PREVALENCE OF CANDIDA ALBICANS AMONG PREGNANT WOMEN

ABSTRACT

Prevalence of Candida albicans among pregnant women at Osu Primary Health Care Isiala Mbano was carried out from August through September, 2013 using a total of 84 urine samples. The demographic characteristics of the study population within the age groups of 15 – 44 years were also determined. The result revealed the occurrence of yeast cells in urine of pregnant women of age group 20 - 24 and 25 - 29 with 2(7.69%) and 1(7.69%) prevalent rates respectively. The highest percentage of pregnant women with Candida albicans occurred in the age groups of 15 – 19 years. Pregnant women with the highest (24.00%) percentage of C. albicans had tertiary level of education and in contrast to the lowest percentage of C. albicans recorded for primary (8.70%) and secondary (9.09%) level of education. Ages of 35 - 39 recorded no presence of C. albicans. High prevalence 7(18.92%) of Candida albicans and Candida species was documented in this study. These findings should be taken into account in further research concerning presence of Candida infections among pregnant women in Nigeria

TABLE OF CONTENTS

Cover page                                                                                                                  i

Certification                                                                                                                ii

Dedication                                                                                                                  iii

Acknowledgement                                                                                                      iv

Table of content                                                                                                          v

List of table                                                                                                                 vii

Abstract                                                                                                                      viii

CHAPTER ONE

1.0        INTRODUCTION AND LITERATURE REVIEW                                                            1

1.2        Biology of Candida albicans                                                                                      3         

1.2.1        Types of Candida infections                                                                                       4

1.3        CANDIDIASIS                                                                                                        7         

1.3.1    Causes of Candidiasis                                                                                                 8

1.3.2    Signs and symptoms of Candidiasis                                                                           9         

1.4        PREVALENCE OF Candida albicans ON HUMAN BODY PARTS                    10

1.4.1    Urogenital tract                                                                                      10

1.4.2    Skin                                                                                                                            11

1.4.3    Mouth and throat                                                                                                      12

1.4.4    Systemic infection                                                                                                      12

1.4.5    Intestinal Candidiasis                                                                                                            13

1.4.6    Fungal Sinusitis                                                                                                         13

1.5       PREGNANT WOMEN AND Candida albicans INFECTION                                13

            CHAPTER TWO

2.0       MATERIALS AND METHODS                                                                              17

2.1       STUDY AREA                                                                                                          17

2.2       STUDY POPULATION                                                                                            17

2.3       SPECIMEN COLLECTION                                                                                     17

2.4       WET PREPARATION, CULTURE ISOLATION AND                                         18

            IDENTIFICATION

2.4.1    Culture                                                                                                                                    18

2.4.2    Yeast Identification                                                                                                    18

2.4.3    Germ Tube Test                                                                                                          18

            CHAPTER THREE

3.0       RESULTS                                                                                                                 20

            CHAPTER FOUR                                                   

4.0       DISCUSSION                                                                                                                        24

4.1       CONCLUSION                                                                                                         27

            References

LIST OF TABLES

Table                                                  Title                                                                Page

1                                  Demographic characteristics of the study population               21

2                                  Occurrence of yeast cells in urine and C. albicans in culture  22

                                    of pregnant women in Osu, Isiala Mbano

3                                      Distribution of C. albicans among pregnant women in Osu,   23

                                Isiala Mbano, according to demographic characteristics

CHAPTER ONE

1.0       INTRODUCTION AND LITERATURE REVIEW

Candida species are opportunistic yeast affecting the genitourinary tracts. It belongs to the subclass Ascomycota and measures 2 - 4 mm in diameter (Prescott et al., 2008). The genus Candida encompasses more than 160 species. The organism variously can be found among humans, other mammals, birds, insects, arthropods, fish, animal waste, plants, mushrooms, honey, necter, fresh water, sea water and in the air. Candida is listed by the Center for Disease Control (CDC) as a cause of sexually transmitted disease (Prescott et al., 2008). No other mycotic pathogen produces as diverse a spectrum of opportunistic disease in humans as does Candida. Candida species are important nosocomial pathogens and can be transmitted sexually (Tatfeng et al., 2004). Candida species are of the art the normal microbiota within the gastrointestinal tracts, respiratory tracts, vaginal area and the mouth (Prescott et al., 2008). Candidiasis refers to a range of infection caused by species of fungal genus Candida. The infections can be acute or chronic, localized or systemic. Disseminated candidiasis is frequently life threatening. The great majority of these infections are caused by Candida albicans (Greenwood et al., 1992).

