Reviewer's report
Title:Highly-cited estimates of the cumulative incidence and recurrence of
vulvovaginal candidiasis are inadequately documented
Version:2Date:19 November 2013
Reviewer: Cathy Watson
Reviewer's report:
- Major Compulsory Revisions
*None identified
- Minor Essential Revisions
1. The authors assert that Sobel is often erroneously cited for the statement that
5-10% of all women experience RVVC. This is misleading, as Sobel himself cites
this figure his later highly cited Lancet publication (Sobel 2007), using Foxman et
al. 1998 as his source (see below), of which he was a co-author.
“The infection - caused by Candida spp- affects 70–75% of women at least once
during their lives, most frequently young women of childbearing age. 40–50% of
women will experience a recurrence.1 5–8% of adult women have recurrent
vulvovaginal candidosis, defined as four or more episodes every year.” (Sobel
2007).
Clarification of the authors’ assertion is requested.
2. The statement “…both self-diagnosis and clinical diagnosis are known to be of
low accuracy” is supported by two secondary references. It would be more
appropriate to use primary references such as Nyrijesy et al. 1997.
3. The sentence “The literature on vulvovaginal candidiasis continues to report
these unsupported estimates for the burden of vulvovaginal candidiasis among
all women, leading women experiencing abnormal vaginal discharge and their
respective medical practitioners to be more likely to make syndromic diagnosis of
VVC” makes an unfounded association between the literature and the
subsequent predictor of diagnostic behaviour. It is well supported in the literature
that self-diagnosis and diagnosis without mycological confirmation are
inaccurate, and that VVC is often over-diagnosed without evidence. However, it
is unlikely that most women are aware of and influenced in their self-diagnosis by
knowledge of the estimates in the literature. It is also possible that clinician
misdiagnosis may be impacted by lack of confidence in diagnosing other vaginal
conditions such as vulval vestibulodynia or vulval dermatitis rather than by being
influenced by inaccurate citations of VVC in the literature. I would suggest that
this section be re-worked to modify this unfounded association.
- Discretionary Revisions / general comments
4. The recommendations proposed are fair but ambitious! A representative
sample of the population would be challenging to obtain, and the lack of
information from non-responders would bias the analysis. This is likely reflect in
the high number of epidemiological studies using self-reported diagnosis of VVC.
5. The fourth recommendation “exclusion of Candida as an innocent bystander’
refers presumably to asymptomatic vaginal colonisation of Candida spp. It is not
proven that asymptomatic colonisation is always ‘innocent’ as several authors
have documented the significance of asymptomatic colonisation such as the
likelihood of developing post-antibiotic symptomatic vaginal candidiasis (e.g.
Pirotta & Garland 2006) and yeast colonisation is a necessary precursor to
symptomatic VVC (e.g. Beigi et al. 2004).
6. In the Discussion section, the authors bring in new material and references
that contribute to the background of the argument. This may be more appropriate
in the previous section.
Quality of written English
--------------------------
As we do not charge for access to published research, we cannot undertake the
costs of editing. If the language is a serious impediment to understanding, you
should choose the first option below, and we will ask the authors to seek help. If
the language is generally acceptable but has specific problems, some or all of
which you have noted, choose the second option.
7. In the references, use of italics is required when referring to species e.g.
Candida glabrata; Lactobacillus rhamnosus e.g. references 5, 12, 24, 37, 51.
8. Inconsistent use of capitalisation in titles references needs correction. Some
titles deviate from lower case e.g. references18, 20, 42, 51, 60, 69.
Level of interest: An article of importance in its field
Statistical review: No, the manuscript does not need to be seen by a statistician.
Declaration of competing interests:
I declare that I have no competing interests