Candida vulvovaginitis medical therapy: Difference between revisions

Jump to navigation Jump to search
VisualWikitext
 
(27 intermediate revisions by 9 users not shown)
Line 1: Line 1:
__NOTOC__
__NOTOC__
{{Candidiasis}}
{{Candida vulvovaginitis}}
{{CMG}}
{{CMG}} {{AE}} {{nuha}}


==Overview==
==Overview==
It is important to consider that ''Candida'' species are frequently part of the human body's normal oral and intestinal flora. Candidiasis is occasionally misdiagnosed by medical personnel as bacterial in nature, and treated with [[antibiotic]]s against bacteria. This can lead to eliminating the yeast's natural competitors for resources, and increase the severity of the condition.  Commonly used drugs include amphotericin, clotrimazole, nystatin, fluconazole and ketoconazole.
Antifungal agents are indicated in candidiasis.  Commonly used drugs include [[Amphotericin]], [[Clotrimazole]], [[Nystatin]], [[Fluconazole]] and [[Ketoconazole]]. It is important to consider that ''Candida'' species are frequently part of the human body's normal oral and intestinal flora. Candidiasis is occasionally misdiagnosed by medical personnel as bacterial in nature, and treated with [[antibiotic]]s against bacteria. This can lead to eliminating the yeast's natural competitors for resources, and increase the severity of the condition.


==Medical Therapy==
==Medical Therapy==
===Acute Pharmacotherapy===
In clinical settings, candidiasis is commonly treated with antimycotics - the [[antifungal drug]]s commonly used to treat candidiasis are topical [[clotrimazole]], topical [[nystatin]], [[fluconazole]], and topical [[ketoconazole]]. In severe infections (generally in hospitalized patients), [[amphotericin B]], [[caspofungin]], or [[voriconazole]] may be used. Local treatment may include vaginal [[suppository|suppositories]] or medicated [[douche]]s. [[Gentian violet]] can be used for breastfeeding thrush, but pediatrician recommends using it sparingly, since in large quantities it can cause mouth and throat ulcerations in nursing babies, and has been linked to mouth cancer in humans and to cancer in the digestive tract of other animals. <ref>[http://extoxnet.orst.edu/newsletters/n115_91.htm extoxnet.orst.edu]</ref>


===Dietary Therapy===
===1. Uncomplicated Vulvovaginal Candidiasis<ref name="urlwww.cdc.gov">{{cite web |url=https://www.cdc.gov/std/treatment-guidelines/STI-Guidelines-2021.pdf |title=www.cdc.gov |format= |work= |accessdate=}}</ref><ref name="urlVulvovaginal Candidiasis - STI Treatment Guidelines">{{cite web |url=https://www.cdc.gov/std/treatment-guidelines/candidiasis.htm |title=Vulvovaginal Candidiasis - STI Treatment Guidelines |format= |work= |accessdate=}}</ref>===
One of the most potent nondrug or natural yeast-fighting substances is caprylic acid, a medium-chain fatty acid derived from coconut oil. Caprylic acid in capsule form is commonly sold as a dietary supplement in health food stores. It is very effective against Candida and other forms of fungi. It is even effective mixed with a little coconut oil or vitamin E oil as a topical application for fungal skin infections. Some cases of fungal infections that have lasted for months clear up in a matter of days using caprylic acid and a little coconut oil. It works just as effectively inside the body, killing fungi without the least bit of harm.


Polynesian women who eat their traditional coconut-based diet rarely, if ever, get yeast infections. Only in more temperate climates where processed vegetable oils are the main source of dietary fat are yeast infections, skin fungus, acne, and other skin infections big problems. Lauric acid, found in coconut oil, kills lipid-coated bacteria but does not appear to harm the friendly intestinal bacteria. Medium-Chain Fatty Acids (MCFA)s also have antifungal properties, so not only will they kill disease-causing bacteria and leave good bacteria alone but also they will kill Candida and other fungi in the intestinal tract, further supporting a healthy intestinal environment. Eating coconut oil on a regular basis, as the Polynesians do, helps to keep Candida and other harmful microorganisms at bay.
*'''1.1 Recommended Regimens'''
**'''1.1.1 Over-the-Counter Intravaginal Agents'''
***[[Clotrimazole]] 1% cream 5 g intravaginally daily for 7–14 days  OR
***[[Clotrimazole]] 2% cream 5 g intravaginally daily for 3 days  OR
***[[Miconazole]] 2% cream 5 g intravaginally daily for 7 days  OR
***[[Miconazole]] 4% cream 5 g intravaginally daily for 3 days  OR
***[[Miconazole]] 100 mg vaginal suppository one suppository daily for 7 days  OR
***[[Miconazole]] 200 mg vaginal suppository one suppository for 3 days  OR
***[[Miconazole]] 1,200 mg vaginal suppository one suppository for 1 day  OR
***[[Tioconazole]] 6.5% ointment 5 g intravaginally in a single application
**'''1.1.2 Prescription Intravaginal Agents'''
***[[Butoconazole]] 2% cream  5 g intravaginally in a single application  OR
***[[Terconazole]] 0.4% cream 5 g intravaginally daily for 7 days  OR
***[[Terconazole]] 0.8% cream 5 g intravaginally daily for 3 days  OR
***[[Terconazole]] 80 mg vaginal suppository one suppository daily for 3 days
**'''1.1.3 Oral Agent'''
***[[Fluconazole]] 150 mg orally in a single dose.
**Note: the creams and suppositories in these regimens are oil based and might weaken latex condoms and diaphragms. Patients should refer to condom product labeling for further information.
**Note: Any woman whose symptoms persist after using an over-the-counter preparation or who has a recurrence of symptoms <2 months after treatment for  Vulvovaginal Candidiasis should be evaluated clinically and tested.
**Note: No substantial evidence exists to support using [[Probiotic|probiotics]] or homeopathic medications for treating  Vulvovaginal Candidiasis.
*'''1.2 Management of Sex Partners'''
**Uncomplicated  Vulvovaginal Candidiasis is not usually acquired through sexual intercourse, and data do not support treatment of sex partners.


