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Abstract

We appreciate the thoughtful comments of Noverr and Fidel as to the findings in our recent publication evaluating the presence of Candida-associated biofilm in women with acute vulvovaginal candidiasis (VVC).1Swidsinski A. Guschin A. Tang Q. et al.Vulvovaginal candidiasis: histologic lesions are primarily polymicrobial and invasive and do not contain biofilms.Am J Obstet Gynecol. 2019; 220: 91.e1-91.e8Abstract Full Text Full Text PDF Scopus (44) Google Scholar The study produced 2 conclusions: (1) the extensive and previously unreported human vaginal mucosal invasion and infiltration by Candida microorganisms as well as the clinical consequences of tissue invasion; and (2) failure to document using a well-described and widely used technique of fluorescent in situ hybridization with ribosomal gene-based probes, the presence of microscopic biofilm, containing Candida species microorganisms. The latter finding is also of clinical significance in that no justification was forthcoming for utilizing biofilm busters as part of the therapy of acute VVC, especially in patients with recurrent VVC.2Sobel J.D. Recurrent vulvovaginal candidiasis.Am J Obstet Gynecol. 2016; 214: 15-21Abstract Full Text Full Text PDF PubMed Scopus (277) Google Scholar Noverr and Fidel are concerned about the vaginal site from which biopsies were taken, the VIZ mid-side wall. This is the traditionally preferred site for obtaining vaginal yeast culture, recognizing the macroscopic appearance similarity of the vagina through 360⁰ with regard to appearance, histology, and microbiome. In addition, there is a lack of access to the vaginal floor and ceiling because of the speculum blades used in examination. Clearly biofilm could be disrupted in the biopsy process, but to be absent to the extent it was, makes this extremely unlikely, and bacterial biofilm was clearly apparent and retained. It is true that extracellular matrix was not stained for. It is critical to emphasize that one should not confuse macroscopic biofilm evident on catheters and in plastic wells containing Candida populations containing extracellular matrix with microscopic biofilm evident only in histopathological vaginal sections (eg, bacterial vaginosis), which is invisible to the naked eye. Clinicians are experienced in separating the grayish white frothy vaginal discharge characteristic of BV from the clumpy white discharge, sometimes adherent and confluent, typical of VVC. The macroscopic white plaques seen in VVC, reflecting large populations of hyphae producing Candida microorganisms together with bound epithelial cells and debris, do not reflect or constitute biofilm. Discharge in our study is entirely irrelevant. We agree that antifungal drug resistance has been infrequent in the past in women with recurrent VVC because of C albicans; however, the frequency has increased significantly as a function of fluconazole drug exposure3Marchaim D. Lamanek L. Bheemreddy S. et al.Fluconazole-resistant Candida albicans vulvovaginitis.Obstet Gynecol. 2012; 120: 1407-1414Crossref PubMed Scopus (131) Google Scholar and unrelated to biofilm existence. Resistance may also emerge as a consequence of deep mucosal persistence of yeast organisms, an observation that deserves further study. Questions remain regarding the presence of fungal species biofilm in women with vulvovaginal candidiasisAmerican Journal of Obstetrics & GynecologyVol. 221Issue 2PreviewIn the insightful publication by Swidsinski et al,1 the authors address important questions regarding the presence of vaginal biofilm in cases of vulvovaginal candidiasis (VVC). They conclude following evaluation of vaginal biopsies that lesions are primarily polymicrobial and do not contain biofilm. Full-Text PDF Should we absolutely reject the hypothesis that epithelium-based Candida biofilms contribute to the pathogenesis of human vulvovaginal candidiasis?American Journal of Obstetrics & GynecologyVol. 221Issue 4PreviewWe read the article by Swidsinski et al1 with great interest. The authors used fluorescent in situ hybridization of human vaginal tissue biopsies to demonstrate the absence of Candida biofilms in patients with vulvovaginal candidiasis (VVC). This is a very important finding because it might reset the treatment target for recurrent VVC (RVVC) from biotic biofilms to invasive fungi. Full-Text PDF