What is the best treatment approach for a 64-year-old female with recurrent vaginal candidiasis (yeast infection) and glucosuria (elevated glucose in urine)?

Treatment Approach for Recurrent Vaginal Yeast Infection with Glucosuria

For a 64-year-old female with recurrent vaginal yeast infection and glucosuria, the optimal treatment approach is a two-pronged strategy addressing both the yeast infection and the underlying glucose abnormality, with fluconazole 150 mg orally every 72 hours for 2-3 doses followed by weekly maintenance therapy for 6 months, along with strict glycemic control. 1, 2

Initial Assessment and Diagnosis

• Glucosuria strongly suggests diabetes mellitus, which is a significant risk factor for recurrent vulvovaginal candidiasis (RVVC) due to high glucose levels promoting yeast attachment, growth, and interfering with immune responses 3
• Confirm the diagnosis with vaginal cultures to identify the specific Candida species, as non-albicans species (particularly C. glabrata) are more common in women with type 2 diabetes and require different treatment approaches 2
• Check vaginal pH (should be 4.0-4.5) and perform wet-mount preparation with saline and 10% potassium hydroxide to demonstrate yeast or hyphae 1

Treatment Algorithm

Step 1: Address the Underlying Glucosuria

• Control blood glucose levels as a primary intervention, as hyperglycemia increases risk for both initial infection and recurrence 3
• Evaluate for diabetes mellitus if not already diagnosed and optimize glycemic control 3

Step 2: Antifungal Treatment for Recurrent Vulvovaginal Candidiasis

For C. albicans infection (most common):

• Initial induction therapy: Fluconazole 150 mg orally with a second dose 72 hours later, followed by a third dose on day 7 2
• Maintenance therapy: Fluconazole 150 mg weekly for 6 months, which achieves control of symptoms in >90% of patients 1, 4

For non-albicans species (if identified):

• For C. glabrata: Boric acid 600 mg in a gelatin capsule vaginally once daily for 14 days (70% eradication rate) 2
• Alternative topical options: Nystatin intravaginal suppositories or topical 17% flucytosine cream 5

Efficacy and Follow-up

• The fluconazole maintenance regimen has been shown to keep 90.8% of women disease-free at 6 months compared to only 35.9% with placebo 4
• After completing the 6-month maintenance regimen, approximately 40-50% of women will experience recurrence, so continued monitoring is essential 2
• Follow-up visits should be scheduled if symptoms persist or recur 6

Special Considerations

Potential Adverse Effects

• Oral fluconazole may cause nausea (7%), abdominal pain (6%), headache (13%), and diarrhea (3%) 7
• Monitor for potential drug interactions with fluconazole, particularly with medications like astemizole, calcium channel antagonists, coumadin, and protease inhibitors 1

Candida Species Considerations

• C. albicans is the dominant cause of vulvovaginal candidiasis in women with diabetes, although C. glabrata is prominent in women with type 2 diabetes 3
• C. glabrata is less virulent but also less susceptible to conventional antifungal treatment, requiring alternative approaches 3

Common Pitfalls to Avoid

• Failing to address the underlying glucosuria/diabetes, which will lead to continued recurrences 3
• Not obtaining cultures before initiating treatment for RVVC, potentially missing non-albicans species that require different treatment 2
• Inadequate induction therapy before starting maintenance regimen 2
• Discontinuing maintenance therapy too early (should be continued for full 6 months) 2
• Self-medication with over-the-counter preparations without proper diagnosis 1

By addressing both the underlying glucosuria and providing appropriate antifungal therapy, this comprehensive approach offers the best chance for symptom resolution and prevention of recurrence in this 64-year-old female patient.