Treatment of Vaginal Candida glabrata Infection
For vaginal Candida glabrata infection unresponsive to oral azoles, use topical intravaginal boric acid 600 mg daily for 14 days as first-line therapy. 1, 2
Understanding C. glabrata Resistance
C. glabrata has intrinsic reduced susceptibility to all azole antifungals, making it fundamentally different from C. albicans vulvovaginitis. 2, 3 This means:
- Fluconazole (the standard single-dose treatment for uncomplicated yeast infections) is frequently ineffective and should not be used as first-line therapy for confirmed C. glabrata. 4, 2
- The organism accounts for 10-20% of recurrent vulvovaginal candidiasis cases and requires species-specific treatment. 2
Recommended Treatment Algorithm
First-Line Treatment
Intravaginal boric acid 600 mg in gelatin capsules, administered daily for 14 days is the preferred treatment according to the Infectious Diseases Society of America guidelines (strong recommendation). 1, 2
- This achieves clinical improvement or cure in 81% of episodes and mycological eradication in 77% of cases. 5
- Boric acid remains effective even in patients who have failed multiple courses of azole therapy. 5
Second-Line Treatment
Nystatin intravaginal suppositories 100,000 units daily for 14 days if boric acid is unavailable or not tolerated (strong recommendation). 1, 2
Third-Line Treatment
Topical 17% flucytosine cream alone or combined with 3% amphotericin B cream, applied daily for 14 days (weak recommendation). 1, 2
Alternative Approach When Boric Acid is Unavailable
In Germany, where boric acid is not approved, high-dose oral fluconazole 800 mg daily for 2-3 weeks is recommended, though this is less effective than boric acid. 3, 6
Critical Diagnostic Considerations
Before initiating treatment:
- Confirm C. glabrata as the causative organism through vaginal culture rather than assuming treatment failure is due to this species. 2
- Perform wet-mount preparation with 10% KOH and verify vaginal pH is 4.0-4.5. 1, 2
- C. glabrata typically causes milder signs and symptoms compared to C. albicans infections. 3, 6
Management of Recurrent C. glabrata Infections
For recurring episodes after successful initial treatment:
- Begin with 10-14 days of induction therapy using boric acid or another effective topical agent. 1, 2
- Follow with long-term suppressive maintenance therapy: Some patients require maintenance boric acid therapy to prevent recurrence. 5
- For recurrent vulvovaginal candidiasis in general (though less effective for C. glabrata specifically), fluconazole 150 mg weekly for 6 months achieves symptom control in >90% of patients during treatment, though relapse rates approach 50% after cessation. 1, 2, 7
Common Pitfalls to Avoid
- Do not use single-dose fluconazole 150 mg (the standard treatment for C. albicans) as it will likely fail. 1, 2, 8
- Do not empirically treat without culture confirmation when C. glabrata is suspected, as treatment differs significantly from C. albicans. 2
- Avoid treating asymptomatic colonization, which does not require antifungal therapy. 4
- Be aware that C. glabrata can present with mixed infections, most commonly with bacterial vaginosis, which may require concurrent treatment. 5
Special Populations
During pregnancy, oral triazoles should not be administered according to manufacturers. 3 Topical treatments remain the safest option, though specific data on boric acid safety in pregnancy is limited.