Vaginal_Candidiasis_Flashcards
What is vaginal candidiasis?
Vaginal candidiasis (‘thrush’) is a common condition, mostly caused by Candida albicans (80%) and other candida species (20%).
What are the predisposing factors for vaginal candidiasis?
Diabetes mellitus, drugs (antibiotics, steroids), pregnancy, immunosuppression (HIV).
What are the clinical features of vaginal candidiasis?
‘Cottage cheese’, non-offensive discharge, vulvitis (superficial dyspareunia, dysuria), itch, vulval erythema, fissuring, satellite lesions.
When is a high vaginal swab indicated in vaginal candidiasis?
It is not routinely indicated if the clinical features are consistent with candidiasis.
What are the first-line treatment options for vaginal candidiasis according to NICE?
Oral fluconazole 150 mg as a single dose or clotrimazole 500 mg intravaginal pessary as a single dose if oral therapy is contraindicated.
What should be considered if there are vulval symptoms in vaginal candidiasis?
Adding a topical imidazole in addition to an oral or intravaginal antifungal.
What treatment is recommended for pregnant women with vaginal candidiasis?
Only local treatments (e.g. cream or pessaries) may be used - oral treatments are contraindicated.
How does BASHH define recurrent vaginal candidiasis?
4 or more episodes per year.
What steps should be taken in managing recurrent vaginal candidiasis?
Check compliance with previous treatment, confirm the diagnosis of candidiasis, high vaginal swab for microscopy and culture, consider a blood glucose test to exclude diabetes, exclude differential diagnoses such as lichen sclerosus, consider the use of an induction-maintenance regime.
What is the induction-maintenance regime for recurrent vaginal candidiasis?
Induction: oral fluconazole every 3 days for 3 doses; Maintenance: oral fluconazole weekly for 6 months.
SUMMARISE THRUSH
Vaginal candidiasis
Vaginal candidiasis (‘thrush’) is an extremely common condition which many women diagnose and treat themselves. Around 80% of cases of Candida albicans, with the remaining 20% being caused by other candida species.
The majority of women will have no predisposing factors. However, certain factors may make vaginal candidiasis more likely to develop:
diabetes mellitus
drugs: antibiotics, steroids
pregnancy
immunosuppression: HIV
Features
‘cottage cheese’, non-offensive discharge
vulvitis: superficial dyspareunia, dysuria
itch
vulval erythema, fissuring, satellite lesions may be seen
Investigations
a high vaginal swab is not routinely indicated if the clinical features are consistent with candidiasis
Management
options include local or oral treatment
NICE Clinical Knowledge Summaries recommends:
oral fluconazole 150 mg as a single dose first-line
clotrimazole 500 mg intravaginal pessary as a single dose if oral therapy is contraindicated
If there are vulval symptoms, consider adding a topical imidazole in addition to an oral or intravaginal antifungal
if pregnant then only local treatments (e.g. cream or pessaries) may be used - oral treatments are contraindicated
Recurrent vaginal candidiasis
BASHH define recurrent vaginal candidiasis as 4 or more episodes per year
compliance with previous treatment should be checked
confirm the diagnosis of candidiasis
high vaginal swab for microscopy and culture
consider a blood glucose test to exclude diabetes
exclude differential diagnoses such as lichen sclerosus
consider the use of an induction-maintenance regime
induction: oral fluconazole every 3 days for 3 doses
maintenance: oral fluconazole weekly for 6 months
You are working in a community sexual health clinic. Your patient is a 16-year-old female who is complaining of vaginal discharge. She reports a 4 week history of ‘clumpy’ white discharge with no odour. She also reports itching and reddening of skin around the vaginal opening.
She has no relevant past medical history and takes the combined oral contraceptive pill. Sexual history reveals that she has recently broken up with her long-term boyfriend, thus has a new sexual partner. She is concerned about the possibility of a sexually transmitted infection.
You decide to test the pH of a sample of the patient’s discharge, which reveals the following result:
pH 3.2
What is the most appropriate treatment for the cause of this patient’s vaginal discharge?
Oral metronidazole
Oral doxycycline
IM ceftriaxone
Clotrimazole cream
No treatment required
Clotrimazole cream
White ‘curdy’ vaginal discharge with pH <4.5 is likely to be candidiasis
Important for meLess important
The patient in this case is suffering from vaginal candidiasis, caused by Candida albicans. This is indicated by the presence of itching and reddening around the vagina, alongside the presence of ‘curdy’ vaginal discharge with pH <4.5. The most appropriate treatment for vaginal candidiasis is vaginal applications of clotrimazole.
Oral metronidazole is used in bacterial vaginosis and Trichomonas vaginalis.
Oral doxycycline is used in Chlamydia infections.
IM ceftriaxone is used in gonorrhoea infections.
A 23-year-old female patient presents to her general practitioner with a thick, white vaginal discharge that is itchy and is distracting her from her university work. She reports having tried over-the-counter remedies before for these symptoms as she has had 3 previous episodes of this in the past 5 months. She is sexually active and uses condoms and the combined oral contraceptive pill. Her urine dip in the surgery is negative for pregnancy and protein, leucocytes and nitrites are also negative.
What would be the best management option for this patient with her recurrent symptoms?
IM ceftriaxone
Oral ciprofloxacin
Oral fluconazole
Oral metronidazole
Topical fluconazole
Oral fluconazole
An induction-maintenance regime of oral fluconazole should be considered for recurrent vaginal candidiasis
This patient is presenting with symptoms consistent with thrush (vaginal candidiasis). Over-the-counter treatments include antifungals (such as clotrimazole cream) and are usually successful for the management of one-off episodes of vaginal candidiasis.
As this patient is experiencing recurrent symptoms, an oral preparation of fluconazole is recommended in the British National Formulary. It is important to ensure that the patient is not taking SSRI medications or has hypersensitivity to ‘azole’ antifungal medications.
IM ceftriaxone and oral ciprofloxacin can be used to manage Neisseria gonorrhoea not thrush.
Oral metronidazole can be used to manage bacterial vaginosis, not thrush.
Topical fluconazole is an uncommon preparation as it is strongly hydrophilic and is not as effective in comparison with other antifungals (such as topical clotrimazole).
