Noninvasive Oral and Vaginal Candidiasis Flashcards
what happens to a healthy vaginal when balance of organisms is disrupted
overproduction or colonization can occur
what is the most prominant time of vaginal discharge
mid cycle around time of ovulation
normal vaginal discharge is (amount, scent, colour)
scant, odorless, and clear/ whitish
3 most common causes of vaginal infections characterized by discharge and vulvovaginitis
BV
trichomoniasis
VVC (yeast infection)
describe the common symptoms of VVC
Severe itching in vulva + vaginal area +/- Stinging and burning
Cottage cheese discharge
what pH is VVC
<4.5
describe the common sx of lactobacillosis
Itching of vaginal or vulva area +/- Burning of vulva (mimics UTI)
White or yellowish vaginal discharge (varies in consistency)
Cyclic sx: 2nd half of menstrual cycle, peaks shortly before menses
what pH is lactobacillosis
3.5-5.5
describe the common sx of BV
Fishy odor
Creamy discharge (yellow-gray)
bacterial vaginosis pH
5-6
BV is most commonly due to
polymicrobial infections
trichomoniasis sx
Frothy, wet discharge +/- Possibly itchy
trichomoniasis pH
->6
which of the following is sexually transmitted
1. VVC
2. lactobacillosis
3. BV
4. trichomoniasis
4
VVC is cased by the overgrowth of
candida albicans
what is the prevalence of VVC
~75% of persons with a vaginal will experience at least 1 episode of VVC in their lifetime
Dramatic ↑ in freq of VVC once one becomes sexually active + ↑ risk with oral-genital contact
what are the 4 criteria for uncomplicated VVC
Sporadic or infrequent
Mild-mod sx or findings
Candida albicans infxn (suspected or proven)
Non Immunocompromised
what are the 4 factors that could indicate complicated VVC
Recurrent (4 or more episodes/ yr)
Severe sx or findings
Nonalbicans candida
Those with diabetes, immunocomp conditions, or immunosuppressive tx
list 3 predisposing factors for VVC
Pregnancy
Medications (abx, corticosteroids, chemo, hormone therapy, oral contraceptives, levonorgestrel IUD, tamoxifen)
Contraceptives (spermicide, sponge, diaphragm)
DM
Immunocompromised conditions
Diet (excess refined carbohydrates)
Chemical irritants (antiseptics, deodorants, sprays, soaps), douching
Stress
Menses
Synthetic undergarments
Tight fitting clothing
list 3 circumstances where you should refer for VVC
Pregnant
Prepubertal (VVC not common)
Presents with vaginal sx for 1st time = refer to MD for testing
Recurrence of VVC within 2 mths of last episode
Immunosuppressed
Underlying illness such as DM
Risk of STI (ex- hx unprotected intercourse, multiple partners, casual sexual encounters)
list 2 nonpharm measures in treating VVC
No spec nonpharm tx but preventative measures are suggested for avoiding recurrences
Good hygiene
Avoid vaginal deodorants, douches, harsh soaps, perfumed products
Avoid tight clothing and synthetic underwear
Diet mods? (incons evidence with lactobacillus in yogurt, no data for yeast or sugar free diets)
T or F: diet modifications like including yogurt and decreasing yeast or sugar intake may decrease VVC recurrence
F- inconsistent/ no data
T or F: asymptomatic VVC does not need to be treated
T
selection of products for uncomplicated VVC should be based on
patient preference
describe the difference between VVC OTC treatments
1, 3, 6, 7 day products- all have the same efficacy (Difference = concentration)
1 day = shorter duration but higher concentration = ↑ risk AEs (irritation, burning)
no stat difference in efficacy between oral vs intravaginal or among topical azole agents
what 2 topical imidazoles are available nonRx in canada
Clotrimazole (creams, tabs) and miconazole (creams, ovules, suppositories)
what is a nonRX PO option for VVC
fluconazole
what is a topical prescription product for VVC
terconazole
common AEs to topical VVC tx
burning, redness, irritation, stinging, itching
Switching brands may alleviate this SE
terconazole HC safety warning includes
anaphylaxis and TEN have been reported- d/c tx if anaphylaxis or TEN develops
which of the following is not information you should counsel your patient on about topical azoles for VVC
1. it may be used at any point in the menstrual cycle, even during bleeding
2. tampons may help keep the cream or ovule within the vaginal canal, enhancing absorption
3. topical and intravaginal azoles can be used concomitantly
4. should be applied at bedtime to increase contact time with vaginal tissues
5. all of the above are valid counselling points
2- avoid tampons as they can absorb the med + cause fungus growth
3 possible interactions of topical azoles
miconazole with warfarin- can increase INR
may decrease effects of vaginal progesterone = avoid concomitant use
ovules may decrease effectiveness of condoms and diaphragms
