Advances in Infectious Diseases, 2013, 3, 238-242
Published Online December 2013 (
Open Access AID
Prevalence of Non-Albicans Candida Infections in Women
with Recurrent Vulvovaginal Symptomatology
Jason D. Mintz1, Mark G. Martens2
1Rutgers-Robert Wood Johnson Medical School, Piscataway, USA; 2Department of Obstetrics and Gynecology, Jersey Shore Uni-
versity Medical Center, Neptune, USA.
Email: mmart e
Received September 8th, 2013; revised October 8th, 2013; accepted October 14th, 2013
Copyright © 2013 Jason D. Mintz, Mark G. Martens. This is an open access article distributed under the Creative Commons Attribu-
tion License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly
Background: Candida vulvovaginitis is one of the most frequently diagnosed conditions in women’s care practices.
Historically, 90% of cultured yeast species were C. albicans. However, due to a variety of interventio ns, the proportion
of non-albicans Candida (NAC) infections appears to be increasing. We sought to estimate the current prevalence of
Candida vulvovaginitis and the species-specific distribution of such infections in recurrent cases. Methods: Women
with recurrent vulvovaginal symptomatology referred to an Obstetrics and Gynecology practice were tested by genital
fungus culture, Candida-specific polymerase chain reaction (PCR), or both between July 2010 and February 2013.
Results: A total of 103 women were tested. Mean age was 45.6 years. Including only their most recent positive test
result, 29.1% (30/103) of women tested positive for Candida by any of the above testing measures. Of those, 50%
(15/30) tested positive for C. albicans and 50% (15/30) tested positive for a NAC species. Across all visits, 60% (18/30)
tested positive for C. albicans, 56.7% (17/30) tested positive for NAC, and 16.7% (5/30) tested positive for both a C.
albicans and a NAC species. Among all isolated NAC species, 28.6% (6/21) were determined to be C. glabrata, 23.8%
(5/21) C. krusei, 23.8% (5/21) C. parapsilosis, and 23.8% (5/21) other Ca ndida species. Conclusion: Approximately
30% of women with recurrent vulvovaginal symptomatology have detectable Candida strains and it appears that NAC
species may cause half of all these infections. This is imperative because NAC infections are usually more difficult to
diagnose and are resistant to most treatments.
Keywords: Recurrent Vulvovaginal Candidiasis; Non-Albicans Candida; Fluconazole; Yeast Infections; Candida
1. Introduction
Candida vulvovaginitis is a frequently diagnosed condi-
tion in women’s care practices [1]. It has been reported
that approximately 75% of women will experience at
least one yeast infection in their lifetime and that 5% -
8% of women will meet the criteria for recurrent vul-
vovaginal candidiasis (RVVC), having more than four
episodes in a given year [2,3]. The cost associated with
diagnosis and treatment of vulvovaginal candidiasis (VVC)
is proposed to be in excess of $3 billion by 2014 [1]. This
figure is likely a gross underestimate, as the number of
Candida infections resistant to conventional therapeutics
appears to be increasing [4].
The reported Candida prevalence in patients with vul-
vovaginal complaints is approximately 30% [5]. Histori-
cally, 85% - 95% of cultured yeast species were C. albi-
cans [6-8]. However, due to a variety of interventions in-
cluding single dose treatment, low-dosage azole mainte-
nance regimens, and the use of over-the-counter antimy-
cotics, the proportion of NAC species appears to be in-
creasing [2,9-11]. Reports published in the most recent
decade suggest a NAC prevalence of 10% - 30% in pa-
tients with VVC [4,12-16]. Among a study involving
RVVC patients, 20% were found to be infected by a NAC
species, but this study cultured only a limited number of
NAC species [17]. Discrepancies in NAC prevalency fi-
gures may be reflective of differences among the respec-
tive patient cohorts sampled with regard to climates, cul-
tures, geographic conditio ns, and prescribing patterns [2].
Within the past few years, there has been some evi-
Prevalence of Non-Albicans Candida Infections in Women with Recurrent Vulvovaginal Symptomatology 239
dence put forth questioning the pathogenicity and overall
significance of NAC species [17,18]. These authors pro-
pose that symptomatic patients testing positive for NAC
species may not need to be treated, as their symptoms
may result from an alternative diagno sis [17,18]. A major
tenet of one such claim is that 27% of patients treated fo r
a NAC infection had a persistence of symptoms despite
negative culture [17]. Though a case-specific determina-
tion of NAC significance may be warranted in women
with other potential diagnoses, it is worth noting that
Candida infection can exist despite negative cultures [19].
