Title: Resistant C. albicans implicated in recurrent vulvovaginal candidiasis (RVVC) among
women in a Tertiary Healthcare facility in Kumasi, Ghana
Version: 2 Date: 30 Oct 2023
Reviewer:  Pedro Miguel Dos Santos Abrantes
Reviewer's report:
Dear authors
Please find my detailed review of your manuscript below.
Some important points:
- Please decide if your manuscript is written in UK English or US English and edit the text
accordingly (it is currently a mix of both).
- Please add line numbering in all pages in future manuscript corrections/submissions in order
to make the review easier.
- I suggest that the manuscript is proofread by a native English speaker, so that the many minor
grammatical inaccuracies currently present can be corrected.
- It would have been interesting to know which other Candida species were present in these
women, apart from C. albicans.
- This study relies heavily on patient questionnaires, which can be inaccurate. In addition,
Candida albicans is not the only culprit when it comes to endogenous vaginal infections, with
both aerobic and anaerobic bacteria usually being involved and sometimes forming biofilms
with Candida. Therefore, the mentioning of vaginal infections in the text and tables needs to
take this into consideration and not relate it only to the presence of Candida.
Abstract, second paragraph: Please change “swap” to “swab”.
Abstract, third paragraph: Delete “In the study”.
Abstract, fourth paragraph: Change “anti-fungal” to “antifungal”.
Key words: Change “candida albicans” to “Candida albicans” in italics.
Background, first paragraph: Change “specie” to “species” and do the same in the rest of the
document (the singular of species is also “species”); Delete “(Center for Disease control”.
Change “specimen” to “specimens” and add a reference to that sentence.
Background, second paragraph: Delete “the medication”.
Background, third paragraph: Change “A lot of factors” to “Various factors”.
Background, fourth paragraph: Change “giving a cause of concern” to “which is a cause of
concern”; change “though” to “although”. In this paragraph you briefly mention reports from
Europe and Asia but fail to include data from other African countries. There are published
reviews on Candida drug resistance in Africa that should be added to this argument, since this
provides important AMR regional data for comparison.
Background, fifth paragraph: The text “Reports from Europe and Asia indicate high resistance
rates of C. albicans and non-Candida albicans to the available antifungals including fluconazole
and voriconazole (Sobel, 2015; Bruna et al., 2015; WHO, 2014). Whereas C. albicans has
not been found to be resistant to fluconazole in previous studies in Ghana, a growing trend
of resistance has been detected in other countries. Ultimately, large gaps in information on
antifungal resistance exist and reports in Ghana are scanty.” is repeated (see paragraphs 4 and
5), please delete.
I suggest changing the “Method” section to  “Methods” or “Materials and Methods”.
Methods section, first paragraph: Please edit the last sentence of this paragraph (commas, capital
letters and semicolons in inappropriate places and grammar).
Methods section, second paragraph: Change “rVVC” to “RVVC” here and in the subsequent
text; delete the semicolon on this paragraph; Change “bleeding per vagina” to “vaginal
bleeding”; Change “antifungal agent(s) and/or antibiotics” to “antifungal or antibiotic therapy”.
Methods section, third paragraph: This whole paragraph is repeated text from the second
paragraph, please delete.
Methods section, fourth paragraph: Only the last sentence pertains to specimen collection, the
rest of the text belongs in the previous section/paragraph. Here you mention “A purposeful
sampling of 350 women” but only 172 respondents are mentioned afterwards, please clarify
(if you initially aimed to interview 350 women, this can be removed). Change “guideline” to
“guidelines”; Please add the details (manufacturer, catalogue number) for the swabs used for
sample collection.
Methods section, fifth paragraph: Consider changing this subheading/merging it with the
previous one. Change “Sterile cotton swab was aseptically” to “Individual sterile cotton swabs
were aseptically”; Please add the manufacturer and catalogue numbers for the media mentioned
here; Move the last sentence to the following paragraph and change “yeast like cells was
identified” to “yeast-like cells were identified”.
Methods section, sixth paragraph: Here you mention that the germ tube test was used to
identify C. albicans. However, C. dubliniensis also gives a positive germ tube test result. The
first sentence is therefore incorrect and needs to be edited. Please change the (Aryal, 2022)
reference since this is a generic webpage – use a published study instead. Change “triplicates”
to “triplicate”. An additional test such as growth on chromogenic, tomato and/or tobacco agar,
which distinguish these two species inexpensively could also have been used.
Methods section, seventh paragraph: Change “Inquaba Biotec Limited” to “Inqaba Biotec”;
Please correct the sentence “The PCR products were then amplified DNA products were
analyzed..”; Please provide the model of the transilluminator.
