Diagnosis and Treatment of Vulvovaginal Candidiasis
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 | If pH paper, KOH, and microscopy are not available, FDA approved commercial tests are available
Classification
Classify as uncomplicated or complicated
Uncomplicated
Sporadic or infrequent
Candida albicans infection (suspected or proven)
Non-immunocompromised
Mild/ moderate symptoms and findings
Complicated
Recurrent: ≥4 infections in 12 months
Severe symptoms and findings
Non-Albicans Candida (NAC)
Immunocompromised, including
Diabetes | Immunosuppression meds | HIV
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 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
3-day therapy
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
7-day therapy
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
Complicated
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)
Acute infection
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
Pregnancy
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”
Other treatments
Data on the efficacy of the following are currently inconclusive
Are Vaginal Antimycotics Associated with an Increased Risk for Miscarriage?
BACKGROUND AND PURPOSE:
Vulvovaginal candidiasis (VVC) may occur in more than 20% of pregnant women
A previous study suggested an increased risk of miscarriage after the use of vaginal-antimycotic agents for vulvovaginal candidiasis
Daniel et al. (AJOG, 2018) examined whether risk for spontaneous abortions is increased following first-trimester exposure to vaginal antimycotics
METHODS:
Population-based retrospective cohort study
Participants: All clinically apparent pregnancies admitted for birth or spontaneous abortion
A computerized database of medication dispensation was linked with computerized databases containing information on births and spontaneous abortion
Time-varying Cox regression models, adjusted for confounding variables such as mother’s age, hypothyroidism, diabetes mellitus, hypercoagulable or inflammatory conditions, recurrent miscarriage, IUD, ethnicity, tobacco use and the year of admission were used to assess the association
RESULTS:
65,457 pregnancies were included in the study
58,949 (90.1%) ended with birth
6,508 (9.9%) ended with spontaneous abortion
Overall, 5% of pregnancies were exposed to vaginal antimycotic medications until the 20th gestational week
4.2% were exposed to clotrimazol
1% were exposed to miconazole
Exposure to vaginal antimycotics was not associated with spontaneous abortions as a group
Crude hazard ratio (HR) 1.11; 95% CI, 0.96–1.29
adjusted HR 1.11; 95% CI, 0.96–1.29
Clotrimazole was not associated with increased risk
adjusted HR 1.05; 95% CI, 0.89–1.25
Miconazole was also not associated with increased risk
adjusted HR 1.34; 95% CI, 0.99–1.80
Dosage did not impact the findings
CONCLUSION:
This study found no evidence that taking antimycotics (clotrimazole and miconazole) during the first trimester is associated with increased risk for miscarriage
Following a Danish study in 2016 by Nielsen et al. (JAMA, 2016), which concluded that fluconazole was associated with miscarriage, the FDA undertook a review to determine the safety of fluconazole in pregnancy. The FDA concluded (October 2019) that
Based on our reviews of several studies, FDA has determined that the available data do not provide conclusive evidence of an increased risk of miscarriage or stillbirth with a single 150 mg dose of oral fluconazole (Diflucan)
We reviewed the 2016 study cited in this DSC and four additional epidemiological studies
We approved updated prescribing information in 2018 to include all available information on the use of fluconazole in women who are pregnant or breastfeeding
It adequately addresses the potential risk of harm to unborn babies
Vulvovaginal candidiasis occurs frequently during pregnancy. Only topical azole therapies, applied for 7 days, are recommended for use among pregnant women
Imidazoles inhibit the enzyme that converts lanosterol to ergosterol, disrupting the structure and function of the fungal membrane
Azole options can be found below in the ObG Related Entry ‘Diagnosis and Treatment of Vulvovaginal Candidiasis’
Screening & Treatment of Gynecologic infections in the HIV-Positive Woman
Gynecologic infections are more common, and may be more difficult to eradicate, in the HIV population. Overall, treatment protocols remain the same, irrespective of HIV status, although there are some differences depending on the disorder.
CLINICAL ACTIONS:
Screen at entry to care and at least annually for the following: N.gonorrhoeae, C. trachomatis, syphilis and vaginal trichomoniasis
Screen for hepatitis C on entry to care
At-risk seronegative individuals should be screened at least annually
Consider type specific HSV serologic testing for those presenting for an STD evaluation
Approximately 70% of persons with HIV are HSV-2 seropositive | 95% are seropositive for either HSV-1 or HSV-2
HSV-2 infection increases the risk of HIV acquisition two- to three-fold and in coinfected patients
HSV-2 reactivation results in increases in HIV RNA levels in blood and genital secretions
Screen on entry to care for hepatitis B with HBsAg, anti-HBc and/or anti-HBs
Offer vaccination to seronegative individuals with hepatitis B or combined hepatitis A and B vaccine
Recheck immunity after vaccination complete
SYNOPSIS:
While it is critical to remain vigilant with regard to STDs and pelvic infections, women with ulcerative conditions of the genitalia, including syphilis and herpes, are at increased risk of HIV acquisition and transmission to partners, lending an urgency to prompt treatment or suppression (see separate entry on ulcerative conditions).
KEY POINTS:
Bacterial vaginosis is more prevalent/persistent in HIV-positive women
Diagnosis and treatment options are the same
Vulvovaginal candidiasis is more common among HIV-positive women and associated with decreased CD4+ counts
Treatment is the same as for HIV-negative women
For azole-refractory Candida glabrata vaginitis
Boric acid 600 mg vaginal suppository once daily for 14 days
Note: Severe or recurrent vaginitis should be treated with oral fluconazole (100 to 200 mg) or topical antifungals for ≥7 days
Treatment for gonorrhea/chlamydia is the same as for HIV-negative women
Retest 3 months after treatment as reinfection is common
Pelvic inflammatory disease is treated with the same antimicrobials for the same duration as for HIV-negative
There is a greater incidence of tubo-ovarian abscess among HIV-positive, but overall response to therapy is the same as for HIV-negative
Trichomoniasis is more prevalent among HIV-positive and should be treated with a one week course of metronidazole
Parasitic conditions such as scabies or pediculosis pubis are treated the same regardless of HIV status
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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.
Disclaimer
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.
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