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KEY CONCEPTS
Vulvovaginal candidiasis (VVC) is a fungal infection of the vagina that can be classified as uncomplicated or complicated. This classification is useful in determining appropriate pharmacotherapy.
Candida albicans is the major pathogen responsible for VVC. The number of cases of non–C. albicans species appears to be increasing.
Signs and symptoms of VVC are not pathognomonic, and reliable diagnosis must be made with laboratory tests including vaginal pH, saline microscopy, and 10% potassium hydroxide (KOH) microscopy.
C. albicans is the predominant species causing all forms of mucosal candidiasis. Important host and exogenous risk factors have been identified that predispose an individual to the development of mucosal candidiasis. In oropharyngeal and esophageal candidiasis, the key risk factor is impaired host immune system.
A topical antimycotic agent is the first choice for treating oropharyngeal candidiasis. Systemic therapy can be used in patients who are not responding to an adequate trial of topical treatment or are unable to tolerate topical agents and in those at high risk for systemic candidiasis. Fluconazole and itraconazole are the most effective azole antimycotic agents.
For esophageal candidiasis, topical agents are not of proven benefit; oral fluconazole or itraconazole solution is the first choice.
Optimal antiretroviral therapy is important for the prevention of recurrent and refractory candidiasis in patients with human immunodeficiency virus (HIV) infection.
Primary or secondary prophylaxis of fungal infection is not recommended routinely for HIV-infected patients; use of secondary prophylaxis should be individualized for each patient.
Topical antimycotic agents are first-line treatment for fungal skin infections. Oral therapy is preferred for the treatment of extensive or severe infection and those with tinea capitis or onychomycosis.
Oral antimycotic agents such as terbinafine and itraconazole are first-line treatment for toenail and fingernail onychomycosis.
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Patient Care Process for Vulcovaginal Candidiasis
Collect
Patient Characteristics (age, pregnancy status)
Patient medical history (previous vaginal infections, diabetes mellitus)
Social history (sexual activity)
Current Meds (oral contraceptives, antibiotics)
Assess
Symptoms consistent with VVC (itching, clumpy white vaginal discharge)
Absence of fever, pelvic pain, colored or foul smelling vaginal discharge
Possibility of sexually transmitted disease
Recurrence of symptoms from previous vaginal infection
Plan*
Remove predisposing risk factors if possible
Select a drug therapy regimen including specific antifungal(s) dose, route, frequency and duration (Table 138-2)
Education of the patient regarding causes of VVC and the selected treatment
Referral to other healthcare providers if complicated or recurrent VVC or risk factors for sexually transmitted disease
Implement
Provide patient counselling (avoid harsh soaps, perfumes, hot tub use, contraceptive use)
Keep vaginal area clean and dry avoid constrictive clothing
Self-assessment of symptom relief is appropriate
Follow-up: Monitor and Evaluate
Monitor for complete resolution of symptoms within 24-48 hours of initiation of therapy (itching, clumpy white discharge)
Determine the presence of adverse effects (nausea, abdominal discomfort, vaginal irritation)
Refer to other healthcare provider if symptoms do not resolve despite adherence