ACTIVITY 18

FUNGAL INFECTIONS
 AGENTS THAT
CAUSES VAGINOSIS
 BACTERIAL VAGINOSIS
✔ This most common cause of vaginitis results from
a change of the normal bacteria found in your
vagina, to overgrowth of one of several other
organisms.
✔ Usually, bacteria normally found in the vagina
(lactobacilli) are outnumbered by other bacteria
(anaerobes) in your vagina.
✔ If anaerobic bacteria become too numerous, they
upset the balance, causing bacterial vaginosis.
 YEAST INFECTIONS
✔ These occur when there's an overgrowth of a
fungal organism — usually C. albicans — in your
vagina.
✔ C. albicans also causes infections in other moist
areas of your body, such as in your mouth (thrush),
skin folds and nail beds.
✔ The fungus can also cause diaper rash.
 TRICHOMONIASIS
✔ This common sexually transmitted infection is
caused by a microscopic, one-celled parasite called
Trichomonas vaginalis. This organism spreads during
sexual intercourse with someone who has the
infection.
✔In men, the organism usually infects the urinary tract,
but often it causes no symptoms. In women,
trichomoniasis typically infects the vagina, and might
cause symptoms. It also increases a women's risk of
getting other sexually transmitted infections.
 NON INFECTIOUS VAGINITIS
✔ Vaginal sprays, douches, perfumed soaps,
scented detergents and spermicidal
products may cause an allergic reaction or
irritate vulvar and vaginal tissues.
✔ Foreign objects, such as tissue paper or
forgotten tampons, in the vagina can also
irritate vaginal tissues.
 VAGINAL ATROPHY
✔ Reduced estrogen levels after menopause
or surgical removal of your ovaries can
cause the vaginal lining to thin, sometimes
resulting in vaginal irritation, burning and
dryness.
 DIAGNOSTIC
PROCEDURES
FOR VAGINOSIS
 WET MOUNT
✔ A sample of vaginal discharge is checked
for bacteria, white blood cells, and unusual
cells called clue cells.
✔ If clue cells are found, it means you may
have bacterial vaginosis.
 WHIFF TEST
✔ A sample of discharge is checked to see if
a strong fishy odor is created when a
special solution is added.
✔ A fishy odor usually means you have
bacterial vaginosis.
 VAGINAL pH
✔ The pH of a sample of vaginal discharge is
measured.
✔ Bacterial vaginosis often causes a pH that
is higher than normal.
 MOLECULE TEST
✔ A sample of vaginal discharge is tested for
the genetic material, or DNA, of this
bacteria.
 SOURCES OF
ORGANISMS FOR
VAGINOSIS
 BACTERIAL VAGINOSIS
✔ It is the most common cause of vaginitis, accounting
for 50% of cases.
✔ As previously mentioned, bacterial vaginosis is
caused by an overgrowth of organisms such as
Gardnerella vaginalis (a gram-variable coccobacillus),
Mobiluncus species, Mycoplasma hominis, and
Peptostreptococcus species.
✔ Risk factors include pregnancy, intrauterine device
(IUD) use, and frequent douching.
 CANDIDA SPECIES
✔ It includes C albicans, C tropicalis, and C glabrata) are
airborne fungi that are natural inhabitants of the vagina in as
many as 50% of women.
✔ Vaginal candidiasis is the second most common cause of
vaginitis. In 85-90% of cases, it is caused by C albicans, and
in 5-10%, it is caused by C glabrata or C parapsilosis.
✔ Risk factors include oral contraceptive use, IUD use, young
age at first intercourse, increased frequency of intercourse,
receptive cunnilingus, diabetes, HIV or other
immunocompromised states, long-term antibiotic use, and
pregnancy.
 T. VAGINALIS INFECTION
✔ The third most common cause of vaginitis, is caused by
trichomonads. T vaginalis is an oval-shaped or fusiform-
shaped flagellated protozoan that is 15 μm long (the size of a
leukocyte).
✔ These organisms primarily infect vaginal epithelium; less
commonly, they infect the endocervix, urethra, and Bartholin
and Skene glands. Trichomonads are transmitted sexually
and can be identified in as many as 80% of male partners of
infected women.
✔ Risk factors include tobacco use, unprotected intercourse
with multiple sexual partners, and the use of an IUD.
VIRULENT
FACTORS
✔ Colonization is aided by the ability of Candida
to adhere to mucosal surfaces.
✔ Overgrowth of Candida may be facilitated by
high estrogen levels particularly in pregnancy.
✔ Normally, other flora (bacteria) resident on
mucosal surfaces prevent uncontrolled
proliferation by Candida, high population density
and subsequent disease are facilitated by
suppression of normal flora by antibacterial
agents, such as ampicillin treatment in our
patient.
✔ Pseudohyphae bind to components of the
extracellular matrix; proteinases help in invasion and
adherence.
✔ High sugars in diabetics enhance production of
surface adherence proteins such as mannoproteins
of the outer febrile surface of Candida.
✔ Disruptions of skin and mucosal surfaces expose
components of the ECM to which Candida can bind.
Corticosteroids and depressed T cell immunity also
predispose to local and invasive disease.
 HUMAN
DEFENSES
✔ Candida albicans is the most important fungal pathogen in
humans, and it causes both mucosal and systemic fungal
infections.
✔ Innate immune recognition by pattern recognition receptors
(PRRs) is the first step for activation of host defence
mechanisms during Candida infections. C-type lectin receptors
(CLRs) are the main family of PRRs involved in recognition of
Candida species, but Toll-like receptors, NOD-like receptors and
RIG-I-like receptors are also involved in the antifungal response.
