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 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
 

 

 

Diagnosis>Opportunistic Infections>
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Candidiasis, vulvovaginal

Brenda Ross, M.D. and Barbara E. Wilgus, CRNP
03-03-2008

  • Epidemiology of candidiasis in Zambia not well described, but based on numerous reports from sub-Saharan Africa, 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

PATHOGENS

  • Candida albicans
  • Candida glabrata
  • other non-albicans Candida spp.

CLINICAL

  • 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

DIAGNOSIS

  • 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

TREATMENT

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 Comments

DrugRecommendations/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
TerconazoleTopical azoles generally interchangeable, but C. glabrata and C. tropicalis not as sensitive to these preparations.
TioconazoleTopical 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.

FOLLOW UP

  • 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

OTHER INFORMATION

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

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