What is the recommended treatment for pain caused by a Candida glabrata vaginal yeast infection?

Treatment of Pain from Candida glabrata Vaginal Yeast Infection

For Candida glabrata vulvovaginitis causing pain, use intravaginal boric acid 600 mg daily for 14 days as first-line therapy, as this organism is inherently resistant to standard azole antifungals including fluconazole. 1

Why C. glabrata Requires Different Treatment

• C. glabrata demonstrates intrinsic resistance to azole antifungals, making standard fluconazole therapy ineffective 1
• This species does not form pseudohyphae or hyphae, making microscopic diagnosis difficult and requiring culture confirmation 2, 1
• C. glabrata accounts for 10-20% of recurrent vulvovaginal candidiasis cases and requires "complicated" treatment protocols distinct from C. albicans 2, 1

First-Line Treatment Protocol

• Boric acid 600 mg intravaginal gelatin capsules daily for 14 days is the Infectious Diseases Society of America's recommended first-line treatment 1
• The full 14-day course must be completed to ensure complete eradication, even if symptoms resolve earlier 1
• This regimen is specifically recommended when oral azoles have failed or for confirmed C. glabrata infection 1

Alternative Treatment Options (in order of preference)

• Nystatin intravaginal suppositories 100,000 units daily for 14 days can be used as an alternative, particularly effective for C. glabrata 1, 3

  • In one study, nystatin achieved 64.3% mycological cure for C. glabrata compared to only 12.5% with fluconazole 3
  • Nystatin was also effective for fluconazole-resistant Candida in 5 of 9 patients 3

• Topical 17% flucytosine cream alone or combined with 3% amphotericin B cream daily for 14 days is another option, though this is a weaker recommendation 1, 4

  • Amphotericin/flucytosine cream achieved clearance in all 18 patients with non-albicans species in one UK study 4

• Non-fluconazole azole drugs for 7-14 days can be attempted, though conventional azole therapies are less effective against C. glabrata than C. albicans 2, 1

What NOT to Use

• Avoid fluconazole monotherapy for confirmed C. glabrata, as it is ineffective at standard doses 2, 1
• Single-dose fluconazole 150 mg (standard for C. albicans) achieves only 40% therapeutic cure in recurrent vaginitis and would be even less effective for azole-resistant C. glabrata 5

High-Dose Azole Regimens (when other options unavailable)

• If boric acid, nystatin, and flucytosine/amphotericin are unavailable, high-dose fluconazole 800 mg daily for 2-3 weeks has been used in Germany, though resistance is increasing 6
• Voriconazole 400 mg twice daily on day 1, then 200 mg twice daily for 14 days showed efficacy in two case reports of fluconazole-resistant C. glabrata 7
• Boric acid remains superior to these high-dose azole approaches based on guideline recommendations 1

Diagnostic Confirmation Before Treatment

• Obtain vaginal cultures to confirm C. glabrata, as microscopy cannot reliably identify this species 2, 1
• Verify normal vaginal pH (4.0-4.5) to rule out bacterial vaginosis or trichomoniasis 1
• Wet-mount preparation with saline and 10% KOH should be performed, though C. glabrata may not show typical hyphae 1

Follow-Up and Monitoring

• Patients should return if symptoms persist or recur after completing the 14-day treatment course 1
• Clinical response should be evaluated after completing therapy 1
• If symptoms persist despite appropriate therapy, consider alternative diagnoses or obtain repeat cultures to assess for persistent resistant infection 1

Important Caveats

• Oil-based vaginal preparations may weaken latex condoms and diaphragms, risking contraceptive failure 2, 1
• Partner treatment is not routinely recommended, as vulvovaginal candidiasis is not sexually transmitted 2
• Male partners with symptomatic balanitis may benefit from topical antifungal therapy 2