Antifungal Resistance Pattern of Candida Species Isolated from High Vaginal Swabs of Women Attending a Hospital in Enugu State, Nigeria

Main Article Content

Joachim Ohiakwu Ezeadila
Ikechukwu Okoli
Christie Amaechi Oyeka


There is an increase in non-albicans Candida (NAC) vulvovaginal candidiasis which is attributed to overuse of antifungal therapy and this has led to antifungal resistance. This study was aimed at determining the antifungal resistance pattern of some clinical isolates of Candida species. Eighty-eight (88) isolates were used which included Candida tropicalis (34), Candida Parapsilosis (21), Candida albicans (20), Candida krusei (7) and Candida glabrata (6). The drugs used were Fluconazole (25µg), Ketoconazole (10µg), Voriconazole (1µg), Nystatin (100Units), Amphotericin B (20µg), Flucytosine (1µg), Clotrimazole (10µg) and Itraconazole (50µg). The susceptibility testing was carried out using the M44-A standard method for yeast disk diffusion testing. Results showed that the percentages of Candida species resistant to Fluconazole, Ketoconazole, Voriconazole, Amphotericin B, Flucytosine, Clotrimazole and Itraconazole and Nystatin were 52.3%, 61.9%, 35.2%, 19.3%, 86.4%, 34.1%,  45.5% and 44.3%,  with inhibition zone diameters ≤14mm, ≤20mm, ≤13mm, <10mm, ≤11mm, ≤11mm, ≤13mm and no inhibition zone diameter respectively. Candida krusei was the most resistant species with 100% resistance to each of Fluconazole, Ketoconazole and Flucytosine. Candida tropicalis was the species with the highest susceptibility (79.4%) to Amphotericin B followed by Candida parapsilosis with inhibition zone diameters ≥15mm. While Candida glabrata showed 100% resistance to each of Flucytosine and Itraconazole, Candida albicans showed 100% resistance to Flucytosine only. Candida glabrata was the only Candida species with 0% resistance to Amphotericin B. The drug to which most of the Candida species were susceptible was Amphotericin B followed by Voriconazole while Flucytosine was the drug with the highest resistance followed by Ketoconazole and Fluconazole. The highest number of susceptible-dose dependent Candida isolates was observed with Ketoconazole (25%), followed by Clotrimazole and Itraconazole, each recording 23.9%. Based on the findings of the present study, Voriconazole is recommended for vaginal candidiasis especially in the study area and also especially for infections caused by Fluconazole-resistant Candida species. This suggests that routine sensitivity testing is pertinent to guiding the choice of antifungal therapy. Thus, indiscriminate use of antifungal drugs should be avoided to reduce the development and spread of resistance.

Resistance, Candida species, Vulvovaginal candidiasis, antifungal drugs, Enugu state.

Article Details

How to Cite
Ezeadila, J. O., Okoli, I., & Oyeka, C. A. (2020). Antifungal Resistance Pattern of Candida Species Isolated from High Vaginal Swabs of Women Attending a Hospital in Enugu State, Nigeria. Journal of Advances in Microbiology, 20(9), 62-72.
Original Research Article


Lortholary O, Desnos-Ollivier M, Sitbon K, Fontanet A, Bretagne S, Dromer F. Recent exposure to Caspofungin or Fluconazole influences the epidemiology of candidemia; A prospective multicenter study involving 2, 441 external icon. Antimicrobial Agents

Martins N, Ferreira IC, Barros L, Silva S, Henriques M. Candidiasis: Predisposing factors, prevention, diagnosis and alternative treatment (PDF). Mycopathologia. 2014;177(5–6):223–240.

CDC. Vaginal Candidiasis; 2019. Accessed 15 July 2020 Available:

Udayalaxmi J, Shani J, D’Souza D. Comparison between virulence factors of Candida albicans and non-albicans species of Candida isolated from genitourinary tract. Journal of Clinical Diagnostic Research. 2014;8(11):DC15-DC17.

Ilkit M, Guzel AB. The epidemiology, pathogenesis, and diagnosis of vulvovaginal candidosis: a mycological perspective. Critical Reviews in Microbiology. 2011;37:250-261.