✔ Neutrophils, monocytes and macrophages are the main
immune cell populations responsible for host defence against
systemic candidiasis, whereas T helper 1 (TH1) cells, TH17 cells
and innate lymphoid cells are mainly responsible for protection
against Candida infections at mucosal surfaces.
✔ C. albicans and components from its cell wall, particularly
β-glucans, have the capacity to induce epigenetic
reprogramming of innate immune cells, generating a de facto
innate immune memory that has been termed 'trained
immunity.
✔ The vaginal environment is a common site of infections,
including Trichomonas and Candida vaginitis, bacterial
vaginosis and many others. This site is defended by a
number of innate immune mechanisms. Epithelial cells, as
well as dendritic cells, recognize pathogens via TLRs, and
respond to this stimulation by producing antimicrobial
peptides as well as chemokines to recruit neutrophils to the
site of infection.
✔ The generally poor adaptive immune responses
observed during vaginal infections likely underlie
the chronic and recurrent nature of many of these
infections.
✔ Finding ways to stimulate an adaptive immune
response and generate immunity to vaginal
pathogens is an important area of research.
✔ Importantly, the vaginal mucosa must retain the
capacity to respond to pathogens while tolerating
the normal flora at this site, largely consisting of
Lactobacillus spp.
✔ The tolerance to normal flora established at
this site may also contribute to poor
immunoresponsiveness.
✔ Lastly, the normal flora itself can be viewed as
an innate immune defense, by competing with
pathogens and generation of an acidic vaginal
pH and hydrogen peroxide.
✔ Accordingly, replenishment of vaginal flora with
probiotic Lactobacillus is being examined as a
therapeutic and preventative strategy.
TREATMENT
OPTIONS
✔ Topical clotrimazole, miconazole, tioconazole,
butoconazole, econazole, terconazole,
fenticonazole, nystatin.
✔ Oral ketoconazole, itraconazole and
fluconazole.
✔ Bacterial vaginosis- metronidazole (Flagyl)
tablets that you take by mouth or metronidazole
(MetroGel) gel or clindamycin (Cleocin) cream
that you apply to your vagina.
✔ Yeast infections usually are treated with an
OTC antifungal cream or suppository, such as
miconazole (Monistat 1), clotrimazole,
butoconazole or tioconazole (Vagistat-1). Yeast
infections may also be treated with a prescription
oral antifungal medication, such as fluconazole
(Diflucan).
✔ The advantages of OTC treatment are
convenience, cost and not waiting to see your
doctor.
✔ Trichomoniasis. Your doctor may prescribe
metronidazole (Flagyl) or tinidazole (Tindamax)
tablets.
✔ Genitourinary syndrome of menopause
(vaginal atrophy). Estrogen — in the form of
vaginal creams, tablets or rings — can
effectively treat this condition. This treatment is
available by prescription from your doctor, after
other risk factors and possible complications are
reviewed.
✔ Noninfectious vaginitis. To treat this type of
vaginitis, you need to pinpoint the source of the
irritation and avoid it. Possible sources include
new soap, laundry detergent, sanitary napkins or
tampons.
 CLINICAL
MANIFESTATIONS
Vaginitis signs and symptoms can include:
✔ Change in color, odor or amount of discharge
from your vagina
✔ Vaginal itching or irritation
✔ Pain during intercourse
✔ Painful urination
✔ Light vaginal bleeding or spotting
✔ Bacterial vaginosis. You might develop a
grayish-white, foul-smelling discharge. The odor,
often described as a fishy odor, might be more
obvious after sexual intercourse.
✔ Yeast infection. The main symptom is itching,
but you might have a white, thick discharge that
resembles cottage cheese.
✔ Trichomoniasis: greenish-yellow, sometimes
frothy discharge.
OTHER CANDIDA
SPECIES
 C glabrata and C albicans
✔ These account for approximately 70%-80% of
Candida species recovered from patients with
candidemia or invasive candidiasis. C glabrata
has recently become very important because of
its increasing incidence worldwide, its
association with fluconazole resistance in up to
20% of clinical specimens, and its overall
decreased susceptibility to other azoles and
polyenes.
 C. krusei
✔ It is important because of its intrinsic
resistance to ketoconazole and fluconazole
(Diflucan); it is also less susceptible to all other
antifungals, including itraconazole (Sporanox)
and amphotericin B.
 C. lusitaniae
✔ Another important Candida species although
not as common as other Candida species, C
lusitaniae is of clinical significance because it
may be intrinsically resistant to amphotericin B,
although it remains susceptible to azoles and
echinocandins.
 C. parapsilosis
✔ It is also an important species to consider in
hospitalized patients. It is especially common in
infections associated with vascular catheters
prosthetic devices. Additionally, in vitro analyses
have shown that echinocandins have a higher
minimum inhibitory concentration (MIC) against
C parapsilosis than other Candida species.
✔ The clinical relevance of this in vitro finding has
yet to be determined.
 C. tropicalis
✔ This has frequently been considered an
important cause of candidemia in patients with
cancer (leukemia) and in those who have
undergone bone marrow transplantation.
 C. tropicalis
✔ It is a globally emerging invasive Candida
species that is associated with a high mortality
rate and that is often resistant to multiple
antifungal drugs.
Health teaching for
fungal infections
 HEALTH TEACHINGS
✔ Good hygiene is also critical for avoiding fungal infections.
✔ Try to: keep your skin clean and dry, particularly the folds of
your skin
✔ Wash your hands often, especially after touching animals or
other people
✔ Avoid using other people’s towels and other personal care
products
✔ Wear shoes in locker rooms, community showers, and
swimming pools
✔ Wipe gym equipment before and after using it.