Prevalence of Candida spp. in cervical-vaginal samples and the in vitro susceptibility of isolates

h tt p : / / w w w . b j m i c r o b i o l . c o m . b r /

Medical

Microbiology

Prevalence

of

Candida

spp.

in

cervical-vaginal

samples

and

the

in

vitro

susceptibility

of

isolates

Tchana

Martinez

Brandolt

_,

_Gabriel

_Baracy

_Klafke

_,

_Carla

_Vitola

_Gonc¸alves

_,

Laura

Riffel

Bitencourt

_,

_Ana

_Maria

_Barral

_de

_Martinez

_,

_Josiara

_Furtado

_Mendes

_,

Mário

Carlos

Araújo

Meireles

_,

_Melissa

_Orzechowski

_Xavier

a_{UniversidadeFederaldoRioGrande,LaboratóriodeMicologia,RioGrande,RS,Brazil}

b_{UniversidadeFederaldoRioGrande,ProgramadePós-Graduac¸ãoemCiênciasdaSaúde,RioGrande,RS,Brazil} c_{UniversidadeFederaldePelotas,Pelotas,RS,Brazil}

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Articlehistory:

Received29April2015 Accepted30May2016

Availableonline4October2016 AssociateEditor:SandroRogériode Almeida Keywords: Vulvovaginalcandidiasis Antifungal Susceptibility Resistance

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Vulvovaginalcandidiasis(VVC)isaninfectionofthegenitalmucosacausedbydifferent speciesofthegenusCandida.ConsideringthelackofdataonthistopicinthesouthofBrazil, thisstudyaimedtoassesstheprevalenceofCandidaspp.inthecervical-vaginalmucosaof patientstreatedatauniversityhospitalinsouthernRioGrandedoSul,aswellasthe eti-ologyandthesusceptibilityoftheisolatesagainstfluconazole,itraconazole,miconazole andnystatin.SampleswerecollectedatthegynecologyclinicoftheFederalHospitalofthe UniversityofRioGrande,andtheisolateswereidentifiedusingphenotypicandbiochemical tests.ThesusceptibilityanalysiswasperformedaccordingtotheCLSIM27-A2protocol.Of the263patientsincluded,Candidaspp.wasisolatedin27%,correspondingtoaprevalence ofapproximately15%forbothVVCandcolonization.Morethan60%oftheisolateswere identifiedasCandidaalbicans;C.non-albicanswasisolatedatarateof8.6%insymptomatic patientsand14.3%inasymptomaticpatients.Theprevalenceofresistanceagainst flucona-zoleanditraconazolewas42%and48%,respectively;theminimalinhibitoryconcentration ofmiconazolerangedfrom0.031to8␮g/mL,andthatofnystatinrangedfrom2to>16␮g/mL. Thehighrateofresistancetotriazolesobservedinourstudysuggeststhenecessityofthe associationoflaboratoryexamstoclinicaldiagnosistominimizethepracticeofempirical treatmentsthatcancontributetothedevelopmentofresistanceintheisolates.

©2016SociedadeBrasileiradeMicrobiologia.PublishedbyElsevierEditoraLtda.Thisis anopenaccessarticleundertheCCBY-NC-NDlicense(http://creativecommons.org/

licenses/by-nc-nd/4.0/).

Introduction

Vulvovaginalcandidiasis(VVC)ischaracterizedbyan infec-tionofthegenital mucosabyCandidayeasts,whichmainly

∗ _{Correspondingauthorat:LaboratóriodeMicologia,FaculdadedeMedicina,UniversidadeFederaldoRioGrande,RioGrande,RS,Brazil.}

E-mail:[email protected](M.O.Xavier).

undertakes the vulva and the vagina. The disease occurs endogenously due to predisposing factors that favor yeast multiplication.Signs and symptoms suchas itching, burn-ing, cracking,erythemaand vulvaredema, leukorrhea and the presence of whitish plaques on the vaginal mucosa

http://dx.doi.org/10.1016/j.bjm.2016.09.006

1517-8382/©2016SociedadeBrasileiradeMicrobiologia.PublishedbyElsevierEditoraLtda.ThisisanopenaccessarticleundertheCC BY-NC-NDlicense(http://creativecommons.org/licenses/by-nc-nd/4.0/).

arecommon.1 _{VVCisconsideredthesecondmostcommon}

causeofgenitalinfectioninwomenofreproductiveage,and althoughitrepresentsaproblemofglobalimportancein pub-lichealth,itsexactincidenceisunknown.2,3

