vaginitis is a common complaint for females and is the most frequent reason for gynecology consultation in primary health care services . vulvovaginal candidiasis ( vvc ) , which accounts for 4050% of all cases of infectious vulvovaginitis , has been known as a common problem worldwide . it is estimated that 75% of women experience at least one episode of vvc throughout her lifetime , and 58% of adult women have recurrent vvc ( rvvc ) which is defined as four or more culture - confirmed episodes in a 12-month period . an increasing prevalence of fungal resistance is also reported in global and local antifungal surveillance studies . the increased rvvc incidence and drugs resistance cause an important public health issue and give great challenge to clinician 's treatment strategy . knowledge of local epidemiological patterns such as clinical characteristics of cases , distribution of strains , and antifungal susceptibilities of candida spp . is important and essential in guiding appropriate clinical decisions since the species distribution and resistance to candida spp . a few studies on the long - term monitoring of the species distribution and antifungal susceptibilities of vulvovaginitis candida spp . have been reported by china . this study aimed to describe the trend of the species distribution and antifungal susceptibilities of vulvovaginitis candida spp . in china from 2006 to 2013 . the study was conducted in peking university first hospital , a teaching facility of peking university health science center in beijing , china . cultures were incubated for 2448 h at 35c in ambient air atmosphere before reading results . this study was an antifungal , susceptibility , surveillance study , and no human rights issues were involved . susceptibility to clotrimazole ( rosco , denmark ) , fluconazole ( rosco ) , miconazole ( rosco ) , itraconazole ( rosco ) , and nystatin ( rosco ) was determined using an agar diffusion method ( neo - sensitabs , rosco ) . the surface of improved shadomy agar plate ( guangzhou detgerm microbiology technology co. , ltd . ) was inoculated using a swab dipped in cell suspension which adjusted to a mcfarland standard turbidity of 0.5 . disks ( rosco ) of clotrimazole ( 10 g ) , fluconazole ( 15 g ) , miconazole ( 10 g ) , itraconazole ( 8 g ) , and nystatin ( 50 g ) were placed onto the surfaces of the inoculated plates . the plates were incubated in air at 35c and read at 24 h. the zone diameters of all isolates were recorded accurately . interpretation of all agents susceptibilities ( susceptible [ s ] , susceptible - dose dependent , and resistant [ r ] ) was done according to the standard instructions . quality control was performed using quality - control strains , atcc 64548 and atcc 64550 . data processing and statistical analysis were performed with spss software ( version 14.0 , inc . , these enumeration data were performed with chi - square test to compare the difference between groups . for all statistical analysis , the study was conducted in peking university first hospital , a teaching facility of peking university health science center in beijing , china . cultures were incubated for 2448 h at 35c in ambient air atmosphere before reading results . this study was an antifungal , susceptibility , surveillance study , and no human rights issues were involved . susceptibility to clotrimazole ( rosco , denmark ) , fluconazole ( rosco ) , miconazole ( rosco ) , itraconazole ( rosco ) , and nystatin ( rosco ) was determined using an agar diffusion method ( neo - sensitabs , rosco ) . the surface of improved shadomy agar plate ( guangzhou detgerm microbiology technology co. , ltd . ) was inoculated using a swab dipped in cell suspension which adjusted to a mcfarland standard turbidity of 0.5 . disks ( rosco ) of clotrimazole ( 10 g ) , fluconazole ( 15 g ) , miconazole ( 10 g ) , itraconazole ( 8 g ) , and nystatin ( 50 g ) were placed onto the surfaces of the inoculated plates . the plates were incubated in air at 35c and read at 24 h. the zone diameters of all isolates were recorded accurately . interpretation of all agents susceptibilities ( susceptible [ s ] , susceptible - dose dependent , and resistant [ r ] ) was done according to the standard instructions . quality control was performed using quality - control strains , atcc 64548 and atcc 64550 . data processing and statistical analysis were performed with spss software ( version 14.0 , inc . , chicago , il , usa ) . count data variables were expressed as frequencies and percentages . these enumeration data were performed with chi - square test to compare the difference between groups . for all statistical analysis , during the study period from 2006 to 2013 , a total of 2204 candida spp . isolated from 2122 patients with vvc were collected . the distribution of candida species was as follows : candida albicans ( c. albicans ) , 80.5% ( n = 1775 ) ; candida glabrata ( c. glabrata ) , 18.1% ( n = 400 ) ; candida krusei ( c. krusei ) 1.2% ( n = 26 ) ; candida tropicalis ( c. tropicalis ) , 0.1% ( n = 3 ) [ table 1 ] . although c. albicans maintained the most common species associated with vulvovaginitis ( 80.5% ) , the percentage reduced from about 90% in 2006 to 77% in 2013 meanwhile the prevalence of c. glabrata increased