregnant women are inherently more susceptible to various infections,
and Candida species represent a substantial threat to their well-being. The current study assessed the
fluconazole susceptibility pattern of Candida species in pregnant women within a tertiary healthcare center. A
total of 323 pregnant women presenting at the University of Port Harcourt Teaching hospital were recruited
for the study. Vaginal swabs were collected from women presenting with abnormal vaginal discharge and
assessed for the presence of Candida spp growth according to standard microbiological culture and
microscopic techniques. Antifungal susceptibility to fluconazole was performed on all candida isolates using
modified Kirby-Bauer disc diffusion technique as outlined in the CLSI M44-A2 documents for disc diffusion
susceptibility testing. The results showed a 57.3% prevalence of Candida spp growth among the study subjects.
Candida albicans (73.5%) was the most occurring followed by C. glabrata (13.0%), C. krusei (7.6%), C.
tropicals (2.7%), C. parapsilosis (2.2%) and C. geotrichum (1.1%). The resistant patterns of C. glabrata, C.
krusei and C. geotrichum, to fluconazole were significantly higher (Fischer’s exact = 0.0036) compared to
other Candida species identified among the pregnant women selected for the study. Based on these findings,
it is recommended that clinicians adopt individualized treatment plans, considering the specific Candida
species identified in each case. The implementation and strengthening of antifungal stewardship programs are
crucial for monitoring and managing resistance patterns, allowing for timely adjustments to treatment
guidelines.

Keywords: Fluconazole, Candida species, Susceptibility pattern, Pregnant women

1.0 INTRODUCTION
Vulvovaginal candidiasis (VVC) is a fungal or yeast infection affecting the lower female genital tract and vulva,
caused by Candida species.1,2 This opportunistic infection often arises from an overgrowth of the normal flora
and tends to recur or relapse in numerous patients. Approximately 75% of women experience this well-known
gynaecologic condition at some point in their lives, with a higher frequency during pregnancy due to elevated
concentrations of glycogen and estrogen in vaginal secretions. Moreover, vulvovaginal candidiasis is also
common among women in their childbearing years. 3–5
In recent years, the prevalence of fungal infections has been on the rise, particularly among vulnerable populations
such as pregnant women.6–8 Candida species, known for causing various infections, pose a significant threat to

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the health of expectant mothers. Among the antifungal agents available, fluconazole is commonly used to treat
Candida infections.6,9,10
Pregnant women are inherently more susceptible to various infections, and Candida species represent a substantial
threat to their well-being. Fluconazole, a widely used antifungal agent, has been effective in treating Candida
infections; however, concerns regarding its safety during pregnancy have prompted the exploration of
susceptibility patterns in this specific demographic.11,12 The problem at hand lies in the limited understanding of
the fluconazole susceptibility profile of Candida species in pregnant women within the context of a tertiary
healthcare center in Nigeria. This knowledge gap hinders the development of targeted and safe antifungal
treatment protocols for this vulnerable population. Hence, investigating the fluconazole susceptibility pattern
becomes imperative for ensuring optimal maternal and fetal health outcomes during pregnancy. However,
understanding the susceptibility pattern of Candida species to fluconazole is crucial for optimizing treatment
strategies, especially in the context of pregnant women. This study assesed the fluconazole susceptibility pattern
of Candida species in pregnant women within a tertiary healthcare center.
2.0 METHODS
2.1 Study Area
This study was carried out in the Department of Medical Microbiology/Parasitology and the Antenatal Clinic of
the University of Port Harcourt Teaching Hospital, Rivers State. The hospital is an 800-bed capacity hospital and
serves as a referral center for other healthcare institutions within Rivers state and neighboring states. The hospital
provides access to general and specialist care for a large proportion of the over 5 million residents of Rivers
state13.
2.2 Study Population
The study population comprised of consenting pregnant women receiving antenatal care in the department of
Obstetrics and Gynaecology in the University of Port Harcourt Teaching Hospital. A sample size of 323 was
calculated based on the sample size for proportions formula n = z2pq/e2 as stated by Kirkwood et al., 14 where z
= 1.96 (standard derivate at a 95% confidence interval), p= 30% (prevalence of vulvovaginal candidiasis reported
in a previous study)15, q = 1 – p and e = 5% (estimated error rate at a 95% confidence interval). The 323 study
participants were selected by systematic random sampling and recruited for the study.
2.3 Specimen Collection and analysis
Two high vaginal swabs were collected from each participant one after the other by inserting a sterile disposable
Cusco’s vaginal speculum into the vagina, with the patient lying supine and comfortably and the sterile cotton
swab was inserted into the posterior vaginal fornix and rotated gently before withdrawing. 16
The first swab was inoculated immediately into Sabouraud dextrose agar containing chloramphenicol (0.05g/L)
and incubated for 16-18 hours. Wet mount preparation and Gram stain was performed for the second swab and
examined under a light microscope using the x40 and x100 objectives of the microscope respectively. 16
The culture plate was incubated at 37oC for 48hours.16 Colony morphology and colour on CHROMagar candida
was noted thereafter. Mixed cultures were identified by their differential colour appearance on CHROMagar
candida and separated by subculturing each representative colony type onto individual Sabouraud dextrose agar
slants.17,18 Antifungal susceptibility to fluconazole was performed on all candida isolates using modified Kirby-
Bauer disc diffusion technique as outlined in the CLSI M44-A2 documents for disc diffusion susceptibility
testing.18 Quality control strains of Candida albicans and C. parapsilosis was used to test each batch of
CHROMagar Candida to be used for the study.

