What is the recommended treatment for a patient with recurrent vaginal candidiasis (candida infection)?

Treatment of Recurrent Vaginal Candidiasis

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

Induction Phase (10-14 Days)

Choose one of the following regimens:

• Oral fluconazole 150 mg on day 1, repeated on day 4 (two doses total, 72 hours apart) 1
• Topical azole therapy for 7-14 days: clotrimazole 1% cream intravaginally, miconazole 2% cream 5g intravaginally, or terconazole 0.4% cream 5g intravaginally 2

The IDSA guidelines provide a strong recommendation with high-quality evidence for this extended induction approach, which differs from the single-dose treatment used for uncomplicated cases. 1

Mandatory Maintenance Phase (6 Months)

After achieving clinical remission, prescribe fluconazole 150 mg orally once weekly for 6 months. 1, 2

• This maintenance regimen achieves symptom control in >90% of patients during the treatment period 1
• Alternative maintenance options (if fluconazole is not tolerated): clotrimazole 500 mg vaginal suppository once weekly for 6 months, or itraconazole 100 mg daily or 400 mg once monthly for 6 months 2

Critical Pre-Treatment Step: Obtain Vaginal Cultures

Before initiating therapy, obtain vaginal cultures to identify the Candida species. 1, 2

This step is essential because:

• Non-albicans species (particularly C. glabrata) are significantly less responsive to conventional azole therapy 1
• Azole therapy, including voriconazole, is frequently unsuccessful for C. glabrata 1

For C. glabrata Vulvovaginitis (Azole-Resistant)

If cultures reveal C. glabrata unresponsive to oral azoles, use:

• First-line: Boric acid 600 mg intravaginal gelatin capsules daily for 14 days 1, 2
• Second-line: Nystatin intravaginal suppositories 100,000 units daily for 14 days 1
• Third-line: Topical 17% flucytosine cream alone or combined with 3% amphotericin B cream daily for 14 days 1

These topical formulations must be compounded by a pharmacist. 1

Expected Outcomes and Recurrence

• After cessation of the 6-month maintenance therapy, expect a 40-50% recurrence rate 1
• During maintenance therapy, >90% of patients achieve symptom control 1
• Patients with a history of recurrent vaginitis are significantly less likely to respond clinically and mycologically compared to those without such history (p < 0.001) 3

Common Pitfalls to Avoid

Do not treat recurrent candidiasis with single-dose fluconazole as used for uncomplicated cases—this is inadequate and will lead to treatment failure. 1

Do not skip the maintenance phase—the extended 6-month suppressive therapy is mandatory, not optional, for recurrent disease. 1, 2

Do not assume all Candida species respond equally to azoles—failure to culture and identify non-albicans species leads to persistent treatment failures. 1, 2

Special Populations

HIV-infected women: Treat with identical regimens as non-HIV-infected women, though infections may be more severe. 1, 2

Pregnant women: Use only topical azole therapy for 7 days; never use oral fluconazole during pregnancy. 2

Partner Management

Routine treatment of sexual partners is not recommended, as recurrent vulvovaginal candidiasis is not sexually transmitted. 2 However, male partners with symptomatic balanitis may benefit from topical antifungal treatment. 2

Safety Profile

Fluconazole is generally well tolerated. 4 In the single-dose vaginitis studies, the most common treatment-related adverse events were headache (13%), nausea (7%), and abdominal pain (6%). 4 Most side effects are mild to moderate in severity. 4