Some home remedies for candidiasis include the consumption or direct application of [[Yoghurt|yogurt]] (which contains [[lactobacillus]]), [[probiotics]], [[acidophilus]] tablets or salves, Pau d'arco tea, and even lightly crushed cloves of [[garlic]], which yield [[allicin]], an antifungal agent. [[Boric acid]] has also been used to treat yeast infections (by inserting gelcaps filled with boric acid powder into the vagina at bedtime for three to four consecutive nights). Eating a diet consisting primarily of green, fresh, raw vegetables also may give relief. Other alternative treatments consist in consuming a fermented beverage called [[Kefir]].  
*1.'''3 Special Considerations'''
**1.3.1 '''Drug Allergy, Intolerance, and Adverse Reactions'''
***Topical agents usually cause no systemic side effects.
***Oral azoles occasionally cause nausea, abdominal pain, and headache.
***Clinically important interactions can occur when oral azoles are administered with other drugs.


While home remedies may offer relief in minor cases of infection (although a peer-reviewed study in Australia found yogurt ineffective as treatment for ''Candida albicans''), seeking medical attention may be necessary, especially if the extent of the infection cannot be judged accurately by the patient.  For instance, oral thrush is visible only at the upper digestive tract, but it may be that the lower digestive tract is likewise colonized by ''Candida'' species.
<br />


Treating candidiasis solely with medication may not give desired results, and other underlying causes require consideration. As an example, oral candidiasis is often linked to the use of inhaled [[corticosteroids]] in [[asthma medication]]. Patients on long-term inhaled corticosteroids should rinse their mouths after each dose of steroids to counteract this effect. Oral candidiasis can also be the sign of a more serious condition, such as [[HIV]] infection, or other immunodeficiency diseases. Following the health tips at [[vulvovaginal health]] can help prevent vaginal candidiasis.
===2. Complicated Vulvovaginal Candidiasis<ref name="urlwww.cdc.gov" /><ref name="urlVulvovaginal Candidiasis - STI Treatment Guidelines" />===


Babies with diaper rash should have their diaper areas kept clean, dry, and exposed to air as much as possible. [[Sugar]]s assist the overgrowth of yeast, possibly explaining the increased prevalence of yeast infections in patients with [[diabetes mellitus]], as noted above. As many ''Candida spp.'' reside in the digestive tract, dietary changes may be effective for preventing or during a ''Candida'' infection. Due to its requirement for readily fermentable carbon sources, such as mono- or dimeric sugars (e.g., [[sucrose]], [[glucose]], [[lactose]]) and starch, avoiding foods that contain these nutrients in high abundance may help to prevent excessive ''Candida'' growth. [[Breast milk]] is a suitable growth substrate for yeasts, and both nursing mother and baby need to be treated (even if both are not symptomatic) to prevent thrush from being passed between mother and child. <ref>[http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=123132 PubMed Central Article]</ref>
*2.1 '''Recurrent Vulvovaginal Candidiasis'''
**Defined as three or more episodes of symptomatic  Vulvovaginal Candidiasis in <1 year.
**Preferred regimen:  topical therapy for 7–14 days, OR [[fluconazole]] 100-mg, 150-mg, or 200-mg  PO every third day for a total of 3 doses [days 1, 4, and 7].
**Maintenance regimen: [[fluconazole]] 100-mg, 150-mg, or 200-mg PO weekly for 6 months. (If this regimen is not feasible, topical treatments used intermittently).
**Note: ''C. albicans'' azole resistance is becoming more common, susceptibility tests, if available, should be obtained among symptomatic patients who remain culture positive despite maintenance therapy. These women should be managed in consultation with a specialist.


===Candiduria===
*2.2 '''Severe Vulvovaginal Candidiasis'''
**Preferred regimen:  either 7–14 days of topical azole or [[fluconazole]] 150 mg PO in two doses 72 hours apart.


====Asymptomatic Candiduria====
*2.3 '''Non–''albicans'' Vulvovaginal Candidiasis'''
It is not recommended to treat asymptomatic candidiuria in otherwise healthy or predisposed patients because mostly it's self limited and resolves spontaneously,and to avoid recurrence and treatment complications. However, removal of the urine catheter is advised when possible. For patients with a risk of disseminated candidiasis or undergoing invasive urological procedure, antifungal therapy is required.
**The optimal treatment of non–''albicans'' Vulvovaginal Candidiasis remains unknown; however, a longer duration of therapy (7–14 days) with a nonfluconazole azole regimen (oral or topical) is recommended.
**If recurrence occurs, [[boric acid]] 600 mg gelatin capsule intravaginally once daily for 3 weeks is indicated.


====Cystitsis====
*2.4 '''Management of Sex Partners'''
**No data exist to support treating sex partners of patients with complicated Vulvovaginal Candidiasis.