Candida is found in the vagina of 35 - 50% of healthy women. Under some conditions, such as reduced immunity, prolonged antibiotics therapy, use of contraceptives, malnutrition, pregnancy, diabetes, obesity, tissue transplant, use of immunosuppression drugs (Corticosteroids), neutropenia, Candida may become pathogenic and cause candidiasis (Okungbowa et al., 2003). Presence of indwelling central venous or pulmonary artery catheters and prior haemodialysis has also been identified as a risk factor. Sexual intercourse with an infected person is the most common mode of spread of genital candidiasis (Tatfeng et al., 2004). Candida species are the second most frequent isolates from blood cultures in hospitals with large populations of immunocompromised patients. Women may complain of dysuria, soreness, irritation, dyspareunia, suprapubic pains, haematuria, white and clumpy vaginal discharge. The discharge is classically described as thick, adherent, and “cottage cheese-like” with a pH of 4.0 - 4.5 (Tatfeng et al., 2004). The diagnosis is confirmed by finding the organism on a wet mount of the discharge. Microscopy may be negative in up to 50% of patients with confirmed genitourinary candidiasis (Sobel et al., 2004). Genitourinary specimens are cultured on fungal media at room temperature or at 37°C. Yeast colonies are examined for the presence of pseudohyphae. C. albicans is identified by the production of germ tubes or chlamydospores. Other Candida isolates are speciated with a battery of biochemical reactions (Jawez et al., 2001). Clinical diagnosis is based on signs and symptoms as stated above.

The many drugs that are available at present to treat fungal infections can be divided into four broad groups on the basis of their mechanism of actions. These antifungal agents inhibit macromolecule synthesis (flucytosine), impair membrane barrier function (polyenes), inhibit ergosterol synthesis (allylamines, thiocarbamates, azole derivatives, and morpholines) or interact with microtubules (griseofulvin) (Vaden et al., 1997). Currently, the azole drugs comprising of miconazole, ketoconazole, fluconazole and itraconazole are widely used for the treatment of fungal infections. They have the advantage of being taken orally, increase potency, decreased toxicity and broader spectrum of activity (Myers, 2006).

C. albicans isolates obtained from sterile body sites tested against fluconazole, ketoconazole and miconazole using microdilution antifungal susceptibility testing method

showed that all isolates were fluconazole susceptible (Tatfeng et al., 2004).

Emergence of drug resistance among yeast isolates and consequent increase in serious fungal infections have been reported (DeMuri et al., 1995). The mechanism of resistance to these antifungal agents by yeast isolates are purely chromosomal as Candida species lack plasmid or other natural mechanism capable of transferring genetic materials between strains (Odds et al., 2003).

Candidiasis is not a communicable disease. The most important preventive measure is to avoid disturbing the normal balance of the microbial flora and intact host defences. Infected patients respond well to antifungal agents such as fluconazole, ketoconazole, amphotericin B, intraconazole and miconazole.

AIMS AND OBJECTIVES

The aim and objective of this study is to determine the prevalence of Candida albicans among pregnant women in Obowo Local Government Area of Imo State.

LITERATURE REVIEW

            1.2   Biology of Candida albicans                                  

Candida albicans is the most common fungal microorganism in healthy individuals, as well as the most common fungal pathogen causing lethal infections (particularly in high-risk groups such as immunocompromised patients). Candida albicans yeast is a part of the gut flora, a group of microorganisms that live in the mouth and intestine. When the Candida albicans population starts getting out of control it weakens the intestinal wall, penetrating through into the bloodstream and releasing its toxic byproducts throughout the body. As they spread, these toxic byproducts cause damage to the body tissues and organs, wreaking havoc on the immune system (Cheng, 2012).

It can be found in up to 70% of healthy individuals at any given time. Candida is considered an opportunistic pathogen because it can harmlessly colonize the human digestive tract, mouth, skin, and genitourinary tract (Kim 2011). However, when the balance of normal bacteria is upset (e.g., after antibiotic treatment) or the immune system of the host is weakened (e.g. treatment with systemic corticosteroids), Candida can proliferate (Murzyn, 2010).

