Incidence and Microbiological Profile of Vulvovaginal Candidiasis Among Pregnant Women Attending a Rural Tertiary Care Centre: A Prospective Observational Study

Vulvovaginal candidiasis (VVC) is one of the most common causes of vaginitis among women of reproductive age and represents a significant health concern during pregnancy. It is estimated that nearly 75% of women experience at least one episode of VVC in their lifetime, with a substantial proportion developing recurrent infections. Pregnancy is a well-recognized predisposing state for vulvovaginal candidiasis due to physiological, hormonal, and immunological changes that favour fungal colonization and overgrowth. Elevated estrogen levels during pregnancy increase vaginal glycogen content, providing a nutrient-rich environment that promotes the proliferation of Candida species.[1]

Among the etiological agents, Candida albicans remains the most frequently isolated organism; however, there has been a growing shift towards non-albicans Candida species such as Candida glabrata, Candida tropicalis, and Candida dubliniensis. These non-albicans species are of particular clinical concern due to their reduced susceptibility or intrinsic resistance to commonly used azole antifungal agents. This changing microbiological spectrum has significant implications for treatment outcomes, especially in pregnant women where therapeutic options are limited due to fetal safety considerations.[2]

Clinically, vulvovaginal candidiasis presents with symptoms such as vulvar itching, curdy white vaginal discharge, erythema, dysuria, and dyspareunia. While the condition is often considered benign, untreated or recurrent infections during pregnancy have been associated with adverse obstetric outcomes including preterm labor, low birth weight, premature rupture of membranes, and neonatal candidiasis. Furthermore, many pregnant women may harbor asymptomatic Candida colonization, which can progress to symptomatic infection under favorable conditions, highlighting the importance of early detection.[3]

The burden of vulvovaginal candidiasis is particularly significant in rural and resource-limited settings where access to diagnostic facilities and targeted antifungal therapy may be inadequate. In such settings, syndromic management is often practiced, which may lead to inappropriate treatment, persistence of infection, and development of antifungal resistance. Microbiological confirmation and species identification are therefore crucial to ensure appropriate management and to monitor emerging resistance patterns.[4]

AIM

To determine the incidence and microbiological profile of vulvovaginal candidiasis among pregnant women attending a rural tertiary care centre.

OBJECTIVES

1.             To estimate the incidence of vulvovaginal candidiasis among pregnant women.

2.             To identify and characterize Candida species causing vulvovaginal candidiasis.

3.             To assess the antifungal susceptibility pattern of isolated Candida species.

Table 1: Baseline Clinicodemographic and Clinical Profile of Study Participants (N = 300)

*Statistically significant                                    

Table 1 summarizes the baseline clinicodemographic and clinical characteristics of the 300 pregnant women enrolled in the study. The mean age of the participants was 24.9 ± 4.3 years, with a narrow 95% confidence interval (24.4-25.4), and did not differ significantly from the reference age of 25 years (p = 0.18). A majority of the study population belonged to the younger age group of less than 25 years (68.3%), followed by those aged 26-30 years (23.7%) and above 30 years (8.0%), with no statistically significant association observed across age groups (p = 0.41).

The mean body mass index (BMI) was 23.6 ± 3.1 kg/m², which was not significantly different from the reference value of 23 kg/m² (p = 0.09). More than half of the participants had a normal BMI (54.3%), while 41.0% were overweight and only 3.7% were obese, with no significant variation across BMI categories (p = 0.52). Regarding parity, multigravida women constituted 57.7% of the study population, whereas primigravida women accounted for 42.3%, with no statistically significant difference (p = 0.27).

Trimester-wise distribution showed that the majority of women were in the third trimester (57.7%), followed by the second trimester (36.0%) and first trimester (6.3%). This distribution was statistically significant (p = 0.03), indicating a higher representation of women in later stages of pregnancy. With respect to clinical symptoms, itching was reported by 34.3% of participants, while 65.7% did not report itching. The presence of itching showed a highly significant association (p < 0.001), highlighting its relevance as an important clinical symptom in the study population.