Amouri I, Sellami H, Borji N, Abbes S, Sellami A, Cheikhrouhou F, et al. Epidemiological survey of vulvovaginal candidosis in Sfax, Tunisia. Mycoses. 2011;54:499–505.

Amouri I, Sellami H, Abbes S, Hadrich I, Mahfoudh N, Makni H, et al. Microsatellite analysis of Candida isolates from recurrent vulvovaginal candidiasis. Journal of Medical Microbiology. 2012;61:1091–1096.

Adane B, Yeshiwork A. Vulvovaginal candidiasis: Species distribution of Candida and their antifungal susceptibility pattern. BMC Womens Health. 2018;18(1): 94.

Skoczylas MM, Walat A, Kordek A, Loniewska B, Rudnicki J, Maleszka R, et al. Congenital candidiasis as a subject of research in medicine and human ecology. Annals of Parasitology. 2014;60(3):179–189.

Prasad R, Goffeau A. Yeast ATP-binding cassette transporters conferring multidrug resistance. Annual Review Microbiology. 2012;66(1):39–63.

Shah DN, Yau R, Lasco TM, Weston J, Salazar M, Palmer HR. Impact of prior inappropriate Fluconazole dosing on isolation of Fluconazole-nonsusceptible Candida species in hospitalized patients with candidemia external icon. Antimicrobial Agents Chemotherapy. 2012; 56:3239–3243

Ezeadila JO, Oyeka CA, Okoli I, Chidi-Onuorah CL. Prevalence of vaginal Candida colonization among women attending University of Nigeria teaching hospital, Enugu State, Nigeria. Global Journal of Advanced Research. 2020; 7(4):88-95.

NCCLS. Reference method for antifungal disk diffusion susceptibility testing of yeasts; approved guideline. NCCLS document M44-A. National Committee for Clinical Laboratory Standards, Wayne; 2004.

CLSI. Method for antifungal disk diffusion susceptibility testing of yeasts; approved guideline. 2nd Ed. CLSI document M44-A2. Clinical and Laboratory Standards Institute, Wayne, Pennsylvania. 2009;29(17):3-7.

Rosco Diagnostica. Susceptibility Testing of Yeasts. Taastrupgaardsvej 30, DK- 2630,Taastrup, Denmark; 2011. Accessed 2 November 2017. Available:

Won EJ, Shin JH, Choi MJ, Lee,WG, Park YJ, Uh Y, et al. Antifungal susceptibilities of bloodstream isolates of Candida species from nine hospitals in Korea: Application of new antifungal breakpoints and relationship to antifungal usage. Plos One. 2015;10(2):1–9.

Fairuz AM, Nazri MA, Hishamshah MI, Atiqah NH, Parameswari S, Hafiza, M. R. et al. In vitro antifungal susceptibilities of Candida isolates from patients with invasive candidiasis in Kuala Lumpur hospital, Malaysia. Journal of Medical Microbiology. 2011;60: 1312 –1316.

Adesiji YO, Ndukwe N, Okanlawon BM. isolation and antifungal sensitivity to Candida isolates in young females. Central European Journal of Medicine. 2011;6(2): 172-176.

Gandhi TN, Patel MG, Jain MR. Antifungal susceptibility of Candida against six antifungal drugs by disk diffusion method isolated from vulvovaginal candidiasis. International Journal of Current Research Review. 2015;7(11):20-25.

Jayalakshmi L, Ratnakumari G. Samson S. Isolation, speciation and antifungal susceptibility testing of Candida from clinical specimens at a tertiary care hospital. Scholars Journal of Applied Medical Sciences. 2014;2(6E):3193–3198.

Okolo MO, Kim EG, Idoko E, Essien UC. Antifungal susceptibility pattern of Clotrimazole and Nystatin against Candida species of vaginal specimens in Jos, North Central Nigeria. European Journal of Biomedical and Pharmaceutical Sciences. 2017;4(9):857-861.

Tsega A, Mekonnem F. Prevalence, risk factors and antifungal susceptibility pattern of Candida species among pregnant women at Debre Markos Referral Hospital, Northwest Ethiopia. BMC Pregnancy and Childbirth. 2019;19:527.

Deepa B, Subbannayya K, Rao PS, Rao TV. Clinic-mycological profile of vaginal candidiasis in a tertiary care hospital in Kerala. International Journal of Research in Biological Sciences. 2013;3(1):55-59.

