What is the recommended treatment regimen for recurrent vaginal yeast infections?

Treatment Regimen for Recurrent Vaginal Yeast Infections

For recurrent vulvovaginal candidiasis (≥4 episodes per year), treat with an induction phase of 10-14 days using either topical azole therapy or oral fluconazole 150 mg every 72 hours for 2-3 doses, followed by maintenance therapy with fluconazole 150 mg once weekly for 6 months. 1, 2

Diagnostic Confirmation Before Treatment

• Obtain vaginal cultures to confirm the diagnosis and identify the Candida species, particularly to detect non-albicans species like C. glabrata, which occurs in 10-20% of recurrent cases and responds poorly to standard azole therapy 1, 2
• Verify normal vaginal pH (4.0-4.5) and demonstrate yeast or hyphae on wet-mount preparation using saline and 10% potassium hydroxide 2
• If wet mount is negative but clinical suspicion remains high, vaginal cultures for Candida are essential 2

Induction Phase (Initial 10-14 Days)

Choose one of the following regimens:

• Topical azole therapy for 10-14 days (any topical agent; no single agent shows superiority over others) 1
• Oral fluconazole 150 mg every 72 hours for 2-3 doses 1, 2

The goal of induction therapy is to achieve mycologic remission before starting maintenance treatment 3

Maintenance Phase (6 Months)

Primary recommendation:

• Fluconazole 150 mg once weekly for 6 months 1, 2
• This regimen achieves symptom control in >90% of patients during the maintenance period 2, 4
• Weekly fluconazole reduces recurrence rates from 64.1% (placebo) to 9.2% at 6 months 4

Alternative maintenance regimens if fluconazole is not suitable:

• Clotrimazole 500 mg vaginal suppository once weekly 3, 1
• Itraconazole 400 mg once monthly or 100 mg once daily 3, 1
• Ketoconazole 100 mg once daily (requires monitoring for hepatotoxicity; 1 in 10,000-15,000 risk) 3, 1

Expected Outcomes and Recurrence Patterns

• During the 6-month maintenance phase, 90.8% of women remain disease-free 4
• After stopping maintenance therapy, expect 40-50% recurrence rate within 6 months 2, 4, 5
• The median time to clinical recurrence after completing therapy is 10.2 months with fluconazole versus 4.0 months with placebo 4
• Long-term fluconazole suppression is highly effective at preventing symptoms but is rarely curative 5

Management of Non-Albicans Species

For C. glabrata infections unresponsive to oral azoles:

• First-line: Boric acid 600 mg intravaginal gelatin capsule daily for 14 days (70% eradication rate) 1, 2
• Second-line options:
  • Nystatin 100,000 units intravaginal suppository daily for 14 days 1, 2
  • Topical 17% flucytosine cream ± 3% amphotericin B cream daily for 14 days 1

Predictors of Treatment Failure

Women more likely to fail maintenance therapy include those with: 6

• Higher number of episodes before treatment initiation
• Longer duration of disease (>6 years)
• Presence of Candida non-albicans species during maintenance

Important Safety Considerations

• Fluconazole can prolong QT interval; use with caution in patients with structural heart disease, electrolyte abnormalities (especially hypokalemia), or concomitant QT-prolonging medications 7
• Avoid concomitant use with erythromycin due to increased risk of torsade de pointes 7
• Drug interactions occur with medications metabolized by CYP2C9, CYP2C19, and CYP3A4, including warfarin, calcium channel blockers, oral hypoglycemics, and protease inhibitors 3, 7
• Fluconazole resistance in C. albicans develops in approximately 7.5% of patients after long-term maintenance therapy, though this remains uncommon 5
• Monitor for rare hepatotoxicity, particularly with ketoconazole; serious hepatic reactions with fluconazole are rare 3, 7

Partner Management

• Routine treatment of sexual partners is not recommended 3, 1
• Consider partner treatment only in women with persistent recurrences or when male partners have symptomatic balanitis (erythematous areas on glans with pruritus) 3, 1

Follow-Up Strategy

• Monitor patients monthly during the first 6 months of maintenance therapy for symptom recurrence 6
• If symptoms recur after completing the 6-month regimen, consider restarting maintenance therapy 2
• Patients should return for evaluation if symptoms persist after treatment or recur within 2 months 3