2.4 Data Collection

A structured PROFORMA data collection sheet was used to collect demographic information and clinical history
from each study participant.

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2.5 Data Analysis
The clinical and laboratory data were analyzed using the SPSS version 25 computer software. Frequency tables
were used to present data. Chi square test were used to test the association between categorical variables. For
variables with frequencies less than 5 in any category, Fischer’s exact test was used. Logistic regression was used
to assess the risk factors for Candida infection among the participants. All tests were done at a 95% confidence
interval and a p-value less than 0.05 was considered significant.

2.6 Ethical consideration

Ethical clearance was obtained from the institutional ethics committee before commencement of patient
recruitment. Informed written consent was obtained from study participants after adequate explanation of the
study and its objectives. Participation was voluntary and at no extra cost to the patients.

3.0 RESULTS
Table 1 shows the demographic data of the subjects, 123 (38.0%) were between 19 – 29 years old, 184 (57.0%)
were between 30 – 39 years old and 16 (5.0%) were between 40 – 49 years old. Only 6 (1.9%) were single and
317 (98.1%) were married. Among the subjects, 3 (0.9%) had primary education, 60 (18.6%) had secondary
education and 260 (80.5%) had tertiary education.

Table 1 Sociodemographic Data of participants

Frequency (n=323) Percent (%)
Age-groups
19 - 29 years 123 38.0
30 - 39 years 184 57.0
40 - 49 years 16 5.0
Marital Status
Single 6 1.9
Married 317 98.1
Education
Primary 3 0.9
Secondary 60 18.6
Tertiary 260 80.5

Figure 1 shows there is 57.3% prevalence of Candida spp growth among the study subjects.

Positive
Negative

138, 42.7%
185, 57.3%

Figure 1: Prevalence of Candida sp infection among participants

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Figure 2 shows the distribution of the 185 Candida spp isolated from the subjects. Candida albicans (73.5%) was
the most occurring Candida spp followed by C. glabrata (13.0%), C. krusei (7.6%), C. tropicals (2.7%), C.
parapsilosis (2.2%) and C. geotrichum (1.1%).

136
140

120

100
Frequency (n)

80

60

40
24
14
20 5 4 2
0
C. albicans C. glabrata C. krusei C. tropicals C. C.
parapsilosis geotrichum
Candida Isolates
Figure 2: Distribution of Candida species

Table 2 outlines the susceptibility patterns of various Candida species to fluconazole, C. albicans exhibited
sensitivity in 27.9% (38 cases) and resistance in 72.1% (98 cases) out of a total of 136 cases. Moving to C. glabrata,
none of the cases were sensitive (0.0%), with all 24 cases demonstrating resistance (100.0%). Similarly, C. krusei
displayed complete resistance (100.0%) with zero cases showing sensitivity. C. tropicalis revealed no sensitivity
(0.0%) and complete resistance in all 5 cases (100.0%), accompanied by a statistically significant association
indicated by a Fischer’s Exact p-value of 0.0036. In the case of C. parapsilosis, sensitivity was observed in 50.0%
(2 cases), and the same percentage was noted for resistance. C. geotrichum, on the other hand, demonstrated
complete resistance (100.0%) with zero cases exhibiting sensitivity. Overall, the comprehensive analysis shows
that out of 185 cases, 21.6% (40 cases) were sensitive, while 78.4% (145 cases) were resistant across all Candida
species. The table indicates that the resistant patterns of C. glabrata, C. krusei and C. geotrichum, to fluconazole
were significantly higher (Fischer’s exact = 0.0036) compared to other Candida species identified among the
pregnant women selected for the study.

