What is the recommended intravaginal treatment for a woman of reproductive age with vaginal candidiasis caused by Candida glabrata?

Intravaginal Treatment for Candida glabrata Vaginitis

For vaginal candidiasis caused by Candida glabrata, intravaginal boric acid 600 mg daily for 14-21 days is the first-line recommended therapy, with intravaginal nystatin suppositories or topical 17% flucytosine cream (alone or combined with 3% amphotericin B cream) as alternative options. 1

Why C. glabrata Requires Different Treatment

C. glabrata represents a complicated form of vulvovaginal candidiasis that is inherently resistant to standard azole therapy. 1 Unlike uncomplicated candidiasis caused by C. albicans (which responds to short-course azoles in 80-90% of cases), C. glabrata requires non-azole intravaginal agents. 2

Specific Intravaginal Treatment Regimens

First-Line: Boric Acid

• Intravaginal boric acid 600 mg capsules daily for 14-21 days 1
• Clinical and mycologic success rates of 64-71% in symptomatic women 3
• No advantage observed in extending therapy beyond 14-21 days 3
• Local side effects are uncommon 3

Second-Line Options (for Boric Acid Failures)

• Topical 17% flucytosine cream intravaginally nightly for 14 days 1

  • 90% success rate in women who failed boric acid and azole therapy 3
  • Can be combined with 3% amphotericin B cream for enhanced efficacy 1

• Nystatin 100,000-unit intravaginal suppositories daily for 14 days 2, 1

  • Less effective than azoles for C. albicans but remains an option for non-albicans species 2

Critical Pitfall to Avoid

Do not use standard azole therapy (clotrimazole, miconazole, terconazole, or fluconazole) for confirmed C. glabrata infections. 1 While the CDC guidelines from 1998 and 2002 list multiple intravaginal azole regimens, these recommendations apply to uncomplicated VVC caused by C. albicans. 2 Recent evidence shows high azole resistance rates in C. glabrata, with itraconazole resistance reaching 81% and fluconazole resistance at 31%. 4

Confirming the Diagnosis

Before initiating treatment, ensure proper diagnosis:

• Vaginal culture is essential to identify C. glabrata specifically (wet mount may be negative) 1
• Vaginal pH should be ≤4.5 (higher pH suggests bacterial vaginosis or trichomoniasis instead) 1
• Clinical symptoms include pruritus, irritation, vaginal discharge, vulvar edema, and erythema 1

Treatment Duration Considerations

C. glabrata requires prolonged treatment courses compared to C. albicans infections. 1 The standard 1-3 day azole regimens effective for uncomplicated VVC are inadequate for this non-albicans species. 2, 1 Minimum treatment duration should be 14 days with boric acid or flucytosine. 1, 3