With the advent of PCR, an additional cohort of women
with vulvovaginal symptoms, yet negative cultures can
be detected.
Other evidence also sug gests that NAC infection s war-
rant significant concern. Several reports note that NAC
species appear to be associated with severe or recurrent
cases of VVC [10,13]. Zeng et al. notes that a greater
percentage of NAC infections th an C. albicans infections
is associated with more severe symptoms [13]. Simi-
larly, Girgoriou et al. reports that NAC caused more fre-
quent vaginal soreness and dyspareunia than C. albicans
[10]. The predominant NAC species cited in these studies,
C. glabrata, as well as other strains including C. krusei,
do not reliably respond to azoles [4,16,20,21]. Therefore,
identification is need ed to better direct therapy.
Due to the significance of NAC species in clinical
practice, we sought to determine the current prevalence
of Candida vulvovaginitis and the species-specific dis-
tribution of such infections in recurrent cases.
2. Methods
2.1. Study Design
From July 2010 to February 2013 a retrospective analysis
of all patients (103 in total) referred to an obstetrics and
gynecology practice for recurrent vulvovaginal sympto-
matology was conducted to determine the prevalence of
C. albicans and NAC infection. All women involved in
the study presented after repeated courses of oral and
topical antifungals for their recurrent symptoms. They
were tested for Candida by genital fungus culture, Can-
dida-specific PCR, or both. Since the compiled database
included results from multiple visits, only the most recent
positive C. albicans or NAC culture and/or PCR result
was used to determine prevalence rates. However, posi-
tive C. albicans and NAC results from multiple visits
were also collected. NAC species frequency was calcu-
lated using the positive NAC culture and/or PCR results
from all visits.
2.2. Specimen Collection
Specimens for each patient were taken by direct vaginal
wall collection during a speculum-assisted vaginal exam
using sterile swabs (BBL CultureSwab, Becton, Dickin-
son and Company, Spar ks, Maryland).
2.3. Culture
Primary genital fungal culture and yeast identification
from the primary culture was performed according to the
methodology of Hazen and Isenbe r g [22].
2.4. PCR
Yeast was detected for the following six species: C. al-
bicans, C. glabrata, C. krusei, C. parapsilosis, C. tropi-
calis, and C. dublinensis utilizing the amplification of
Candida species target DNA by PCR based on dual pri-
ming oligonucleotide technology per the method of Luo
and Mitchell [23].
3. Results
From July 2010 to February 2013, 103 women were ex-
amined and tested by culture and/or PCR for the etiolog y
of their recurrent vulvovag inal symptoms. In to tal, 29 .1%
(30/103) of the women tested positive for any Candida
species (Figure 1). An analysis of the diagnoses in these
women suggested that Candida was the sole pathogen in
60% (18/30) of the patients with the remaining 40%
(12/30) having a mixed infection of Candida plus a bac-
terial pathogen. Of the thirty woman who tested positive
for Ca n d id a , 50% (15/30) tested positive for C. albicans,
while 50% (15/30) tested positive for a NAC species (Fi-
gure 1). These numbers reflect the most recent positive
culture and/or PCR result in each woman.
Across all visits and inclusive of any positive culture
and/or PCR result in the thirty patients testing positive
for Candida, 60% (18/30) had a C. albicans infection and
56.7% (17/30) had a NAC infection. Among these wo-
men, 16.7% (5/30) were infected by both C. albicans and
a NAC species at some point in the study period with one
woman having a simultaneous C. albicans and NAC in-
Throughout the duration of the study, a positive NAC
result was obtained in 21 samples in 17 different women.
Of the four recurrent positive results, three women had
different NAC species from an earlier visit and one wo-
man had two different NAC species detected on the same
visit. Among the NAC species identified, 28.6% (6/21)
were determined to be C. glabrata, 23.8% (5/21) C. kru-
sei, 23.8% (5/21) C. parapsilosis, 9.5% (2/21) C. lusita-
niae, and 4.8% each C. famata, C. tropicalis, and C. dub-
linensis (Figure 2).
4. Discussion
Vulvovaginal symptomatology is a frequent complaint
prompting a physician’s of fice visit, with yeast infectio ns
Open Access AID
Prevalence of Non-Albicans Candida Infections in Women with Recurrent Vulvovaginal Symptomatology
Figure 1. Prevalence of Candida in patients with recurrent
symptoms, n = 103. I, percent prevalence in which Candida
was not detected; II, percent prevalence in which Candida
was detected; IIa, percent of II in which Candida albicans
was detected; IIb, percent of II in which a non-albicans
Candida species was det ected.
