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Vaginal thrush Flashcards

1
Q

What is the technical term for vaginal thrush?

A

Vulvovaginal candidiasis

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2
Q

What is vulvovaginal candidiasis?

A

Symptomatic inflammation of vagina and/or vulva caused by a superficial fungal infection

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3
Q

What is the causative organism in most cases of vulvovaginal thrush?

A

Candida yeast

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4
Q

What are the 2 classes of vulvovaginal candidiasis?

A
  1. Uncomplicated: sporadic or infrequent, mild to moderate, likely due to Candida albicans, not assoc with pregnancy or poorly controlled diabetes
  2. Complicated: recurrent, severe, infection with other yeasts, pregnancy, infection in diabetic or immunocompromised
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5
Q

What are 4 things that make an episode of vulvovaginal candidiasis uncomplicated?

A
  1. Sporadic or infrequent
  2. Mild to moderate
  3. Likely due to candida albicans
  4. Not associated with risk fators e.g. pregnancy or poorly controlled diabetes
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6
Q

What are 5 factors that make vulvovaginal candidiasis ‘complicated’?

A
  1. Recurrent: 4 or more episodes in 1 year, with at least partial resolution between episodes
  2. Severe
  3. Yeasts other than candida albicans
  4. Pregnancy
  5. Immunocompromised or diabetic
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7
Q

What are 5 possible symptoms of vulvovaginal candidiasis?

A
  1. Vulval itching
  2. Vulval soreness and irritation
  3. Vaginal discharge - usually white, cheese-like, non-offensive
  4. Superficial dyspareunia
  5. Dysuria
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8
Q

What are 3 possible signs of vulvovaginal candidiasis?

A
  1. Vulvovaginal inflammation and erythema
  2. Vaginal fissuring (splitting or tearing of vulvar skin)
  3. Excoriation of vulva
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9
Q

When is microscopy and fungal culture of vaginal secretions recommended in thrush? 3 instances

A
  1. For supporting the diagnosis,
  2. and in cases of severe or recurrent vulvovaginal candidiasis,
  3. or treatment failure
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10
Q

What are 6 groups that vulvovaginal candidiasis can be divided up into for the treatment?

A
  1. Uncomplicated infection
  2. Severe infection
  3. Recurrent infection
  4. Uncontrolled diabetes or immunocompromised patient
  5. Pregnant
  6. 12-15 years old
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11
Q

What are 4 situations when specialist advice should be sought or urgent referral arranged for vulvovaginal candidiasis?

A
  1. Diagnosis is unclear
  2. Symptoms do not improve following treatment
  3. Non-albicans Candida species infection is present
  4. Systemic symptoms occur
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12
Q

What are 9 differentials for vaginal thrush?

A
  1. Bacterial vaginosis
  2. Trichomoniasis
  3. Chlamydia
  4. Gonorrhoea
  5. Genital herpes
  6. Vulval eczema, psoriass
  7. Lichen simplex or sclerosus
  8. Atrophic vaginitis - postmenopausal
  9. Malignancy of vulva, vagina, cervix, uterine lining
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13
Q

What are 4 general self care pieces of advice to give to patients with vulvovaginal candidiasis?

A
  1. Avoid predisposing factors: washing and cleaning area with soap or shower gels, cleaning area more than once a day, washing underwear in biological washing powder and using fabric conditioners, vaginal douching, wearing tight fitting and/or non-absorbent clothing
  2. Wash vulval area wih soap substitute external, no more than once a day
  3. Use simple emollient to moisturise area
  4. Consider probiotics (such as live yoghurts) orally or topically
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14
Q

What is the management of uncomplicated vulvovaginal candidiasis?

A
  1. Prescribe intravaginal antifungal cream or pessary (clotrimazole, miconazole) OR oral antifungal (fluconazole or itraconazole)
  2. Topical imidazole in addition, if vulval symptoms: clotrimazole 1% or 2% cream, 2-3 times a day
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15
Q

What is the best approach for vulvovaginal candidiasis treatment for breastfeeding women?

A

Prescribe an initial course of intravaginal clotrimazole or miconazole, or oral fluconazole

Topical imidazole if vulval symptoms

(i.e. same as normal)

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16
Q

What safety netting advice should you give a woman receiving treatment for vulvovaginal candidiasis?

A

If symptoms have not resolved within 7-14 days, return to GP

17
Q

What are the doses and regimens for intravaginal pessaries to treat uncomplicated thrush? 2 examples

A
  1. clotrimazole 200mg pessaries x3 over 3 nights, or 500mg single dose pesary, 1 night dose
  2. miconazole 1.2g single-dose vaginal capsules
18
Q

What are the doses and regimes for oral treatment of uncomplicated vulvovaginal candidiasis?

A
  1. fluconazole: 150mg single dose
  2. itraconazole: 200mg bd for 1 day
19
Q

What are the 2 options for vulvovaginal candidiasis intravaginal creams?

A
  1. Clotrimazole 10% cream: insert 5g into vagina as single dose at night
  2. Fenticonazole 2% cream: insert 5g into vagina in morning and evening for 3 days
20
Q

What are 8 things to do in the case of treatment failure of uncomplicated vulvovaginal candidiasis?