{| style="background: #FFFFFF;"
===3. Special Considerations<ref name="urlVulvovaginal Candidiasis - STI Treatment Guidelines" />===
| valign=top |
{| style="float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Cystitis Treatment}}
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Preferred Regimen'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Fluconazole]]200 mg/day (3 mg/kg) x 14 days'''''
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Alternative Regimen'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Amphotericin B]] 0.5 mg/kg x 7 days'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | OR
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Flucytosine]]25 mg/kg qid x 7-10 days'''''
|-
|}
|}


*For recurrent or persistent infections, a further evaluation for the renal system is required to rule out anatomy abnormalities or obstruction by fungus ball. Thus indicating a surgical intervention.  
*3.1 '''Pregnancy'''
**Preferred regimen:  topical azole for 7 days
**Note: Epidemiologic studies indicate a single 150-mg dose of [[fluconazole]] might be associated with spontaneous abortion and congenital anomalies; therefore, it should not be used.


*Bladder irrigation with 50 mcg Amphotericin B/mL sterile water should only be used with catheterized patients as an alternative therapy.
*'''3.2 HIV Infection'''
**Treatment for uncomplicated and complicated  Vulvovaginal Candidiasis among women with HIV infection should not differ from that for women who do not have HIV.
**Long-term prophylactic therapy with [[fluconazole]] 200 mg weekly has been effective in reducing ''C. albicans'' colonization and symptomatic  Vulvovaginal Candidiasis, however this regimen is not recommended for women with HIV infection in the absence of complicated  Vulvovaginal Candidiasis.


*[[Fluconazole]] and [[Amphotericin B]] has the best accessibility to the renal tissues, other azoles like [[itraconazole]], [[voriconazole]], and [[posaconazole]], Liposomal Amphotericin B and echinocandins have poor urinary levels and used as alternatives.
===4. Follow-Up===
 
Follow-up typically is not required. However, women with persistent or recurrent symptoms after treatment should be instructed to return for follow-up visits.
====Ascending pyelonephritis====
 
{| style="background: #FFFFFF;"
| valign=top |
{| style="float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center |{{fontcolor|#FFF|Candida Pyelonephritis Treatment}}
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Preferred Regimen'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Fluconazole]] 400 mg/day x 14 days'''''
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Alternative Regimen'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Amphotericin B]] 0.5-0.7 mg/kg x 14 days'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | OR
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Flucytosine]] 25 mg/kg qid x 14 days'''''
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Pyelonephritis via Hematogenous Seeding'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Fluconazole]] 400 mg (6 mg/kg) daily IV or PO; '''''
|-
 
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | OR
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Echinocandins]]'''''<br>▸ '''''[[Micafungin]] 100 mg IV daily'''''<br>OR<br>  ▸ '''''[[Anidulafungin]] 200 mg IV loading dose then 100 mg IV daily'''''<br>OR<br>▸ '''''[[Capsofungin]] 70 mg IV loading dose, then 50 mg IV daily  (35 mg for moderate hepatic insufficiency'''''
 
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Alternative Regimen'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Amphotericin B]] 0.7 mg/kg IV daily; OR Voriconazole 400 mg (6 mg/kg) twice daily for 2 doses then  200 mg q12h '''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | OR
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''Lipid-based [[amphotericin B]] 3–5 mg/kg daily'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | OR
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Voriconazole]] 400 mg (6 mg/kg) twice daily for 2 doses then  200 mg q12h'''''
|-
|}
|}
 
===Antimicrobial Regimen===
*Candidiasis
:*'''1. Candidemia'''
::*'''1.1. Nonneutropenic adults'''
:::*Preferred regimen (1): [[Fluconazole]] 800 mg (12 mg/kg) loading dose, {{then}} 400 mg (6 mg/kg) daily
:::*Preferred regimen (2): [[Caspofungin]] 70 mg loading dose, {{then}} 50 mg daily
:::*Preferred regimen (3): [[Micafungin]] 100 mg daily
:::*Preferred regimen (4): [[Anidulafungin]] 200 mg loading dose, {{then}} 100 mg daily
:::*Alternative regimen (1): Lipid formulation of amphotericin B(LFAmB) 3–5 mg/kg daily
:::*Alternative regimen (2): Amphotericin B deoxycholate(AmB-d) 0.5–1.0 mg/kg daily
:::*Alternative regimen (3): [[Voriconazole]] 400 mg (6 mg/kg) bid for 2 doses, {{then}} 200 mg (3 mg/kg) bid
:::*Note (1): Echinocandin includes Anidulafungin, Micafungin and Caspofungin.
:::*Note (2): Choose an echinocandin for moderately severe to severe illness and for patients with recent azole exposure.
:::*Note (3): Treat for 14 days after first negative blood culture result and resolution of signs and symptoms associated with candidemia.
:::*Note (4): Ophthalmological examination recommended for all patients.
 
::*'''1.2. Neutropenic patients'''
:::*Preferred regimen (1): [[Caspofungin]] 70 mg loading dose, {{then}} 50 mg daily
:::*Preferred regimen (2): [[Micafungin]] 100 mg daily
:::*Preferred regimen (3): [[Anidulafungin]] 200 mg loading dose, {{then}} 100 mg daily
:::*Preferred regimen (4): Lipid formulation of amphotericin B(LFAmB) 3–5 mg/kg daily
:::*Alternative regimen (1): [[Fluconazole]] 800 mg (12 mg/kg) loading dose, {{then}} 400 mg (6 mg/kg) daily
:::*Alternative regimen (2): [[Voriconazole]] 400 mg (6 mg/kg) bid for 2 doses, {{then}} 200 mg (3 mg/kg) bid
:::*Note: Fluconazole is recommended for patients without recent azole exposure and who are not critically ill.
 
