From the Guidelines
For a patient with bacterial vaginosis (BV) and a detected Candida glabrata and Candida krusei infection, I recommend a two-part treatment approach, prioritizing the treatment of BV with oral metronidazole 500 mg twice daily for 7 days or metronidazole gel 0.75% intravaginally once daily for 5 days, and for the Candida infections, using boric acid vaginal suppositories (600 mg) once daily for 14 days, as both C. glabrata and C. krusei are often resistant to standard azole antifungals like fluconazole 1.
Treatment Approach
To address both infections effectively, it's crucial to understand that bacterial vaginosis is caused by an imbalance of vaginal bacteria, while Candida species are fungi. The presence of C. glabrata and C. krusei complicates treatment due to their inherent resistance to common antifungal medications.
- Treat bacterial vaginosis with:
- Oral metronidazole 500 mg twice daily for 7 days
- Or metronidazole gel 0.75% intravaginally once daily for 5 days
- For Candida glabrata and Candida krusei infections:
- Use boric acid vaginal suppositories (600 mg) once daily for 14 days
- Alternatively, flucytosine cream 17% with amphotericin B can be effective, as suggested by the clinical practice guideline for the management of candidiasis 1
Considerations
During treatment, it's essential to:
- Avoid sexual intercourse or use condoms
- Wear cotton underwear
- Avoid douching
- Maintain good hygiene
These measures help prevent the spread of infection and support the healing process. Completing the full course of treatment, even if symptoms improve quickly, is crucial to prevent recurrence.
Evidence Basis
The recommendation for using boric acid vaginal suppositories for C. glabrata and C. krusei infections is based on the clinical practice guideline for the management of candidiasis, which notes that these species are often resistant to standard azole antifungals like fluconazole 1. This approach prioritizes the most recent and highest quality evidence available, focusing on the effective management of both bacterial vaginosis and Candida infections to improve patient outcomes in terms of morbidity, mortality, and quality of life.
From the FDA Drug Label
The overall clinical and mycological success rates by Candida species in Study 150-608 are presented in Table 15. Table 15: Overall Success Rates Sustained From EOT To The Fixed 12-Week Follow-Up Time Point By Baseline Pathogen C. glabrata 12/36 (33%) C krusei 1/4
The treatment for a patient with bacterial vaginosis (BV) and a detected Candida glabrata and Candida krusei infection is not directly addressed in the provided drug labels for the treatment of BV. However, for the treatment of Candida glabrata and Candida krusei infections,
- Voriconazole had a clinical and mycological success rate of 33% for C. glabrata and 25% for C. krusei 2.
- Fluconazole is not recommended for C. krusei as it is considered to be resistant to fluconazole, and for C. glabrata, the highest fluconazole dose is recommended for isolates with intermediate MIC (16 to 32 mcg/mL) 3.
It is essential to note that bacterial vaginosis (BV) is a bacterial infection and would require a different treatment approach than fungal infections caused by Candida species.
From the Research
Treatment for Bacterial Vaginosis (BV) and Candida Infection
The treatment for a patient with bacterial vaginosis (BV) and a detected Candida glabrata and Candida krusei infection involves addressing both conditions.
- For bacterial vaginosis, the standard treatment is oral metronidazole in a dosage of 500 mg twice daily for seven days 4, 5, 6.
- For Candida glabrata infection, voriconazole can be used as a therapeutic alternative, with a suggested dosage of 400 mg/12 h the first day and then 200 mg every 12 h for 14 days 7.
- For Candida krusei infection, boric acid has been shown to be effective, with four of six patients treated with boric acid achieving clinical and mycological cure 8.
Considerations for Treatment
It is essential to note that the treatment of vulvovaginal candidiasis, including Candida glabrata and Candida krusei, may require a more extensive regimen than uncomplicated infections 4, 6.