From the Guidelines
For a woman with recurrent vulvovaginal candidiasis (VVC) presenting to the ED with a new episode after recent treatment, the recommended approach is a longer course of antifungal therapy, specifically fluconazole 150 mg orally every 72 hours for three doses, followed by maintenance therapy of fluconazole 150 mg once weekly for 6 months, as supported by the most recent and highest quality study 1.
Treatment Options
The treatment of recurrent VVC requires an extended approach to prevent recolonization by Candida species, particularly C. albicans. The following options are recommended:
- Fluconazole 150 mg orally every 72 hours for three doses (days 1,4, and 7), followed by maintenance therapy of fluconazole 150 mg once weekly for 6 months 1
- Alternative options include topical treatments such as clotrimazole 2% cream applied vaginally daily for 7-14 days, or miconazole suppositories 200 mg vaginally daily for 7 days 1
- For severe or resistant cases, higher doses of fluconazole (up to 200 mg) may be needed 1
Prevention of Recurrence
To prevent recurrence, patients should be advised to avoid potential triggers like:
- Tight-fitting clothing
- Scented hygiene products
- Unnecessary antibiotic use
Diagnosis and Testing
If symptoms persist despite appropriate therapy, culture and sensitivity testing should be considered to identify possible resistant species or alternative diagnoses 1.
Key Considerations
Recurrent VVC, defined as four or more symptomatic episodes within a year, requires this extended treatment approach because short courses often fail to fully eradicate the infection 1. The maintenance therapy helps prevent recolonization by Candida species, particularly C. albicans.
From the FDA Drug Label
Dosage and Administration in Adults: Single Dose Vaginal candidiasis: The recommended dosage of fluconazole tablets for vaginal candidiasis is 150 mg as a single oral dose. The recommended treatment for a woman with recurrent vulvovaginal candidiasis (VVC) who presents to the emergency department (ED) with a new episode after being treated for a yeast infection last month is fluconazole 150 mg as a single oral dose 2.
- Key points:
- The patient should be treated with a single dose of fluconazole.
- The dosage is the same for oral administration.
- Treatment should be continued until clinical parameters or laboratory tests indicate that active fungal infection has subsided.
- Important consideration: An inadequate period of treatment may lead to recurrence of active infection 2.
From the Research
Treatment Options for Recurrent Vulvovaginal Candidiasis (VVC)
- For a woman with recurrent VVC who presents to the ED with a new episode after being treated for a yeast infection last month, treatment options include:
- The choice of treatment should be individualized, taking into consideration the severity of disease, history of recurrent vaginitis, and patient preference 3, 6
Efficacy of Treatment Options
- Single oral dose fluconazole has been shown to be as effective as 7-day intravaginal clotrimazole therapy for acute Candida vaginitis 3
- Weekly treatment with fluconazole (150 mg) for 6 months has been shown to be effective in preventing symptomatic VVC in women with recurrent disease 7
- Sequential doses of fluconazole have been shown to achieve higher clinical cure rates in women with severe vaginitis 6
Considerations for Treatment
- Women with a history of recurrent vaginitis are less likely to respond clinically and mycologically to treatment 3
- Non-albicans Candida species may be more resistant to treatment, and alternative therapies may be necessary 6
- Fluconazole is generally well-tolerated, but long-term use may be associated with adverse effects 7