:*'''2. Suspected candidiasis treated with empiric antifungal therapy'''
::*'''2.1. Nonneutropenic patients'''
:::*Preferred regimen (1): [[Fluconazole]] 800 mg (12 mg/kg) loading dose, {{then}} 400 mg (6 mg/kg) daily
:::*Preferred regimen (2): [[Caspofungin]] 70 mg loading dose, {{then}} 50 mg daily
:::*Preferred regimen (3): [[Micafungin]] 100 mg daily
:::*Preferred regimen (4): [[Anidulafungin]] 200 mg loading dose, {{then}} 100 mg daily
:::*Alternative regimen (1): Lipid formulation of amphotericin B(LFAmB) 3–5 mg/kg daily
:::*Alternative regimen (2): Amphotericin B deoxycholate(AmB-d) 0.5–1.0 mg/kg daily
:::*Note (1): Duration of therapy is uncertain, but should be discontinued if cultures and/or serodiagnostic tests have negative results.
:::*Note (2): Echinocandin includes Anidulafungin, Micafungin and Caspofungin.
:::*Note (3): Echinocandin is preferred for patients with recent azole exposure, patients with moderately severe to severe illness, or patients who are at high risk of infection due to C. glabrata or C. krusei.
:::*Note (4): Empirical antifungal therapy should be considered in critically ill patients with risk factors for invasive candidiasis and no other known cause of fever and should be based on clinical assessment of risk factors, serologic markers for invasive candidiasis, and/or culture data from nonsterile sites
 
::*'''2.2. Neutropenic patients'''
:::*Preferred regimen (1): Lipid formulation of amphotericin B(LFAmB) 3–5 mg/kg daily
:::*Preferred regimen (2): [[Caspofungin]] 70 mg loading dose, {{then}} 50 mg daily
:::*Preferred regimen (3): [[Voriconazole]] 400 mg (6 mg/kg) bid for 2 doses, {{then}} 200 mg (3 mg/kg) bid
:::*Alternative regimen (1): [[Fluconazole]] 800 mg (12 mg/kg) loading dose, {{then}} 400 mg (6 mg/kg) daily
:::*Alternative regimen (2): [[Itraconazole]] 200 mg (3 mg/ kg) bid
:::*Note (1): In most neutropenic patients, it is appropriate to initiate empiric antifungal therapy after 4 days of persistent fever despite antibiotics.
:::*Note (2): Do not use an azole in patients with prior azole prophylaxis.
 
:*'''3. Urinary tract infection'''
::*'''3.1. Asymptomatic cystitis'''
:::*Preferred regimen: Therapy not usually indicated, unless patients are at high risk (e.g., neonates and neutropenic adults) or undergoing urologic procedures.
:::*Note (1): Elimination of predisposing factors recommended
:::*Note (2): For high-risk patients, treat as for disseminated candidiasis
:::*Note (3): For patients undergoing urologic procedures, fluconazole, 200–400 mg (3–6 mg/kg) daily or Amphotericin B deoxycholate(AmB-d) 0.3–0.6 mg/kg daily for several days before and after the procedure.
 
::*'''3.2. Symptomatic cystitis'''
:::*Preferred regimen: [[Fluconazole]] 200 mg (3 mg/kg) daily for 2 weeks
:::*Alternative regimen (1): Amphotericin B deoxycholate(AmB-d) 0.3–0.6 mg/kg for 1–7 days
:::*Alternative regimen (2): [[Flucytosine]] 25 mg/kg qid for 7–10 days
:::*Note: Amphotericin B deoxycholate(AmB-d) bladder irrigation is recommended only for patients with refractory fluconazole-resistant organisms (e.g., Candida krusei and Candida glabrata).
 
::*'''3.3 Pyelonephritis'''
:::*Preferred regimen (1): [[Fluconazole]] 200–400 mg (3–6 mg/kg) daily for 2 weeks
:::*Alternative regimen (1): Amphotericin B deoxycholate(AmB-d) 0.5–0.7 mg/kg daily {{withorwithout}} [[Flucytosine]] (5-FC) 25 mg/kg qid
:::*Alternative regimen (2): [[Flucytosine]] (5-FC) 25 mg/kg qid for 2 weeks
:::*Note: For patients with pyelonephritis and suspected disseminated candidiasis, treat as for candidemia.
 
:*'''4. Urinary fungus balls'''
::*Preferred regimen (1): Surgical removal strongly recommended
::*Preferred regimen (2): [[Fluconazole]] 200–400 mg (3–6 mg/kg) daily
::*Preferred regimen (3): Amphotericin B deoxycholate(AmB-d) 0.5–0.7 mg/kg daily {{withorwithout}} [[Flucytosine]] (5-FC) 25 mg/kg qid
::*Note: Local irrigation with Amphotericin B deoxycholate(AmB-d) may be a useful adjunct to systemic antifungal therapy.
 
