Treatment of Candida glabrata Vaginitis
For Candida glabrata vulvovaginitis, intravaginal boric acid 600 mg daily for 14 days is the first-line treatment, as oral azoles are unreliable for this non-albicans species. 1, 2
Why C. glabrata Requires Different Treatment
- C. glabrata is inherently less susceptible to azole antifungals (fluconazole, itraconazole, ketoconazole) compared to C. albicans, making standard oral therapies ineffective 1, 3
- This infection is classified as "complicated" vulvovaginal candidiasis and requires extended treatment duration (14 days minimum) rather than the short courses used for C. albicans 1, 2
- Azole therapy achieves clinical and mycological success rates below 50% for C. glabrata, compared to 80-90% for C. albicans 4, 5
First-Line Treatment: Boric Acid
Intravaginal boric acid 600 mg in a gelatin capsule, inserted daily for 14 days 1, 2
- Clinical improvement or cure occurs in 64-81% of cases 4, 5
- Mycological eradication achieved in 71-77% of cases 4, 5
- No advantage to extending therapy beyond 14 days 5
- Local side effects are uncommon 5
Second-Line Treatment Options
If boric acid fails or is not tolerated:
Nystatin intravaginal suppositories 100,000 units daily for 14 days 1, 2
- This is a strong recommendation despite being an alternative option 1
Topical flucytosine 17% cream alone or combined with amphotericin B 3% cream, applied daily for 14 days 1, 2
- Achieves 90% success rate in azole-refractory cases 5
- Particularly useful when both boric acid and azoles have failed 5
Important Clinical Caveats
- Confirm the diagnosis before treatment: Obtain wet-mount preparation with 10% KOH to demonstrate yeast/hyphae, check vaginal pH (should be 4.0-4.5), and obtain vaginal cultures to identify the specific Candida species 1, 2
- Do not use oral fluconazole as monotherapy for confirmed C. glabrata—it will fail in the majority of cases 1
- Oil-based vaginal preparations can weaken latex condoms and diaphragms 2
- Patients should complete the full 14-day course even if symptoms resolve earlier 2
When to Reassess
- Instruct patients to return if symptoms persist after completing the 14-day treatment course 1, 2
- If symptoms recur within 2 months or persist despite appropriate therapy, consider alternative diagnoses, mixed infections (commonly with bacterial vaginosis), or resistant organisms 1, 2, 4
- Approximately one-third of patients may require maintenance therapy with boric acid to prevent recurrence 4