Noninvasive oral and vaginal candidiasis Flashcards
Vaginal Physiology: What is normal?
● Healthy vagina is host to a number of microorganisms
○ live in balance without adverse effects
● Harmony disrupted:
○ overproduction of host organisms or colonization can occur
● Some vaginal discharge is normal
○ most prominent mid-cycle around time of ovulation
● Normal discharge is scant, odorless and clear or whitish in colour
● Vaginal pH normally 3.5-5.5
Common causes of vaginal infections characterized by
discharge & vulvovaginitis
- Bacterial vaginosis (BV)
- Trichomoniasis
- Vulvovaginal candidiasis (VVC) * “Yeast Infection”
Differential Diagnosis
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VVC - Vulvovaginal Candidiasis
● Usually caused by overgrowth of Candida albicans (80 – 92%), but other
species may be responsible
● Approximately 75% of persons with vaginas will experience at least one
episode of VVC during their lifetime
● Other species are more resistant to imidazole antifungals
● Not usually considered sexually transmitted, although sexual factors can be
important. There is a dramatic increase in the frequency of VVC once one becomes sexually active. In addition, oral-genital contact can increase the risk
Classification of VVC
Uncomplicated VVC (all of the following):
● sporadic or infrequent
● mild-to-moderate symptoms or findings
● Candida albicans infection (suspected or proven)
● non-immunocompromised
Complicated VVC (any of the following):
● recurrent (4 or more episodes/12 months)
● severe symptoms or findings
● non-albicans Candida
● Those with diabetes, immunocompromising conditions, or immunosuppressive therapy
Predisposing Factors for VVC
● Pregnancy
● Medications (antibiotics, corticosteroids, chemotherapy, hormone therapy,
oral contraceptives, levonorgestrel intrauterine systems, tamoxifen),
contraceptive agents (spermicide, sponge, diaphragm)
● Diabetes mellitus
● Immunocompromised conditions
● Diet (excess refined carbohydrates)
● Chemical irritants (antiseptics, deodorants, sprays, soaps), douching
● Stress
● Menses
● Synthetic undergarments
● Tight-fitting clothing
Which patients may need referral for further evaluation?
● Pregnant individuals
● Prepubertal (VVC not common)
● Presents with vaginal symptoms for 1st time
● Recurrence of VVC within 2 months of last episode
● Immunosuppressed
● Underlying illness such as diabetes
● Risk of STI (e.g., history of unprotected intercourse, multiple
partners, casual sexual encounters
CPS Algorithm
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Goals of Treatment VVC
● Relieve symptoms
● Cure the infection
● Prevent recurrence
● Prevent misdiagnosis and delayed treatment
Non Pharmacological Measures
● Although there is no specific nonpharmacologic therapy for
vulvovaginal candidiasis, preventive measures are suggested for
those wishing to avoid recurrences.
● Good hygiene
● Avoid vaginal deodorants, douches, harsh soaps and perfumed
products
● Avoid tight clothing and synthetic underwear
● ?Dietary modifications (ie. yogurt with lactobacillus - inconsistent
results in studies, yeast or sugar free diets - no data)
Uncomplicated VVC Treatment
May be safely and effectively treated with non-prescription
antifungal agents
80-95% cure rate in healthy individuals with topical or oral azoles
Asymptomatic treatment is unnecessary
Selection based on patient preferences/experiences
TOPICAL VS ORAL TREATMENT????
● No statistical difference for clinical cure rate shown between oral and
intra-vaginal antifungal treatment
● Some patients may prefer oral therapy because of its convenience
Difference amongst topical agents?
● There are no significant differences in in vitro activity or clinical efficacy among
the topical azole agents
● The selection of a topical azole antimycotic agent should be based primarily on an
the individual’s preference as to product formulation.