:*'''5. Vulvovaginal candidiasis'''
::*Preferred regimen (1): [[Butoconazole]] 2% cream 5 g intravaginally for 3 days
::*Preferred regimen (2): [[Butoconazole]] 2% cream 5 g (butoconazole1-sustained release), single intravaginal application
::*Preferred regimen (3): [[Clotrimazole]] 1% cream 5 g intravaginally for 7–14 days
::*Preferred regimen (4): [[Clotrimazole]] 100-mg vaginal tablet for 7 days
::*Preferred regimen (5): [[Clotrimazole]] 100-mg vaginal tablet, 2 tablets for 3 days
::*Preferred regimen (6): [[Miconazole]] 2% cream 5 g intravaginally for 7 days
::*Preferred regimen (7): [[Miconazole]] 100-mg vaginal suppository, 1 suppository for 7 days
::*Preferred regimen (8): [[Miconazole]] 200-mg vaginal suppository, 1 suppository for 3 days
::*Preferred regimen (9): [[Miconazole]] 1200-mg vaginal suppository, 1 suppository for 1 day
::*Preferred regimen (10): [[Nystatin]] 100,000-unit vaginal tablet, 1 tablet for 14 days
::*Preferred regimen (11): [[Tioconazole]] 6.5% ointment 5 g intravaginally in a single application
::*Preferred regimen (12): [[Terconazole]] 0.4% cream 5 g intravaginally for 7 days
::*Preferred regimen (13): [[Terconazole]] 0.4% cream 5 g intravaginally for 3 days
::*Preferred regimen (14): [[Terconazole]] 80-mg vaginal suppository, 1 suppository for 3 days
::*Preferred regimen (15): [[Fluconazole]] 150 mg single dose for uncomplicated vaginitis
::*Note: For recurring Candida Vulvovaginal candidiasis (VVC), 10–14 days of induction therapy with a topical or oral azole, followed by fluconazole at a dosage of 150 mg once per week for 6 months, is recommended
 
:*'''6. Chronic disseminated candidiasis'''
::*Preferred regimen (1): [[Fluconazole]] 400 mg (6 mg/kg) daily for stable patients
::*Preferred regimen (2): Lipid formulation of amphotericin B(LFAmB) 3–5 mg/kg daily
::*Preferred regimen (3): Amphotericin B deoxycholate(AmB-d) 0.5–0.7 mg/kg daily for severely ill patients
::*Alternative regimen (1): [[Caspofungin]] 70 mg loading dose, {{then}} 50 mg daily, followed by oral fluconazole when clinically appropriate
::*Alternative regimen (2): [[Micafungin]] 100 mg daily, followed by oral fluconazole when clinically appropriate
::*Alternative regimen (3): [[Anidulafungin]] 200 mg loading dose, {{then}} 100 mg daily, followed by oral fluconazole when clinically appropriate
::*Note (1): Transition from Lipid formulation of amphotericin B(LFAmB) or Amphotericin B deoxycholate(AmB-d) to fluconazole is favored after several weeks in stable patients.
::*Note (2): Duration of therapy is until lesions have resolved (usually months) and should continue through periods of immunosuppression (e.g., chemotherapy and transplantation).
::*Note (3): Therapy should be continued for weeks to months, until calcification occurs or lesions resolve.
 
:*'''7. Candida osteoarticular infection'''
::*'''7.1. Osteomyelitis'''
:::*Preferred regimen (1): [[Fluconazole]] 400 mg (6 mg/kg) daily for 6–12 months
:::*Preferred regimen (2): Lipid formulation of amphotericin B(LFAmB) 3–5 mg/kg daily for at least 2 weeks, then [[Fluconazole]] 400 mg daily for 6–12 months
:::*Alternative regimen (1): [[Caspofungin]] 70 mg loading dose, {{then}} 50 mg daily for at least 2 weeks followed by [[Fluconazole]] at a dosage of 400 mg daily for 6–12 months
:::*Alternative regimen (2): [[Micafungin]] 100 mg daily for at least 2 weeks followed by [[Fluconazole]] at a dosage of 400 mg daily for 6–12 months
:::*Alternative regimen (3): [[Anidulafungin]] 200 mg loading dose, {{then}} 100 mg daily for at least 2 weeks followed by [[Fluconazole]] at a dosage of 400 mg daily for 6–12 months
:::*Alternative regimen (4): Amphotericin B deoxycholate(AmB-d) 0.5–1.0 mg/kg daily followed by [[Fluconazole]] at a dosage of 400 mg daily for 6–12 months
:::*Note (1): Duration of therapy usually is prolonged (6–12 months)
:::*Note (2): Surgical debridement is frequently necessary
 
::*'''7.2. Septic arthritis'''
:::*Preferred regimen (1): [[Fluconazole]] 400 mg (6 mg/kg) for at least 6 weeks
:::*Preferred regimen (2): Lipid formulation of amphotericin B (LFAmB) 3–5 mg/kg daily for at least 2 weeks followed by [[Fluconazole]] at a dosage of 400 mg daily
:::*Alternative regimen (1): [[Caspofungin]] 70 mg loading dose, {{then}} 50 mg daily for at least 2 weeks followed by [[Fluconazole]] at a dosage of 400 mg daily
:::*Alternative regimen (2): [[Micafungin]] 100 mg daily for at least 2 weeks followed by [[Fluconazole]] at a dosage of 400 mg daily
:::*Alternative regimen (3): [[Anidulafungin]] 200 mg loading dose, {{then}} 100 mg daily for at least 2 weeks followed by [[Fluconazole]] at a dosage of 400 mg daily
:::*Note (1): Duration of therapy usually is for at least 6 weeks, but few data are available.
:::*Note (2): Surgical debridement is recommended for all cases.
:::*Note (3): For infected prosthetic joints, removal is recommended for most cases.
 
:*'''8. CNS candidiasis'''
::*Preferred regimen (1): Lipid formulation of amphotericin B(LFAmB) at a dosage of 3–5 mg/kg daily {{withorwithout}} [[Flucytosine]] at a dosage of 25 mg/kg qid for several weeks followed by [[Fluconazole]] 400–800 mg (6–12 mg/kg) daily
::*Alternative regimen (1): [[Fluconazole]] 400–800 mg (6–12 mg/ kg) daily for patients unable to tolerate Lipid formulation of amphotericin B (LFAmB)
::*Note (1): Treat until all signs and symptoms, CSF abnormalities, and radiologic abnormalities have resolved.
::*Note (2): Removal of intraventricular devices is recommended.
 
