Treatment of Vaginal Candida glabrata
For vaginal Candida glabrata infection, use intravaginal boric acid 600 mg daily for 14 days as first-line therapy. 1
Why Boric Acid is First-Line
C. glabrata represents a "complicated" vulvovaginal candidiasis that differs fundamentally from C. albicans infections due to inherent azole resistance. 1 The Infectious Diseases Society of America specifically recommends topical intravaginal boric acid in a gelatin capsule, 600 mg daily for 14 days, as the preferred first-line treatment, particularly when oral azoles have failed or are expected to be ineffective. 1
Fluconazole monotherapy should be avoided for confirmed C. glabrata, as this organism demonstrates resistance to azole antifungals including fluconazole, making standard C. albicans treatments ineffective. 1
Alternative Treatment Options (When Boric Acid Fails or is Unavailable)
If boric acid is not available or has failed, consider these alternatives in order:
Nystatin intravaginal suppositories 100,000 units daily for 14 days can serve as second-line therapy. 1
Topical 17% flucytosine cream alone or combined with 3% amphotericin B cream, administered daily for 14 days, represents another option, though this carries a weaker recommendation. 1, 2
Non-fluconazole azole drugs (such as clotrimazole, miconazole, or terconazole) can be used for 7-14 days, though these are less effective than for C. albicans. 1
Diagnostic Confirmation Before Treatment
Before initiating therapy, confirm the diagnosis through:
Wet-mount preparation with saline and 10% potassium hydroxide to demonstrate yeast (note: C. glabrata doesn't form pseudohyphae or hyphae, making microscopic recognition difficult). 1
Vaginal cultures are essential for proper identification of C. glabrata, as microscopy alone is often insufficient. 1
Verify normal vaginal pH (4.0-4.5) before starting treatment; elevated pH suggests bacterial vaginosis or trichomoniasis instead. 1, 2
Treatment Duration and Monitoring
Complete the full 14-day course regardless of symptom improvement to ensure complete eradication. 1
Evaluate clinical response after completing the 14-day regimen; patients should return for follow-up if symptoms persist or recur. 1
If symptoms persist despite appropriate therapy, consider alternative diagnoses, resistant infection, or obtain repeat cultures to confirm species identification. 1
Important Caveats and Pitfalls
Oil-based creams and suppositories weaken latex condoms and diaphragms, so counsel patients about potential contraceptive failure during treatment. 1
C. glabrata accounts for 10-20% of recurrent vulvovaginal candidiasis cases, making species identification critical for treatment success. 1
Treatment approach does not differ based on HIV status, with identical response rates expected in both HIV-positive and HIV-negative women. 1, 3
Self-diagnosis is unreliable; microscopic and culture confirmation should be obtained before treatment, especially for recurrent cases. 3
Emerging Evidence for Refractory Cases
For chronic recurrent C. glabrata vulvovaginitis that fails standard therapies, limited research suggests voriconazole (400 mg twice daily on day 1, then 200 mg twice daily for 14 days) or micafungin combined with topical ciclopirox olamine may be effective, though these lack guideline-level recommendations. 4, 5