What is the best approach to manage recurrent vaginitis in a woman of reproductive age?

Management of Recurrent Vaginitis

Confirm Diagnosis and Identify Causative Organism

Obtain vaginal cultures before initiating any treatment to confirm the diagnosis and identify the specific Candida species, as 10-20% of recurrent vulvovaginal candidiasis (RVVC) cases are caused by non-albicans species like C. glabrata that require different treatment approaches. 1, 2

• RVVC is defined as ≥4 episodes of symptomatic vulvovaginal candidiasis within 12 months, affecting approximately 5% of women 1, 2
• PCR testing demonstrates superior sensitivity (90.9%) and specificity (94.1%) compared to microscopy alone (sensitivity 57.5%) 1
• Screen for predisposing conditions: uncontrolled diabetes mellitus, HIV infection (in appropriate clinical contexts), immunosuppression, corticosteroid use, and recent broad-spectrum antibiotic use 3, 1

Two-Phase Treatment Algorithm for RVVC

Induction Phase (10-14 Days)

Initiate intensive induction therapy for 10-14 days to achieve mycologic remission before starting maintenance therapy. 1, 2

Option 1 (Oral): Fluconazole 150 mg orally every 72 hours for 2-3 doses 1, 2

Option 2 (Topical): Any topical azole for 10-14 days (no superiority of one agent over another for C. albicans) 1

• Examples: Clotrimazole 1% cream for 7-14 days, terconazole 0.4% cream for 7 days 4

Maintenance Phase (6 Months)

After achieving initial mycologic remission, start fluconazole 150 mg once weekly for 6 months, which achieves symptom control in >90% of patients and improves quality of life in 96% of women. 1, 2, 4

Alternative maintenance regimens (if fluconazole is contraindicated or not tolerated):

• Clotrimazole 500 mg vaginal suppository once weekly 1, 4
• Itraconazole 400 mg once monthly or 100 mg once daily 1, 4
• Ketoconazole 100 mg once daily (monitor for hepatotoxicity; 1 in 10,000-15,000 risk) 3, 1

Management of Non-Albicans Species

For C. glabrata infections unresponsive to oral azoles, use boric acid 600 mg intravaginal gelatin capsule daily for 14 days, which achieves 70% eradication rate. 1, 2, 4

Second-line options for C. glabrata:

• Nystatin 100,000 units intravaginal suppository daily for 14 days 1, 4
• Topical 17% flucytosine cream ± 3% amphotericin B cream daily for 14 days 1

For non-albicans species in general, use 7-14 days of non-fluconazole azole therapy (such as terconazole), as these agents have better activity against non-albicans species at vaginal pH 4

Critical Caveats and Follow-Up

Set realistic expectations: 30-40% of women will experience recurrence after stopping the 6-month maintenance regimen. 2, 4

• Women with higher numbers of episodes before treatment, longer duration of disease, or presence of non-albicans species during maintenance are more likely to fail therapy 1
• Regular follow-up evaluations are essential to monitor treatment effectiveness and side effects 3
• Partner treatment is not routinely recommended but may be considered for women with persistent recurrences or male partners with symptomatic balanitis 3, 1

Important Drug Interactions and Contraindications

Fluconazole and other oral azoles have clinically important interactions with: terfenadine, astemizole, calcium channel antagonists, cisapride, warfarin, cyclosporine, oral hypoglycemic agents, phenytoin, protease inhibitors, rifampin, and theophylline 3, 4

In pregnancy: Use only topical azole therapies for 7 days (butoconazole, clotrimazole, miconazole, or terconazole); never use oral agents 3, 4

Azole creams and suppositories are oil-based and may weaken latex condoms and diaphragrams 4

When to Consider Bacterial Vaginosis

If cultures are negative for Candida or symptoms persist despite appropriate antifungal therapy, consider recurrent bacterial vaginosis, which requires extended metronidazole 500 mg twice daily for 10-14 days, followed by metronidazole vaginal gel 0.75% twice weekly for 3-6 months if initial treatment fails 5, 6