Risk factors for vulvovaginitis include pregnancy, use oforalcontraceptives,geneticpredisposition,and previous antibiotictherapy,amongothers.Theincidenceofinfection, aswellastheincreaseincolonizationofthemucosabythe yeast, is alsohigher in women with diabetes due totheir higherglycogenlevelsandinthosewithHIVduetoimmune suppression.4,5

Studiesshowthat70–75%ofallwomenofreproductiveage developatleastonecaseofVVCduringtheirlifetime.6,7_The

recurrencerateis40–50%,andapproximately 5–8%develop recurrentvulvovaginalcandidiasis(RVVC), whichis charac-terizedbyfourormoreepisodesofdiseaseoveraperiodof twelvemonths.6–8

ThemainetiologicagentisCandidaalbicans,accountingfor 70–90%ofVVC cases.7,8 _{Amongthe non-albicansspeciesC.}

glabrataishighlighted7–9_{duetoitsprevalenceandresistance}

toazoles.10,11

AnincreasingnumberofCandidaspp.clinicalisolatesare resistant to antifungalagents routinely usedfor the treat-mentofVVC.Inaddition,studiesindifferentregionsofBrazil suggestthatgeographicalfactorsinterfereintheprevalence ofCandidaspeciesaswellasinthesensitivityofisolatesto antifungals.1,11–13 _{Consideringthis and the lack ofdataon}

this topic inRio Grandedo Sul,this study aimedto iden-tifytheprevalenceofCandidaspp.isolatedfromthevaginal mucosaofpatientswithand withoutvulvovaginitistreated atauniversityhospitalinextremesouthernBrazil,aswellas thesusceptibilityoftheseisolatestofourantifungalsusedin gynecologicalroutines.

Materials

and

methods

Thestudyincluded263patientsattendedonfromApril2013to October2014atthegynecologyclinicoftheUniversity Hospi-taloftheFederalUniversityofRioGrande(FURG)–RioGrande doSul–Brazil.Thewomenagreedtoparticipatebysigningthe ClarifiedInformedConsentform.Thesamplesize,calculated usingEpiInfo6.0andconsideringaprevalenceof30%,a con-fidencelevelof99%,maximumpermissibleerrorof20%and lossesof10%,wasestimatedtobeasampleof249patients.

During the gynecological exam, a sample of cervical-vaginalmucosa wascollected using asterilebrush, which wasstoredinsteriletubescontainingPBSandkept refriger-ateduntilprocessing.ThesamplewassenttotheMycology Laboratory of the Medicine Faculty from FURG, where it was processed within 12h. The cultures were processed in Sabouraud agar with chloramphenicol 0.01% (SCl) and incubated at37◦Cforsevendayswithdailyassessmentof growth.Theyeastswereidentifiedusingphenotypictestssuch as micromorphology, chromogenic medium (CHROM Agar Candida®_{), germ tube test, and microculturein agar}

corn-mealandwereconfirmedbybiochemicalautomatedmethod (VITEK® _{2).Eachisolatewasmaintainedonpotatodextrose}

agar(PDA)inthe mycologycollectionatroomtemperature

underfreezingat−20◦_{Cinsalinewith30%glycerolfor}

subse-quentsusceptibilitytesting.

Thevariablesevaluatedinthestudywereobtainedby self-administeredpre-codedquestionnaireandincludedage,skin color, educationallevel, maritalstatus, family income,HIV infectionstatus,pregnancy,contraceptionandvaginalpHat thetimeofsamplecollection.Signsandsymptomsassessed duringthegynecologicalexamwereusedtoconsiderwomen ascolonizedorpresentingVVC,thelatterbeingthosethathad leukorrhea, pruritus, edema and/or vulvovaginal erythema associatedwiththepresenceofwhitishplaquesinthemucosa andtheisolationofCandidaspp.inmycologicalcultivation.

Theinvitrosusceptibilityanalysisofclinicalisolateswas performedbybrothmicrodilutionusingtheM27-A2standard protocolCLSI(2002).14_{Forthestandardizationoffungal}

inocu-lum,isolatesweresubculturedonPDAfor24hat37◦C,young colonieswerehomogenizedinsterilesaline,andtheturbidity wasadjustedto0.5ontheMcFarlandscaleby spectrophoto-metry(530nm)toobtainaconcentrationof1–5×106_CFU/mL.

