Management of Azole-Refractory Candida Species Using Boric Acid Preparations: A Case Study in Dar Es Salaam, Tanzania

The aim of this study was to determine the antifungal agents and boric acid susceptibility to the azole-resistant Candida species, as well as clinical outcomes following treatment with antifungal agents that are commonly prescribed in Dar es Salaam and boric acid which is not available in Tanzania market. Microscopic examination of the vaginal discharge during prolonged therapy with three antifungal agents (clotrimazole, miconazole, and nystatin) and boric acid were carried out. Samples were collected from 150 women of reproductive age group (13 to 45 years) with chronic vaginal candidal infections. The samples were cultured in Sabouraud’s dextrose agar (supplemented with 0.005% chloramphenicol and 0.05% cycloheximide) followed by aerobic incubation for 48 hours at 37ºC in order to obtain pure cultures. Identification was done by Gram stain, while the test for ability to ferment and assimilate different sugars was done on API Candida and API 20C AUX. The stock cultures of Candida albicans (ATCC 32354), Candida glabrata (ATCC2001) and Candida guilliermondii (ATCC6260) were used as controls. Patients were dispensed together with 10 ml syringes for self douching of boric acid solution, and three commonly used antifungal vaginal drugs for Candida vaginitis. The results revealed a total of 167 Candida species dominated by C. albicans 116 (69.46%), followed by C. glabrata 21 (12.57%), C. krusei 8 (4.8%), C. tropicalis 7 (4.2%), C. famata 6 (3.59%), C. lusitaniae 5 (3.0%), C. parapsilosis, Trichosporon 2 (1.2%) and C. guilliermondii 1(0.6%). The results further showed that out of 116 C. albicans isolates, 23 (19.83%) were resistant to clotrimazole while 14 (12.1%) were resistant to miconazole in vitro test. Interestingly, all C. albicans isolates and the nonalbicans candida species were very sensitive to boric acid at a very low MIC values (0.025μg/ml). Generally, the overall success rate for clotrimazole in treating C. albicans infections was 41.7%, miconazole 56.5%, nystatin 77.3% and boric acid 100%. This study shows that, compared to other commonly used drugs in the country, the best performance of boric acid envisage the need to update the national treatment guidelines for the treatment of Candida vaginitis.Key words: Non-albicans Candida species, azole resistance, boric acid

Prevalence and risk factors for vaginal candidiasis among women seeking primary care for genital infections in Dar es Salaam, Tanzania

Objective: To determine the prevalence and risk factors for vaginal candidiasis (VC) among women seeking primary care for genital infections. Design: Cross-sectional study. Setting: Ilala Municipal Hospital in Dar es Salaam, Tanzania. Subjects: Four hundred and sixty four women presenting with complaints of genital infections. Results: Of the 464 women examined, 177 (38.1%) had abnormal vaginal discharge, 68(14.7%) had genital ulcers, 272 (58.6%) had genital pruritis, 18 (3.9%) had genital warts and 58 (12.5%) had chancre. The prevalencies of VC, bacterial vaginosis, HIV, T vaginalis, N. gonorrhoeae and syphilis were 45%, 48.4%, 22%, 93%, 1.5% and 4.3%, respectively. The occurrence of VC was positively associated with HIV, (OR=1.81, 95% CI (1.0-2.67), bacterial vaginosis; (OR=2.6, 95%CI (1.7-3.9), genital pruritis; (OR=1.8 1, 95%CI (1.2- 2.7) genital discharge; (OR=1.867, 95% (1.28-2.73) and negatively with T. vaginalis (OR=0.27, 95% CI (0.12 - 0.6), occupation (OR=0.65, 95%CI (0.35-0.86)) and with education (OR=0.43, 95% CI (0.11-0.73). There were increased but non-significant odds for VC in patients with syphilis (OR=1.6 95%CI (0.6-4.3) and venereal warts (OR=2.5 95% CI (0.92-6.8) VC was not associated with N. gonorrhoeae, genital ulcers, age at first intercourse, number of sexual partners, marital status or antibiotic usage. Conculsion: The high prevalence of vaginal candidiasis among women with genital infections should be taken into account when updating policies concerning syndromic management of sexually transmitted diseases. More gender specific approach to syndromic management of sexually transmitted infections in females should be considered. East African Medical Journal Vol.82(3) 2005: 139-14

Screening of Tanzanian medicinal plants for anti-Candida activity

BACKGROUND: Candida albicans has become resistant to the already limited, toxic and expensive anti-Candida agents available in the market. These factors necessitate the search for new anti-fungal agents. METHODS: Sixty-three plant extracts, from 56 Tanzanian plant species obtained through the literature and interviews with traditional healers, were evaluated for anti-Candida activity. Aqueous methanolic extracts were screened for anti-Candida activity by bioautography agar overlay method, using a standard strain of Candida albicans (ATCC 90028). RESULTS: Twenty- seven (48%) out of the 56 plants were found to be active. Extracts of the root barks of Albizia anthelmintica and Balanites aegyptiaca, and roots of Plectranthus barbatus showed strong activity. CONCLUSION: The extracts that showed strong anti-Candida activity are worth of further investigation in order to isolate and identify the active compounds

Identification of Candida strains isolated from Tanzanian pregnant women with vaginal candidiasis

Objective: To identify Candida strains isolated from Tanzanian women (13 to 45 years) with vaginal candidiasis. Design: A cross-sectional study. Setting: Antenatal clinic in llala district hospital in Dar es Salaam, Tanzania from March 1998 to December 2000. Results: The identities of the 272 isolates tested with API Candida were: Candida albicans 180(66.2%), Candida tropicalis 13(4.7%), Candida glabrata 20(7.35%), Candida famata 6(2.2%), Candida parapsilosis 6 (2.2%) and Candida lusitaniae one (0.37%). API Candida could not speciate 43 (15.8%) isolates of these; two (0.7%) fell between C. albicans and C. tropicalis, 17(6.25%) C. Iusitaniael, C. guilliermondii/C. famata, 14(5.15%) C. krusei, C. inconspicua, and C. norvegensis and nine (3.3%) either C. parapsilosis, C. krusei, C. incospicua or Geotrichum spp. Four (1.5%) isolates had an assimilation pattern of Trichosporo spp, but were all germ tube positive and had morphological features on cornemeal agar that were consistent with C. albicans. API 20C AUX was used for testing 29 isolates and results showed: 11/29 (37.9%) C. albicans, 1/29 (3.4%) C. tropicalis, 4/29 (13.8%) C. glabrata, 1/29 (3.4%) C. parapsilosis, 1/29 (3.4%) C. famata, 1/29 (3.4%) C. lusitaniae, 1/29 (3.4%) C. colliculosa/C. magnoliae, 5/29(17.2%) C. albicans/ C. tropicals 2/29 (6.8%) C. norvegensis/C. parapsilosis, and 2/29(6.8%) C. kruseil/C. inconspicua. Results of 20 isolates identified by Randomly Amplified Polymorphic DNA (RAPID) technique showed a 95% agreement with API Candida and a 100% agreement with API 20C AUX. Conclusion: Although most (66.3%) of the species isolated from Dar es Salaam women with vaginal candidiasis were C. albicans, a considerable percentage (33.7%) were nonalbicans, mainly C. glabrata, C. krusei and C. tropicalis. The high prevalence of non-albicans Candida spp observed in this population may have therapeutic implications.East African Medical Journal Vol. 82(5) 2005: 226-23