            1.2.1        Types of Candida infections

i.                    Thrush (Oropharyngeal / Esophageal Candidiasis)

ii.                  Vaginal Yeast Infections (Genital / Vulvovaginal Candidiasis)

iii.                Invasive Candidiasis

i.                    Thrush (oropharyngeal/ Esophageal candidiasis

Oropharyngeal candidiasis (thrush), a fungal disease of the oral mucosa and tongue, is the most common intraoral lesion among persons infected with HIV. In the absence of other known causes of immunosuppression, oral thrush in an adult is highly suggestive of HIV infection (Monteiro, 2012). Although thrush in the absence of esophageal disease is not an AIDS-defining condition, it usually occurs with CD4 counts of <200 cells/µL. Three clinical presentations of thrush are common in people with HIV: pseudomembranous, erythematous, and angular cheilitis. Candida also may infect the esophagus in the form of esophageal candidiasis, which causes dysphagia (difficulty with swallowing) or odynophagia (pain with swallowing). Esophageal candidiasis is an AIDS-defining condition, generally occurring in individuals with CD4 counts of <200 cells/µL. It is the most common cause of esophageal infection in persons with AIDS (Monteiro, 2012).

Oropharyngeal and esophageal candidiasis are caused most commonly by Candida albicans, although non- Candida albicans species increasingly may cause disease and may be resistant to first-line therapies (Kauffman, 2012). During the surface of the symptoms, the patient may complain of painless white patches on the tongue and oral mucosa, smooth red areas on the dorsal tongue, burning or painful areas in the mouth, a bad or unusual taste, sensitivity to spicy foods, or decreased appetite (Kauffman, 2012).

ii.                  Candidal vulvovaginitis or vaginal thrush

This  is an infection of the vagina’s mucous membranes by Candida albicans. Up to 75% of women will have this infection at some point in their lives, and approximately 5% will have recurring episodes. It is the second most common cause of vaginal inflammation after bacterial vaginosis (Williams et al., 2006).

It is most commonly caused by a type of fungus known as Candida albicans. The Candida species of fungus is found naturally in the vagina, and is usually harmless. However, if the conditions in the vagina change, Candida albicans can cause the symptoms of thrush. Symptoms of thrush can also be caused by Candida glabrata, Candida krusei, Candida parapsilosis, and Candida tropicalis. Non-Candida albicans are commonly found in complicated cases of vaginal thrush such that first line treatment is ineffective (Egan and Lipsky, 2000). These cases are more likely in immunocompromised patients.

Symptoms of vulvovaginal candidiasis, i.e., an overgrowth of Candida albicans, include: Itching, soreness and/or burning discomfort in the vagina and vulva, heavy white curd-like vaginal discharge, Bright red rash affecting inner and outer parts of the vulva, sometimes spreading widely in the groin to include pubic areas, inguinal areas and thighs (Egan and Lipsky, 2000).

It is not known exactly how changes in the vagina trigger thrush, but it may be due to a hormone (chemical) imbalance. In most cases, the cause of the hormonal changes is unknown. Some possible risk factors have been identified, such as taking antibiotics (Ilkit and Guzel, 2011).

iii.                Invasive candidiasis

Invasive candidiasis: Invasive candidiasis is a fungal infection that occurs when Candida species enter the blood, causing bloodstream. Invasive candidiasis are severe fungal infection usually in immunocompromised         persons (AAFP, 2008).

Invasive candidiasis may result when a person’s own Candida organisms, normally found in the digestive tract, enter the bloodstream. On rare occasions, it can also occur when medical equipment or devices become contaminated with Candida. In either case, the infection may spread throughout the body. Risk factors of persons at high risk for candidemia include low-birth-weight babies, surgical patients, and those whose immune systems are deficient. Risk factors for Invasive candidiasis are factors that do not seem to be a direct cause of the disease, but seem to be associated in some way (Abdelmonem et al., 2012).

