A longitudinal study on fluconazole resistance in Candida albicans vaginal isolates

BackgroundRecurrent vulvovaginal candidiasis (RVVC), despite its worldwide prevalence, has limited treatment options; and a long-term prophylactic regimen utilising fluconazole is the dominant choice. ObjectivesAn increase in fluconazole resistance is reported, and little information is available about the reversibility of resistance status following the withdrawal of fluconazole. MethodsRepeated antifungal susceptibility tests (ASTs) for fluconazole at a median interval of 3 months between them were evaluated in women with refractory or recurrent VVC patients at the Vaginitis clinic from 2012 to 2021 (10 years) and performed at pH 7 and pH 4.5 using the broth microdilution tests based on the CLSI M27-A4 reference method. ResultsOf 38 patients with long-term follow-up with repeat ASTs, 13 patients (13/38, 34.2%) tested at pH 7.0 remained susceptible to fluconazole with MIC <= 2 mu g/mL. Nineteen patients (19/38, 50%) remained resistant to fluconazole with MIC >= 8 mu g/mL, whereas four (4/38, 10.5%) changed from susceptible to resistant and two (2/38, 5.2%) changed from resistant to susceptible over time. At pH 4.5, among the 37 patients with repeated MIC values, nine (9/37, 24.3%) remained susceptible to fluconazole and 22 (22/37, 59.5%) remained resistant. Three isolates (3/37, 8.1%) changed from susceptible to resistant, while 3 (3/37, 8.1%) changed from resistant to susceptible over time. ConclusionFluconazole susceptibility in Candida albicans vaginal isolates obtained longitudinally in women with RVVC remains stable with rare reversal of resistance despite azole avoidance.