what is the oral fluconazole dose for uncomplicated VVC
150mg PO F1D
AEs of oral fluconazole
N/V/D, cramping, HA
oral fluconazole is not recommended in
<12yrs, pregnancy (consider alternatives + use caution)
VVC symptoms being treated with fluconazole should completely resolve by
day 7
why is caution recommended with fluconazole during pregnancy
↑ risk of spontaneous abortion
1st trimester high dose = ↑ risk of cardiac septal closure anomalies
1st trim =↑ risk of congenital malformations + sig ↑ risk of spontaneous abortions
severe VVC sx
extensive vulvar erythema, edema, excoriation of fissure formation
tx for severe VVC
Fluconazole 150mg PO q72h F2 doses
or
Intravaginal azole (same as uncomplicated) F10-14d
what is induction tx for complicated or recurrent VVC
Fluconazole or intravaginal azole + boric acid
fluconazole 150mg PO F3 doses
topical azole F10-14d
boric acid 300-600mg gelatin capsule intravaginally daily F14d
boric acid is CI in
pregnancy
boric acid SEs
local irritation, vaginal burning, more pronounced with higher doses
how is boric acid used in complicated or recurrent VVC
300-600mg compounded gelatin capsule intravaginal once daily F14d
what is maintenance tx for complicated/ recurrent VVC
Fluconazole 150mg PO qwk
or
Clotrimazole 500mg intravaginally qmth
or
Boric acid 300mg capsule intravaginally F5d/mth- Start 1st day of cycle
Duration = minimum 6mths
T or F: sexual partners of a patient with VVC should be treated if they are uncircumcized
F- only tx if symptomatic or balanitis or partner has recurrent infections
what is balanitis?
inflammation on glans of penis + pruritus or irritation
how should you treat balanitis
Topical azole 1-2x/d F7d or oral fluconazole 150mg PO single dose
what is the evidence about probiotic use in VVC/
- overall quality
- ST effects
- LT effects
- interactions
Overall evidence quality low/ v low
may be used adj to antifungals to enhance ST effects / relapse
doesn’t influence LT effects
no interference with tx but combo unlikely to reduce occurrence of VVC
what is oral candidiasis
mucocutaneous opportunistic infxn caused by candida species
what is the most common fungal infection in both immunocompetent and immunocompromised pts
oral candidiasis
list 3 disease RFs for oral candidiasis
addison disease, anemia (iron, folic, B12), DM, HIV, hypothyroidism, leukemia, head and neck cancer, psoriasis, xerostomia
list 3 meds that are Rfs for oral candidiasis
broad spectrum abx (normal usually ok), chemo, immunosuppressive drugs, inhaled CS
list 3 RFs for oral candidiasis that are not disease states or meds
infants/ children, local mucosal trauma, poor dental hygiene, pregnancy, smoking, surgery
what is the classic marker of oral candidiasis
easy to wipe off plaques leaving behind erythematous surface
what are some sx of oral candidiasis
white plaque on tongue, buccal mucosa, hard palate, soft palate, and oropharynx
oral candidiasis is typically
1. asymptomatic
2. resulting in white powder on back of throat that does not wipe off
3. transmitted through oral-genital contact
4. none of the above
1
pts with symptomatic oral candidiasis may have
burning sensation or changes in taste
2 pharm tx for oral candidiasis
topical nystatin oral suspension
fluconazole
how should adults use topical nystatin oral syspension
400,000-600,000 (~4-6mL of 100,000 unit suspension) units QID (swish and swallow) F7-14d
how to tx infant thrush with topical nystatin oral suspension
100,000 units (1mL) in each side ofmouth QID F7-14d
In BF infant- consider topical tx nipple (clotrimazole, nystatin, miconazole- but lacks safety data- refer for assessment of latching + possible dual tx)
which is preferred for initial or mild cases of oral thrush
1. nystatin oral suspension
2. fluconazole
1
fluconazole is 2nd line for oral candidiasis due to
azole resistant candidiasis strains
fluconazole is used in oral candidiasis for _______ and _____________
`mod-severe disease
preventative tx for recurrent infections
describe the 5 counselling points for topical nystatin
Shake bottle well before you measure each dose
Swish nystatin around mouth then swallow liquid. Retain in mouth for as long as possible (ex- several minutes if possible)
Do not eat/ drink anything for 5-10+ minutes after each dose
Try to brush teeth 20-30 min after taking nystatin (contains sugar) + brush at least BID (esp before bed)
Avoid concomitant topical use with chlorhexidine (ex- denture wearers) as it will negate effect
improvement in oral thrust should be seen within
2-3 days
once antifungal tx has been started for oral candidiasis, advise pt to monitor symptoms on a daily basis _______ and for up to ________________
daily basis during tx
up to 2 weeks after clearing of sx