Having a risk factor for Invasive candidiasis makes the chances of getting a condition higher but does not always lead to Invasive candidiasis. Also, the absence of any risk factors or having a protective factor does not necessarily guard you against getting Invasive candidiasis. Symptoms of invasive candidiasis includes fevers, chills and failure of antibiotics (Abe, 2004).

            1.3              CANDIDIASIS

Candidiasis or thrush is a fungal infection (mycosis) of any of the Candida species (all yeasts), of which Candida albicans is the most common. This is commonly referred to as a yeast infection, candidiasis is also technically known as candidosis, moniliasis, and oidiomycosis (Kourkoumpetis et al., 2010).

Candidiasis encompasses infections that range from superficial, such as oral thrush and vaginitis, to systemic and potentially life-threatening diseases. Candida infections of the latter category are also referred to as candidemia and are usually confined to severely immunocompromised persons, such as cancer and transplant patients, as well as nontrauma emergency surgery patients (Williams et al., 2006).

Occasionally the yeast multiplies uncontrollably, causing pain and inflammation. Candidiasis may affect the skin. This includes the external surface skin and the skin of the vagina, the penis, and the mouth. Candidiasis may also infect the blood stream or internal organs such as the liver or spleen. By far the most common problems are skin, mouth and vaginal infections. It also is a common cause of diaper rash. These can be bothersome infections, but are not life threatening (Walsh and Dixon, 1996).

Candidiasis can kill if it reaches the bloodstream or vital organs such as the heart, but this is rare even in people with damaged immune systems and is almost unheard of in healthy people. Nevertheless, candidiasis is a constant nuisance, and sometimes a serious threat to people with AIDS and some cancer patients who lack the immune resources to fight it (Walsh and Dixon, 1996).

1.3.1        Causes of Candidiasis

The leading cause is overuse of antibiotics. Yeast must compete for the right to live on us with various other organisms, many of them bacteria. These bacteria, which live on the skin and in the intestine and vagina, among other places, are harmless but good at fighting off yeast. When we take antibiotics to deal with less friendly bacteria, we kill off these harmless ones as well. Yeast, which is unaffected by antibiotics, moves into the vacated spots once occupied by bacteria, and starts to grow and multiply (Badiee and Alborzi., 2011).

Steroids and some cancer medications weaken the immune system and can allow yeast to flourish. Candida albicans infections of the mouth (known as oral thrush) most often develop in people with diseases such as cancer and AIDS. They can also develop in people with diabetes or in people who have long-term irritation resulting from dentures. Taking birth control pills increases your chances of getting vaginal candidiasis. Hot weather and tight clothing are also risk factors, as they create the ideal environment for candida (Aridogan et al., 2011).

Other conditions that tend to encourage yeast include obesity and pregnancy. Yeast generally infects intertriginous areas, that is, areas where skin contacts skin. Overweight people have more folds in their skin. They also sweat more, and Candida albicans is fond of moist skin. Pregnancy causes temporary obesity and may weaken the immune system, increasing the risk of yeast infections (Abe, 2004).

Experts disagree on the question of sexual transmission. Some research has suggested that it's very unlikely for an infected woman to give a man candidiasis (Abe, 2004). On the other hand, it's not unlikely that a man could give candidiasis back to his partner once he has it. Recent research has actually found Candida albicans in the sperm of men whose partners suffered from recurrent yeast infections (Akpan and Morgan, 2002).

1.3.2    Signs and symptoms of Candidiasis

Symptoms of candidiasis vary depending on the area affected.  Most candidial infections result in minimal complications such as redness, itching and discomfort, though complications may be severe or even fatal if left untreated in certain populations. In immunocompetent persons, candidiasis is usually a very localized infection of the skin or mucosal membranes, including the oral cavity (thrush), the pharynx or esophagus, the gastrointestinal tract, the urinary bladder, or the genitalia (vagina, penis) (Nyirjesy and Sobel et al., 2013).

         1.4              PREVALENCE OF Candida albicans ON HUMAN BODY PARTS

1.4.1    Urogenital tract

            Although Candida is often found in the lower female urogenital tract in asymptomatic women, proliferation and subsequent infestation of this fungal species accounts for approximately one-third of all infections in the vulva and/or vagina (i.e., vaginitis) (Sobel, 2012). Also known as vulvovaginal candidiasis (VVC) or “yeast infection” (Powell 2010), this fungal infection represents the second most common cause of vaginitis in the U.S. (after bacterial vaginosis), and is diagnosed in up to 40% of women who present to their primary care provider with vaginal complaints (Ilkit 2011). Approximately 75% of women report having had at least one episode of VVC, and between 40%-45% will suffer from at least two or more episodes within their lifetime (Workowski, 2010).