Then,adilutionwasperformedat1:100and1:20inRPMI1640, resultinginaconcentrationof5×102_to2.5×103_CFU/mL.The

inoculumconcentrationwasconfirmedusingthePour-plate technique.Thesusceptibilitytestwasperformedat concen-trations of 64␮g/mL to 0.125␮g/mL forfluconazole and at concentrationsrangingfrom16␮g/mLto0.031␮g/mLfor itra-conazole,miconazoleandnystatin.

The 96-well microplates were filled with 100␮L of the antifungalconcentrationsand100␮Lofinoculumandwere incubatedat37◦Cfor48halongwithgrowthandsterility con-trols.Eachisolatewastestedinduplicate,andtheresultswere visuallyevaluatedbyturbidity,comparingthefungalgrowth inthewellwiththegrowthcontrol.Theminimuminhibitory concentration(MIC)offluconazole,itraconazoleand micona-zolewasonethatinhibited80%ofyeastgrowth,andtheMIC ofnystatininhibited100%ofgrowth.

AccordingtotheMICresultforfluconazoleand itracona-zole, theisolateswereclassified asSforsensitive,SDDfor sensitivedose-dependentandRforresistant,asestablished bythecutoffpointprotocolM27-A2.Formiconazoleand nys-tatin,theMIC50andMIC90werecalculatedcorrespondingto

theantifungalconcentrationcapableofinhibitingthegrowth of50%and90%,respectively,oftheisolatestested.After read-ingtheresultsofMIC,10␮Lofthesolutionsfromthewells relatedtoconcentrationshigherthan andequaltotheMIC wereplatedonaPetridishcontainingagarSClandwere incu-batedat37◦Cfor48htodeterminethefungicideminimum concentration(FMC).

Thestudywasconductedaccordingtoethicalprinciples andwasapprovedbytheResearchEthicsCommitteeofthe FederalUniversityofRioGrande(65/2012).Theresultswere compiledbyconductingdescriptiveanalysisofthedataand chi-square tests for categorical variables using SPSS 19.0®

software.p-valuesbelow0.05wereconsideredstatistically sig-nificant.

Results

Thestudy populationconsistedmostly ofwomenwho had partners(64.5%),hadwhiteskincolor(65.3%),werepregnant

Table1–Descriptiveanalysisofthestudypopulation (n=263)andtheinfluenceofthevariablesstudied (chi-squaretest)inthedevelopmentofvulvovaginal candidiasis(VVC)(n=35). Variables n(%) VVC(n) pvalue HIV-positive 71(27.1) 10 0.833 HIV-negative 191(72.9) 25 Pregnant 158(60.3) 26 0.069 Notpregnant 104(39.7) 09 Skincolor 0.542 White 160(65.3) 20 Notwhite 85(34.7) 13 Maritalstatus 0.891 Withoutapartner 89(35.5) 11 Withpartner 162(64.5) 21 Educationallevel 0.326 8yearsorless 131(51) 20 9yearsormore 126(49) 14 Familyincome 0.577

Lessthan1wage 56(21.3) 09 1–2wages 86(32.7) 12 2.1ormore 79(30) 08

Contraception 0.599

Hormonal 135(54.7) 20 Nothormonal 112(45.3) 14

(60.3%)andwereHIV-negative(72.9%).Themeanagewas28.5 yearsandrangedfrom12and68years,withmorethan65%of thewomenunder31yearsofage(n=176)and54.7%(n=135) usinghormonalcontraception(Table1).

Ofthe263patients,Candidaspp.wasisolatedinthe myco-logicalculturefromcervical-vaginalsamplesin27%(n=71). Ofthese, vulvovaginal candidiasis was diagnosedin 49.3% (n=35),resultinginaprevalenceinthepopulationof13.3%. Theremaining50.7%(n=36)thathadnosignsorsymptoms ofvulvovaginitiswereclassifiedascolonizationcases.

The predominant species was Candida albicans in both groups,correspondingto62.9%(n=22)ofisolatesoriginating fromthegroupofwomencolonizedand 74.3%(n=26)from thewomenwithVVC.Theotherspeciesidentifiedcolonizing the vaginal mucosa ofhealthy women were C. glabrata in 14.3% (n=5),followed byC. sphaerica in 8.6% (n=3) and C. parapsilosiscomplexin2.9%(n=1).AmongcasesofVVCbyC.

