What is the recommended treatment for Candida glabrata vaginal infections?

Treatment of Candida glabrata Vaginal Infections

For Candida glabrata vulvovaginitis that fails to respond to oral azoles, use intravaginal boric acid 600 mg daily for 14 days as first-line therapy. 1

Initial Diagnostic Confirmation

Before treating, confirm the diagnosis and identify the specific Candida species:

• Obtain a wet-mount preparation with saline and 10% potassium hydroxide to visualize yeast (note: C. glabrata does not form pseudohyphae or hyphae, making microscopic identification difficult) 1, 2
• Check vaginal pH, which should be 4.0-4.5 in candidiasis 1, 2
• Obtain vaginal cultures to definitively identify C. glabrata, as this species requires different treatment than C. albicans 1, 2

Treatment Algorithm for C. glabrata Vaginitis

First-Line Treatment

Intravaginal boric acid 600 mg in gelatin capsules, administered daily for 14 days 1, 2

• This regimen achieves clinical and mycologic cure rates of approximately 64-71% 3, 4
• Boric acid is particularly effective for C. glabrata infections and is superior to fluconazole for this species 2, 4
• The IDSA provides a strong recommendation for this approach, though acknowledges low-quality evidence 1
• No advantage exists in extending therapy beyond 14 days 3

Second-Line Treatment

Nystatin intravaginal suppositories 100,000 units daily for 14 days 1, 2

• Use this option if boric acid fails or is not tolerated 1
• IDSA gives this a strong recommendation despite low-quality evidence 1

Third-Line Treatment

Topical 17% flucytosine cream alone or combined with 3% amphotericin B cream, administered daily for 14 days 1, 2, 5

• This combination achieves approximately 90% success rates in azole-refractory cases 3
• IDSA provides a weak recommendation due to low-quality evidence 1
• Requires compounding pharmacy access 2
• Consider referral to a specialist for this option 1

Critical Pitfalls to Avoid

Do not use fluconazole as primary treatment for C. glabrata vaginitis 1, 2

• C. glabrata has intrinsic reduced susceptibility to all azoles, including fluconazole and voriconazole 6, 2
• In diabetic patients with C. glabrata VVC, fluconazole achieves only 28-33% mycological cure compared to 64-72% with boric acid 4
• The CDC notes that conventional antimycotic therapies are not as effective against C. glabrata as against C. albicans 1

Do not confuse C. glabrata with C. albicans treatment protocols 1, 2

• C. glabrata accounts for 10-20% of recurrent vulvovaginal candidiasis cases 1
• Failure to identify the causative species leads to ineffective treatment 2
• C. glabrata does not form hyphae on microscopy, making visual identification unreliable 1

Special Considerations

For Recurrent C. glabrata Infections

If infections recur after successful treatment with boric acid or alternative agents:

• Consider maintenance therapy, though optimal regimens for C. glabrata specifically are not well-established 1
• For recurrent vulvovaginal candidiasis in general (≥4 episodes per year), use 10-14 days of induction therapy followed by maintenance 1, 2
• Without maintenance therapy, expect recurrence rates of 40-50% 2

Medication Access Issues

• Boric acid capsules and flucytosine cream require compounding pharmacy services 2
• Local burning or irritation may occur with topical agents but systemic side effects are uncommon 1
• Boric acid and flucytosine both demonstrate acceptable safety profiles with minimal local side effects 5, 3

Patient Counseling

• Sexual partners do not require routine treatment, as VVC is not typically sexually transmitted 1
• Male partners with symptomatic balanitis may benefit from topical antifungal treatment 1