Table 2: Incidence of Vulvovaginal Candidiasis Among Antenatal Women (N = 300)

Table 2 depicts the incidence of vulvovaginal candidiasis among the 300 antenatal women studied. Out of the total participants, 37 women (12.3%) were found to be positive for Candida infection, with a 95% confidence interval ranging from 8.8% to 16.6%. The remaining 263 women (87.7%) tested negative for Candida. The observed incidence of vulvovaginal candidiasis was significantly lower than the expected prevalence of 20%, as demonstrated by a one-sample proportion Z-test (p < 0.001).

Table 3: Distribution of Candida Species Isolated in Pregnancy (N = 300)

*Statistically significant predominance of Candida albicans

Table 3 presents the distribution of Candida species isolated from the study population. Among the total 300 participants, Candida albicans was the predominant species, isolated in 29 women (9.67%), accounting for 78.4% of all Candida-positive cases. This predominance was statistically significant (p < 0.001). Non-albicans Candida species were isolated less frequently, with Candida dubliniensis and Candida tropicalis each accounting for 1.0% of the total study population and 8.1% of positive cases, while Candida glabrata was isolated in 0.67% of participants, representing 5.4% of positive cases. No fungal growth was observed in 87.7% of the samples. These findings clearly demonstrate that Candida albicans remains the most common etiological agent of vulvovaginal candidiasis in pregnancy, with non-albicans species contributing to a smaller proportion of infections.

Table 4: Antifungal Susceptibility Pattern of Isolated Candida Species (n = 37)

Table 4 illustrates the antifungal susceptibility pattern of the 37 Candida isolates obtained in the study. All isolates (100%) were sensitive to Amphotericin B and Voriconazole, with statistically significant results (p = 0.02 for both), indicating excellent efficacy of these agents. Sensitivity to Fluconazole was observed in 81.1% of isolates, while 16.2% showed resistance, a finding that was statistically significant (p = 0.01), suggesting emerging resistance to this commonly used antifungal drug.

High sensitivity was also noted for Micafungin, Caspofungin, and Flucytosine, with 91.9% of isolates being sensitive to each agent. A small proportion (8.1%) showed resistance or intermediate susceptibility, and these findings were statistically significant (p = 0.04).

Table 1: Clinicodemographic and Clinical Profile: In the present study, the mean age of pregnant women was 24.9 ± 4.3 years, with nearly two-thirds of participants belonging to the age group below 25 years. This age distribution is consistent with studies by Maheshwari P et al.(2025)[5], who reported that vulvovaginal candidiasis (VVC) is most commonly encountered in young women of reproductive age, likely due to heightened hormonal activity, increased vaginal glycogen content, and higher sexual activity. The lack of a statistically significant association between age groups and candidiasis in the present study mirrors findings by Weldegebreal F et al.(2025)[2], who also observed no significant age-related difference in VVC prevalence among pregnant women.

The mean BMI in this study was 23.6 ± 3.1 kg/m², with over half of the participants having a normal BMI. Although obesity has been implicated as a potential risk factor for candidiasis due to altered glucose metabolism and immune dysregulation, no significant association between BMI categories and candidiasis was observed in the present study. Similar observations were reported by Gedefie A et al.(2025)[4], who found that BMI alone was not an independent predictor of VVC in pregnancy.

Parity-wise analysis showed a higher proportion of multigravida women (57.7%), though parity did not demonstrate a statistically significant association with candidiasis. This finding aligns with studies by Maheshwari P et al.(2025)[5], suggesting that parity by itself may not be a decisive factor in the development of VVC.

Trimester-wise distribution revealed a statistically significant predominance of women in the third trimester, which is in agreement with earlier reports by Moursi SA et al.(2025)[6], who noted increasing Candida colonization with advancing gestational age. Elevated estrogen levels, increased vaginal glycogen, and relative immunosuppression in late pregnancy may explain this trend. The presence of itching showed a highly significant association with candidiasis (p < 0.001), reinforcing the role of pruritus as a key clinical indicator of VVC, as similarly reported by Yasin J et al.(2021)[7].

