From the Guidelines
For recurrent vaginal candidiasis with Candida glabrata and Candida albicans that is not responding to fluconazole (Diflucan) in a patient with uncontrolled diabetes, I recommend a multi-faceted approach, prioritizing diabetes control and antifungal treatment with boric acid vaginal suppositories (600mg) inserted once daily for 14 days, as this approach is supported by the most recent and highest quality study 1.
Key Considerations
- Diabetes control is essential, as high blood sugar creates an environment conducive to fungal growth, and improving glycemic control through medication adjustment, diet, and regular glucose monitoring is crucial 1.
- Antifungal treatment with boric acid vaginal suppositories is effective against both C. glabrata and C. albicans, and is a recommended treatment option for complicated vulvovaginal candidiasis, including cases with non-albicans species 1.
- Alternative treatment options, such as topical flucytosine cream 17% combined with amphotericin B, or extended-duration oral voriconazole 200mg twice daily for 14-28 days, may be considered for severe cases, but boric acid suppositories are a preferred initial treatment due to their efficacy and safety profile 1.
Maintenance Therapy and Prevention
- Maintenance therapy with weekly boric acid suppositories for 6 months may prevent recurrence, as recommended by the Infectious Diseases Society of America 1.
- Patients should be advised to wear cotton underwear, avoid tight clothing, minimize sugar intake, and use unscented hygiene products to reduce the risk of recurrence.
- Reconsider treatment if symptoms persist, as susceptibility testing may be needed to guide therapy, and partner treatment is generally not necessary unless the partner is symptomatic 1.
From the FDA Drug Label
The overall clinical and mycological success rates by Candida species in Study 150-608 are presented in Table 15. Table 15: Overall Success Rates Sustained From EOT To The Fixed 12-Week Follow-Up Time Point By Baseline Pathogen C. albicans 46/107 (43%) 30/63 (48%) C. tropicalis 17/53 (32%) 1/16 (6%) C. parapsilosis 24/45 (53%) 10/19 (53%) C. glabrata 12/36 (33%) 7/21 (33%) C krusei 1/4 0/1
Recommended treatments for recurrent vaginal candidiasis culture showing Candida glabrata and Albicans not responding to diflucan in a patient with uncontrolled diabetes are:
- Voriconazole
- Amphotericin B followed by fluconazole The success rates for C. glabrata were 33% for both voriconazole and amphotericin B followed by fluconazole 2. The success rates for C. albicans were 43% for voriconazole and 48% for amphotericin B followed by fluconazole 2. It is essential to note that these treatments may have varying degrees of effectiveness and potential side effects, and the choice of treatment should be made under the guidance of a healthcare professional.
From the Research
Treatment Options for Recurrent Vaginal Candidiasis
The patient's condition of recurrent vaginal candidiasis, with cultures showing both Candida glabrata and Candida albicans and not responding to diflucan, presents a challenge. Given the patient's uncontrolled diabetes, managing the underlying condition is crucial [ 3 ].
Recommended Treatments
- For Candida albicans, any azole antifungal can be effective [ 4 ].
- For Candida glabrata, treatment with boric acid is recommended [ 4 ].
- Clotrimazole, miconazole, terconazole, and intravaginal boric acid are suggested for recurrent vulvovaginitis caused by both Candida albicans and non-albicans species [ 5 ].
- Micafungin in combination with topical ciclopirox olamine has shown success in treating chronic recurrent vulvovaginal candidiasis caused by C. glabrata [ 6 ].
Considerations
- Maintenance therapy should be started immediately after treatment of the acute episode and should last for six months [ 4 ].
- Identification of the species will influence treatment decisions, and treatment may be modified based on prior response to a specific agent, especially in non-albicans species [ 5 ].
- Controlling risk factors such as diabetes mellitus is essential in managing recurrent vaginal candidiasis [ 3 ].