Vulvovaginal candidiasis in rural pregnant populations from Uttar Pradesh, India: species shift, biofilm formation, and resistance trends.

Vulvovaginal candidiasis (VVC) is a common infection in pregnancy, with increasing concern over the emergence of non-albicans Candida (NAC) species and antifungal resistance, particularly in biofilm-forming strains. A total of 913 pregnant women with clinically suspected VVC were evaluated. Demographic and clinical data were collected, and specimens were processed using KOH mount and fungal culture. Isolates were identified to the species level using matrix-assisted laser desorption ionization time-of-flight mass spectrometry (MALDI-TOF MS), assessed for biofilm formation by the tissue culture plate (TCP) method, and tested for antifungal susceptibility by Kirby-Bauer disk diffusion method. The highest prevalence was observed in women aged 23-28 years (35.7%) and those from rural areas (61.7%). Illiteracy (54.5%), third-trimester pregnancy (43.7%), and multigravida status (57.6%) were predominant. Mixed symptoms, especially the triad of itching, burning, and discharge (27.2%), were most common. Culture had a higher sensitivity (83.6%) than KOH microscopy (77.2%). Candida albicans was the predominant species (59.8%), followed by Candida glabrata (15.3%) and Candida tropicalis (9.8%). NAC species accounted for 40.2% of isolates. Biofilm production was highest in C. albicans (85.1%), C. tropicalis (74.7%), and C. glabrata (59.8%). Antifungal resistance was significantly higher in biofilm producers, particularly to azoles: ketoconazole (83.3% vs. 16.7%, p < 0.001) and fluconazole (81.5% vs. 18.5%, p < 0.001). Amphotericin B also showed reduced efficacy in biofilm producers (66.7% vs. 33.3%, p < 0.05). This study reports a high prevalence of VVC (83.6%) in pregnant women, predominantly in rural, less-educated, and multigravida groups. C. albicans remained the leading pathogen, but the notable presence of non-albicans species reflects a shifting epidemiology. Biofilm formation, especially by C. albicans, C. tropicalis, and C. glabrata, correlated with marked azole resistance. Routine species-level identification, biofilm evaluation, and antifungal susceptibility testing are essential for optimizing treatment in pregnancy.