The present finding revealed that the prevalence proportion of Candida sp. was 61.4% among pregnant women, which is close to the finding reported among pregnant women in Ibb City [14]. This outcome is less than a report conducted in Kenya, which found that 90.38% of pregnant women were infected by Candida sp. [15]. In contrast, the current finding is lower than several reports that showed that the prevalence rate of Candida species among pregnant women was 55.4% in Cameroon [16], 60.8% in Egypt [17], 51.6% in Sana’a, Yemen [18], 34% in Saudi Arabia [19], and 25% in northwestern Ethiopia [20]. The great variation in frequency rate might be due to the differences in geographical locations, study population, sample size, hygienic conditions, socioeconomic status, and diagnostic methods employed by the participants.
In the current study, it was found that the frequency rate of C. albicans isolates was 59.26% and that of non-albicans Candida isolates was 40.74%. This result is similar to some reports performed in different countries [2, 19, 20]. The widespread use of antifungal drugs over-the-counter, inappropriate use, incomplete description of treatment, longer treatment for recurrent candidiasis, and use of effective agents to eliminate C. albicans have all been proposed as potential explanations for the increased isolation of non-albicans Candida species from vulvovaginitis patients.
Remarkably, the highest rate of Candida infections in this study was noticed in pregnant women aged between 24 and 30 years (71.9%). Similar reports documented that a high frequency of Candida species was found at 60% among the ages 26–35 [15], 38.5% in the ages 34–40 [20], 37.4% in the ages 20–34 [21], and 44.4% in the ages 26–35 [22].
The cause of this might be explained by the fact that women in this age range release many reproductive hormones, which can inhibit the immune system and foster Candida infection. The use of antibiotics, which kill bacteria, including natural flora, is another factor that might be involved. This will give Candida a chance to attack the vaginal wall [20]. Additionally, this high proportion is caused by the vagina's higher glycogen content and high estrogen hormone levels. It offers a reliable source of carbon, which helps with Candida proliferation.
The present outcome showed that the highest rate of Candida infections was recorded among those living in urban areas (64.5%). The outcome, consistent with Abdul-Aziz et al. [10], revealed that the highest distribution of VVC was among pregnant women in the urban area at 88.44%. The prevalence of the infection was higher in uneducated women than in patients with basic school education and above, and there was a statistically significant correlation between vulvovaginal candidiasis and educational level (P = 0.004). This finding was compatible with earlier reports [21-22] that revealed a high frequency of Candida sp. among those with basic education. The difference in infection rates between illiterate individuals and those with more education could be explained by improvements in personal cleanliness and/or economic position brought on by education [23].
Compared to primigravidae (63.8%), multigravidae (66.1%) women exhibited a higher rate of Candida colonization, with significant differences (P = 0.000) in the present study. Similarly, research conducted in Pakistan found that multigravidae women experienced the condition more frequently than primigravidae women, with results of 60% and 40%, respectively [24]. Further research from Nepal [25] supports our findings. The rationale is that the rate of infection rises with the frequency of pregnancies (3rd > 2nd > 1st), which lowers immunity and may lead to extensive Candida colonization. Additionally, a study by Tsega and Mekonnen [20] showed that Candida infection was more common among women with multigravidae (61.5%) than among those with primigravidae (38.5%).
According to these data, females with recurrent infections had a greater prevalence rate of vulvovaginal candidiasis (67.7%) than those who had it for the first time (29.5%). This result conflicts with research performed in Nigeria by Aguin and Sobel [26]. The significantly rising rate of recurrent vaginal candidiasis infections in this research may be due to an increase in Candida species that are resistant to widely used antifungal medications.
The current results revealed that there were significant differences between the gestational period and Candida colonization (80%; P = 0.000). The highest rate of vaginal Candida species was detected in the third-trimester participants at 80%, while the lowest was in the first trimester (40%). A similar finding was further reported: the highest rate of Candida species was in the third trimester, at 68.09% in Kenya [15] and 57.4% in Candida [22]. According to research, third-trimester pregnant women were most likely to develop an illness. Pregnancy raises the risk of VVC, and the risk might reach 50% during the final trimester [21-22].
This is because during pregnancy, particularly in the third trimester, elevated oestrogen levels generate larger glycogen stores in the vagina, which serve as an excellent source of carbon and encourage the growth of Candida sp. Additionally, oestrogen makes vaginal epithelial cells' yeast cytosol receptors more attractive to Candida species [27].
The current findings showed that 92.4% of C. albicans were sensitive to amphotericin B. This finding was similar to reports that recorded 93.8% in Ethiopia [20] and 87.2% in Ghana [28]. Amphotericin-B is more sensitive than other antibiotics because it is not frequently given and used extensively due to its high cost, difficulties in administration, and severe renal toxicity. Therefore, the less a drug is used, the less likely it is to develop resistance to it [20].
The overall rate of Candida species in the present investigation was highly resistant to clotrimazole (30.5%), voriconazole (26.7%), nystatin (25.5%), and fluconazole (21.0%). These results are lower than the results of Khan et al. [9], who detected a high resistance rate of Candida sp. against fluconazole (62%), clotrimazole (59.3%), itraconazole (40.7%), and voriconazole (10.2%). Another study by Tsega and Mekonnen [20] revealed that a high resistance rate of Candida sp. (57.3%) was found for ketoconazole and itraconazole. In addition, approximately 17.2% and 5.7% of Candida species were resistant to fluconazole and flucytosine, respectively [23].
The current study showed that ketoconazole was the most effective antifungal drug when compared to tested antifungal agents that had 89.7% effectiveness. In different reports, Bitew and Abebaw [23] reported that fluconazole was the most effective antifungal drug, while Tsega and Mekonnen [20] documented clotrimazole as an effective antifungal agent. Earlier studies demonstrated that the resistance rate in Candida sp. to voriconazole and fluconazole has remained constant over a decade [23, 29, 30].
According to the multidrug resistance results, a high proportion of Candida albicans (46.2%) was resistant to one type of antifungal drug, while 38.7% of isolated non-albicans Candida were resistant to three types of antifungal drugs. A study by Tsega and Mekonnen [20] revealed that 46.29% of isolated C. albicans were resistant to three types of antifungal agents, and non-albicans Candida, including C. glabrata (35.29%) and C. krusei (57.17%), were resistant to one type of antifungal.
Limitations of the study
The limitation of this study is the absence of advanced diagnostic techniques for isolating and identifying different types of Candida species, such as selective and differential media, as well as serological tests.