:*'''9. Candida endophthalmitis'''
::*Preferred regimen (1): Amphotericin B deoxycholate(AmB-d) 0.7–1 mg/kg {{and}} [[Flucytosine]] 25 mg/ kg qid
::*Alternative regimen (1): Lipid formulation of amphotericin B(LFAmB) at a dosage of 3–5 mg/kg daily
::*Alternative regimen (2): [[Voriconazole]] 6 mg/kg q12h for 2 doses, then 3–4 mg/kg q12h
::*Alternative regimen (3): [[Caspofungin]] 70 mg loading dose, {{then}} 50 mg daily
::*Alternative regimen (4): [[Micafungin]] 100 mg daily
::*Alternative regimen (5): [[Anidulafungin]] 200 mg loading dose, {{then}} 100 mg daily
::*Note (1): Alternative therapy is recommended for patients intolerant of or experiencing failure of Amphotericin B and Flucytosine therapy
::*Note (2): Duration of therapy is at least 4–6 weeks as determined by repeated examinations to verify resolution.
::*Note (3): Diagnostic vitreal aspiration should be done if etiology unknown.
::*Note (4): Fluconazole at a dosage of 400–800 mg daily (loading dose of 12 mg/kg then 6–12 mg/kg daily) is an acceptable alternative for less severe endophthalmitis
 
:*'''10. Candida infection of the cardiovascular system'''
::*'''10.1. Endocarditis'''
:::*Preferred regimen (1): Lipid formulation of amphotericin B(LFAmB) at a dosage of 3–5 mg/kg daily {{withorwithout}} [[Flucytosine]] at a dosage of 25 mg/kg qid
:::*Preferred regimen (2): Amphotericin B deoxycholate AmB-d 0.6–1 mg/kg daily {{withorwithout}} [[Flucytosine]] 25 mg/kg qid
:::*Preferred regimen (3): [[Caspofungin]] 50–150 mg daily
:::*Preferred regimen (4): [[Micafungin]]  100–150 mg daily
:::*Preferred regimen (5): [[Anidulafungin]]  100–200 mg daily
:::*Alternative regimen (1): Step-down therapy to [[Fluconazole]] 400–800 mg (6–12 mg/kg) daily for susceptible organism in stable patient with negative blood culture results
:::*Note (1): Valve replacement is strongly recommended.
:::*Note (2): For those who are unable to undergo surgical removal of the valve, chronic suppression with fluconazole 400–800 mg (6–12 mg/kg) daily is recommended.
:::*Note (3): Lifelong suppressive therapy for prosthetic valve endocarditis if valve cannot be replaced is recommended.
 
::*'''10.2. Pericarditis or myocarditis'''
:::*Preferred regimen (1): Lipid formulation of amphotericin B (LFAmB) at a dosage of 3–5 mg/kg daily
:::*Preferred regimen (2): [[Fluconazole]] 400–800 mg (6–12 mg/kg) daily
:::*Preferred regimen (3): [[Caspofungin]] 50–150 mg daily
:::*Preferred regimen (4): [[Micafungin]] 100–150 mg daily
:::*Preferred regimen (5): [[Anidulafungin]] 100–200 mg daily
:::*Alternative regimen (1): After stable, step-down therapy to [[Fluconazole]] 400–800 mg (6–12 mg/kg) daily
:::*Note(1): Therapy is often for several months, but few data are available
:::*Note(2): A pericardial window or pericardiectomy is recommended.
 
::*'''10.3. Suppurative thrombophlebitis'''
:::*Preferred regimen (1): Lipid formulation of amphotericin B (LFAmB) at a dosage of 3–5 mg/kg daily
:::*Preferred regimen (2): [[Fluconazole]] 400–800 mg (6–12 mg/kg) daily
:::*Preferred regimen (3): [[Caspofungin]] 50–150 mg daily
:::*Preferred regimen (4): [[Micafungin]] 100–150 mg daily
:::*Preferred regimen (5): [[Anidulafungin]] 100–200 mg daily
:::*Alternative regimen (1): After stable, step-down therapy to [[Fluconazole]] 400–800 mg (6–12 mg/kg) daily
:::*Note(1): Surgical incision and drainage or resection of the vein is recommended if feasible.
:::*Note(2): Treat for at least 2 weeks after candidemia has cleared.
 
::*'''10.4. Infected pacemaker, ICD, or VAD'''
:::*Preferred regimen (1): Lipid formulation of amphotericin B(LFAmB) at a dosage of 3–5 mg/kg daily {{withorwithout}} [[Flucytosine]] at a dosage of 25 mg/kg qid
:::*Preferred regimen (2): Amphotericin B deoxycholate (AmB-d) 0.6–1 mg/kg daily {{withorwithout}} [[Flucytosine]] 25 mg/kg qid
:::*Preferred regimen (3): [[Caspofungin]] 50–150 mg daily
:::*Preferred regimen (4): [[Micafungin]]  100–150 mg daily
:::*Preferred regimen (5): [[Anidulafungin]]  100–200 mg daily
:::*Alternative regimen (1): Step-down therapy to [[Fluconazole]] 400–800 mg (6–12 mg/kg) daily for susceptible organism in stable patient with negative blood culture results
:::*Note(1): Removal of pacemakers and ICDs strongly recommended.
:::*Note(2): Treat for 4–6 weeks after the device removed.
:::*Note(3): For VAD that cannot be removed, chronic suppressive therapy with fluconazole is recommended.
 
