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
Susan J. Gross, MD, FRCSC, FACOG, FACMG
President and CEO, The ObG Project
Disclosure of Conflicts of Interest
Postgraduate Institute for Medicine (PIM) requires faculty, planners, and others in control of educational content to disclose all their financial relationships with ineligible companies. All identified conflicts of interest (COI) are thoroughly vetted and mitigated according to PIM policy. PIM is committed to providing its learners with high quality accredited continuing education activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of an ineligible company.
The PIM planners and others have nothing to disclose. The OBG Project planners and others have nothing to disclose.
Faculty: Susan J. Gross, MD, receives consulting fees from Cradle Genomics, 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 07/15/2022, 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.
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
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 | If pH paper, KOH, and microscopy are not available, FDA approved commercial tests are available
Classify as uncomplicated or complicated
Sporadic or infrequent
Candida albicans infection (suspected or proven)
Mild/ moderate symptoms and findings
Recurrent: ≥4 infections in 12 months
Severe symptoms and findings
Non-Albicans Candida (NAC)
Diabetes | Immunosuppression meds | HIV
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.
Candida albicans is the most common cause of VVC
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
Butoconazole 2% sustained-release cream intravaginally 5 g or
Fluconazole 150 mg po (Note – only oral agent) or
Miconazole 1,200 mg vaginal suppository or
Tioconazole 6.5% ointment 5 gram intravaginally
Clotrimazole 2% cream 5 g daily intravaginally or
Miconazole 200 mg vaginal suppository daily or
Miconazole 4% cream 5 g intravaginally daily or
Terconazole 0.8% cream 5 gm intravaginally daily or
Terconazole 80 mg vaginal suppository daily
Clotrimazole 1% cream 5 g intravaginally daily or
Miconazole 2% cream 5 g intravaginally daily or
Miconazole 100 mg vaginal suppository
Terconazole 0.4% cream 5g intravaginally daily
Fluconazole “is an effective and convenient treatment”
Recurrence (Candida albicans)
Intensive therapy for 7–14 days
Followed by prolonged treatment with fluconazole (first line)
Fluconazole 150 mg weekly for 6 months
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
Severe Infection (erosions, fissures, edema)
Topical intravaginal azoles for 10 to 14 days or
Oral fluconazole every 3 days (day 1, 4 and 7)
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 subspecialist
Topical imidazole therapy for “probably” 7 days (CDC)
Note: Oral fluconazole used at high doses for extended periods of time may be associated with a small increase in birth defects | There have been conflicting studies regarding miscarriage and stillbirth | The FDA did not find conclusive evidence for risk of stillbirth or miscarriage with single 150 mg dose (see ‘Related ObG Topics’ below) | The FDA does “advise cautious prescribing of oral fluconazole in pregnancy”
Data on the efficacy of the following are currently inconclusive
OBG Project CME requires a modern web browser (Internet Explorer 10+, Mozilla Firefox, Apple Safari, Google Chrome, Microsoft Edge). Certain educational activities may require additional software to view multimedia, presentation, or printable versions of their content. These activities will be marked as such and will provide links to the required software. That software may be: Adobe Flash, Apple QuickTime, Adobe Acrobat, Microsoft PowerPoint, Windows Media Player, or Real Networks Real One Player.
Disclosure of Unlabeled Use
This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA. The planners of this activity do not recommend the use of any agent outside of the labeled indications.
The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of the planners. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.
Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information
presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patient’s conditions and possible contraindications and/or dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.
Jointly provided by
NOT ENOUGH CME HOURS
It appears you don't have enough CME Hours to take this Post-Test. Feel free to buy additional CME hours or upgrade your current CME subscription plan