Is Rezafungin (an echinocandin) effective for treating vaginal candidiasis?

Rezafungin Does Not Treat Vaginal Candidiasis

Rezafungin is not approved or recommended for the treatment of vaginal candidiasis and should not be used for this indication. While rezafungin demonstrates potent antifungal activity against Candida species in laboratory studies simulating vaginal conditions, it is only approved for invasive candidiasis and candidemia, not mucosal infections 1.

Standard Treatment for Vaginal Candidiasis

The established first-line treatments for uncomplicated vulvovaginal candidiasis remain:

• Oral fluconazole 150 mg as a single dose is the preferred systemic option 2
• Topical azole preparations including:
  • Clotrimazole 1% cream 5g intravaginally for 7-14 days 3, 2
  • Miconazole 2% cream 5g intravaginally for 7 days 3, 2
  • Terconazole 0.4% cream 5g intravaginally for 7 days 3, 2
  • Tioconazole 6.5% ointment 5g intravaginally as a single application 3, 2

Why Rezafungin Is Not Used for Vaginal Candidiasis

Route of administration mismatch: Rezafungin is only available as an intravenous formulation designed for once-weekly administration in systemic infections 1. There is no topical or intravaginal formulation available for mucosal candidiasis 4, 5.

Approved indication: Rezafungin is specifically approved for invasive candidiasis and candidemia in adults, not for superficial mucosal infections like vulvovaginal candidiasis 1.

Clinical trial focus: All clinical development and regulatory approval for rezafungin has centered on bloodstream and deep-seated invasive Candida infections, not vaginal infections 6, 1.

Laboratory Evidence Does Not Equal Clinical Use

While in vitro studies demonstrate that rezafungin retains fungicidal activity against Candida species under vaginal pH conditions (pH 4.2), showing fungicidal or near-fungicidal activity against 14/14 tested strains 7, this laboratory finding does not translate to clinical applicability for several reasons:

• No intravaginal formulation exists 4
• No clinical trials have evaluated rezafungin for vaginal candidiasis 7
• The intravenous route is inappropriate for uncomplicated vaginal infections 1

When to Consider Systemic Echinocandins

Echinocandins (including rezafungin) are reserved for:

• Invasive candidiasis and candidemia in critically ill patients 3, 8
• Patients with azole-resistant Candida species causing systemic infection 8
• Disseminated Candida infections, not localized mucosal disease 3

Critical distinction: Vulvovaginal candidiasis is not a systemic or invasive infection and does not warrant echinocandin therapy 3.

Practical Management Algorithm

For uncomplicated vulvovaginal candidiasis:

1. Confirm diagnosis with wet mount showing yeast/pseudohyphae and normal vaginal pH ≤4.5 2
2. Use oral fluconazole 150 mg single dose OR topical azole for 3-7 days 2
3. Reserve multi-day regimens (7 days) for severe or complicated cases 3, 2

For recurrent vulvovaginal candidiasis (≥4 episodes/year):

1. Consider fluconazole 150 mg weekly for 6 months after initial control 3
2. Alternative agents like ibrexafungerp (oral glucan synthase inhibitor) or oteseconazole (long-acting azole) may be considered for recurrent disease 4

Never use intravenous echinocandins like rezafungin for vaginal candidiasis - this represents inappropriate use of a systemic antifungal for a localized mucosal infection 3, 1.