:*'''11. Neonatal candidiasis'''
::*Preferred regimen (1): Amphotericin B deoxycholate (AmB-d) 1 mg/kg daily for 3 weeks
::*Preferred regimen (2): [[Fluconazole]] 12 mg/kg daily for 3 weeks
::*Alternative regimen (1): Lipid formulation of amphotericin B (LFAmB) 3–5 mg/kg daily for 3 weeks
::*Note (1): A lumbar puncture and dilated retinal examination should be performed on all neonates with suspected invasive candidiasis.
::*Note (2): Intravascular catheter removal is strongly recommended.
::*Note (3): Duration of therapy is at least 3 weeks.
::*Note (4): Lipid formulation of amphotericin B (LFAmB) used only if there is no renal involvement.
::*Note (5): Echinocandins should be used with caution when other agents cannot be used.
 
:*'''12. Candida isolated from respiratory secretions'''
::*Preferred regimen (1): Therapy not recommended
::*Note (1): Candida lower respiratory tract infection is rare and requires histopathologic evidence to confirm a diagnosis.
 
:*'''13. Nongenital mucocutaneous candidiasis'''
::* '''13.1. Oropharyngeal'''
:::*Preferred regimen (1): [[Clotrimazole]] troches 10 mg 5 times daily
:::*Preferred regimen (2): [[Nystatin]] suspension at a concentration of 100,000 U/mL and a dosage of 4–6 mL qid {{or}} 1–2 [[Nystatin]] pastilles (200,000 U each) administered qid
:::*Preferred regimen (3): [[Fluconazole]] 100–200 mg daily
:::*Alternative regimen (1): [[Itraconazole]] solution 200 mg daily
:::*Alternative regimen (2): [[Posaconazole]] suspension at a dosage of 400 mg twice daily for 3 days, {{then}} 400 mg daily for up to 28 days
:::*Alternative regimen (3): [[Voriconazole]] 200 mg bid
:::*Alternative regimen (4): Amphotericin B deoxycholate (AmB-d) 1-mL oral suspension administered at a dosage of 100 mg/mL qid
:::*Alternative regimen (5): [[Caspofungin]] 70 mg IV loading dose, {{then}} 50 mg daily
:::*Alternative regimen (6): [[Micafungin]] 100 mg IV daily
:::*Alternative regimen (7): [[Anidulafungin]] 200 mg IV loading dose, {{then}} 100 mg daily
:::*Alternative regimen (8): Amphotericin B deoxycholate (AmB-d) 0.3 mg/kg daily
:::*Note(1): [[Fluconazole]] is recommended for moderate-to-severe disease, and topical therapy with clotrimazole or nystatin is recommended for mild disease.
:::*Note(2): Treat uncomplicated disease for 7–14 days.
:::*Note(3): For refractory disease, itraconazole, voriconazole, posaconazole, or AmB suspension is recommended.
 
::*'''13.2. Esophageal'''
 
:::*Preferred regimen (1): Fluconazole 200–400 mg (3–6 mg/kg) PO/IV daily
 
:::*Preferred regimen (2): [[Caspofungin]] 70 mg IV loading dose, {{then}} 50 mg daily
:::*Preferred regimen (3): [[Micafungin]] 100 mg IV daily
:::*Preferred regimen (4): [[Anidulafungin]] 200 mg IV loading dose, {{then}} 100 mg daily
:::*Preferred regimen (4): AmB-d 0.3–0.7 mg/kg daily
 
:::*Alternative regimen (1): [[Itraconazole]] oral solution 200 mg daily
:::*Alternative regimen (2): [[Posaconazole]] 400 mg bid
:::*Alternative regimen (3): [[Voriconazole]] 200 mg bid
:::*Note(1): Oral fluconazole is preferred.
:::*Note(2): For patients unable to tolerate an oral agent, IV fluconazole, an echinocandin, or AmB-d is appropriate.
 
:::*Note(3): Treat for 14–21 days.
 
:::*Note(4): For patients with refractory disease, the alternative therapy as listed or AmB-d or an echinocandin is recommended.


==References==
==References==
{{Reflist|2}}
{{Reflist|2}}


 
[[Category:Disease]]
[[Category:Infectious disease]]
[[Category:Up-To-Date]]
[[Category:Nephrology]]
[[Category:Dermatology]]
[[Category:Gynecology]]
[[Category:Gynecology]]
[[Category:Microbiology]]
[[Category:Obstetrics]]
[[Category:Overview complete]]
 
 
{{WikiDoc Help Menu}}
{{WS}}

Latest revision as of 16:28, 17 September 2021

Candida vulvovaginitis Microchapters

Home

Patient Information

Overview

Historical Perspective

Classification

Pathophysiology

Causes

Differentiating Candidiasis from other Diseases

Epidemiology and Demographics

Risk Factors

Screening

Natural History, Complications and Prognosis

Diagnosis

History and Symptoms

Physical Examination

Laboratory Findings

X Ray

CT

Other Imagining Findings

Other Diagnostic Studies

Treatment

Medical Therapy

Surgery

Primary Prevention

Secondary Prevention

Cost-Effectiveness of Therapy

Future or Investigational Therapies

Case Studies

Case #1

Candida vulvovaginitis medical therapy On the Web

Most recent articles

Most cited articles

Review articles

CME Programs

Powerpoint slides

Images

American Roentgen Ray Society Images of Candida vulvovaginitis medical therapy

All Images
X-rays
Echo & Ultrasound
CT Images
MRI

Ongoing Trials at Clinical Trials.gov

US National Guidelines Clearinghouse

NICE Guidance

FDA on Candida vulvovaginitis medical therapy

CDC on Candida vulvovaginitis medical therapy

Candida vulvovaginitis medical therapy in the news

Blogs on Candida vulvovaginitis medical therapy

Directions to Hospitals Treating Candidiasis

Risk calculators and risk factors for Candida vulvovaginitis medical therapy

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Nuha Al-Howthi, MD[2]

Overview

Antifungal agents are indicated in candidiasis. Commonly used drugs include Amphotericin, Clotrimazole, Nystatin, Fluconazole and Ketoconazole. It is important to consider that Candida species are frequently part of the human body's normal oral and intestinal flora. Candidiasis is occasionally misdiagnosed by medical personnel as bacterial in nature, and treated with antibiotics against bacteria. This can lead to eliminating the yeast's natural competitors for resources, and increase the severity of the condition.

