Goswami Deepti, Goswami Ravinder, Banerjee Uma, Dadhwal Vatsla, Miglani Sunita, Lattif Ali Abdul, Kochupillai Narayana
Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, Ansari Nagar, Delhi 110029, India.
J Infect. 2006 Feb;52(2):111-7. doi: 10.1016/j.jinf.2005.03.005.
Patients with diabetes mellitus are at increased risk of vulvovaginal candidiasis (VVC). Besides Candida albicans, they often have infection due to non-C. albicans Candida species such as C. glabrata. Oral single dose fluconazole (150 mg) is commonly used to treat VVC in non-diabetic individuals with response rate varying from 70 to 90%. However, there is paucity of related information in diabetic women with VVC. Present study has been conducted to systematically assess the effect of fluconazole therapy among diabetic patients with clinically symptomatic VVC.
Study subjects included 85 consecutive patients with diabetes mellitus (type 2=70 and type 1=15) and 62 non-diabetic women who had clinical signs and symptoms of VVC and in whom evidence of candidiasis was documented by presence of yeast on direct microscopy followed by culture. Single dose fluconazole (150 mg) was given orally to all the subjects in a supervised manner. Subjects were reassessed on 14th day after fluconazole therapy and a repeat high vaginal swab was taken for direct microscopy and fungal culture. Total glycosylated haemoglobin (HbA1) was measured to assess glycaemic control.
There were no significant differences in the frequency of pruritus (55.9 vs. 56.7%), vaginal discharge (63.8 vs. 69.0%), dyspareunia (25.0 vs. 20.0%), and percentage yeast positivity (67.5 vs. 54.7%) between diabetic and control groups before the start of fluconazole therapy. Following fluconazole therapy, vaginal discharge on examination and yeast positivity on direct microscopy continued to remain positive in higher percentage of subjects in the diabetic group as compared to non-diabetic subjects (52.5 vs. 36.4%; P =0.22 and 50.7 and 29.0%, respectively, P =0.07, respectively). Overall 67.1% of patients with diabetes and 47.3% of controls continued to show persistence of Candida growth on high vaginal swab culture following fluconazole treatment (P=0.042). Candida glabtara was the most common species isolated in patients with diabetes mellitus and its frequency was significantly higher in them when compared to control group (54.1 vs. 22.6%, P<0.001). C. albicans was the most common species isolated in controls. Species-specific response to fluconazole showed that 81.3% of patients in the diabetic group and 78.6% of the non-diabetic controls continued to show fungal growth when C. glabrata was the organism grown (P=0.99). However, in case of C. albicans, 45.4% of the patients in the diabetic group and only 21.5% of the controls had persistent Candida growth following fluconazole therapy (P=0.22).
Overall only one third of patients with diabetes mellitus and VVC respond to single dose 150 mg of fluconozole therapy. Limited response in the clinical symptoms and culture negativity following single dose fluconazole therapy in diabetic subjects with VVC is explained by the high prevalence of C. glabrata in them. The present study involved only 85 patients and majority of them had type-2 diabetes mellitus. There is need to perform similar study in large number of diabetics subjects including patients with type-1 diabetes mellitus and assess various alternative treatment protocol which are also effective in C. glabrata infection.
糖尿病患者发生外阴阴道念珠菌病（VVC）的风险增加。除白色念珠菌外，他们还常因非白色念珠菌属念珠菌如光滑念珠菌感染。口服单剂量氟康唑（150mg）常用于治疗非糖尿病个体的VVC，有效率在70%至90%之间。然而，关于糖尿病合并VVC女性的相关信息较少。本研究旨在系统评估氟康唑治疗对有临床症状的糖尿病VVC患者的疗效。
研究对象包括85例连续的糖尿病患者（2型糖尿病70例，1型糖尿病15例）和62例有VVC临床症状且直接显微镜检查发现酵母并经培养证实有念珠菌感染的非糖尿病女性。所有受试者均在监督下口服单剂量氟康唑（150mg）。氟康唑治疗14天后对受试者进行重新评估，并再次采集高阴道拭子进行直接显微镜检查和真菌培养。检测总糖化血红蛋白（HbA1）以评估血糖控制情况。
在开始氟康唑治疗前，糖尿病组和对照组在瘙痒频率（55.9%对56.7%）、阴道分泌物（63.8%对69.0%）、性交困难（25.0%对20.0%）以及酵母阳性率（67.5%对54.7%）方面均无显著差异。氟康唑治疗后，与非糖尿病受试者相比，糖尿病组中检查时阴道分泌物阳性和直接显微镜检查酵母阳性的受试者比例更高（分别为52.5%对36.4%；P = 0.22；以及分别为50.7%和29.0%，P = 0.07）。总体而言，糖尿病患者中有67.1%，对照组中有47.3%在氟康唑治疗后高阴道拭子培养仍显示念珠菌持续生长（P = 0.042）。光滑念珠菌是糖尿病患者中分离出的最常见菌种，其在糖尿病患者中的频率显著高于对照组（54.1%对22.6%，P < 0.001）。白色念珠菌是对照组中分离出的最常见菌种。氟康唑的菌种特异性反应显示，当培养出的菌种为光滑念珠菌时，糖尿病组81.3%的患者和非糖尿病对照组78.6%的患者仍有真菌生长（P = 0.99）。然而，对于白色念珠菌，糖尿病组45.4%的患者和对照组仅21.5%的患者在氟康唑治疗后有念珠菌持续生长（P = 0.22）。
总体而言，只有三分之一的糖尿病合并VVC患者对150mg单剂量氟康唑治疗有反应。糖尿病VVC患者单剂量氟康唑治疗后临床症状缓解有限且培养阴性，这是由于其中光滑念珠菌的高流行率所致。本研究仅涉及85例患者，且大多数为2型糖尿病患者。有必要在包括1型糖尿病患者在内的大量糖尿病患者中进行类似研究，并评估对光滑念珠菌感染也有效的各种替代治疗方案。
