The socio-demographic characteristics of 165 respondents are summarized in Table 1; 49% of women who participated were between the ages of 36 to 40 years old. The majority completed their university degree (62.4%). The rate of normal vaginal delivery was 43.6% and 69.7% of women had labor induction. Gestational complications occurred in 59.1% of women and 25.5% of women had gestational diabetes mellitus. Anemia was reported in 14.5% of women.
Table 1: Socio-demographic characteristics of 165 respondents
Age group
|
20-25 years
|
19 (11.5%)
|
26-30 years
|
14 (8.5%)
|
30-36 years
|
49 (29.7%)
|
36-40 years
|
81 (49.1%)
|
≥41 years
|
2 (1.2%)
|
Education status
|
Primary
|
32 (19.4%)
|
Secondary
|
30 (18.2%)
|
University
|
103 (62.4%)
|
Delivery type
|
Normal
|
72 (43.6%)
|
Cesarean section
|
24 (14.5%)
|
Missing
|
69 (41.8%)
|
Induced labor
|
Yes
|
50 (30.3%)
|
No
|
115 (69.7%)
|
Recurrent UTI
|
Yes
|
4 (2.4%)
|
No
|
161 (97.6%)
|
Gestational complications
|
Yes
|
97 (59.1%)
|
No
|
67 (40.9%)
|
Missing
|
1 (0.6%)
|
Gestational diabetes mellitus
|
Yes
|
42 (25.5%)
|
No
|
123 (74.5%)
|
Anemia
|
Yes
|
24 (14.5%)
|
No
|
141 (85.5%)
|
The data presented in the table are number (%) of patients. Missing are missing data since patients’ information were not provided; those were excluded from the analysis. Gestational complications include intrahepatic cholestasis, mitral valve prolapse, asthma, hypothyroidism, oligohydramnios and gestational thrombocytopenia.
Among the cultures from the 258 women tested, 100 (39%) were positive for Candida species.'
C. albicans was isolated from 42% of the women (N=42) and NCAC from the remaining 58%. Figure 1 summarizes the distribution of Candida species isolated from vaginal swabs from population-based studies conducted in different countries including our study over the last decade. China, Brazil, Tunis, Kuwait, India, Greece and Turkey have reported that C. albicans remains the most commonly isolated yeast (60%-80%) in women diagnosed with VVC [21-27]. On the other hand, an increasing trend in the occurrence of NCAC (58%-60%) over time has also been observed in Pakistan and Burkina Faso [28, 29]. The main identified NCAC in our study were C. glabrata (71%, N=41) followed by C. krusei (29%, N=17). Four women were co-infected with both C. albicans and C. glabrata. All of the three identified Candida species were isolated from women in the age group 30-40 years.
The observed susceptibility rates of C. albicans isolates to AMB, FCZ, ICZ and VCZ were 97.5%, 90%, 87.5% and 97.5%, respectively. MIC50 and MIC90 of the antifungal agents tested against 40 strains of C. albicans are presented in Table 2. Two of the isolates were lost during processing, Although ICZ presented the lowest MIC90 value of 0.125 µg/mL, it showed highest resistance rate (12.5%) among all the agents tested.
Table 2: Ranges of MICs, MIC50 and MIC90 and percentage resistance in 40 C. albicans isolates
Antifungal drugs
|
MIC 50
|
MIC 90
|
MIC Range
|
Percentage resistance
|
Amphotericin B
|
0.5
|
1
|
0.38- 3.00
|
2.5%
|
Fluconazole
|
2
|
6
|
0.047-32
|
10.0%
|
Itraconazole
|
0.125
|
0.125
|
0.032-32
|
12.5%
|
Voriconazole
|
0.094
|
1
|
0.032- 256
|
2.5%
|
MIC50 = Minimum Inhibitory Concentration required to inhibit the growth of 50% of organisms. MIC90 = Minimum Inhibitory Concentration required to inhibit the growth of 90% of organisms. MIC range is the range of the lowest and highest MIC values obtained from 40 C. albicans isolates tested. Percentage resistance is the percentage of isolates resistant to a specific antifungal drug
The association between the presence of Candida species, isolated from 48 women who filled the questionnaire, was assessed with preterm delivery, delivery type, gestational complications, gestational diabetes, recurrent UTI infection and induced labor (Table 3). C. albicans was significantly associated only with patients with gestational diabetes; 33% of C. albicans positive and 24% of NCAC participants had gestational diabetes (p=0.04). C. albicans had non-significant associations with gestational complications, induced labor and recurrent UTI. On the other hand, the presence of C. krusei and C. glabrata had strong significant association with premature delivery and gestational complications (p<0.05): 94% of women with C. glabrata and 71.4% of women with C. krusei had gestational complications compared to 28.4% and 29.7% of women who did not have C. glabrata and C. krusei respectively (p-value ≤0.001). No significant associations were observed between the isolated Candida species and induced labor or recurrent UTI (Table 3) .
Results of the three multiple regression models with neonatal outcomes (weight, height and Apgar score) as dependent variables are displayed in Table 4. Results revealed significant positive association between delivery time and neonatal height and significant negative association between C-section and height. Height increased 0.41 centimeter with one week increase in delivery time (p=0.001) and decreased 0.46 centimeter with C-section (p=0.002). Height also decreased with the presence of all identified Candida species. This reduction was statistically significant in both C. krusei or C. glabrata infections (Beta=-0.46, p=0.05 for C. albicans and Beta=-0.77; p=0.006). The other covariates did not yield significant associations with height. Neonatal weight had significant positive association with delivery time and significant negative association with C-section. There was 0.32g increase in weight with an additional delivery week (p=0.01) and 0.34g decrease in weight with C-section (p=0.02). Although weight decreased with the presence of Candida species (C. albicans: Beta=0.16, C. krusei or C. glabrata: Beta=0.43), this reduction was not statistically significant. The other covariates did not yield significant associations with weight. Apgar score did not show significant correlation with the presence of any Candida species or with any of the other independent variables.