from about 10% in 2003 to 20% in 2013 . the proportion of c. krusei and c. tropicalis was very low ( 1.2% , 0.1% , respectively ) in our survey . of all the patients with positive candida cultures , 76 ( 3.6% ) cases isolated more than one culture ( 158 isolates ) in different time . the prevalence of non - albicans candida spp . among patients with multiple positive cultures was higher than among patients with a single positive culture ; however , there was no statistical significance between two groups ( p = 0.054 ,  = 3.718 ) . species distributions of candida isolates from patient with vulvovaginal candidiasis during 8-year period the susceptibility results for each species are presented in tables 2 and 3 . the results revealed that nystatin exhibited excellent activity against c. albicans and the whole resistance rates was only 0.2% [ table 2 ] . notably , decreasing susceptibility to fluconazole , miconazole , and itraconazole was seen with c. albicans during 8-year period . resistance to fluconazole increased from 2.4% in 2006 to 55.4% in 2012 , but the rate dropped to 8.9% in 2013 . with regards to miconazole and itraconazole , resistance rate increased from 2.4% , 7.1% in 2006 to 59.8% , 58.9% in 2013 , respectively . there was only slightly fluctuant trend toward increased resistance to clotrimazole among c. albicans during the study period . trends in vitro susceptibilities to clotrimazole , fluconazole , miconazole , itraconazole , and nystatin among candida albicans over an 8-year period r : resistant ; s : susceptible ; sdd : susceptible - dose dependent . antifungal activities of clotrimazole , fluconazole , miconazole , itraconazole and nystatin against non - albicans species r : resistant ; s : susceptible ; sdd : susceptible - dose dependent . the susceptibilities of the non - albicans species to five antifungal drugs are shown in table 3 . the results revealed that nystatin exhibited not only excellent antifungal activity against c. albicans but also one of the best choices for non - albicans species . moreover , the resistance rates among c. glabrata , c. tropicalis , and c. krusei were 0.3% , 0 , and 3.8% , respectively . however , resistant to different azole drugs was various among these species . the activity of all the four azole agents was low against c. glabrata ( clotrimazole 16.6% s , fluconazole 9.2% s , itraconazole 35.2% s ) , and only miconazole was active against 56.5% of the isolates . however , resistance to fluconazole ( 57.7% ) , miconazole ( 73.1% ) , and itraconazole ( 83.3% ) was frequent among c. krusei isolates . during the study period from 2006 to 2013 , a total of 2204 candida spp . isolated from 2122 patients with vvc were collected . the distribution of candida species was as follows : candida albicans ( c. albicans ) , 80.5% ( n = 1775 ) ; candida glabrata ( c. glabrata ) , 18.1% ( n = 400 ) ; candida krusei ( c. krusei ) 1.2% ( n = 26 ) ; candida tropicalis ( c. tropicalis ) , 0.1% ( n = 3 ) [ table 1 ] . although c. albicans maintained the most common species associated with vulvovaginitis ( 80.5% ) , the percentage reduced from about 90% in 2006 to 77% in 2013 meanwhile the prevalence of c. glabrata increased from about 10% in 2003 to 20% in 2013 . the proportion of c. krusei and c. tropicalis was very low ( 1.2% , 0.1% , respectively ) in our survey . of all the patients with positive candida cultures , 76 ( 3.6% ) cases isolated more than one culture ( 158 isolates ) in different time . the prevalence of non - albicans candida spp . among patients with multiple positive cultures was higher than among patients with a single positive culture ; however , there was no statistical significance between two groups ( p = 0.054 ,  = 3.718 ) . the results revealed that nystatin exhibited excellent activity against c. albicans and the whole resistance rates was only 0.2% [ table 2 ] . notably , decreasing susceptibility to fluconazole , miconazole , and itraconazole was seen with c. albicans during 8-year period . resistance to fluconazole increased from 2.4% in 2006 to 55.4% in 2012 , but the rate dropped to 8.9% in 2013 . with regards to miconazole and itraconazole , resistance rate increased from 2.4% , 7.1% in 2006 to 59.8% , 58.9% in 2013 , respectively . there was only slightly fluctuant trend toward increased resistance to clotrimazole among c. albicans during the study period . trends in vitro susceptibilities to clotrimazole , fluconazole , miconazole , itraconazole , and nystatin among candida albicans over an 8-year period r : resistant ; s : susceptible ; sdd : susceptible - dose dependent . antifungal activities of clotrimazole , fluconazole , miconazole , itraconazole and nystatin against non - albicans species r : resistant ; s : susceptible ; sdd : susceptible - dose dependent . the susceptibilities of the non - albicans species to five antifungal drugs are shown in table 3 . the results revealed that nystatin exhibited not only excellent antifungal activity against c. albicans but also one of the best choices for non - albicans species . moreover , the resistance rates among c. glabrata , c. tropicalis , and c. krusei were 0.3% , 0 , and 3.8% , respectively . however , resistant to different azole drugs was various among these species . the activity of all