What is the best treatment approach for a patient with recurrent yeast infections, particularly those with underlying health conditions such as diabetes?

Treatment of Recurrent Yeast Infections

For recurrent vulvovaginal candidiasis (≥4 episodes per year), treat with 10-14 days of induction therapy using either topical azole or oral fluconazole, followed by fluconazole 150 mg weekly for 6 months. 1, 2

Initial Induction Phase (10-14 Days)

The goal is to achieve mycologic remission before starting maintenance therapy. 1

Choose one of the following induction regimens:

• Oral fluconazole 150 mg every 72 hours for 2-3 doses (most convenient) 1, 2
• Topical intravaginal azole daily for 10-14 days 1, 2

Before initiating treatment, confirm diagnosis with wet mount preparation using saline and 10% potassium hydroxide to demonstrate yeast or hyphae, and verify normal vaginal pH (4.0-4.5). 2 This step is critical because symptoms are nonspecific and can result from other infectious or noninfectious causes. 1

Maintenance Suppressive Therapy (6 Months)

After completing induction, prescribe fluconazole 150 mg orally once weekly for 6 months. 1, 2 This regimen achieves control of symptoms in >90% of patients and is the most convenient and well-tolerated option. 1, 3

Alternative maintenance regimens if fluconazole is not feasible:

• Clotrimazole 200 mg intravaginally twice weekly 1, 2
• Clotrimazole 500 mg vaginal suppository once weekly 1
• Ketoconazole 100 mg orally once daily (requires hepatotoxicity monitoring) 1
• Itraconazole 400 mg once monthly or 100 mg once daily 1

Managing Underlying Conditions

For patients with diabetes, optimize glycemic control before and during antifungal therapy. 4 High blood glucose levels promote yeast attachment and growth while interfering with immune responses. 4 Poorly controlled diabetes significantly increases risk of both incident infection and recurrence. 4

Other modifiable factors to address:

• Discontinue or minimize corticosteroid use if possible 4
• Complete any ongoing antibiotic courses and avoid unnecessary antibiotic exposure 4
• Consider alternative contraception if using high-dose estrogen oral contraceptives 4

Expected Outcomes and Recurrence

Counsel patients that 40-50% will experience recurrence after stopping the 6-month maintenance regimen. 1, 2 Weekly fluconazole maintains clinical remission in 90.8% at 6 months, 73.2% at 9 months, and 42.9% at 12 months, compared to 35.9%, 27.8%, and 21.9% respectively with placebo. 3 The median time to clinical recurrence with fluconazole is 10.2 months versus 4.0 months with placebo. 3

Special Considerations for Non-Albicans Species

If Candida glabrata is identified (occurs in 10-20% of recurrent cases and is more common in type 2 diabetes), standard azole therapy is frequently unsuccessful. 1, 4

For C. glabrata unresponsive to oral azoles, use the following sequential approach:

1. First-line: Boric acid 600 mg in gelatin capsules intravaginally daily for 14 days (requires compounding by pharmacist; achieves ~70% clinical and mycologic eradication) 1, 2

2. Second-line: Nystatin intravaginal suppositories 100,000 units daily for 14 days 1, 2

3. Third-line: Topical 17% flucytosine cream alone or combined with 3% amphotericin B cream daily for 14 days (requires compounding) 1, 2

Candida krusei responds to all topical antifungal agents but is resistant to fluconazole. 1

Critical Pitfalls to Avoid

Do not treat with short-course therapy (single dose or 3-day regimens) for recurrent infections. 1 These regimens achieve >90% response in uncomplicated cases but are inadequate for recurrent disease. 1, 5

Do not routinely treat sexual partners. 1 This remains controversial with no proven benefit, though partners with symptomatic infection should receive treatment. 4

Do not assume azole resistance in C. albicans. 1, 2 Azole-resistant C. albicans infections are extremely rare, though recent evidence documents resistance following prolonged azole exposure. 1

Monitor for fluconazole resistance development during long-term therapy. 3 While surveillance studies show no evidence of resistance development with weekly fluconazole or superinfection with C. glabrata, prudent monitoring of recurrent isolates is recommended. 1, 3

HIV-Infected Patients

Treatment regimens should not differ based on HIV status, as identical response rates occur in HIV-positive and HIV-negative women. 1, 2 However, vaginal Candida colonization rates are higher in HIV-infected women and correlate with immunosuppression severity. 1 Long-term prophylactic fluconazole 200 mg weekly is effective but not recommended for routine primary prophylaxis in the absence of recurrent disease. 1