Title: Resistant C. albicans implicated in recurrent vulvovaginal candidiasis (RVVC) among
women in a Tertiary Healthcare facility in Kumasi, Ghana
Version: 2 Date: 07 Aug 2023
Reviewer's report:
Comments
Abstract
1. The authors stated in the result section that “… vaginal infection was most prevalent amongst
females in their reproductive age (21 to 30 years) and cut across all levels of education”. It is
unclear what the percentage prevalence is in the sampled population. Authors should consider
providing this info.
2. Rephrase “The study found a significant association between vaginal infections and sexual
practices, antibiotic misuse, poor personal hygiene and birth control methods.” And possibly
add their concomitant p-values.
Introduction
1. An in – text reference is needed for the first and second sentences.
2. Authors should consider improving grammar throughout the manuscript.
Methods:
Study site and study design
1. The authors stated the study was cross sectional, conducted on 350 women and 172 women
who consented for face – to – face interview. It is difficult to tell how the sample size for the
study was calculated. Kindly clarify.
2. Kindly provide a reference for the description of the study site.
3. Is it possible to kindly provide the average number of cases of VVI at the facility? This will
be very informative.
4. Authors should consider including running appropriate logistic regression analysis to establish
risk factors with strength of association depicted with OR (either crude or/and Adjusted OR)
or proportional OR.
Germ tube formation assay and PCR confirmation of C. albicans
1. Figures 1 and 2 seem to be missing at the rightful position in the manuscript. It should be at
the methods section and not the results as is the case currently. Kindly improve.
Results
1. Lines 1 to 3 should rather be stated in the methods section.
2. Kindly provide the p-value for “Association between Age Category and Sexual Activeness”
in table 1.
3. Kindly take note and correct, “Participants between the ages of 46 to 60 years (1.7%) and 61
to 80 years (1.7%) were observed to have a lower prevalence of vaginal infection” is in table
1 not table 2.
4. Is there a reason why authors were silent on chronic disease status, type of chronic disease,
pregnancy status, hormonal control and birth control methods of respondents in the narrative
of table 1?
5. These is no info presented in the table 1 regarding association of chronic disease and vaginal
infection. However, reference was made of it in the narrative. Kindly improve.
6. The use of correlation in “Antibiotic Use: Antibiotic use by participants had a significant
correlation (p=0.001)” is inappropriate, kindly revise.
7. For table 2, I suggest the authors consider revising the analysis as it difficult to understand the
table. A re-categorization into less frequent (never + once) and more frequent (2 – 3 times and
#4 times) would make the interpretation of the chi – square analysis more informative with the
associated p –value. Additionally, it should be presented as figure (percentages). Then crude OR
and Adjusted OR could also be calculated for those factors with significant p-values (<0.005)
or having a p – value of less than 0.01.   Alternatively, an ordinal logistic regression analysis
could be done with the outcome being the frequency (never, once, 2 – 3 times and #4 times) and
report the proportional odd ratios and p-values.
8. I suggest the authors focus only on significant p – values in their narratives as these are of
more interest to the reader.
Discussion:
1. Following the re-analysis for table 2 very likely there will be a need to update the discussion
accordingly.
Conclusion:
The conclusion needs a review keeping the mind the results of the analysis. Factors found in the
analysis to have p – values greater than 0.05 should not be reported as being significant factors
associated with VVC infection. A case in point is “type of toilet facility” which has a p – value
of 0.1 but reported in the conclusion to be a significantly associated factor “There is a significant
association between behavioral related factors and practices such as frequency and number of
sexual partners, antibiotic use, personal hygiene, type of toilet facility used, mode of underwear
cleaning and the frequency of VVC infection.”