Vulvovaginal candidiasis Flashcards
What is the primary laboratory investigation for acute vulvovaginal candidiasis?
Microscopy
When is culture recommended in management of vulvovaginal candidiasis? Why?
Recurrent presentations
Speciation and sensitivity testing
What is the definition of recurrent vulvovaginal candidiasis?
4 episodes per year with 2 episodes confirmed by microscopy or culture
What type of organism is Candida?
Yeast
Eukaryotic, unicellular microorganisms
able to develop multicellular characteristics
What are the multicellular characteristics of Candida?
Form pseudohyphae and biofilms
What is candidiasis?
Fungal infection caused by yeasts
What is the most common candida species that causes infection?
Candida albicans
What proportion of vulvovaginal candidiasis is caused by Candida albicans?
80-89%
What are species have been known to cause vulvovaginal candidiasis?
C. glabrata C. tropicalis C. krusei C. parapsilosis Saccharomyces cerevisiae
What proportion of women will have at least one episode of vulvovaginal candidiasis?
75%
What are the host factors that lead to recurrent vulvovaginal candidiasis?
persistence of Candida on PCR poorly controlled diabetes mellitus immunosupression endogenous or exogenous oestrogen (pregnancy, COCP, HRT) recent antibiotic use (<3 months)
What is the pathophysiology that correlates with symptomatic vulvovaginal candidiasis?
fungal burden
neutrophil infiltration
What signs may be identified in vulvovaginal candidiasis?
erythema fissuring swelling/oedema vaginal discharge (typically non-offensive and curdy but may be thin or absent) satellite lesions and excoriation marks.
What are the differential diagnoses for vulvovaginal candidiasis?
dermatitis/eczema lichensclerosus other infections (HSV, trichomonas vaginalis) vulvodynia aerobic vaginitis cytolytic vaginosis
When should aerobic vaginitis be considered over vulvovaginal candidiasis?
primary complaint - purulent non-offensive discharge
When might you consider Cytolytic vaginosis over vulvovaginal candidiasis?
very similar clinical features:
curdy discharge
pruritus
microscopy and fungal cultures are negative
What sampling technique should be used to diagnose vulvovaginal candidiasis?
high vaginal swab (HVS)
What may be seen on microscopy that confirms high vaginal swab (HVS)?
blastospores
pseudohyphae
neutrophils
If you see blastosphores and neutrophils only, what might this suggest infection with?
Candida glabrata
If there are no neutrophils but evidence of candida on microscopy what does this suggest?
colonisation with Candida not infection
At what pH is in vitro susceptibility testing performed for Candida?
pH 7.0
What is the typical vaginal pH in vulvovaginal candidiasis?
pH 4 - 4.5
What are the practical implications of susceptibility testing performed for Candida at higher pH?
standard treatment may not work despite being designated as susceptible
What general advice should be given to women with symptoms of vulvovaginal candidiasis?
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
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
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
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
What is the recommended treatment for vulvovaginal candidiasis? Oral? Topical?
Oral:
Fluconazole 150mg STAT
Topical:
Clotrimazole 500mg STAT intravaginal
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
When should oral fluconazole be avoided?
pregnancy
risk of pregnancy
breastfeeding
What is the risk with intravaginal/topical treatments for vulvovaginal candidiasis?
damage latex condoms and diaphragms
risk of unplanned pregnancies
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
What cardiac risk is associated with azaleas including fluconazole?
prolongation of the QT interval
What signs may be present in severe VVC?
extensive vulval erythema
oedema
excoriation
fissure formation
What is the treatment for severe VVC?
Fluconazole 150mg orally on day 1 and 4
Vaginal pessary - clotrimazole or miconazole - alternative
What other treatment may accelerate symptomatic relief of VVC?
Low-potency corticosteroid creams
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
When should an antihistamine be considered in the treatment of VVC?
Relapse between suppressive therapy doses
history of allergy ie atopy
Why is ketoconazole NO longer used as treatment for fungal infections?
risk of hepatotoxicity outweighs the potential benefits
What treatments may be considered for non-albicans candida or azole resistance?
Nystatin pessaries
Boric acid vaginal suppositories
Amphotercin B vaginal suppositories
Flucytosine pessary
How long should treatment be given for azole resistant Candida?
2 weeks
When might a higher dose and increased frequency of fluconazole be used for VVC?
isolates with an elevated MIC but still designated susceptible
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%