○ Consider: cost, convenience, adherence, portability and history of response
or side effects to prior treatments
Treatment Overview
● Self-treatment recommended for patients who have been previously
diagnosed with a yeast infection
● 2 imidazoles are available as non-prescription treatment in Canada
○ Clotrimazole
○ Miconazole
● Topical prescription product
○ Terconazole (0.4% vaginal cream)
● Non-prescription oral option: Fluconazole (Diflucan One, CanesOral,
generics)
Treatment: Topical and Intravaginal
clotrimazole
miconazole
Adverse Effects: Topical
Common = burning, redness, irritation, stinging and itching
Switching brands may alleviate this side effect
Note: Terconazole - Health Canada safety warning: Anaphylaxis and
toxic epidermal necrolysis (TEN) have been reported during
terconazole therapy. Therapy should be discontinued if anaphylaxis
or TEN develops
Topical Azoles
Interactions:
● Possible interaction of miconazole with warfarin
○ May increase INR (monitor for bleeding or switch to
clotrimazole)
● Topical Imidazoles may diminish effects of vaginal progesterone -
avoid concomitant use
● Ovules diminish effectiveness of condoms & diaphragms
Information for the Patient: Topical
● Must be used for the specified number of days, consecutively
● Should recommend using during any part of the menstrual
cycle, even during menstruation
● Should not use tampons with topical treatment
○ Potentially absorbs medication
○ Provides a hospitable environmental medium for fungus to grow on
● Applicator for intravaginal creams/tabs/ovules
● If vulvar symptoms significant – topical can be used externally
to vulva and/or perineum
● Applied at bedtime to increase contact time with vaginal
tissues
Treatment Oral
fluconazole
Fluconazole in pregnancy
SOGC Statement on the Use of Fluconazole during
Pregnancy (2018)
A recent CMAJ publication by Bérard et al.1 has again
highlighted that clinicians must exert caution and carefully
consider alternative antifungal preparations prior to
prescribing or recommending Fluconazole during pregnancy. q
Recent analysis of Quebec pregnancy cohort (1998-2015) compared women*
exposed to low dose (≤ 150 mg) and high dose ≥ 150mg fluconazole (Berard et al.
CMAJ 2019;191:E179-87)
Use of fluconazole associated with increased risk of spontaneous abortion compared with no
exposure (OR 2.23, 95% CI 1.96-2.54)
Exposure to high dose fluconazole during first trimester associated with increase risk of cardiac septal
closure anomalies (OR 1.81; 95% CI 1.04-3.14)
Systematic review (Zhang et al. BJOG 2019;126:1546-52)
Oral fluconazole use during first trimester marginally increased risk of congenital malformations (OR
1.09;95% CI 0.99-1.2; p=0.088); high-dose users OR 1.19; 95% CI 1.01-1.4; p=0.039)
Significantly increased risk of spontaneous abortion (OR 1.99; 95% CI 1.38-2.88; p< 0.001)
Severe - may require further assessment
Extensive vulvar erythema, edema, excoriation of fissure
formation
Fluconazole 150mg PO q72hr x 2 doses
Intravaginal azole (same as uncomplicated) x 10-14 days
Time to symptomatic relief and follow up
If no relief after 1 week, REFER
Increased irritation or symptoms (may indicate adverse reaction
to product or inappropriate therapy), REFER
Complications VVC - Recurrent
● For patients prone to recurrent VVC who require antibiotics,
prophylactic topical or oral azoles, such as fluconazole 150mg po can
be initiated
● Non-albicans Candida species are found in 10-20% of patients
○ Conventional antifungal therapy is not as effective
Recurrent VVC - Induction Treatment
Fluconazole or intravaginal azole + boric acid
● Fluconazole 150 mg po once every 72 hours x 3 doses
○ Efficacy 92%
○ Should be avoided in pregnancy where possible
OR
● Topic azole x 10-14 days
○ Ex - clotrimazole × 7–14 days to achieve mycologic remission
Boric acid 300-600 mg gelatin capsule intravaginally once daily
for 14 days.
● Contraindicated in pregnancy
● Efficacy 80%
● Local irritation, vaginal burning; more pronounced with
higher dose.
Compounded product - boric acid in gelatin capsule
Recurrent VVC - Maintenance Treatment
● Fluconazole 150 mg po once weekly. Recurrence occurred in 10%
while receiving therapy.
● Clotrimazole 500 mg intravaginally once a month.
● Boric acid 300 mg capsule intravaginally for 5 days each month; start
1st day of cycle. Recurrence 30%
Maintenance therapy duration: minimum 6 months