non-albicans(n=5),8.6%(n=3) wereduetoC.glabrata,2.9% (n=1)wereduetoC.parapsilosiscomplex,and2.9%(n=1)were

duetoC.tropicalis.Inaddition,11.4%(n=4)oftheisolatesfrom colonization,and11.4%(n=4)oftheetiologicagentsofVVC wereidentifiedonlyingeneral,beingclassifiedasCandidaspp. Regardingthevariablesanalyzed,82.4%(n=28)ofpatients diagnosedwithVVCbelongedtothegroupofwomenaged30 yearsoryounger(p=0.047).Fortheothervariablessuchasskin color,maritalstatus,educationallevel,familyincome, contra-ception,pregnancyandHIVinfection,therewasnosignificant differencebetweenthegroupofwomenwithandwithoutVVC

(Table1).ThesameoccurredwiththevaginalpHatthetimeof

collection,inwhich133patientshadpH≤4.5,butonly14.3% (n=19)ofthemwerediagnosedwithVVC(p=0.948).

Ofthe 71 clinical isolates ofCandidaspp., 50 were sub-jectedtoinvitrosusceptibilitytesting,25fromhealthywomen and25from womenwithVVC.Consideringalltheisolates, regardless of species, the MIC to miconazole rangedfrom 0.031to8␮g/mL,withMIC50=0.5␮g/mLandMIC90=4␮g/mL,

andtheMICtonystatinrangedfrom2to>16␮g/mL,witha MIC50=4␮g/mLandMIC90=8␮g/mL.Concerningfluconazole

and itraconazole,resistancewasobservedin42% and48%, respectively,oftheisolates(Table2).Nosignificantdifference inMICvalueswasobservedbetweenclinicalisolatesofVVC andcolonization.Concerningfluconazole,100%oftheisolates ofC.albicansandC.glabratashowedanFMC>64␮g/mL,andfor itraconazole,100%ofC.glabrataand97%ofC.albicansshowed anFMC>16␮g/mL(Table3).

Discussion

The present study provides data about Candidaspp. isola-tionfromthevulvovaginalmucosaofwomeninsouthernRio GrandedoSul,Brazil.Wedetectedtheyeastin27%ofthestudy population,correspondingtoaprevalenceofapproximately 13% bothforcolonizationand forvulvovaginalcandidiasis. Similarandlowerratesoffungalisolationinwomenwithand withoutvulvovaginitishavebeendescribedinotherstudiesof thesouthernregion:11and24.7%inpatientsinthestateof Paraná,12–15_{23.8%inpatientsinthestateofSantaCatarina}12

and18.2%inthecityofSantoÂngelo-RS,16_{thelatterbeing}

theonlystudyheldinRioGrandedoSul.Thesedifferences intheisolationofCandidaspp.fromvaginalmucosacanbe explainedbyculturalhabitsofdifferentregions,especiallyin regardtohygienepractices,asthisfactorisdirectlyrelated toself-contaminationbecausetheyeastbelongstothe nor-malgastrointestinaltractmicrobiota.3,17,18_{Ontheotherhand,}

Table2–ResultsoftheinvitrosusceptibilitytestofCandidaspp.fromcolonizedand/orVVCpatientsagainstfour antifungalagents.S-sensitive,SDD-sensitivedose-dependentandR-resistant.

Species Fluconazole Itraconazole Miconazole Nystatin S n(%) SDD n(%) R n(%) S n(%) SDD n(%) R n(%) MIC (␮g/mL) MIC50/MIC90 (␮g/mL) MIC (␮g/mL) MIC50/MIC90 (␮g/mL) C.albicans(n=37) 12(32.4) 4(10.8) 21(56.8) 8(21.6) 9(24.3) 20(54.1) 0.031–8.0 1.0/4.0 2.0–>16 4.0/8.0 C.glabrata(n=6) 1(16.7) 5(83.3) – 1(16.7) 2(33.3) 3(50) 0.031–0.250 0.031/0.125 4.0–8.0 4.0/8.0 C.parapsilosiscomplex(n=2) 2(100) – – 1(50) – 1(50) 0.031–0.125 0.031/0.125 8.0 8.0/8.0 C.tropicalis(n=1) 1(100) – – 1(100) – – 1.0 1.0/1.0 8.0 8.0/8.0 C.sphaerica(n=3) 3(100) – – 3(100) – – 0.031 0.031/0.031 2.0–4.0 2.0/4.0 Candidaspp.(n=1) 1(100) – – – 1(100) – 0.5 0.5/0.5 2.0 2.0/2.0

Table3–FungicideMinimumConcentration(FMC)resultsofthefourantifungalstestedagainstCandidaspp.isolated

fromcolonizedand/orVVCpatients.

