What is the recommended treatment for a sexually active adult female with a history of Sexually Transmitted Infections (STIs) presenting with symptoms of vulvovaginal candidiasis?

Treatment of Vulvovaginal Candidiasis in Sexually Active Women with STI History

For uncomplicated vulvovaginal candidiasis in a sexually active woman, treat with a single oral dose of fluconazole 150 mg or short-course topical azole therapy (1-3 days), as both achieve 80-90% cure rates and are equally effective. 1, 2

First-Line Treatment Options

Oral Therapy (Preferred for Convenience)

• Fluconazole 150 mg as a single oral dose is the most convenient option and achieves therapeutic cure rates of 55-76% with clinical cure rates of 69-86% 1, 2
• Therapeutic concentrations in vaginal secretions are rapidly achieved and sustained for sufficient duration to produce high clinical and mycological responses 3
• Clinical improvement occurs within several days, with 94% showing cure or improvement at 14-day evaluation 4

Topical Therapy (Alternative)

• Over-the-counter options include clotrimazole 2% cream 5g intravaginally daily for 3 days, miconazole 200 mg suppository daily for 3 days, or tioconazole 6.5% ointment 5g as a single application 1
• Prescription options include terconazole 0.8% cream 5g intravaginally daily for 3 days or terconazole 80 mg suppository daily for 3 days 1
• Topical azoles achieve 80-90% cure rates, comparable to oral fluconazole 1

Critical Diagnostic Confirmation

• Confirm diagnosis before treating, as less than 50% of patients clinically treated for VVC actually have confirmed fungal infection 1
• Look for vaginal pH <4.5, pruritus as the most specific symptom, and white discharge 1, 5
• Wet mount showing yeasts or pseudohyphae confirms diagnosis, though microscopy has poor sensitivity 1
• If symptoms persist after OTC treatment or recur within 2 months, obtain fungal culture or PCR testing to identify non-albicans species 1, 5

Special Considerations for This Patient Population

STI History Does Not Change VVC Treatment

• VVC can occur concomitantly with STDs or following antibacterial therapy, but treatment remains the same 1
• Approximately 10-20% of women harbor Candida species asymptomatically and do not require treatment 1, 5

Partner Management

• Do not routinely treat sexual partners, as VVC is not sexually transmitted 1, 5
• Consider partner treatment only if male partner has symptomatic balanitis (erythematous glans with pruritus), treated with topical antifungals 1

Oil-Based Topical Preparations

• Creams and suppositories may weaken latex condoms and diaphragms—counsel patients accordingly 1

Management of Treatment Failure

If Symptoms Persist After Initial Treatment

• Treatment failure suggests misdiagnosis as the most common cause, since true VVC responds in 80-90% of cases 1, 5
• Obtain vaginal culture to identify non-albicans Candida species (particularly C. glabrata), which are present in 10-20% of recurrent cases and less responsive to standard azoles 1, 6
• Consider longer-duration therapy: 7-14 days of topical azole or fluconazole 150 mg repeated after 3 days 1, 6

Recurrent VVC (≥4 Episodes Per Year)

• Initial therapy: Use 7-14 days of topical azole or fluconazole 150 mg repeated after 3 days to achieve mycologic remission 1
• Maintenance therapy: Fluconazole 100-150 mg weekly for 6 months reduces recurrence rates to 90.8% disease-free at 6 months (versus 35.9% with placebo) 1, 7
• Evaluate for predisposing conditions including diabetes, immunosuppression, or HIV 1, 6
• After stopping maintenance therapy, 30-40% will have recurrent disease, with median time to recurrence of 10.2 months 1, 7

Common Pitfalls to Avoid

• Do not continue empiric antifungal therapy without confirmed diagnosis, as this delays appropriate treatment for other causes of vulvovaginitis 1
• Do not use OTC preparations for first-time symptoms—reserve self-treatment only for women with previously confirmed VVC experiencing identical recurrent symptoms 1
• Do not overlook non-albicans species in treatment failures, as C. glabrata requires longer therapy or alternative agents like boric acid 600 mg intravaginally daily for 14 days 1, 5

Adverse Effects and Monitoring

• Oral fluconazole causes mild gastrointestinal symptoms (nausea 7%, abdominal pain 6%, diarrhea 3%) and headache (13%) in most cases 2
• Topical agents cause minimal systemic effects but may cause local burning or irritation 1
• Rare hepatotoxicity with oral azoles—no routine monitoring needed for single-dose therapy 1, 2

Follow-Up

• Return only if symptoms persist or recur within 2 months 1, 5
• No routine follow-up cultures needed for uncomplicated cases that respond clinically 1