            The most common symptoms of VVC include unrelenting itch, painful intercourse, malodorous vaginal discharge, and painful urination (Workowski, 2010).

            Researchers have identified several factors that may increase susceptibility to fungal infections including:

·Diabetes (with poor glycemic control)

·Exposure to antibiotics (both during and after therapy)

·High levels of estrogen (e.g., oral contraceptives or estrogen therapy)

·Weakened immune system from drugs (e.g., corticosteroids) or disease (e.g., HIV/AIDS)

·Contraceptive device utilization (e.g., vaginal sponges, diaphragms, and intrauterine devices)

            Although less common, men can get genital fungal infections as well (Aridogan, 2011).

1.4.2    Skin

            Fungal infections of the skin (i.e., cutaneous fungal infections) are a common phenomenon, affecting millions of people worldwide. While cutaneous fungal infection is not normally life threatening, it can be very uncomfortable and associated with a significant decrease in quality of life (Katoh, 2009; Errol et al., 2011). Candida is just one of a variety of microorganisms commonly found on human skin. In healthy individuals, the overgrowth of candida is inhibited by resident skin microorganisms (normal bacterial skin flora). However, when there is an imbalance of this normal skin flora, candida can begin to reproduce in sufficient amounts to cause infection (i.e., candidiasis) (Evans, 2003; Manevitch et al., 2010; Konje et al., 1991).

            Individuals whose hands and/or feet remain wet for prolonged periods of time may be prone to fungal infection around or under their finger and toe nails. In these cases, the nail area commonly becomes red and swollen. The nails themselves will become thick and brittle, ultimately becoming destroyed and detached. Although anyone’s nails can become infected by fungus, these types of infections are more common among adults older than 60, and among individuals with diabetes or poor circulation (AAFP, 2008).

1.4.3    Mouth and throat

            Candida infections of the mouth (i.e., oral candidiasis) are widespread among humans (Giannini, 2011). In addition to the general factors that predispose an individual to candida infection (e.g., immunosuppressive drugs and antibiotics), oral candidiasis may also be caused by chronic dry mouth and oral prosthesis (dentures) (Junqueira, 2012). Although oral infection can be caused by a variety of Candida species, Candida albicans is the most common causative agent.

            Oral candidiasis (thrush) is characterized by whitish, velvety sores or patches appearing on the mucous membranes lining the inside of the mouth (e.g., roof of the mouth and inside the lips and cheeks), as well as the throat and tongue (Abe, 2004).

1.4.4    Systemic infection

            Although Candida species are normal residents of the gastrointestinal and genitourinary tracts of humans, they occasionally cause a deep-seated or systemic (disseminated) infection. These serious fungal infections usually indicate the host has a weakened immune system, and can occur as a result of a superficial skin infection that invades deeper tissues, eventually reaching the blood stream (i.e., candidemia). Once the fungus is circulating throughout the body, it has the capacity to reach vital organs such as the brain, heart, and kidneys. This form of candidiasis is rare, it is the most severe (Jayatilake, 2011).

1.4.5    Intestinal Candidiasis

            Intestinal Candida colonization can also lead to superficial and systemic candidiasis if the innate host barriers (i.e., mucosa, immune system, intestinal microflora) are not stable. Benign strains of intestinal candida can also become more virulent when their gene expression is altered in such a way that they are able to form biofilms, destroy tissues, and escape host immune system defenses (Kumamoto, 2011 and Schulze, 2009). While antimycotics (e.g., nystatin) are available for the treatment of intestinal candida overgrowth, probiotics (having demonstrated positive results in controlled clinical trials) may also be beneficial (Schulze, 2009).

