Treatment of Candida glabrata Vaginal Infections (Non-Nystatin Options)
For Candida glabrata vulvovaginal infections, use intravaginal boric acid 600 mg daily for 14 days as first-line therapy, particularly when oral azoles have failed. 1
First-Line Treatment: Boric Acid
- Intravaginal boric acid 600 mg daily for 14 days is the preferred treatment for C. glabrata vulvovaginitis unresponsive to oral azoles, as recommended by the Infectious Diseases Society of America 1
- Boric acid in gelatin capsules achieves clinical and mycologic success in 64-71% of symptomatic women with C. glabrata vaginitis 1, 2
- No advantage is observed in extending boric acid therapy beyond 14 days 2
Second-Line Treatment: Topical Flucytosine
- Topical 17% flucytosine cream applied intravaginally nightly for 14 days can be used when boric acid fails or is not tolerated 1
- Flucytosine cream (alone or combined with 3% amphotericin B cream) achieves successful outcomes in approximately 90% of women whose condition failed to respond to boric acid and azole therapy 1, 2
Why Oral Azoles Are Problematic for C. glabrata
- C. glabrata has intrinsic reduced susceptibility to all azole antifungals, including fluconazole and voriconazole, making standard oral therapy frequently ineffective 1
- Fluconazole shows only 50% efficacy against C. glabrata infections, compared to 93% for other Candida species 3
- The Centers for Disease Control and Prevention notes that C. glabrata accounts for 10-20% of recurrent vulvovaginal candidiasis cases 1
Critical Diagnostic Step Before Treatment
- Obtain vaginal cultures to confirm C. glabrata as the causative organism rather than assuming treatment failure is due to this species 1
- Verify diagnosis with wet-mount preparation (10% KOH) and check vaginal pH (should be 4.0-4.5) 1
Long-Term Suppressive Maintenance (If Needed)
- Following successful induction therapy with boric acid or flucytosine, consider clotrimazole 500 mg vaginal suppository once weekly as maintenance therapy, given C. glabrata's reduced azole susceptibility 1
- Alternative maintenance: clotrimazole cream 200 mg twice weekly 1
- While fluconazole 150 mg weekly for 6 months achieves symptom control in >90% of patients with recurrent vulvovaginal candidiasis generally 1, 4, it is often ineffective specifically for C. glabrata 1
Common Pitfalls to Avoid
- Do not use empirical fluconazole for suspected C. glabrata infections due to high resistance rates 1
- Local side effects with boric acid and flucytosine are uncommon, making these safer alternatives to systemic therapy 2
- Nystatin (which you specifically asked to exclude) would be 100,000 units daily for 14 days as a second-line alternative 1, 5