Candidiasis, vulvovaginal

	Zambia HIV National Guidelines
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	Guide Editors
	Editor In Chief Joel E. Gallant, MD, MPH Pharmacology Editor Paul Pham, PharmD, BCPS Zambia Guideline Team Peter Mwaba MMed PhD FRCP Alywn Mwinga MMed Isaac Zulu MMed MPH Velepie Mtonga MMed Albert Mwango MBChB Jabbin Mulwanda MMed FCS

Candidiasis, vulvovaginal

Brenda Ross, M.D. and Barbara E. Wilgus, CRNP
08-17-2009

Zambia Specific Information

Epidemiology of vulvovaginal candidiasis in Zambia not well described, but it should be considered common.
Typically managed on syndromic basis in Zambia.
Fungal culture and sensitivity testing generally unnecessary, and not readily available in Zambia.
In Zambia, recommended adult treatment for vaginal candidasis is fluconazole 150 mg PO x1 (avoid in 1st trimester of pregnancy).
In Zambia, recommended alternative regimens for adults include clotrimazole 100 mg vaginal tablet, 2 tabs intra-vaginal x 3 days OR miconazole 200 mg vaginal suppository intra-vaginal daily x 3 days.

Zambia Information Author: Larry William Chang, MD, MPH

Affects 75% of immunocompetent women, 40-50% have >2 episodes over lifetime
5 -10% of immunocompetent women have recurrent episodes, defined as >4 episodes/yr
Uncomplicated vulvovaginal candidiasis affects 90% of HIV-infected women; occurs at higher CD4 counts than other forms of candidiasis
Among HIV infected women, severity, frequency, duration and response to standard therapy may be altered with advanced immunosuppression. Topical therapy should be continued for 7-14 days.
80% caused by C. albicans
10-20% caused by C. glabrata or other non-albicans spp.
Sx: pruritis, discharge, vulvar burning, external dysuria, erythema and labial swelling

Microscopic examination of vaginal discharge with 10% KOH or gram stain demonstrates presence of yeast or pseudohyphae
Vaginal fungal Cx may be useful to demonstrate presence of non-albicans spp. or resistant strains
Candida may also be identified on cytologic specimens

Principles of Therapy

Should be treated similarly in HIV+ and negative women
Pts with recurrent candidiasis may benefit from long-term prophylactic therapy with fluconazole150 mg po q wk x 6 mos or topical clotrimazole 200 mg twice a week.
Oil-based suppositories and creams have adverse effect on latex condoms, which could cause condom failure.
Treatment of sex partners is generally not necessary, as not acquired through sexual intercourse (see Follow-up below)

Topical therapy

Miconazole: 2% cream 5 g intravaginally qd x7d, or one 100 mg vaginal suppository qd x7d, or one 200 mg vaginal suppository qd x3d
Butoconazole: 2% cream 5 g intravaginally x3d, or 2% cream 5 g (Butaconazole1-sustained release) as single intravaginal application
Clotrimazole: 1% cream 5 g intravaginally x7-14d, or one100 mg vaginal tab x7d, or two100 mg vaginal tabs x3d, or one 500 mg vaginal tab as single application
Nystatin: one100,000 unit vaginal tab qd x14d
Terconazole: 0.4% cream 5 g intravaginally x7d, or 0.8% cream 5 g intravaginally qd x3d, or one 80 mg vaginal suppository qd x3d
Tioconazole: 6.5% ointment 5 g intravaginally as single application

Systemic therapy

Drug	Recommendations/Comments
Miconazole	Topical azoles generally interchangeable, but C. glabrata and C. tropicalis not as sensitive to these preparations.
Butoconazole	Topical azoles generally interchangeable, but C. glabrata and C. tropicalis not as sensitive to these preparations.
Clotrimazole	Topical azoles generally interchangeable, but C. glabrata and C. tropicalis not as sensitive to these preparations.
Nystatin	Less effective than topical azole preparations
Terconazole	Topical azoles generally interchangeable, but C. glabrata and C. tropicalis not as sensitive to these preparations.
Tioconazole	Topical azoles generally interchangeable, but C. glabrata and C. tropicalis not as sensitive to these preparations.
Fluconazole	Single dose oral fluconazole effective, generally safe, and well tolerated. Rare cases of acute hepatitis reported. Should not be used during pregnancy or lactation.

Test of cure generally unnecessary if asymptomatic after treatment
Consider fungal Cx to identify strain if persistent Sx after treatment
Treatment of sex partners not recommended, but may be considered in women who have recurrent infection
A minority of male sex partners may have balanitis, treat with topical antifungal agents

Vulvovaginal candidiasis associated with increased cell-associated and cell-free HIV-1 RNA in cervicovaginal secretions

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Abbreviations