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Vulvovaginal candidiasis Flashcards

1
Q

What is the primary laboratory investigation for acute vulvovaginal candidiasis?

A

Microscopy

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2
Q

When is culture recommended in management of vulvovaginal candidiasis? Why?

A

Recurrent presentations

Speciation and sensitivity testing

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3
Q

What is the definition of recurrent vulvovaginal candidiasis?

A

4 episodes per year with 2 episodes confirmed by microscopy or culture

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4
Q

What type of organism is Candida?

A

Yeast
Eukaryotic, unicellular microorganisms
able to develop multicellular characteristics

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5
Q

What are the multicellular characteristics of Candida?

A

Form pseudohyphae and biofilms

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6
Q

What is candidiasis?

A

Fungal infection caused by yeasts

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7
Q

What is the most common candida species that causes infection?

A

Candida albicans

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8
Q

What proportion of vulvovaginal candidiasis is caused by Candida albicans?

A

80-89%

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9
Q

What are species have been known to cause vulvovaginal candidiasis?

A 
C. glabrata
C. tropicalis
C. krusei
C. parapsilosis
Saccharomyces cerevisiae
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10
Q

What proportion of women will have at least one episode of vulvovaginal candidiasis?

A

75%

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11
Q

What are the host factors that lead to recurrent vulvovaginal candidiasis?

A 
persistence of Candida on PCR
poorly controlled diabetes mellitus
immunosupression
endogenous or exogenous oestrogen (pregnancy, COCP, HRT)
recent antibiotic use (<3 months)
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12
Q

What is the pathophysiology that correlates with symptomatic vulvovaginal candidiasis?

A

fungal burden

neutrophil infiltration

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13
Q

What signs may be identified in vulvovaginal candidiasis?

A 
erythema
fissuring
swelling/oedema
vaginal discharge (typically non-offensive and curdy but may be thin or absent)
satellite lesions and excoriation marks.
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14
Q

What are the differential diagnoses for vulvovaginal candidiasis?

A 
dermatitis/eczema
lichensclerosus
other infections (HSV, trichomonas vaginalis)
vulvodynia
aerobic vaginitis
cytolytic vaginosis
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15
Q

When should aerobic vaginitis be considered over vulvovaginal candidiasis?

A

primary complaint - purulent non-offensive discharge

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16
Q

When might you consider Cytolytic vaginosis over vulvovaginal candidiasis?

A

very similar clinical features:
curdy discharge
pruritus
microscopy and fungal cultures are negative

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17
Q

What sampling technique should be used to diagnose vulvovaginal candidiasis?

A

high vaginal swab (HVS)

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18
Q

What may be seen on microscopy that confirms high vaginal swab (HVS)?

A

blastospores
pseudohyphae
neutrophils

19
Q

If you see blastosphores and neutrophils only, what might this suggest infection with?

A

Candida glabrata

20
Q

If there are no neutrophils but evidence of candida on microscopy what does this suggest?

A

colonisation with Candida not infection

21
Q

At what pH is in vitro susceptibility testing performed for Candida?

22
Q

What is the typical vaginal pH in vulvovaginal candidiasis?

A

pH 4 - 4.5

23
Q

What are the practical implications of susceptibility testing performed for Candida at higher pH?

A

standard treatment may not work despite being designated as susceptible

24
Q

What general advice should be given to women with symptoms of vulvovaginal candidiasis?

A

avoiding the use of local irritants
emollient for personal hygiene as a soap substitute, moisturiser and a barrier cream
Sex can continue
Women may wish to avoid sex until symptoms have improved particularly if there is fissuring of the skin

25
What genital hygiene practices have been linked with recurrent vulvovaginal candidiasis?
washing hair in bath excessive cleaning wearing incorrectly fitted clothing made from non-breathable fabric using intermenstrual or daily panty liners vaginal douching
26
What additional investigations should be considered in recurrent vulvovaginal candidiasis?
urinalysis, random blood glucose or HbA1c for diabetes | full blood count or serum ferritin for iron-deficiency anaemia
27
When should screening for mannose binding lectin (MBL) deficiency be considered in vulvovaginal candidiasis?
Recurrent infection history of recurrent upper respiratory tract infections otitis media autoimmune conditions
28
What is the recommended treatment for vulvovaginal candidiasis? Oral? Topical?
Oral: Fluconazole 150mg STAT Topical: Clotrimazole 500mg STAT intravaginal
29
How effective are intravaginal and oral treatments for vulvovaginal candidiasis?
>80% clinical and mycological cure rate in acute VVC All intravaginal imidazoles and oral azoles
30
When should oral fluconazole be avoided?
pregnancy risk of pregnancy breastfeeding
31
What is the risk with intravaginal/topical treatments for vulvovaginal candidiasis?
damage latex condoms and diaphragms | risk of unplanned pregnancies
32
Fluconazole is a moderate inhibitor of cytochrome P450 (CYP) isoenzyme 2C9 and a moderate inhibitor of CYP3A4 - how long does this effect last?
4-5days | due to the long half-life
33
What cardiac risk is associated with azaleas including fluconazole?
prolongation of the QT interval
34
What signs may be present in severe VVC?
extensive vulval erythema oedema excoriation fissure formation
35
What is the treatment for severe VVC?
Fluconazole 150mg orally on day 1 and 4 | Vaginal pessary - clotrimazole or miconazole - alternative
36
What other treatment may accelerate symptomatic relief of VVC?
Low-potency corticosteroid creams
37
What is the treatment for recurrent VVC? induction? Maintenance?
Induction: fluconazole 150mg orally every 72 hours x 3 doses Maintenance: fluconazole 150mg orally once a week for 6 months
38
When should an antihistamine be considered in the treatment of VVC?
Relapse between suppressive therapy doses | history of allergy ie atopy
39
Why is ketoconazole NO longer used as treatment for fungal infections?
risk of hepatotoxicity outweighs the potential benefits
40
What treatments may be considered for non-albicans candida or azole resistance?
Nystatin pessaries Boric acid vaginal suppositories Amphotercin B vaginal suppositories Flucytosine pessary
41
How long should treatment be given for azole resistant Candida?
2 weeks
42
When might a higher dose and increased frequency of fluconazole be used for VVC?
isolates with an elevated MIC but still designated susceptible
43
What is the difference in cure rate of VVC in pregnancy between 4 day and 7 day course?
4 days topical imidazole: >50% | 7 days: >90%

DipGUM (39 decks)

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