What is the recommended treatment for a Candida (C.) glabata vaginal infection?

Treatment of Candida glabrata Vaginal Infection

For Candida glabrata vulvovaginitis that is unresponsive to oral azoles, topical intravaginal boric acid, administered in a gelatin capsule, 600 mg daily for 14 days is the recommended first-line treatment. 1

Treatment Algorithm

First-line options:

1. Topical intravaginal boric acid
   • Dosage: 600 mg daily in a gelatin capsule
   • Duration: 14 days
   • Strength of recommendation: Strong (low-quality evidence) 1
   • Clinical success rate: 64-71% 2

Alternative options (if boric acid fails):

1. Nystatin intravaginal suppositories

   • Dosage: 100,000 units daily
   • Duration: 14 days
   • Strength of recommendation: Strong (low-quality evidence) 1

2. Topical 17% flucytosine cream

   • Used alone or in combination with 3% amphotericin B cream
   • Applied daily for 14 days
   • Strength of recommendation: Weak (low-quality evidence) 1
   • Clinical success rate: 90% in boric acid failures 2

Clinical Considerations

Diagnosis

• Confirm diagnosis through clinical evaluation, microscopic examination of vaginal secretions, and vaginal pH measurement
• C. glabrata infections may present with less typical symptoms than C. albicans infections
• C. glabrata is inherently less susceptible to azole antifungals 3

Treatment Challenges

• C. glabrata vaginitis is more difficult to eradicate than C. albicans infections 3
• Oral fluconazole (typically used for C. albicans) is often ineffective against C. glabrata 4
• Treatment failure rates are higher with C. glabrata compared to other Candida species 5

Important Caveats

• No advantage has been observed in extending boric acid therapy beyond 14 days 2
• Local side effects are uncommon with both boric acid and flucytosine regimens 2
• Avoid oral azoles as first-line therapy due to high rates of resistance in C. glabrata 4
• Consider amphotericin B-based treatments for refractory cases that fail to respond to first and second-line options 4

For Recurrent Infections

• After successful treatment of the acute episode, consider maintenance therapy
• For recurring vulvovaginal candidiasis, 10-14 days of induction therapy followed by fluconazole 150 mg weekly for 6 months is recommended for C. albicans, but this regimen may not be effective for C. glabrata 1
• Address potential risk factors and predisposing conditions (diabetes, immunosuppression, antibiotic use)

Monitoring and Follow-up

• Reevaluation is necessary if symptoms persist after completing treatment
• For persistent infections, consider culture and susceptibility testing to guide further therapy
• In cases of recurrent treatment failure, consider alternative diagnoses or complications