A
  1. Confirm initial treatment was used as recommended
  2. Reassess for risk factors and remove/control
  3. Consider alternative diagnoses
  4. Send vaginal specimen for mciroscopy, culture and sensitivity if appropriate
  5. Consider measuring vaginal pH to assess likelihood of candida (<4.5) bacterial vaginosis (>4.5) or Trichomonas vaginalis (>4.5)
  6. Treat infection - consider changing to different formulation if poor compliance, consider extended course
  7. Reinforce self management advice
  8. Refer or seek specialist advice if aged 12-15, doubt about diagnosis, treatment failure unexplained, non-albicans identified, treatment fails again
21
Q

What are the 2 options for extended courses of intra-vaginal antifungal cream in treatment failure of uncomplicated vulvovaginal candidiasis?

A
  1. Miconazole 2% cream - 5g into vagina once daily for 10-14 days, or 5g into vagina twice daily for 7 days
  2. Econazole 1% cream - 5g into vagina and apply to vulva at night for at least 14 nights
22
Q

What are the 3 options for extended courses of intra-vaginal pessaries in treatment failure of uncomplicated vulvovaginal candidiasis?

A
  1. Clotrimazole 100mg pessaries - 1 each night for 12 nights
  2. Clotrimazole 200mg pessaries - 1 into vagina once at night for 6 nights
  3. Econazole nitrate 150mg pessaries - 1 into vagina once at night for 6 nights
23
Q

What are the 2 options for extended courses of oral antifungals in treatment failure of uncomplicated vulvovaginal candidiasis?

A
  1. Fluconazole 100mg od 7 days
  2. Itraconazole 200mg od 7 days
24
Q

What are 6 aspects of management of severe vulvovaginal candidiasis?

A
  1. Send vaginal specimen for microscopy, culture and sensitivity
  2. Prescribe antifungal: 2 doses oral fluconazole 150mg to be taken 3 days apart. if CI, 2 doses of clotrimazole pessaries 500mg, 3 days apart
  3. Topical imidazole if vulval symptoms. e.g. clotrimazole 1% or 2%
  4. advise to return if symptoms have not resolved within 7-14 days
  5. follow up and test of cure not necessary if symptoms resolve
  6. do not routinely treat asymptomatic sexual partner
25
Q

What management and investigation would you consider if there is treatment failure for severe vulvovaginal candidiasis? 2 aspects

A
  • Investigation: send vaginal specimen, measure vaginal pH
  • Treat infection. Use alternative formulation if poor compliance with initial treatment
26
Q

What is the definition of recurrent vulvovaginal candidiasis?

A

4 or more documented episodes in 1 year, with at least partial resolution of symptoms between episodes

27
Q

What is the pharmacological management of recurrent vulvovaginal candidiasis?

A
  • give induction course of 3 doses of oral fluconazole 150mg (to be taken 3 days apart) OR
  • intravaginal antifungal for 10-14 days (according to response)
  • Once induction completed:
  • give prescription for ‘treatment as required’ (for example oral fluconazole 150mg once a week or intravaginal clotrimazole 500mg once weekly) if symptoms recur OR
  • prescribe maintenance regimen of 6 months’ treatment with oral or intravaginal antifungal (off label)
    • e.g. intravaginal clotrimazole 500mg once a week, oral fluconazole 150mg once a week, or oral itraconazole 50-100mg daily
  • Review after 6 months
28
Q

When should you review a patient undergoing treatment for recurrent vulvovaginal candidiasis?

A

after 6 months (or sooner if clinically indicated)

29
Q

What is the management of vulvovaginal candidiasis in a woman who is diabetic or is immunocompromised (e.g. HIV, taking steroids)? 3 options

A
  • extended course of intravaginal antifungal or oral antifungal
    • e.g. intravaginal creams
    • intravaginal pessaries
    • oral antifungals
30
Q

What are 2 regimen options for intravaginal creams for an extended course in diabetic and immunocompromised patients?

A
  1. Miconazole 2% cream - 5g into vagina once daily for 10-14 days or 5g into vagina twice daily for 7 days
  2. Econazole 1% cream - 1g into vagina and apply to vulva at night for at least 14 nights
31
Q

What are 3 regimen options for intravaginal pessaries for an extended course in diabetic and immunocompromised patients?

A
  1. Clotrimazole 100mg pessaries - 1 pessary into vagina once a night for 12 nights
  2. Clotrimazole 200mg pessaries (3 pesaries) - insert 1 into vagina once at night for 6 nights
  3. Econazole nitrate 150mg pessaries - insert 1 into the vagina once at night for 6 nights (off-label use)
32
Q

What are 2 regimen options for oral antifungals for an extended course in diabetic and immunocompromised patients?

A
  1. Oral fluconazole - 100mg once a day for 7 days
  2. Oral itraconazole - 200mg once a day for 7 days
33
Q

What is the recommended pharmacological management of vulvovaginal candidiasis in pregnant women who are >16y?

A
  • Intravaginal clotrimazole or miconazole for at least 7 days
  • Do not prescribe oral antifungal
  • Advise to take care when using applicator to avoid physical damage to cervix (some insert by hand)
  • If vulval symptoms, consider prescribing topical imidazole in addition to intravaginal clotrimazole or miconazole
34
Q

What is the recommended pharmacological management of vulvovaginal candidiasis in pregnant women who are 12-15y?

A
  • Consider prescribing topical clotrimazole 1% or 2% to be applied 2-3 times a day or seek specialist advie
  • Do not prescribe intravaginal or oral antifungal

GP (43 decks)

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