Diagnosis and Treatment of Vulvovaginal Candidiasis

Learning Objectives and CME/Disclosure Information

This activity is intended for healthcare providers delivering care to women and their families.

After completing this activity, the participant should be better able to:

1. Describe the symptoms, exam findings and diagnostic testing of vulvovaginal candidiasis
2. Apply the recommended treatment of uncomplicated and complicated VVC

Estimated time to complete activity: 0.25 hours

Faculty:

Susan J. Gross, MD, FRCSC, FACOG, FACMG
President and CEO, The ObG Project

Disclosure of Conflicts of Interest

Postgraduate Institute for Medicine (PIM) requires instructors, planners, managers and other individuals who are in a position to control the content of this activity to disclose any real or apparent conflict of interest (COI) they may have as related to the content of this activity. All identified COI are thoroughly vetted and resolved according to PIM policy. PIM is committed to providing its learners with high quality CME activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of a commercial interest.

Faculty: Susan J. Gross, MD, receives consulting fees from Genoox, Inc., and has financial interest in The ObG Project, Inc.

Planners and Managers: The PIM planners and managers, Trace Hutchison, PharmD, Samantha Mattiucci, PharmD, CHCP, Judi Smelker-Mitchek, MBA, MSN, RN, and Jan Schultz, MSN, RN, CHCP have nothing to disclose.

Method of Participation and Request for Credit

Fees for participating and receiving CME credit for this activity are as posted on The ObG Project website. During the period from Jan 9 2019 through Jan 9 2020, participants must read the learning objectives and faculty disclosures and study the educational activity.

If you wish to receive acknowledgment for completing this activity, please complete the post-test and evaluation. Upon registering and successfully completing the post-test with a score of 100% and the activity evaluation, your certificate will be made available immediately.

For Pharmacists: Upon successfully completing the post-test with a score of 100% and the activity evaluation form, transcript information will be sent to the NABP CPE Monitor Service within 4 weeks.

Joint Accreditation Statement

In support of improving patient care, this activity has been planned and implemented by the Postgraduate Institute for Medicine and The ObG Project. Postgraduate Institute for Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

Physician Continuing Medical Education

Postgraduate Institute for Medicine designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Continuing Nursing Education

The maximum number of hours awarded for this Continuing Nursing Education activity is 0.2 contact hours.

Designated for 0.1 contact hours of pharmacotherapy credit for Advance Practice Registered Nurses.

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CLINICAL ACTIONS:

Vulvovaginal candidiasis (VVC) presents with symptoms of itching, redness and discharge. Recurrent VVC (RVVC) is diagnosed when women have ≥4 episodes of VVC within 12 months.

Focus on the following when obtaining the history
- Location | Duration | Relation to menses | Response to prior treatment and self-treatment | Sexual partners | Contraception
- Note: Self-diagnosis and telephone diagnosis are unreliable
Physical exam includes examination of vulva and vaginal vault
- Signs of inflammation | Ulcers | Excoriation
Diagnosis
- Blastospores or pseudohyphae on saline or 10% KOH microscopy or
- Positive culture in the presence of symptoms suggestive of candidiasis

Note: Diagnosis based on history and physical alone are unreliable

Classification

Classify as uncomplicated or complicated

Uncomplicated
- Sporadic or infrequent
- Candida albicans infection
- Nonpregnant patient
- No medical complications
- Mild/ moderate symptoms and findings
Complicated
- Recurrent
- Severe symptoms and findings
- Non-Albicans Candida (NAC)
- Pregnancy
- Comorbidities, including
  - Diabetes | Immunosuppression | Severe medical conditions

SYNOPSIS:

VVC is a common clinical condition with most infections due to C. albicans. Uncomplicated infections respond promptly to 1-,3- and 7- day treatment options (see below). Complicated/recurrent VVC may require longer duration of treatment and higher doses of medication. NAC subtypes may be resistant to typical treatment.

KEY POINTS:

Candida albicans is the most common cause of VVC
NAC
- Accounts for an increasing number of cases
- NAC species include
  - glabrata | C. tropicalis | C. krusei | C. parapsilosis | C. guilliermondii
- Correct identification is important as NACs have resistance/decreased susceptibilities to commonly used treatment

Treatment

Uncomplicated

One day therapy
- Butoconazole 2% sustained-release cream 5 g or
- Clortrimazole 500 mg vaginal suppository or
- Fluconazole 150 mg po or
- Miconazole 1,200 mg vaginal suppository or
- Tioconazole 6.5% cream 5 gram
3-day therapy
- Clotrimazole 2% cream 5 g daily or
- Clotrimazole 200 mg vaginal suppository daily or
- Miconazole 200 mg vaginal suppository daily or
- Terconazole 0.8% cream 5 gm daily
7-day therapy
- Clotrimazole 1% cream 5mg daily or
- Clotrimazole 100 mg vaginal suppository daily or
- Miconazole 2% cream 5 gm daily or
- Terconazole 0.4% cream 5gm daily

Complicated

Fluconazole
- Second 150 mg po dose 3 days after first dose
  - Cure rate may improve from 67% to 80%

Recurrence (Candida albicans)

Intensive therapy for 7–14 days
Followed by prolonged treatment with fluconazole (first line)
- Fluconazole 150 mg weekly for 6 months
- Fluconazole drug of choice vs ketoconazole (risk of liver toxicity)
Acceptable alternative prolonged therapy (second line) if patient does not want or cannot tolerate fluconazole
- Clotrimazole 500 mg weekly or
- Clotrimazole 200 mg twice a week
Pregnancy
- Topical imidazole therapy for “probably” 7 days
  - Butoconazole | Clotrimazole | Miconazole | Terconazole | Tioconazole
- Note: Fluconazole used briefly and at low-doses “is not associated with known birth defects”, but there may be risk at higher doses and FDA cautions against its use in pregnancy (see ‘Related ObG Topics’ below)

If NAC confirmed

Approximately 50% of patients may respond to topical imidazole treatment
If unresponsive to topical imidazole treatment use
- Boric acid 600 mg vaginal capsules daily x 14 days (minimum)
- Note: Boric acid should not be used during pregnancy or lactation
If unresponsive patient “should be referred to a specialist experienced in handling such cases”

Other treatments

Data on the efficacy of the following are currently inconclusive
- Probiotics | Yogurt | Garlic | Tea tree oil | Low carb diet | Depot medroxyprogesterone | Douching