Maintenance Therapy for Recurrent Candidal Vaginitis
For recurrent vulvovaginal candidiasis (≥4 episodes per year), treat with 10-14 days of induction therapy followed by fluconazole 150 mg once weekly for 6 months as maintenance therapy. 1
Induction Phase (First 10-14 Days)
Before starting any treatment, obtain vaginal cultures to confirm the diagnosis and identify the specific Candida species, particularly to detect C. glabrata (present in 10-20% of recurrent cases), which requires different management. 1, 2
Choose one of these induction regimens:
- Topical azole therapy for 10-14 days (any topical agent; no single agent is superior) 1
- Oral fluconazole 150 mg every 72 hours for 2-3 doses 1
Maintenance Phase (6 Months)
For C. albicans (Most Common)
Primary recommendation: Fluconazole 150 mg once weekly for 6 months 1, 3
This regimen achieves:
- 90.8% disease-free at 6 months 3
- 73.2% disease-free at 9 months 3
- 42.9% disease-free at 12 months 3
- Median time to recurrence of 10.2 months versus 4.0 months with placebo 3
Alternative maintenance regimens if fluconazole is not feasible:
- Clotrimazole 500 mg vaginal suppository once weekly 1
- Itraconazole 400 mg once monthly or 100 mg once daily 1
- Ketoconazole 100 mg once daily (monitor liver function; hepatotoxicity risk 1 in 10,000-15,000) 4, 1
For C. glabrata (Azole-Resistant Species)
Do NOT use fluconazole as first-line therapy due to intrinsic azole resistance. 5, 2
First-line treatment: Boric acid 600 mg intravaginal gelatin capsule daily for 14 days (70% eradication rate) 1, 2
Second-line options if boric acid fails:
- Nystatin 100,000 units intravaginal suppository daily for 14 days 1, 2
- Topical 17% flucytosine cream ± 3% amphotericin B cream daily for 14 days (requires compounding pharmacy) 1, 2
Important: No well-established maintenance regimen exists for C. glabrata; obtain follow-up cultures to confirm eradication. 5
Predictors of Treatment Failure
Women more likely to fail maintenance therapy include those with: 1
- Higher number of episodes before treatment initiation
- Longer duration of disease (>6 years)
- Presence of Candida non-albicans species during maintenance 6
Critical Caveats
Partner treatment is not routinely recommended but may be considered for women with persistent recurrences or male partners with symptomatic balanitis. 4, 1
Drug interactions: Fluconazole can interact with astemizole, calcium channel antagonists, cisapride, warfarin, cyclosporine, oral hypoglycemics, phenytoin, protease inhibitors, tacrolimus, terfenadine, theophylline, and rifampin. 4
Pregnancy considerations: Only topical azole therapies should be used during pregnancy for 7 days; avoid all oral azoles, fluconazole, and boric acid. 4, 1
Laboratory pitfall: Standard susceptibility testing at pH 7 underestimates resistance because all antifungals have significantly higher MICs at vaginal pH 4. 1
Underlying Conditions to Address
Screen for and optimize management of: 1
- Uncontrolled diabetes mellitus (requires 7-14 days therapy, not short courses)
- HIV infection (higher colonization rates correlating with immunosuppression severity)
- Immunosuppression from corticosteroids or other conditions
- Recent or repeated antibiotic courses
Follow-Up Strategy
Monitor patients receiving maintenance therapy regularly for treatment effectiveness and side effects. 4 Obtain repeat vaginal cultures 1 month post-treatment to document mycological cure, especially for C. glabrata cases. 2
Recurrence after maintenance: Up to 50% of women experience recurrence after completing 6 months of fluconazole maintenance therapy, though the median time to recurrence is significantly extended compared to no maintenance. 3, 7