Antifungal resistance among Candida albicans isolates from vulvovaginal candidiasis patients at a referral hospital in Malawi

Abstract Background Antifungal resistance (AFR) is a growing global health concern, particularly among Candida species including Candida albicans , contributing to increased morbidity and treatment failure. In Malawi, despite antimicrobial resistance (AMR) surveillance strategies outlined in the National Action Plan on AMR, antifungal treatment remains largely empirical, with limited AFR interventions. Methods This study investigated phenotypic resistance in Candida albicans isolates from patients at Bwaila District Hospital in Lilongwe, Malawi. We employed a laboratory-based, cross-sectional, analytical design and analysed 123 high vaginal swab samples from patients with suspected vulvovaginal candidiasis. Isolation was performed using culture methods, and antifungal susceptibility testing was conducted by determining minimum inhibitory concentrations (MICs). Results Of the 123 samples analyzed, 28.5% (35/123) yielded Candida albicans isolates. Out of the 17 isolates tested for antifungal drug susceptibility, 41.2% (7/17) of isolates exhibited resistance to at least one antifungal agent, with the highest resistance observed against voriconazole 41.2% 7/17). Echinocandins (caspofungin and micafungin) showed the lowest resistance, 18% (3/17). Fluconazole and Flucytosine displayed dose-dependent susceptibility and had intermediate effects of 35.3% (6/17) and 29.4% (5/17), respectively. Minimum inhibitory concentration (MIC) profiles demonstrated significant variation across antifungal agents (ANOVA, p < 0.001; η² = 0.217). Conclusions The resistance and dose-dependent susceptibility observed among the antifungal drugs highlight the need for strengthened AFR surveillance and antifungal stewardship to guide treatment and clinical decision-making.