What is the treatment for a vaginal Candida Albicans infection?

Treatment of Vaginal Candida Albicans Infection

For uncomplicated vaginal Candida albicans infection, a single 150 mg oral dose of fluconazole or a 3-7 day course of topical azole therapy (such as clotrimazole) is the recommended first-line treatment. 1, 2, 3

First-Line Treatment Options

Oral Treatment:

• Fluconazole 150 mg as a single oral dose 2
  • Therapeutic cure rate of 55% (complete resolution of symptoms plus negative KOH and culture)
  • Particularly effective for acute vaginitis (80% clinical cure rate)
  • Advantages: Single dose, convenient administration

Topical Treatments:

• Clotrimazole options 1, 3:
  • 1% cream 5 g intravaginally for 7-14 days
  • 100 mg vaginal tablet daily for 7 days
  • 100 mg vaginal tablet, two tablets for 3 days
  • 500 mg vaginal tablet, one tablet in a single application
• Miconazole options 1:
  • 2% cream 5 g intravaginally for 7 days
  • 200 mg vaginal suppository, one suppository for 3 days
  • 100 mg vaginal suppository, one suppository for 7 days
• Butoconazole 2% cream 5 g intravaginally for 3 days 1

Special Populations

Pregnancy:

• Only topical azole therapies applied for 7 days are recommended during pregnancy 1
• Oral fluconazole should be avoided

Immunocompromised Patients (including HIV):

• More prolonged therapy (7-14 days) is recommended 1
• Patients with underlying debilitating conditions (e.g., uncontrolled diabetes, corticosteroid treatment) require 7-14 days of conventional antimycotic treatment 1

Severe Vulvovaginitis

For severe cases (extensive vulvar erythema, edema, excoriation, and fissure formation):

• Either 7-14 days of topical azole therapy OR
• Fluconazole 150 mg in two sequential doses (second dose 72 hours after initial dose) 1

Recurrent Vulvovaginal Candidiasis (RVVC)

For women with 4 or more episodes per year:

1. Induction phase: 7-14 days of topical therapy or fluconazole 150 mg repeated after 3 days to achieve mycologic remission 1
2. Maintenance phase: 6-month regimen with one of the following 1, 4:
   • Fluconazole 100-150 mg once weekly
   • Clotrimazole 500 mg vaginal suppositories once weekly
   • Ketoconazole 100 mg once daily (monitor for hepatotoxicity)
   • Itraconazole 400 mg once monthly or 100 mg once daily

Weekly fluconazole maintenance therapy has been shown to keep 90.8% of women disease-free at 6 months compared to 35.9% with placebo 4.

Non-albicans Candida Infections

For non-albicans species (found in 10-20% of RVVC cases):

1. Longer duration (7-14 days) with a non-fluconazole azole drug as first-line therapy 1
2. If recurrence occurs, 600 mg of boric acid in a gelatin capsule vaginally once daily for 2 weeks (70% eradication rate) 1
3. Additional options include topical 4% flucytosine (specialist referral advised) 1
4. For recurrent non-albicans VVC, maintenance with 100,000 units of nystatin daily via vaginal suppositories 1

Clinical Pearls and Pitfalls

• Diagnosis should include examination of discharge characteristics, pH measurement, and microscopic examination with saline and 10% KOH preparations 5
• Vaginal cultures should be obtained from patients with RVVC to confirm diagnosis and identify unusual species 1
• C. albicans azole resistance is rare in vaginal isolates, but surveillance for resistance development is prudent in recurrent cases 1
• Identifying Candida in culture without symptoms should not lead to treatment (10-20% of women normally harbor Candida) 1
• Treatment of sex partners is generally not recommended for uncomplicated cases 1
• After treatment, 30-40% of women with RVVC will have recurrent disease once maintenance therapy is discontinued 1