What is the recommended regime for using probiotic vaginal pessaries and oral probiotics (Colony-Forming Units) for the management of recurrent vaginal candidiasis (thrush)?

Management of Recurrent Vaginal Thrush with Probiotics and Vaginal Pessaries

Current guidelines do not recommend probiotics as primary treatment for recurrent vulvovaginal candidiasis (RVVC), as there is insufficient evidence supporting their efficacy compared to conventional antifungal treatments. 1

Diagnosis Confirmation

• Confirm diagnosis with vaginal cultures to identify Candida species, particularly non-albicans species like C. glabrata (found in 10-20% of RVVC cases) 1
• Use wet mount preparation with saline and 10% potassium hydroxide to demonstrate presence of yeast or pseudohyphae 2

First-Line Treatment for RVVC

• Initial treatment should focus on achieving mycologic remission with conventional antifungal therapy before considering maintenance regimens 1
• For C. albicans infections, use either:
  • 7-14 days of topical azole therapy OR
  • 150 mg oral fluconazole with a second dose 72 hours later 1

Maintenance Regimen for RVVC

• After initial treatment, implement a maintenance antifungal regimen for 6 months 1
• Recommended maintenance options include:
  • Clotrimazole 500 mg vaginal suppositories once weekly 1
  • Fluconazole 100-150 mg orally once weekly (most convenient regimen with >90% control rate) 1, 2
  • Ketoconazole 100 mg orally once daily (requires liver function monitoring) 1
  • Itraconazole 400 mg orally once monthly or 100 mg once daily 1

Role of Probiotics in RVVC Management

• Current CDC guidelines do not recommend probiotics as primary treatment for RVVC 1, 2
• Low to very low quality evidence suggests probiotics may be beneficial as adjunctive therapy to conventional antifungals, potentially:
  • Increasing short-term clinical and mycological cure rates 3
  • Decreasing one-month relapse rates 3
  • Helping restore normal vaginal microbiota 4
• However, this benefit does not translate to improved long-term clinical or mycological cure rates 3

For Non-albicans Candida Infections

• Use longer duration (7-14 days) of non-fluconazole azole drugs as first-line therapy 1, 2
• If recurrence occurs, use boric acid 600 mg in a gelatin capsule vaginally once daily for 2 weeks (70% eradication rate) 1, 2
• For persistent non-albicans VVC, consider maintenance with 100,000 units of nystatin vaginal suppositories daily 1, 2

Important Considerations and Caveats

• After cessation of maintenance therapy, 30-40% of women will experience recurrence 1, 2
• Routine treatment of sexual partners is not recommended but may be considered for women with recurrent infection 1
• For pregnant women, only topical azole therapies should be used 1, 2
• Patients should return for follow-up if symptoms persist or recur within 2 months 1

Empirical Use of Probiotics

• While not recommended as primary treatment, empirical use of probiotics may be considered in women with frequent recurrences (>3 episodes per year), especially those with contraindications to antifungal agents 5
• If using probiotics as adjunctive therapy, they should be administered after completing conventional antifungal treatment 4, 6
• Women should be clearly informed about the unproven efficacy of probiotics for this purpose 5