What is the best course of treatment for a patient with vulvovaginal candidiasis (Candida albicans), a history of Pelvic Inflammatory Disease (PID), and current symptoms of vaginal itch, who has undergone a high vaginal swab and urine test, and is currently taking Sertraline?

Treatment of Vulvovaginal Candidiasis with History of PID

For this patient with confirmed Candida albicans vulvovaginal candidiasis, no further testing is needed—treat with either topical azole therapy (clotrimazole 1% cream 5g intravaginally for 7-14 days or miconazole 2% cream 5g intravaginally for 7 days) or oral fluconazole 150mg as a single dose. 1, 2

No Additional Testing Required

• The diagnosis is already confirmed by high vaginal swab showing Candida albicans with moderate growth, and urine MCS has excluded urinary tract infection. 1
• The history of PID does not change the management of vulvovaginal candidiasis, as these are distinct conditions—PID is a bacterial infection of the upper genital tract, while this is a fungal infection of the lower genital tract. 1
• Approximately 10-20% of women harbor Candida species in the vagina asymptomatically, so the presence of yeast alone without symptoms would not require treatment, but this patient has symptomatic infection. 1

First-Line Treatment Options

Topical azole therapy:

• Clotrimazole 1% cream 5g intravaginally for 7-14 days (available over-the-counter). 1, 2
• Miconazole 2% cream 5g intravaginally for 7 days (available over-the-counter). 1, 2
• Terconazole 0.4% cream 5g intravaginally for 7 days. 1
• These topical formulations achieve 80-90% cure rates with symptom relief and negative cultures after therapy completion. 1, 2

Oral therapy:

• Fluconazole 150mg as a single oral dose is equally effective to topical agents for uncomplicated vulvovaginal candidiasis. 1, 3
• In clinical trials, fluconazole achieved 55% therapeutic cure (complete symptom resolution plus negative culture), 69% clinical cure, and 61% mycologic eradication—rates comparable to 7-day vaginal azole products. 3

Important Considerations for This Patient

Sertraline interaction:

• There are no clinically significant interactions between fluconazole and sertraline that would preclude use of oral fluconazole if chosen. 3

History of PID:

• The nausea mentioned in the chief complaint is likely unrelated to the vulvovaginal candidiasis, as typical symptoms include vulvar pruritus, vaginal discharge, vaginal soreness, vulvar burning, dyspareunia, and external dysuria—not gastrointestinal symptoms. 2, 4
• Since the patient reports improvement in gastrointestinal symptoms and urine culture is negative, there is no evidence of ascending infection or recurrent PID. 1

Treatment Selection

For uncomplicated vulvovaginal candidiasis (mild-to-moderate, sporadic, nonrecurrent disease with C. albicans):

• Both short-term topical azoles and single-dose oral fluconazole are appropriate. 1
• The choice between topical and oral therapy depends on patient preference—oral therapy offers convenience, while topical therapy avoids systemic absorption and potential side effects. 1, 5

Common side effects to counsel about:

• Topical agents: Local burning or irritation may occur but are usually mild. 1
• Oral fluconazole: Most common side effects include headache (13%), nausea (7%), and abdominal pain (6%), though most are mild to moderate. 3
• Note that oil-based vaginal creams and suppositories may weaken latex condoms and diaphragms. 1

Follow-Up and Safety Netting

• Follow-up is only needed if symptoms persist or recur within 2 months. 1, 2
• If symptoms do not resolve after treatment, consider alternative diagnoses, non-albicans Candida species (though culture confirmed C. albicans here), or need for longer therapy duration. 2, 4
• Recurrent vulvovaginal candidiasis is defined as 4 or more episodes per year—if this develops, the patient would require vaginal cultures to confirm diagnosis and identify species, followed by longer initial therapy (7-14 days) and consideration of maintenance therapy with fluconazole 100-150mg weekly for 6 months. 2, 6, 7

Partner Treatment

• Routine treatment of sexual partners is not recommended, as vulvovaginal candidiasis is not typically acquired through sexual intercourse. 1, 4
• Partners should only be treated if they have symptomatic balanitis (erythematous areas on the glans with pruritus or irritation), in which case topical antifungal agents may provide relief. 1, 4