Figure 2. Non-albicans Candida species frequency, n = 21.
CG, Candida glabrata; CK, Candida krusei; CP, Candida pa-
rapsilosis; CL, Candida lusitaniae; OC, other non-albicans
Candida species.
representing one of the most common etiologies [1]. Ap-
proximately 5% - 8% of women experience RVVC, re-
sulting in a significant cost to th e healthcare system [1-3].
In this study, it was determined that 29.1% of women
with recurrent vulvovagin al symptoms tested positive for
Candida by culture and/or PCR. Among these women,
50% were determined to be infected by a NAC species.
Historically, limited data has been published on the
prevalence of NAC infections in RVVC populations,
most likely due to the focus on the preponderance of C.
albicans infections in non-recurrent cases. However, NAC
inf ections may cause mor e severe s ymptoms [ 10,13] an d
are often more difficult to treat [2]. In 2010, Kennedy et
al. estimated the prevalence of NAC infection in RVVC
patients to be 20% [17]. Although a large study, this pre-
valence was limited by the culture identification of a
small subset of NAC species including C. glabrata, C.
parapsilosis, and C. lusitaniae [17]. As evidenced by our
data, other species such as C. krusei may also significant-
ly contribute to the prevalence of clinically relevant NAC
This greater NAC prevalence likely reflects an increas-
ing trend. In a large retrospective study o f a vaginitis cli-
nic population, Spinillo et al. reported an increase in
NAC prevalence from 9.9% to 17.2% between 1988 and
1995, a trend which was upheld even after a subgroup
analysis of self-referred patients without a history of
RVVC [9]. Similarly, Mar tens et al. reported a NAC pre-
valence of 18.9 % in a cohort of women with yeast inf ec-
tions from 1994-1996, two years following over-the-coun-
ter approval for topical antifungals, but prior to the po-
pularization of oral fluconazole [24]. In a gynecology in-
fectious disease practice, Nyirjesey et al. found a 25%
NAC prevalence among a population of chronic vaginitis
patients between 1991 and 1993 [25]. Most recently in
2011, Guzel et al. reported a 50% NAC prevalence in
their mixed acute and chronic vaginitis patient po pulation
With regard to patients diagnosed with RVVC, the re-
cent, sharp increase in NAC in fection possibly stems from
the increased and repeated usage of fluconazole. Fluco-
nazole was Food and Drug Administration approved for
the treatment of vulvovaginal candidiasis in 1994 and
since then its prescription by physicians has risen [26].
Unlike C. albicans, which has demonstrated uniform sus-
ceptibility to fluconazole withou t a significant increase in
the MIC50 or MIC90 between 1986 and 2008, NAC spe-
cies including C. glabrata, C. lusitaniae, and C. krusei
do not reliably respond to fluconazole [4,16,20,21].
Fluconazole, rather than topical azoles, is likely the
major etiologic factor for increased NAC prevalence be-
cause it is absorbed through the gastrointestinal tract.
Previous studies indicate that the gut serves as the initial
reservoir for vulvovaginal colonization2 and that there is
a high degree of homology between yeast found in both
the intestines and vagina [2,27,28]. We suspect that re-
peated trials of fluconazole select for more resistant NAC
species in the gut, particularly in RVVC patients who
have received multiple courses over several years. These
species then colonize and infect the vulvovagina relative-
ly unopposed from competing yeast species. Consequent-
ly, it is expected that an analysis of primary referral data
may reveal, a preponderance of patien ts initially infected
by C. albicans who developed NAC infections over the
course of repeated fluconazole treatment.
Along with the increased prevalence of NAC infec-
tions due to increased fluconazole use, the advent of PCR
has allowed us to detect a greater proportion of such in-
fections. Culture is only able to detect infection in pa-
tients harboring 103 organisms per milliliter; yet, as few
as 102 organisms are sufficient to cause symptoms [19].
PCR can identify an additional group of patients in which
definitive diagnostic evidence would not otherwise be
available. However, despite the heightened sensitivity of
PCR, concordance between both culture and PCR may be
lacking [22]. In their study, Mardh et al. reported a 43%
concordance rate between culture and PCR with 21% of
vulvovaginal Candida samples positive only by culture
and 18% positive only by PCR [22]. Reduced concordance
rates may be partially attributable to detection threshold s
Open Access AID
Prevalence of Non-Albicans Candida Infections in Women with Recurrent Vulvovaginal Symptomatology 241
set by laboratories. Standardization among laboratories
should be adopted.