Methods section, eight paragraph: Please combine the first two sentences, the CLSI
methodology is mentioned twice; Italicise “Candida”; Delete “All antifungals used were
purchased from Oxoid Ltd, Basingstoke, UK” and add “Oxoid Ltd, Basingstoke, UK” after the
last antimicrobial disc is mentioned; Change “test” to “testing” and add the model and brand
of the densitometer; Change “using a disc dispenser (Oxoid 6-place, 90 mm)” to “using a 90
mm 6-place disc dispenser (Oxoid, Cat. no. xxx)”; Delete “of the” and change “was” to “were”;
Place brackets in “2018”.
Methods section, ninth paragraph: Please correct “extracted and into”; Close the bracket after
“USA” and add a final mark.
Results section, first paragraph: “Participants who were included in the study were mostly
residents of the Ashanti region” – please add the relevance of this information. If there is no
relevance, please delete. The text repeats a lot of information contained in the tables and could
be summarised.
Results section, table 1: I would suggest changing “sexual activeness” to “current sexual
activity” (if it relates to the patient reporting that she was sexually active during the time of
sample collection).
Results section, third paragraph: “Most participants who used the private but shared water closet
experienced a recurrent infection than those who used the public pit latrine and public water
closet” – this unexpected result will need to be addressed in the Discussion.
Results section, fourth paragraph: This will also need to be discussed. Is the sale of prescription
drugs regulated in Ghana? Are these patients self-medicating with antibiotics or are these
prescribed for aerobic vaginitis/bacterial vaginosis?
Results section, fifth paragraph: this appears to suggest that if the used underwear is left in the
washing basket before it is washed, the patient has a higher chance of infection. Would you
recommend that underwear is immediately washed after use and/or a hot water wash aid in
reducing infections?
Results section, sixth paragraph: In the 6th line of this paragraph, please change “partners” to
“partner”; Please add a final mark at the end of this paragraph.
Results section, seventh paragraph: “Four (4) of the females used vaginal cream and antiseptics
in washing the vagina” – please add the recurrent infection rate as you did for the other groups.
Results section, eight paragraph: “Such birth control methods may serve as a reservoir for the
adhesion of yeast to form biofilms (p=0.049)” – please explain where this p value comes from
and how it is related to biofilms; Please change “Twelve and two tenths” to “Twelve point two”.
Results section, table 2: Remove double spacing between words; Change “vagina creams” to
“vaginal creams”.
Results section, ninth paragraph: The text “Growth of C. albicans on Sabouraud dextrose agar
produced whitish or creamish colonies.  A wet preparation of these colonies showed yeast-like
cells of Candida species when observed under the microscope.” should be summarised (e.g.,
presumptive identification was performed by observing colony colour and morphology and yeast
cell observation using microscopy) and should appear immediately after SDA is mentioned.
Results section, Figure 1: In my opinion this figure in its current form can be deleted.
Results section, Figure 2: The positive control mentioned in the figure legend is not on the
picture; Isolate numbers 1-74 are mentioned in the legend but only 38-76 are shown. What are
samples 75 and 76? Also, the numbers do not align with the gel columns. This figure needs to
be improved.
Results section, Figure 3: This figure shows a heavy inoculum, imperfect FCA and VOR zones of
inhibition and the writing. I suggest using a clearer picture. Please change “Muellar” to “Muller”
in the legend. Figures 1 and 3 could be combined as a flow diagram (from sample collection to
the characterisation steps, including the sample/isolate numbers), to make it easier for the reader
to follow what was done
Results section, Figure 4: The following bar graph sequence should be used: S, I, R. The
Intermediate results need to be discussed in the Discussion section.
Discussion section: Please correct the typesetting and grammatical inaccuracies in this
section; Spores are mentioned in this section when mentioning the underwear washing.
However, Candida doesn’t produce the same type of spores that filamentous fungi do (only
chlamydospores, which allow them to survive in unfavourable conditions). Please correct
this; The mentioning that “Frequent coitus disturbs the ecosystem of the vagina” needs to be
elaborated on, since monogamous couples are known to share protective lactobacilli, which
prevents infection by maintaining a low pH. Non-sexually active women are also affected
by vaginitis; Please change “environ” to “environment” throughout the text; The end of the
Discussion section is confusing and needs to be edited for clarity – the differences and mode of
action of antifungals should be briefly mentioned in the Introduction section, not the Discussion.
It must be added to the discussion that a questionnaire is insufficient in gathering accurate data
(e.g., seropositive patients might have not reported their HIV status due to stigma; patients could
be unaware of other conditions asked). Patient hospital files should also have been looked at.
This must be added as a limitation of the study.
Conclusion section: I have serious reservations when it comes to the conclusions stated here,
since most of what is mentioned is based on patient questionnaires which might not be accurate.
There is no mentioning of the linkage between patient details and the antifungal susceptibility
results, which would have strengthened this study.