Species Fluconazole Itraconazole Miconazole Nystatin FMC (␮g/mL) FMC50/ FMC90 (␮g/mL) FMC (␮g/mL) FMC50/ FMC90 (␮g/mL) FMC (␮g/mL) FMC50/ FMC90 (␮g/mL) FMC (␮g/mL) FMC50/ FMC90 (␮g/mL) C.albicans(n=37) >64 >64/>64 16–>16 >16/>16 2.0–>16 >16/>16 4.0–8.0 8.0/80 C.glabrata(n=6) >64 >64/>64 >16 >16/>16 16–>16 >16/>16 4.0–8.0 8.0/8.0 C.parapsilosiscomplex(n=2) 4.0–>64 4.0/>64 2.0–>16 2.0/>16 2.0–>16 2.0/>16 8.0 8.0/8.0 C.tropicalis(n=1) >64 >64/>64 >16 >16/>16 >16 >16/>16 8.0 8.0/8.0 C.sphaerica(n=3) 1.0–>64 1.0/>64 0.031–1.0 0.031/1.0 0.031–2.0 0.031/2.0 2.0–4.0 4.0/4.0 Candidaspp.(n=1) >64 >64/>64 1.0 1.0/1.0 8 8.0/8.0 2.0 2.0/2.0

similarstudiesinnortheasternBrazilshowfungalisolationin womenwithandwithoutvulvovaginitisofupto46%.1,17,19,20_It

isassumedthatotherfactorsbesidesthosementionedabove mayexplainthehighprevalenceofCandidaspp.inthisregion, suchasweatherconditionsandsocialandenvironmental fac-torsthatarefavorabletothereproductionofyeast.20

Therateofcolonizationof13.7%observedinourstudyis consistentwith the literature,3,9 _{which describes that}

Can-dida spp. is part of the genital microbiota of up to 30% ofhealthywomen.1,18 _{Whereasthe diseaseoccurs}

endoge-nously,isimportanttodifferentiatebetweenthecolonization andinfectionofthevaginalmucosa.3,18

Ferrazzaandco-workers12_{foundaVVCprevalenceof19.2%}

inSantaCatarinaandof9.3%inParaná;thesedataare sim-ilartotheprevalenceofVVCfoundinourstudy.12_However,

itisbelowthe69%foundbyHolandaandco-workers17_ina

studyconductedinNatal,the47.9%foundbyAndrioliand co-workers1_{inBahia,the42.7%describedbySáandco-workers}20

inMaranhãoandthe39.6%foundbyDiasandco-workers7_in

MatoGrosso.Consideringthatthisdisease isopportunistic, thisdiscrepancymayberelatedtoseveralfactorsrelatedto theetiologicagent,thespeciesdistributionand/orvirulence ofthestrains,theimmunestatusofthehost,orthe environ-ment,whichinfluencesthemaintenanceoftemperatureand humidityconducivetofungalproliferation.1,12,20,21

Thedifferencesingeographicallocationshouldbe consid-eredamongtheepidemiologicfactorsthatalsointerfereinthe prevalenceofCandidaspp.isolatedfromvaginalmucosa.12_In

thisstudy,C.albicanswaspredominant,accountingforover 60%oftheisolatesbothincolonized patientsandinthose withVVC.Infact,thisspeciesisthemostpathogenicofthe gender, beingrelated tomostcases ofVVC described,and generallyrepresentsmorethanhalfoftheisolatesidentified inother studies.7,15,16,22 _{Ferrazaandco-workers}12 _described

theidentification ofthisspeciesinSanta Catarina in100% and72%ofisolatesfromtheasymptomaticandsymptomatic patients,respectively,and in66.7%ofpatientswithVVC in stateofParaná.Similarly,Camargoandco-workers16

identi-fiedC.albicansinmorethan80%oftheisolatesfrompatients withandwithoutVVCinSantoÂngelo-RS.

Approximately 25% of cases of VVC were caused by non-albicansspeciesinourstudy.Amongthese,C.glabrata,

described as the second most important species in cases of VVC due to its frequency10,12,15,18,23 _{and greater}

resis-tancetoantifungals10,22,24_{wasfoundin8.6%ofsymptomatic}

patientsandin14.3%ofcolonizedpatientsinourstudy,which

highlightstheimportanceoflaboratorytestsforcorrect iden-tificationoftheetiologicagent,althoughtheclinicaldiagnosis ofthediseaseiseasilyperformedandcommonlyapplied.2,25