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 Table 2: Antifungal susceptibility profile to fluconazole

Sensitive Resistant Total Fischer’s

Species n (%) n (%) n (%) Exact
C. albicans 38 (27.9) 98 (72.1) 136 (100.0)
C. glabrata 0 (0.0) 24 (100.0) 24 (100.0)
C. krusei 0 (0.0) 14 (100.0) 14 (100.0)
C. tropicals 0 (0.0) 5 (100.0) 5 (100.0) 0.0036
C. parapsilosis 2 (50.0) 2 (50.0) 4 (100.0)
C. geotrichum 0 (0.0) 2 (100.0) 2 (100.0)

Total 40 (21.6) 145 (78.4) 185(100.0)

4.0 DISCUSSION
The elevated resistance patterns of C. glabrata, C. krusei, and C. geotrichum to fluconazole, as indicated by the
statistically significant as shown in the current study, have notable clinical and public health implications. From
a clinical perspective, the findings underscore the need for alternative treatment strategies, as the conventional use
of fluconazole may prove less effective against infections caused by these specific Candida species. Clinicians
should consider individualized treatment plans, accounting for the identified resistance, to optimize therapeutic
outcomes and minimize the risk of recurrent or persistent infections.
In the current study, C. albicans displayed a sensitivity rate of 27.9% and a resistance rate of 72.1%, contrasting
with Emmanuel et al's19 study where 15.48% of C. albicans isolates were resistant to fluconazole. This discrepancy
indicates that the prevalence of fluconazole resistance among C. albicans strains differs between the two studies.
Furthermore, the current study highlights high resistance rates for C. glabrata, C. krusei, and C. geotrichum, all
reaching 100%. In contrast, Emmanuel et al's19 study carried out in southwest Nigeria does not provide
information on the susceptibility patterns of these specific Candida species to fluconazole. This discrepancy
underscores the importance of considering regional and population-specific variations in antifungal susceptibility.
Moreover, the observed resistance patterns necessitate ongoing monitoring and surveillance of antifungal
resistance within the local population. This proactive approach allows healthcare providers to adapt treatment
guidelines promptly, ensuring that they remain aligned with emerging resistance trends. The clinical implications
stress the importance of judicious antifungal use and the implementation of antifungal stewardship programs to
prevent the further development and dissemination of resistance, preserving the efficacy of available antifungal
medications.
Upon comparing the outcomes of the presented table with the research conducted by Ikenyi et al, 20 notable
differences and similarities emerge. In our study, 57.3% of pregnant women were found to have Candida isolates,
a proportion higher than the 48.5% reported by Ikenyi et al. 20 This variance may be attributed to factors such as
differences in sample sizes, geographic locations, or the specific demographics studied.
Regarding the distribution of Candida species, isolated in the current study. In contrast, Ikenyi et al identified
Candida albicans, Candida glabrata, Candida tropicalis, Candida parapsilopsis, and Candida famata. While
there is some overlap, the specific species identified in each study differ, underscoring the diversity of Candida
species across populations. Notably, our study reveals a significant resistance rate of 78.4% to fluconazole,
whereas Ikenyi et al reported a higher susceptibility rate, with 88.9% of isolates being susceptible. This

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discrepancy emphasizes potential variations in fluconazole susceptibility among different populations,
highlighting the influence of regional factors on antifungal resistance. 12,21,22
On a broader public health scale, initiatives should be directed toward preventive measures. Education and
awareness campaigns targeting both pregnant women and healthcare providers can play a crucial role in
emphasizing hygiene practices, encouraging early symptom detection, and promoting prompt reporting. 5,6 These
efforts collectively contribute to reducing the overall burden of Candida infections and their associated
complications during pregnancy. Additionally, the identified resistance patterns highlight the imperative for
continued research and development of new antifungal agents. 8,10 Investing in innovative treatment options is
essential to address the evolving challenges posed by resistant Candida species and to ensure a diverse and
effective array of therapeutic interventions. In essence, addressing these clinical and public health implications is
paramount for improving patient outcomes, enhancing treatment strategies, and advancing the control of fungal
infections, particularly in the unique context of pregnancy. 2,23

5.0 CONCLUSION
The diversity in species distribution and resistance rates underscores the intricate nature of Candida infections in
this demographic. Additionally, the statistically significant association between C. tropicalis and fluconazole
resistance adds complexity to our understanding. Based on these findings, it is recommended that clinicians adopt
individualized treatment plans, considering the specific Candida species identified in each case. The
implementation and strengthening of antifungal stewardship programs are crucial for monitoring and managing
resistance patterns, allowing for timely adjustments to treatment guidelines. Continued research into novel
antifungal agents and therapeutic strategies is essential to address the emerging challenge of resistance,
particularly in species with high resistance rates. Public health initiatives should prioritize raising awareness
among pregnant women and healthcare providers about the risk factors, symptoms, and preventive measures for
Candida infections. Collaborative efforts with other healthcare centers and research institutions can provide a
broader perspective on Candida susceptibility patterns in diverse populations, contributing to a more
comprehensive understanding of the issue. By implementing these recommendations, the clinical management of
Candida infections in pregnant women can be enhanced, mitigating the risk of resistance and contributing to the
development of effective and targeted antifungal strategies.
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