1.4.6    Fungal Sinusitis

            Overgrowth of fungus in the nasal cavity (i.e., fungal sinusitis or fungal rhinosinusitis) and the subsequent human immune response (e.g., allergic fungal sinusitis) is currently believed to be responsible for some cases of chronic sinusitis. This condition can be classified as either invasive or non-invasive, depending on the extent of fungal infection. Invasive forms of fungal sinusitis are largely limited to immunocompromised populations and are characterized by infection of the submucosal tissue, which often causes tissues, necrosis and destruction (Riechelmann, 2011).

1.5       PREGNANT WOMEN AND Candida albicans INFECTION

For pregnant women, the risk of developing infection associated with Candida overgrowth is quite common during pregnancy. Controlling Candida overgrowth through proper diet, during pregnancy, is crucial to maintaining and improving health and protecting the health of the fetus during pregnancy (Balish and Wagner, 1998). With natural hormonal fluctuations, Candida often become imbalanced within a pregnant woman's body, leading many obstetricians to place a greater focus on proper diet and nutrition during pregnancy. Understanding the natural balance of Candida within the body of a pregnant woman, and the foods which trigger an adverse response, promoting overgrowth of Candida during pregnancy, is the first step to maintaining health during the gestational period and minimizing the need for prescription medications which may impact fetal development (Badiee and Alborzi, 2011).

Candida is a normal, healthy organism found within the body and, when in proper balance, is found in the intestines providing for a healthy response to the natural flora of the gastrointestinal tract. When overgrowth of Candida occurs, in response to hormonal changes in a pregnant woman, a condition known as Candidiasis sets in, leading to absorption of Candida into the skin and creating complicating health conditions, including risks to the cardiovascular system. This pregnancy complication leads to more common fungal or yeast infections of the mouth, known as Oral Thrush, vaginal yeast infections and even kidney and bladder infections during pregnancy (Badiee and Alborzi, 2011). More subtle Candidiasis complications may involve sore throat, abdominal pain and even symptoms of depression or emotional complications during pregnancy; all of which require additional medical attention by the obstetrician.

In an effort to control the overgrowth of Candida during pregnancy, many obstetricians will work to avoid prescribing prescription drugs to control yeast and fungal infections. Instead, the obstetrician will provide, and highly recommend, suggestions for controlling Candida naturally through dietary modifications during pregnancy. While pregnant women are generally very well versed in healthy food intake during the gestational period, especially in terms of yogurt consumption, there are a variety of foods which should be avoided as part of a healthy dietary program during pregnancy; such as other dairy products including cow's milk and cheese (Azimi, et al., 2011).

Additionally, the pregnant woman, when working to avoid Candida overgrowth, should avoid spikes in glucose levels through avoidance of drinks which contain sugar as increased in blood glucose levels may promote Candidiasis. From fruit to chocolate, Candida grows best when exposed to high blood glucose levels and, for this reason, complex carbohydrates, such as bread, should also be avoided unless the product is made with a true whole grain ingredient (Azimi et al., 2011).

Any product which contains or may be subject to mold, should be avoided during pregnancy, as with mold intake Candida will flourish within the gastrointestinal tract. Mold products might include nuts and even condiments such as black pepper. Additionally, the use of mushrooms, during pregnancy, should be avoided and eliminating other spices and herbs serves prudent so as to maintain the normal and healthy composition of the GI tract of the pregnant woman (Baddley et al., 2011).

While fruits are highly discouraged, the consumption of fresh vegetables is encouraged with allowance for only a specific type of fruit, such as avocado, tomato and lemon, in pregnant women seeking to naturally control Candida overgrowth. In fact, most dieticians and obstetricians will recommend a pregnant woman consume, at least, half of her diet in fresh or steamed vegetables. Health recommendations, drinking plenty of water and healthy fluids is crucial to eliminating toxins from the body. For this reason, avoiding caffeinated and sugary drinks is essential during pregnancy, while promoting healthy intake of fresh vegetable juice and even some forms of Chinese tea. The key to fluid intake is to ensure a proper balance of water is consumed to flush the gastrointestinal system of unwanted toxins, including the overproduction of Candida (Baddley et al., 2011).

As with most health considerations during pregnancy, controlling the onset of co morbid health complications will provide for a more healthy lifestyle and healthier infant at birth. Of the co morbid complications associated with pregnancy, conditions such as yeast infections and oral thrush are generally the result of an overgrowth of Candida (Balish and Wagner, 1998).

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