5. Conclusion
As a result of the increased prevalence of NAC species in
patients with recurrent symptoms, the identification of
offending Candida strains is of high priority to better di-
rect therapy and eradicate infection early. Further inves-
tigation into the most reliable and co st effective means of
identification shou ld be performed.
[1] B. Foxman, R. Barlow, H. D’Arcy, B. Gillespie and J. So-
bel, “Candida Vaginitis: Self-Reported Incidence and As-
sociated Costs,” Sexually Transmitted Diseases, Vol. 27,
No. 4, 2000, pp. 230-235.
[2] J. D. Sobel, “Vulvovaginal Candidosis,” Lancet, Vol. 369,
No. 9577, 2007, pp. 1961-1971.
[3] B. Foxman, J. V. Marsh, B. Gillespie and J. Sobel, “Fre-
quency and Response to Vaginal Symptoms among White
and African American Women: Results of a Random Di-
git Dialing Survey,” Journal of Womens Health, Vol. 7,
No. 9, 1998, pp. 1167-1174.
[4] T. G. Bauters, M. A. Dhont, M. I. Temmerman and H. J.
Nelis, “Prevalence of Vulvovaginal Candidiasis and Sus-
ceptibility to Fluconazole in Women,” American Journal
of Obstetic Gynecology, Vol. 187, No. 3, 2002, pp. 569-
[5] A. Paulitsch, W. Weger, G. Ginter-Hanselmayer, E. Marth
and W. Buzina, “A 5 Year (2000-2004) Epidemiological
Survey of Candi da and Non-Candida Yeast Species Caus-
ing Vulvovaginal Candidiasis in Graz, Austria,” Mycoses,
Vol. 49, No. 6, 2006, pp. 471-475.
[6] F. C. Odds, “Candida and Candidosis: A Review and Bi-
bliography,” Bailliere Tindall, London, 1988, p. 124.
[7] J. D. Sobel, “Epidemiology and Pathogenesis of Recur-
rent Vulvovaginal Candidiasis,” American Journal of Ob-
stetic Gynecology, Vol. 152, No. 7, 1985, pp. 924-935.
[8] J. D. Sobel, “Recurrent Vulvovaginal Candidiasis: A Pro-
spective Study of the Efficacy of Maintenance Ketoco-
nazole Therapy,” The New England Journal of Medicine,
Vol. 315, No. 23, 1986, pp. 1455-1458.
[9] A. Spinillo, E. Capuzzo, R. Gulminetti, R. Marone, L. Co-
lonna and G. Piazzi, “Prevalence and Risk Factors for
Fungal Vaginitis Caused by Non-Albicans Species,”
American Journal of Obstetic Gynecology, Vol. 176, No.
1, 1977, pp. 138-141.
[10] O. Grigoriou, S. Baka, E. Makrakis, D. Hassiako s, G. Kap-
paros and E. Kouskouni, “Prevalence of Clinical Vaginal
Candidiasis in a University Hospital and Possible Risk
Factors,” The European Journal of Obstetrics & Gyneco-
logy and Reproductive Biology, Vol. 126, No. 1, 2006, pp.
[11] A. B. Guzel, M. Ilkit, T. Akar, R. Burgut and S. C. Demir,
“Evaluation of Risk Factors in Patients with Vulvovaginal
Candidiasis and the Value of chromID Candida Agar Ver-
sus CHROMagar Candida for Recovery and Presumptive
Identification of Vaginal Yeast Species,” Medical Myco-
logy, Vol. 49, No. 1, 2011, pp. 16-25.
[12] T. Weissenbacher, S. S. Witkin, W. J. Ledger, V. Tolbert,
A. Gingelmaier, C. Scholz, et al., “Relationship between
Clinical Diagnosis of Recurrent Vulvovaginal Candidiasis
and Detection of Candida Species by Culture and Poly-
merase Chain Reaction,” Archives of Gynecology and Ob-
stetrics, Vol. 279, No. 2, 2009, pp. 125-129.
[13] J. Zeng, L. L. Zong, T. Mao, Y. X. Huang and Z. M. Xu,
“Distribution of Candida albican Genotype and Candida
Species Is Associated with the Severity of Vulvovaginal
Candidiasis,” Journal of Southern Medical University,
Vol. 31, No. 10, 2011, pp. 1649-1653.
