Seyedebrahim Hashemi - Student Research Committee, School of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
Tahereh Shokohi - Invasive Fungi Research Centre (IFRC), Mazandaran University of Medical Sciences, Sari, Iran
Mahdi Abastabar - Invasive Fungi Research Centre (IFRC), Mazandaran University of Medical Sciences, Sari, Iran
Narges Aslani - Infectious and Tropical Diseases Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
Mahbobeh Ghadamzadeh - Gynecology and Obstetrics Department of Hazrat-e- Zainab Hospital, Babolsar, Iran.
Iman Haghani - Department of Medical Mycology, School of Medicine, Mazandaran University of Medical Sciences, Sari, Iran

Background and Purpose: The aim of the current study was to investigate the epidemiology of vulvovaginal candidiasis (VVC) and recurrent VVC (RVVC), as well as the antifungal susceptibility patterns of Candida species isolates. Materials and Methods: A cross-sectional study was carried out on ۲۶۰ women suspected of VVC from February ۲۰۱۷ to January ۲۰۱۸. In order to identify Candida species isolated from the genital tracts, the isolates were subjected to polymerase chain reaction restriction fragment length polymorphism (PCR-RFLP) using enzymes Msp I and sequencing. Moreover, antifungal susceptibility testing was performed according to the Clinical and Laboratory Standards Institute guidelines (M۲۷-A۳). Results: Out of ۲۵۰ subjects, ۷۵ (۲۸.۸%) patients were affected by VVC, out of whom ۱۵ (۲۰%) cases had RVVC. Among the Candida species, C. albicans was the most common species (۴۲/۹۵; ۴۴.۲۱%), followed by C. lusitaniae (۱۸/۹۵; ۱۸.۹۵%), C. parapsilosis (۱۳/۹۵; ۱۳.۶۹%),  C. glabrata (۸/۹۵; ۸.۴۲%), C. kefyr (۶/۹۵; ۶.۳۱%), C. famata (۵/۹۵; ۵.۲۶%), C. africana (۲/۹۵; ۲.۱۱%), and C. orthopsilosis (۱/۹۵; ۱.۰۵%), respectively. Multiple Candida species were observed in ۲۸% (۲۱/۷۵) of the patients. Nystatin showed the narrowest range of minimum inhibitory concentration (MIC) (۰.۲۵-۱۶ μg/ml) against all Candida strains, whereas fluconazole (۰.۰۶۳-۶۴ μg/ml) demonstrated the widest MIC range. In the current study, C. lusitaniae, as the second most common causative agent of VVC, was susceptible to all antifungal agents. Furthermore, ۶۱.۱% of C. lusitaniae isolates were inhibited at a concentration of ≤ ۲ μg/ml, while۳۸.۹% (n=۷)of them exhibited fluconazole MICs above the epidemiologic cutoff values (ECV). Candida species showed the highest overall resistance against fluconazole (۶۱.۳%), followed by itraconazole (۴۵.۲%) and caspofungin (۲۳.۷%). All of C. albicans strains were resistant to itraconazole with a MIC value of ≥ ۱ μg/ml; in addition, ۸۷.۵% of them were resistant to fluconazole. Moreover, ۱۰۰% and ۸۷.۵% of C. glabrata strains were resistant to caspofungin and fluconazole, respectively. Conclusion: As the findings revealed, the majority of VVC cases were caused by non-albicans Candida species which were often more resistant to antifungal agents. Candida lusitaniae generally had fluconazole MICs above the ECV. Given the propensity of C. lusitaniae to develop resistance under drug pressure, antifungals should be administered with caution. The emergence of these species justify the epidemiological surveillance surveys to watch out the distribution of yeast species.

Vulvovaginal candidiasis, Candida species, PCR-RFLP, Antifungal Susceptibility testing, C. lusitaniae