Dagi HT, Findik D, Senkeles C, Arslan U. Identification and antifungal susceptibility of Candida species isolated from bloodstream infections in Konya, Turkey. Annals of Clinical Microbiology and Antimicrobials. 2016;15(36):1-5.

Hope WW, Tabernero L, Denning DW, Anderson MJ. Molecular mechanisms of primary resistance to Flucytosine in Candida albicans. Antimicrobial agents and chemotherapy. 2004;48(11):4377-4386.

Panizo MM, Reviákina V, Dolande M, Selgrad S. Candida spp. In vitro susceptibility profile to four antifungal agents. Resistance surveillance study in Venezuelan strains. Medical Mycology. 2009;47(2):137–143.

Jasem M, Mahsa M, Jafar P, Mohamad RH, Ali D, Mitra A, et al. Anti-Fungal Resistance in Candida Isolated from Oral and Diaper Rash Candidiasis in Neonates Bioinformation. 2014;10(11):667-670.

Emam SM, Elazm, AA., Morad AW. Exoenzymes production and antifungal susceptibility of Candida species isolated from pregnant women with vulvovaginitis. Journal of American Science. 2012;8(12): 1392-1399.

Fahriye E. Efgan DG, Iclal B. In vitro susceptibility of Candida Species to four antifungal agents assessed by the reference broth microdilution method. The Scientific World Journal. 2013;236903.

Almeida AA, Mesquita CSS, Svidzinski TIE, Oliveira KMP. Antifungal susceptibility and distribution of Candida spp. isolates from the University hospital in the municipality of Dourados, State of Mato Grosso do Sul, Brazil. Revista da Sociedade Brasileira de Medicina Tropical. 2013;46(3):335- 339.

Silva CR, Magalhães HIF, Moraes MO. Júnior HVN. Susceptibility to Amphotericin B of Candida spp. strains isolated in Ceará, Northeastern Brazil. Revista da Sociedade Brasileira de Medicina Tropical. 2013;46(2):244-245.

Nicolaou KC, Chen JS, Dalby SM. From Nature to the laboratory and into the clinic. Bioorganic and Medicinal Chemistry. 2009; 17:2290-2303.

Volmer AA, Szpilman AM, Carreira EM. Synthesis and biological evaluation of Amphotericin B derivatives. Natural Product Reports. 2010;27:1329-1349.

Nasira S, Vilas J, Sarita K, Basavraj N. Antifungal drug resistance in Candida species. European Journal of General Medicine. 2013;10(4):254-258.

Sheikh N, Jahagirdar V, Kothadia S, Nagoba B. Antifungal drug resistance in Candida species. European Journal of General Medicine. 2013;10(4):254-258.

Pfaller MA, Diekema DJ, Gibbs DL, Newell VA, Ellis D, Tullio V, et al. Results from the ARTEMIS DISK global antifungal surveillance study, 1997 to 2007: A 10.5-year analysis of susceptibilities of Candida Species to Fluconazole and Voriconazole as determined by CLSI standardized disk diffusion. Journal of Clinical Microbiology. 2010;48:1366–1377.

Rodloff C, Koch D, Schaumann R. Epidemiology and antifungal resistance in invasive candidiasis. European Journal of Medical Research. 2011;16:187–95.

CLSI. Reference Method for Broth Dilution Antifungal Susceptibility Testing of Yeasts, in Approved standard. 3rd ed. CLSI Document M27-A3. Wayne, PA: Clinical and Laboratory Standards Institute; 2008.

Fothergill AW, Rinaldi MG, Sutton DA. Antifungal susceptibility testing. Infectious Disease Clinics of North America, 2006;20: 699-709.

Whaley SG, Berkow EL, Rybak JM, Nishimoto AT, Barker KS, Rogers PD. Azole antifungal resistance in Candida albicans and emerging non-albicans Candida species. Frontiers in Microbiology. 2017;7:2173.

Lee I, Fishman NO, Zaoutis TE, Morales KH, Weiner MG, Synnestvedt M, et al. Risk factors for Fluconazole-resistant Candida glabrata blood stream infections. Archives of Internal Medicine. 2009;169: 379–383.