Medical Therapy

1. Uncomplicated Vulvovaginal Candidiasis[1][2]

  • 1.1 Recommended Regimens
    • 1.1.1 Over-the-Counter Intravaginal Agents
      • Clotrimazole 1% cream 5 g intravaginally daily for 7–14 days OR
      • Clotrimazole 2% cream 5 g intravaginally daily for 3 days OR
      • Miconazole 2% cream 5 g intravaginally daily for 7 days OR
      • Miconazole 4% cream 5 g intravaginally daily for 3 days OR
      • Miconazole 100 mg vaginal suppository one suppository daily for 7 days OR
      • Miconazole 200 mg vaginal suppository one suppository for 3 days OR
      • Miconazole 1,200 mg vaginal suppository one suppository for 1 day OR
      • Tioconazole 6.5% ointment 5 g intravaginally in a single application
    • 1.1.2 Prescription Intravaginal Agents
      • Butoconazole 2% cream 5 g intravaginally in a single application OR
      • Terconazole 0.4% cream 5 g intravaginally daily for 7 days OR
      • Terconazole 0.8% cream 5 g intravaginally daily for 3 days OR
      • Terconazole 80 mg vaginal suppository one suppository daily for 3 days
    • 1.1.3 Oral Agent
    • Note: the creams and suppositories in these regimens are oil based and might weaken latex condoms and diaphragms. Patients should refer to condom product labeling for further information.
    • Note: Any woman whose symptoms persist after using an over-the-counter preparation or who has a recurrence of symptoms <2 months after treatment for Vulvovaginal Candidiasis should be evaluated clinically and tested.
    • Note: No substantial evidence exists to support using probiotics or homeopathic medications for treating Vulvovaginal Candidiasis.
  • 1.2 Management of Sex Partners
    • Uncomplicated Vulvovaginal Candidiasis is not usually acquired through sexual intercourse, and data do not support treatment of sex partners.
  • 1.3 Special Considerations
    • 1.3.1 Drug Allergy, Intolerance, and Adverse Reactions
      • Topical agents usually cause no systemic side effects.
      • Oral azoles occasionally cause nausea, abdominal pain, and headache.
      • Clinically important interactions can occur when oral azoles are administered with other drugs.


2. Complicated Vulvovaginal Candidiasis[1][2]

  • 2.1 Recurrent Vulvovaginal Candidiasis
    • Defined as three or more episodes of symptomatic Vulvovaginal Candidiasis in <1 year.
    • Preferred regimen: topical therapy for 7–14 days, OR fluconazole 100-mg, 150-mg, or 200-mg PO every third day for a total of 3 doses [days 1, 4, and 7].
    • Maintenance regimen: fluconazole 100-mg, 150-mg, or 200-mg PO weekly for 6 months. (If this regimen is not feasible, topical treatments used intermittently).
    • Note: C. albicans azole resistance is becoming more common, susceptibility tests, if available, should be obtained among symptomatic patients who remain culture positive despite maintenance therapy. These women should be managed in consultation with a specialist.
  • 2.2 Severe Vulvovaginal Candidiasis
    • Preferred regimen: either 7–14 days of topical azole or fluconazole 150 mg PO in two doses 72 hours apart.
  • 2.3 Non–albicans Vulvovaginal Candidiasis
    • The optimal treatment of non–albicans Vulvovaginal Candidiasis remains unknown; however, a longer duration of therapy (7–14 days) with a nonfluconazole azole regimen (oral or topical) is recommended.
    • If recurrence occurs, boric acid 600 mg gelatin capsule intravaginally once daily for 3 weeks is indicated.
  • 2.4 Management of Sex Partners
    • No data exist to support treating sex partners of patients with complicated Vulvovaginal Candidiasis.

3. Special Considerations[2]

  • 3.1 Pregnancy
    • Preferred regimen: topical azole for 7 days
    • Note: Epidemiologic studies indicate a single 150-mg dose of fluconazole might be associated with spontaneous abortion and congenital anomalies; therefore, it should not be used.
  • 3.2 HIV Infection
    • Treatment for uncomplicated and complicated Vulvovaginal Candidiasis among women with HIV infection should not differ from that for women who do not have HIV.
    • Long-term prophylactic therapy with fluconazole 200 mg weekly has been effective in reducing C. albicans colonization and symptomatic Vulvovaginal Candidiasis, however this regimen is not recommended for women with HIV infection in the absence of complicated Vulvovaginal Candidiasis.

4. Follow-Up

Follow-up typically is not required. However, women with persistent or recurrent symptoms after treatment should be instructed to return for follow-up visits.

References

  1. ↑ 1.0 1.1 "www.cdc.gov" (PDF).
  2. ↑ 2.0 2.1 2.2 "Vulvovaginal Candidiasis - STI Treatment Guidelines".
Retrieved from "https://www.wikidoc.org/index.php?title=Candida_vulvovaginitis_medical_therapy&oldid=1714114"