From the Guidelines
Vaginal candidiasis can be present even when cultures from swabs don't show growth, and treatment may still be necessary based on symptoms and clinical diagnosis. According to the 2021 Centers for Disease Control and Prevention (CDC) guidelines for the treatment of sexually transmitted infections, including vulvovaginal candidiasis (VVC) 1, diagnosis of VVC can be challenging due to the limitations of microscopy, clinical suspicion, and culture. While culture remains the gold standard for diagnosis, it can lead to a delay in diagnosis and treatment, and microscopy and clinical diagnosis have poor sensitivity.
Diagnosis and Treatment Considerations
- The CDC guidelines recommend treating VVC with over-the-counter intravaginal agents such as clotrimazole 1% cream (5 g intravaginally daily for 7–14 days) or miconazole 2% cream (5 g intravaginally daily for 7 days) 1.
- Alternatively, prescription intravaginal agents like terconazole 0.4% cream (5 g intravaginally daily for 7 days) or oral fluconazole 150 mg (single dose) can be used 1.
- Molecular testing, such as polymerase chain reaction (PCR), has shown high clinical accuracy for diagnosing VVC, with sensitivity and specificity of 90.9% and 94.1%, respectively 1.
- Clinicians should be aware that some commercially available PCR tests for yeast are not Food and Drug Administration (FDA) approved, and their performance characteristics may vary 1.
Clinical Approach
If symptoms of vaginal yeast infection (itching, burning, abnormal discharge) are present but swab results are negative, treatment may still be appropriate. Consider using over-the-counter antifungal medications like miconazole or clotrimazole as vaginal suppositories or creams for 3-7 days, following package instructions. Alternatively, a healthcare provider might prescribe oral fluconazole 150mg as a single dose 1. False negatives can occur due to sampling technique, prior antifungal use, low fungal load, or non-Candida species causing symptoms. If symptoms persist after treatment, consult a healthcare provider for further evaluation, as recurrent symptoms might indicate resistant infection, non-Candida vaginitis, or an underlying condition like diabetes or immunosuppression. Maintaining good hygiene, wearing cotton underwear, avoiding douches, and limiting sugar intake may help prevent recurrences.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Vaginal Candida Diagnosis
- The diagnosis of vaginal candida can be challenging, especially when it doesn't grow on a swab 2, 3.
- Studies have shown that non-albicans Candida species, such as C. glabrata, can be difficult to diagnose and treat 2, 3.
- The use of oral fluconazole and topical antifungal agents, such as clotrimazole and metronidazole, can be effective in treating vaginal candida 4, 3.
Treatment Options
- Boric acid vaginal suppositories have been shown to be effective in treating C. glabrata vaginitis, especially in diabetic patients 2.
- Combined systemic and topical therapy, using fluconazole and metronidazole/clotrimazole, has been proposed as a new approach to treating recurrent vulvovaginal candidiasis 4.
- Fluconazole has been shown to be effective in treating vaginal Candida species, including non-albicans species 3.
Diagnostic Criteria
- Chronic vulvovaginal candidiasis (CVVC) can be diagnosed using a set of criteria, including a history of positive vaginal Candida swab, discharge, dyspareunia, and exacerbation of symptoms with antibiotics 5.
- The use of oral antifungal medication, such as fluconazole, can be effective in treating CVVC 5.