What is the recommended treatment for a Candida (C.) glabrata vaginal infection?

Treatment of Candida glabrata Vaginal Infection

For C. glabrata vulvovaginitis unresponsive to oral azoles, use topical intravaginal boric acid 600 mg daily in a gelatin capsule for 14 days as first-line therapy. 1, 2

Why C. glabrata Requires Different Treatment

• C. glabrata demonstrates intrinsic reduced susceptibility and frequent resistance to azole antifungals, including fluconazole, making standard treatments for C. albicans ineffective 1, 2
• This organism causes "complicated" vulvovaginal candidiasis requiring specific treatment approaches distinct from typical Candida infections 2
• C. glabrata accounts for less than 10% of vulvovaginal candidiasis cases but presents with milder symptoms than C. albicans infections 3, 4

Recommended Treatment Algorithm

First-Line Treatment

• Topical intravaginal boric acid 600 mg daily in a gelatin capsule for 14 days 1, 2
• This is a strong recommendation despite low-quality evidence, reflecting the limited effective options available 1
• Complete the full 14-day course to ensure eradication 2

Second-Line Alternatives

• Nystatin intravaginal suppositories 100,000 units daily for 14 days if boric acid is unavailable or not tolerated 1, 2
• Topical 17% flucytosine cream alone or combined with 3% amphotericin B cream daily for 14 days as a third option (weaker recommendation) 1, 2

Systemic Options for Refractory Cases

• High-dose oral fluconazole 800 mg daily for 2-3 weeks can be considered in Germany and some regions where topical options are unavailable 3, 4
• Non-fluconazole azole drugs for 7-14 days may be attempted as first-line therapy 2
• Avoid standard-dose fluconazole monotherapy as it is frequently ineffective against C. glabrata 1, 2

Emerging Therapies for Resistant Cases

• Micafungin (an echinocandin) combined with topical ciclopirox olamine showed success in small case series of 14 patients with chronic recurrent C. glabrata vulvovaginitis 5
• Oral posaconazole 400 mg twice daily plus local ciclopirox olamine or nystatin for 15 days has been discussed for resistant cases 4
• These options are expensive, not approved for this indication, and lack robust clinical evidence 3

Diagnostic Confirmation Before Treatment

• Obtain vaginal cultures for species identification, as C. glabrata doesn't form pseudohyphae or hyphae, making microscopic recognition difficult 2
• Perform wet-mount preparation with saline and 10% potassium hydroxide, though this may be negative with C. glabrata 1, 2
• Verify normal vaginal pH (4.0-4.5) 1, 2
• Determine minimum inhibitory concentration (MIC) for non-albicans species to guide therapy 3

Critical Pitfalls to Avoid

• Do not use standard single-dose fluconazole 150 mg as recommended for C. albicans—this will fail with C. glabrata 1, 2
• Do not rely on microscopy alone for diagnosis, as C. glabrata may not be visible without culture 2
• Boric acid treatment is not allowed in some countries (e.g., Germany), requiring alternative approaches 3
• Oil-based vaginal preparations may weaken latex condoms and diaphragms 2

Monitoring and Follow-Up

• Evaluate clinical response after completing the 14-day treatment regimen 2
• Instruct patients to return if symptoms persist or recur after treatment 2
• If symptoms persist despite appropriate therapy, consider alternative diagnoses, resistant infection, or need for culture-guided therapy 2

Special Considerations

• Treatment approach does not differ based on HIV status, with identical response rates expected 1
• For recurrent C. glabrata infections, suppressive therapy regimens used for C. albicans (weekly fluconazole) are unlikely to be effective given azole resistance 1, 6
• Side effects from fluconazole include headache (13%), nausea (7%), and abdominal pain (6%) with single-dose therapy, though higher doses for C. glabrata may increase these rates 7