What is the recommended treatment for Candida (Candida) glabrata vaginitis?

Treatment of Candida glabrata Vaginitis

For Candida glabrata vulvovaginitis, topical intravaginal boric acid in a gelatin capsule, 600 mg daily for 14 days, is the first-line treatment, especially when oral azoles are ineffective. 1, 2

First-Line Treatment Options

• C. glabrata infections are considered "complicated" vulvovaginal candidiasis and require specific treatment approaches different from those used for C. albicans 1, 2
• Boric acid 600 mg in a gelatin capsule, administered intravaginally once daily for 14 days, is the recommended first-line therapy 1, 2
• Clinical improvement rates with boric acid are approximately 81% with mycological eradication in 77% of cases 3
• The full 14-day course should be completed to ensure complete eradication of the infection 2

Why Azoles Are Not Effective for C. glabrata

• C. glabrata often demonstrates resistance to azole antifungals, including fluconazole, making standard treatments for C. albicans ineffective 2
• At vaginal pH (4.0-4.5), there is a dramatic increase in MIC values for all azole drugs against C. glabrata, explaining the clinical failure despite in vitro susceptibility testing at pH 7.0 4
• Clinical response and mycological eradication rates associated with topical and systemic azoles are typically <50% for C. glabrata infections 3

Alternative Treatment Options

• Nystatin intravaginal suppositories, 100,000 units daily for 14 days, can be used as an alternative treatment 1, 2
• Topical 17% flucytosine cream alone or in combination with 3% amphotericin B cream administered daily for 14 days is another option 1, 2
• For refractory cases, some studies have shown success with:
  • Voriconazole 400 mg/12h on the first day followed by 200 mg every 12h for 14 days 5
  • Micafungin in combination with topical ciclopirox olamine 6

Diagnostic Confirmation

• Before initiating treatment, confirm the diagnosis through:
  • Wet-mount preparation with saline and 10% potassium hydroxide to demonstrate yeast or hyphae 1, 2
  • Vaginal cultures to identify the specific Candida species, particularly important for recurrent cases 1, 2
  • Verification of normal vaginal pH (4.0-4.5) 1, 2

Treatment Monitoring and Follow-up

• Patients should return for follow-up if symptoms persist or recur after completing the treatment course 1, 2
• For recurring vulvovaginal candidiasis, consider maintenance therapy after initial 14-day treatment 1
• One-third of patients with C. glabrata vaginitis may require maintenance therapy with boric acid 3

Special Considerations

• C. glabrata vaginitis is more challenging to treat than C. albicans infections and may require longer courses of therapy 7
• Oil-based creams and suppositories might weaken latex condoms and diaphragms, so patients should be advised about potential contraceptive failure 1, 2
• For persistent or recurrent infections despite appropriate therapy, consider alternative diagnoses or resistant infection 1, 2

Treatment Algorithm

1. Confirm diagnosis with microscopy and culture to identify C. glabrata
2. First-line: Boric acid 600 mg intravaginal capsule daily for 14 days 1, 2
3. If no response, try alternative options:
   • Nystatin intravaginal suppositories 100,000 units daily for 14 days 1, 2
   • Topical 17% flucytosine cream alone or with 3% amphotericin B cream daily for 14 days 1, 2
4. For refractory cases, consider newer agents like voriconazole or micafungin under specialist guidance 6, 5
5. Evaluate for maintenance therapy if recurrence is likely 1, 3