Candidal Vaginitis

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Vulvovaginal candidiasis (VVC) is the second most common cause of vaginitis after BV, with a lifetime prevalence in women of 70% to 75% (Spence, 2007). Candida albicans is the most common etiology (80%-90%). Type 1 diabetes

KEY TREATMENT

All symptomatic women with BV should be treated (BAASH, 2006). Asymptomatic women undergoing abortion or hysterectomy should be treated to decrease the risk for infectious complications (BAASH, 2006).

Oral or vaginal metronidazole (BAASH, 2006) and vaginal clindamycin are effective and equivalent in nonpregnant women (Kane, 2001). Treatment of male partners does not decrease relapse rates (BASHH, 2006).

Tinidazole is effective with no serious side effects but is more expensive than metronidazole (Livengood et al., 2007) (SOR: A).

In recurrent BV, suppressive therapy with metronidazole 0.75% gel for 10 days then twice weekly for 4 to 6 months may be successful (Alfonsi et al., 2004) (SOR: C).

is the strongest risk factor for VVC; other risk factors include recent antibiotic use, condom and diaphragm use, spermicide use, receptive oral sex, OC use, pregnancy, and immunosup-pression. Patient self-diagnosis of VVC is incorrect 50% of the time and is therefore unreliable. Asymptomatic treatment of VVC is not recommended, even in women who have a positive swab for Candida (Spence, 2007). Because VVC is not sexually transmitted, routine partner treatment is also not recommended. Recurrent VVC is defined as four or more symptomatic episodes in a year. Rare complications of VVC include vulvar vestibulitis and chorioamnionitis (French et al., 2004).

The most common complaint associated with culture confirmed VVC is burning or pruritus. A thick, curdled-appearing discharge, signs of inflammation, and lack of odor all have high positive predictive value for diagnosing VVC (Anderson et al., 2004). In one study, however, a thin discharge was present in about half of women, later found to have VVC (French et al., 2004).

Although office microscopy is the first line for diagnosis of VVC, culture is the "gold standard" (Fig. 25-2) (ACOG,

2006). With Candida albicans, the vaginal pH is usually 5.0 or less but may be higher with non-albicans species. A wet mount should be performed to exclude trichomoniasis or BV. Potassium hydroxide (KOH) examination should also be performed, but it has a wide range of sensitivity. Thus, if candidiasis is suspected in a patient with persistent or recurrent symptoms and a wet mount and KOH are negative, a culture should be performed (French et al., 2004). The use of rapid antigen testing to detect vaginal yeast is more sensitive than a wet mount and is feasible for office practice. However, a negative result lacks sensitivity to rule out yeast, and a culture needs to be sent (Chatwani et al., 2007).

The imidazoles are the cornerstone of VVC treatment. Intravaginal OTC imidazoles (e.g., clotrimazole, miconazole, tioconazole) come in 1-, 3-, and 7-day therapy regimens and are equivalent to oral therapies for treatment, and singledose therapy seems as efficacious as multidose therapy over days. The comparative efficacy of different azoles and of different durations of multidose regimens is unclear (Spence,

2007). Lactobacillus, administered vaginally, orally, or both, does not prevent postantibiotic-associated vaginal candidia-sis (Priotta et al., 2004).

Recurrent VVC occurs in 5% to 8% of women. The Infectious Diseases Society of America recommends treating recurrent VVC for 10 to 14 days, followed by suppressive therapy using fluconazole, a single 150-mg dose weekly for

Candidal Vaginitis

Figure 25-2 Candidal vaginitis (vulvovaginal candidiasis). Candidal organisms in a saline wet-mount preparation clearly demonstrate hyphae and conidia under high-power magnification.

(From Kaufman RH, Faro S: Benign Disease of the Vulva and Vagina, ed 4. St. Louis, Mosby, 1994.)

Figure 25-2 Candidal vaginitis (vulvovaginal candidiasis). Candidal organisms in a saline wet-mount preparation clearly demonstrate hyphae and conidia under high-power magnification.

(From Kaufman RH, Faro S: Benign Disease of the Vulva and Vagina, ed 4. St. Louis, Mosby, 1994.)

6 months (Pappas et al., 2009). It is unclear if oral regimens are better than intravaginal administration. In preventing recurrence, there is no evidence of benefit with intravaginal boric acid, tea tree oil, garlic, oral yogurt, douching, or treating a woman's male sexual partner. Douching is associated with increased pelvic infections (Spence, 2007). For specific treatment regimens: see http://www.cdc.gov/std/treatment/.

KEY TREATMENT

Oral fluconazole and itraconazole are both effective for vulvovaginal candidiasis (Spence, 2007) (SOR: A).

Oral and intravaginal regimens are equivalent, so cost and patient preference should guide choice (Nurbhai et al., 2009) (SOR: B). Intravaginal imidazoles are equivalent to oral therapies for VVC treatment, and single-dose seems as efficacious as multidose therapy (Spence, 2007) (SOR: B).

Treat recurrent VVC for 10 to 14 days, followed by suppressive therapy using fluconazole, single 150-mg dose weekly for 6 months (Pappas et al., 2009) (SOR: A)

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Cure Your Yeast Infection For Good

Cure Your Yeast Infection For Good

The term vaginitis is one that is applied to any inflammation or infection of the vagina, and there are many different conditions that are categorized together under this ‘broad’ heading, including bacterial vaginosis, trichomoniasis and non-infectious vaginitis.

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