Table 2: Incidence of Vulvovaginal Candidiasis: The incidence of vulvovaginal candidiasis in the present study was 12.3%, which is significantly lower than the assumed prevalence of 20%. This incidence is comparable to findings from rural Indian settings reported by Hussen I et al.(2024)[1], who documented prevalence rates ranging from 10-15%. However, higher prevalence rates (25-36%) have been reported in urban and referral-based studies, such as those by Jain R et al.(2025)[8], likely reflecting differences in hygiene practices, antibiotic usage, and healthcare-seeking behavior. The relatively lower incidence in the present study may also be attributed to early antenatal registration and improved health education in the rural population studied.

Table 3: Candida Species Distribution: Microbiological analysis revealed Candida albicans as the predominant species (78.4% of positive cases), a finding that is statistically significant and consistent with most published literature. Studies by Agarwal S et al.(2025)[9] similarly reported C. albicans as the leading etiological agent in VVC. The isolation of non-albicans Candida species such as Candida dubliniensis, Candida tropicalis, and Candida glabrata, although less frequent, is clinically important, as these species are increasingly associated with antifungal resistance. The proportion of non-albicans species in the present study parallels observations by Wiliiam TA et al.(2022)[10], highlighting an emerging epidemiological shift.

Table 4: Antifungal Susceptibility Pattern: All Candida isolates in the present study demonstrated 100% sensitivity to Amphotericin B and Voriconazole, corroborating findings by Okonkwo N et al.(2020)[11], who reported high efficacy of these agents against vaginal Candida isolates. Sensitivity to Fluconazole was observed in 81.1% of isolates, with 16.2% resistance, which is comparable to resistance rates reported by Yasin J et al.(2021)[7], indicating a rising trend of azole resistance, particularly among non-albicans species.

Echinocandins such as Micafungin and Caspofungin showed high sensitivity (91.9%), consistent with data from Ali M et al.(2024)[12], supporting their role as effective alternatives in resistant cases. The predominantly sensitive response to Flucytosine further reinforces its utility, though the presence of intermediate susceptibility highlights the need for judicious use.

This prospective observational study conducted among pregnant women attending a rural tertiary care centre provides valuable insight into the incidence, microbiological profile, and antifungal susceptibility patterns of vulvovaginal candidiasis (VVC). The incidence of VVC in the present study was 12.3%, indicating that vulvovaginal candidiasis remains a significant though not overwhelming health concern in the antenatal population of rural settings.

The condition was predominantly observed in women of younger reproductive age and was more frequently encountered in the third trimester of pregnancy, suggesting that advancing gestational age plays a role in increased susceptibility, likely due to hormonal and immunological changes. The presence of itching showed a strong and statistically significant association with candidiasis, reinforcing its importance as a key clinical indicator warranting microbiological evaluation.

Microbiological analysis revealed Candida albicans as the predominant etiological agent, accounting for the majority of culture-positive cases, while non-albicans Candida species constituted a smaller but clinically relevant proportion. The emergence of non-albicans species underscores the evolving epidemiology of VVC and highlights the need for accurate species identification rather than empirical treatment alone.

Antifungal susceptibility testing demonstrated high sensitivity to Amphotericin B, Voriconazole, echinocandins, and Flucytosine, whereas a notable proportion of isolates exhibited reduced susceptibility or resistance to Fluconazole, a commonly used antifungal agent. This finding emphasizes the growing concern of azole resistance and the importance of antifungal susceptibility testing to guide effective and rational therapy.

LIMITATIONS OF THE STUDY 

1.             Single-centre design: The study was conducted at a single rural tertiary care centre, which may limit the generalizability of the findings to other geographic regions or urban populations.

2.             Convenience sampling: Use of convenience sampling may have introduced selection bias, as only women attending the antenatal outpatient department during the study period were included.

3.             Lack of molecular identification: Advanced molecular techniques for Candida species identification and resistance mechanisms were not employed, which could have provided deeper epidemiological insights.

4.             Cross-sectional assessment: The study did not include follow-up to assess recurrence rates, treatment outcomes, or the impact of candidiasis on pregnancy outcomes.

5.             Limited evaluation of risk factors: Although major clinical parameters were assessed, detailed evaluation of lifestyle factors, hygiene practices, and sexual behavior was not undertaken.