Table 3 : Association between candida species isolated from vaginal swabs of pregnant women and various clinical outcomes (n=165).
|
Delivery week (preterm delivery)
|
Delivery Type
(C-section)
|
Gestational
Diabetes
n (%)
|
Gestational
Complications
n (%)
|
Induced
Labor
n (%)
|
Recurrent
urinary track
infection
n (%)
|
C. albicans
|
Yes n=24
|
15 (62.5%)
|
p=0.57
|
5 (20.1%)
|
p=0.76
|
8 (33.3%)
|
p=0.04
|
10 (41.7%)
|
p= 0.93
|
8 (33.3%)
|
p=0.72
|
1 (4.2%)
|
p=0.55
|
No
n=141
|
72 (51.1%)
|
19 (13.5%)
|
34 (24.1%)
|
57 (40.7%)
|
42 (29.8%)
|
3 (2.1%)
|
C. glabrata
|
Yes n=17
|
13 (66.5%)
|
P=0.02
|
6 (35.3%)
|
p=0.32
|
6 (35.3%)
|
p=0.13
|
16 (94.1%)
|
p≤ 0.001
|
6 (35.3%)
|
p=0.54
|
1 (0.06%)
|
p=0.52
|
No
n=148
|
63 (42.6%)
|
38 (25.7%)
|
33 (22.3%)
|
42 (28.4%)
|
41 (27.7%)
|
2 (0.01%)
|
C. krusei
|
Yes n=7
|
5 (71.4%)
|
P=0.01
|
4 (57.1%)
|
p=0.24
|
2 (28.5%)
|
p=0.19
|
5 (71.4%)
|
p≤ 0.001
|
3 (42.8%)
|
p=0.46
|
1 (14.3%)
|
p=0.43
|
No
n=158
|
55 (34.8%)
|
61 (38.6%)
|
33 (20.8%)
|
47 (29.7%)
|
48 (30.3%)
|
4 (0.02%)
|
p value <0.05 was considered significant
Table 4. Effect of different variables on the height, weight and Apgar score of the neonates
|
Height
|
Weight
|
Apgar Score
|
Beta
|
p-value
|
C.I
|
Beta
|
p-value
|
C.I
|
Beta
|
p-value
|
C.I
|
Age (≥41 years)
|
-0.15
|
0.15
|
-1.44; 0.22
|
0.05
|
0.64
|
-177.75; 284.12
|
-0.105
|
0.385
|
-0.432; 0.16
|
Previous Miscarriage
|
0.03
|
0.79
|
-0.79; 1.03
|
-0.01
|
0.92
|
-264.92; 241.54
|
0.15
|
0.20
|
-0.11; 0.54
|
Domestic Animals
|
0.11
|
0.30
|
-0.62; 1.97
|
-0.07
|
0.51
|
-477.07; 242.68
|
-0.04
|
0.72
|
-0.59; 0.41
|
Delivery Week
|
0.41
|
0.001
|
0.34; 1.34
|
0.32
|
0.01
|
36.97; 311.59
|
0.01
|
0.94
|
-0.17; 0.18
|
Delivery Type
|
-0.46
|
0.002
|
-3.30; -0.73
|
-0.34
|
0.02
|
-755.78; -45.68
|
-0.16
|
0.29
|
-0.69; 0.21
|
Induced Labor
|
-0.09
|
0.48
|
-1.38; 0.65
|
-0.07
|
0.61
|
-353.76; 209.41
|
-0.04
|
0.76
|
-0.41; 0.30
|
Gestational Diabetes mellitus
|
0.11
|
0.27
|
-0.39; 1.39
|
0.003
|
0.98
|
-243.86; 249.62
|
0.10
|
0.37
|
-0.17; 0.46
|
Other gestational complications
|
0.18
|
0.10
|
-0.14; 1.68
|
0.25
|
0.04
|
16.61; 523.28
|
0.05
|
0.67
|
-0.26; 0.40
|
Anemia
|
-0.01
|
0.94
|
-1.20; 1.13
|
0.029
|
0.80
|
-281.52; 364.01
|
-0.005
|
0.96
|
-0.42; 0.40
|
Recurrent UTI
|
0.19
|
0.07
|
-0.23; 4.38
|
0.23
|
0.03
|
33.84; 1310.25
|
-0.12
|
0.29
|
-1.26; 0.38
|
Candida albicans infection
|
-0.46
|
0.05
|
-4.84; 0.08
|
-0.16
|
0.53
|
-896.85; 465.31
|
0.09
|
0.73
|
-0.72; 1.02
|
Candida glabrata/ krusei infection
|
-0.77
|
0.006
|
-6.14; -1.04
|
-0.43
|
0.14
|
-1228.04; 181.31
|
0.19
|
0.52
|
-0.61; 1.20
|
|
R2 =0.32
|
R2 =0.25
|
R2 = 0.17
|
Standardized beta coefficients (Beta) for each individual independent variable was calculated to compare the strength of the effect of each to the dependent variable. The higher the absolute value of the beta coefficient, the stronger the effect. Coefficient of determination (R2) was calculated to evaluate the proportion of the variance in the dependent variable that is predictable from the independent variables. The coefficient of determination assesses how well the model explains and predicts future outcomes. Confidence interval (CI) is the margin of error of the Beta. P value determines the significance of the results. P value <0.05 was considered significant.