Regarding the variables studied, the largest number of patientswithVVCwasfromthegroupofwomenyoungerthan 31years,beingwithinthereproductiveagegroup,3_whichis

consideredariskfactorforVVCduetosexualactivity.8

How-ever,thisdifferenceinagebetweenthegroupofwomenwith VVC and theotherwise healthy groupwas notdetectedby otherauthors.1,17,19,23 _{Similarly,useofhormonal}

contracep-tionorintrauterinedevices,vaginalpH≤4.5,pregnancyand HIV infection,which are considered as riskfactors for the developmentofVVC3,5,20,26_{werenotsignificantlyassociated}

withVVCinfectioninourstudy.Thisdiscrepancymaybedue tothesmallnumberofwomenwithVVCinourstudy(n=35), whichdoesnotallowforarobuststatisticalanalysisforrisk factorsforthedisease.

Accordingtoourstudy aswellasthat ofRodrigues and co-workers23_{theothervariablessuchasmaritalstatus,}

educa-tionallevelandskincolordonotexertsignificantinfluenceon thedevelopmentofVVC.Moreover,Álvaresandco-workers4

statethatthevaginalmicrobiotaofblackwomenhasalower incidence of bacterial species, and there would thus be a decrease innaturaldefensesagainstfungalgrowth, predis-posingthemtoinfectionbyCandidaspp.4,20

In vitro studies have shown different resistance rates of Candida spp. from the vaginal mucosa to the azole drugs commonlyusedinthetreatment andprophylaxisof VVC.7,8,10,11,13,22,24,27,28_{Concerningfluconazole,theresistance}

ratesrangefrom0.8%to12.5%.7,10,11,24,28_{Thesevaluesare}

con-siderablylowerthantheresultsfoundinourstudy,inwhich 42% ofthe isolateswere resistant tofluconazole.However, Dalazenandco-workers22_{inastudyconductedinSanta}

Cata-rina, found100%offluconazoleresistance.Withrespectto itraconazole,resistanceratesdescribedinotherstudiesrange from1.9to43%,10,13,27,28_{alsolowerthanthe48%foundinour}

study.Inadditiontothe highrateofresistanceto flucona-zoleanditraconazoleobserved,theFMCofmorethan90%of theisolateswasgreaterthanthemaximumantifungal con-centrationtested.Therefore,thereisatendencytoavoidthe prophylacticuseoflowdosesofantifungalsingynecological routinestopreventtheemergenceofdrug-resistantisolates.2

Another groupofazoledrugsusedfortopicaltreatment ofVVCismiconazole.22 _{Inourstudy,the MICforthisdrug}

rangedfrom0.031to8␮g/mL.Thesedataweresimilartothose foundinastudybyChoukriandco-workers29 _inwhichthe

MIC to miconazole variedbetween 0.015 and 8␮g/mL and inastudy byRichterand co-workers10 _{inwhich the}

varia-tionwasbetween0.007and4␮g/mL.Moreover,Dalazenand co-workers22 _{foundavariationintheMICofmiconazoleof}

between0.097and≥100␮g/mL.Thedifferentgenotypesofthe samespeciesmaybesignificantlydifferentintheir suscepti-bilitytoazoles.27

Thepolyenicagentsareanothergroupofdrugsusedfor thetreatmentofVVC;thisgroupincludesnystatin,whichis themostusedinBrazilandisfreelyavailableintheUnified HealthSystem(SUS)inBrazil.30_{TheMICofnystatin found}

inourstudyrangedfrom2to>16␮g/mL;however,inastudy byChoukriandco-workers,29_{theMICvariedbetween1and}

4␮g/mL, and in a study by Richter and co-workers,10 _the

concentrationrangedfrom1to16␮g/mL.Knowledgeofthe patternsofsusceptibilitytotypicaldrugsinisolatesfrom dif-ferentregionswillallowfortherationalizationoftheempirical useofantifungalagents,thuscontributingtothecontrolofthe isolatedresistancetodrugs.2

Ourresultswillencouragethedevelopmentofother stud-iesrelatedtotheresistancemechanismsoftheseyeastsand alsoofclinicaltrialsinthehospitaltodeterminewhetherthe highresistancetoantifungalsdetectedinvitroactually corre-spondstotherapeuticfailure.

Accordingtothisdatadiscrepanciesandthelackof epi-demiologicaldatainthestateofRioGrandedoSul,thepresent studyhasbeencollaboratingwithlocalepidemiology, eluci-datingtheetiologicalfactorsofVVCandwarningofthehigh resistanceratesfoundinvitroinCandidaspp.isolates evalu-ated.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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