[14] J. P. Vermitsky, M. J. Self, S. G. Chadwick, J. P. Trama,
M. E. Adelson, E. Mordechai, et al., “Survey of Vaginal-
Flora Candida Species Isolates from Women of Different
Age Groups by Use of Species-Specific PCR Detection,”
Journal of Clinical Microbiology, Vol. 46, No. 4, 2008,
pp. 1501-1503.
[15] S. Corsello, A. Spinillo, G. Osnengo, C. Penna, S. Gua-
schino, A. Beltrame, et al., “An Epidemiological Survey
of Vulvovaginal Candidiasis in Italy,” The European
Journal of Obstetrics & Gynecology and Reproductive
Biology, Vol. 110, No. 1, 2003, pp. 66-72.
[16] J. Holland, M. L. Young, O. Lee and S. C.-A. Chen,
“Vulvovaginal Carriage of Yeasts Other than Candida
Albicans,” The European Journal of Obstetrics & Gyne-
cology and Reproductive Biology, Vol. 79, No. 3, 2003,
pp. 249-250.
[17] M. A. Kennedy and J. D. Sobel, “Vulvovaginal Candidi-
asis Caused by Non-Albicans Candida Species: New In-
sights,” Current Infectious Disease Reports, Vol. 12, No.
6, 2010, pp. 465-470.
[18] G. J. Dennerstein, D. E. Ellis, C. S. Reed and C. M. Ben-
nett, “The Pathogenicity of Non-Albicans Yeasts in the
Vagina,” Journal of Lower Genital Tract Disease, Vol.
15, No. 1, 2011, pp. 33-36.
[19] R. Kaufman and S. Faro, “Candida Benign Diseases of
the Vulva and Vaginia,” 4th Edition, Mosby, St. Louis,
1994, p. 321.
[20] S. S. Richter, R. P. Galask, S. A. Messer, R. J. Hollis, D.
J. Diekema and M. A. Pfaller, “Antifungal Susceptibili-
ties of Candida Species Causing Vulvovaginitis and Epi-
demiology of Recurrent Cases,” Journal of Clinical Mi-
crobiology, Vol. 43, No. 5, 2005, pp. 2155-2162.
Open Access AID
Prevalence of Non-Albicans Candida Infections in Women with Recurrent Vulvovaginal Symptomatology
Open Access AID
[21] S. Singh, J. D. Sobel, P. Bhargava, D. Boikov and J. A.
Vasquez, “Vaginitis Due to Candida Krusei: Epidemiol-
ogy, Clinical Aspects, and Therapy,” Current Infectious
Disease, Vol. 35, No. 9, 2002, pp. 1066-1070.
[22] K. C. Hazen, “Mycology and Aerobic Actinomycetes,” In:
H. D. Isenberg, Ed., Essential Procedures for Clinical Mi-
crobiology, ASM, Washington DC, 1998, pp. 280-342.
[23] G. Luo and T. Mitchell, “Rapid Identification of Patho-
genic Fungi Directly from Cultures by Using Multiplex
PCR,” Journal of Clinical Microbiology, Vol. 40, No. 8,
2002, pp. 2860-2865.
[24] M. G. Martens, P. Hoffman and M. El-Zaatari, “Fungal
Species Changes in the Female Genital Tract,” Journal of
Lower Genital Tract Disease, Vol. 8, No. 1, 2004, pp. 21-
[25] P. Nyirjesy, S. M. Seeney, M. H. Grody, C. A. Jordan and
H. R. Buckley, “Chronic Fungal Vaginitis: The Value of
Cultures,” American Journal of Obstetrics & Gynecology,
Vol. 173, No. 3, 1995, pp. 820-823.
[26] L. McCaig and M. McNeil, “Trends in Prescribing for
Vulvovaginal Candidiasis in the United States,” Pharma-
coepidem Dr S, Vol. 14, No. 2, 2005, pp. 113-120.
[27] M. R. Miles, L. Olsen and A. Rogers, “Recurrent Vaginal
Candidiasis: Importance of an Intestinal Reservoir,”
JAMA, Vol. 238, No. 17, 1977, pp. 1836-1837.
[28] X. L. Lin, Z. Li and X. L. Zuo, “Study on the Relation-
ship between Intestinal Candida in Patients with Vulvo-
vaginal Candidiasis,” Chinese Journal of Obstetrics and
Gynecology, Vol. 46, No. 7, 2011, pp. 496-500.