the four azole agents was low against c. glabrata ( clotrimazole 16.6% s , fluconazole 9.2% s , itraconazole 35.2% s ) , and only miconazole was active against 56.5% of the isolates . however , resistance to fluconazole ( 57.7% ) , miconazole ( 73.1% ) , and itraconazole ( 83.3% ) was frequent among c. krusei isolates . antifungal susceptibility surveillance study was playing an increasingly important role in tracking the development of antifungal resistance and starting initial antifungal treatment . with the increasing use of antimicrobial agents , the distribution and susceptibilities of pathomycete may be changing from time to time . in our study , we found a descending prevalence of c. albicans ( 9077% ) and a rising prevalence of c. glabrata ( 1020% ) from 2006 to 2013 , similar as described in other surveys . factors such as antimicrobial agents , tumor chemotherapy agents , human organs transplantation , and human immunodeficiency diseases were deemed to contribute to the changing of species distribution . as we all know , treatment choice based on local susceptibility tests was indispensable and credible . in our study , we found that nystatin exhibited excellent activity against all candida species ( < 4% r ) , which was in accordance with other reports . besides the unique mechanism of changing cell membrane permeability , the excellent antifungal activity of nystatin was likely associated with relatively low - frequency use in clinical setting . in accordance with previous reports , increasing resistant to fluconazole was obviously among all species . although the susceptibility of fluconazole was descending , it was still active against c. albicans ( 70% s ) in our study . however , when implemented on c. glabrata and c. krusei , fluconazole had little effect to these species due to intrinsic resistance which prompted reconsideration of fluconazole as the first - line therapy to these species . with regard to clotrimazole , it maintained activity against c. albicans ( > 90% s ) and c. krusei ( > 90% s ) but shows less effect to c. glabrata ( < 20% s ) . the activity of miconazole and itraconazole against all species , especially for c. krusei was not sufficient . in a study by fan et al . richter et al . showed that resistance to fluconazole was observed infrequently ( 3.7% ) . pfaller et al . reported that 90.2% of the candida isolates tested were susceptible to fluconazole . the data shown in our study were relatively higher compared to other reports , requiring the attention of clinicians in this situation . however , the possibility of some system bias can not be excluded due to the potential reasons of the different specimen , test method , and regional disparity . first , some uncommon species may be absent using chromogenic culture media as a prequalification test limits the variety of species that can grow . second , susceptibility tests were conducted using commercially available products , agar diffusion method ( neo - sensitabs , rosco , denmark ) based in clsi m44-a2 document . third , expanding the scope of monitoring was necessary and more drug agents should be involved . in conclusion , this study found that non - albicans candida , especially c. glabrata , which was associated with rvvc was increasing . the drugs in vitro susceptibility were different among different vulvovaginal candida species and it had changed over time . this study was supported by a grant from the national natural science foundation of china ( no . this study was supported by a grant from the national natural science foundation of china ( no .
background : vulvovaginal candidiasis ( vvc ) was a common infection associated with lifelong harassment of woman 's social and sexual life . 
 the purpose of this study was to describe the species distribution and in vitro antifungal susceptibility of candida species ( candida spp . ) isolated from patients with vvc over 8 years.methods:species which isolated from patients with vvc in peking university first hospital were identified using chromogenic culture media . 
 susceptibility to common antifungal agents was determined using agar diffusion method based on clsi m44-a2 document . 
 spss software ( version 14.0 , inc . 
 , chicago , il , usa ) was used for statistical analysis , involving statistical description and chi - square test.results:the most common strains were candida ( c. ) albicans , 80.5% ( n = 1775 ) followed by c. glabrata , 18.1% ( n = 400 ) . 
 nystatin exhibited excellent activity against all species ( < 4% resistant [ r ] ) . 
 resistance to azole drugs varied among different species . 
 c. albicans : clotrimazole ( 3.1% r ) < fluconazole ( 16.6% r ) < itraconazole ( 51.5% r ) < miconazole ( 54.0% r ) ; c. glabrata : miconazole ( 25.6% r ) < clotrimazole ( 50.5% r ) < itraconazole ( 61.9% r ) < fluconazole ( 73.3% r ) ; candida krusei : clotrimazole ( 0 r ) < fluconazole ( 57.7% r ) < miconazole ( 73.1% r ) < itraconazole ( 83.3% r ) . 
 the susceptibility of fluconazole was noticeably decreasing among all species in the study period.conclusions:nystatin was the optimal choice for the treatment of vvc at present . the species distribution and in vitro antifungal susceptibility of candida spp . 
 isolated from patients with vvc had changed over time .