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Candida - female genital - Management
How should I manage treatment failure in uncomplicated vulvovaginal candidiasis?

  • Review:
    • Check that treatments have been used as recommended.
    • Topical azole therapies can cause vulvovaginal irritation, so consider this if symptoms persist or worsen.
    • A wrong diagnosis is a common cause for treatment failure, therefore consider alternative diagnoses.
    • Reassess for predisposing risk factors, and remove or control as far as possible.
  • Investigate:
    • Send a vaginal specimen for microscopy and culture to identify:
      • Non-albicans Candida species (if feasible).
      • A mixed infection such as candidiasis together with bacterial vaginosis or trichomoniasis (up to 10% of infections are mixed). See the CKS topics on Bacterial vaginosis and Trichomoniasis.
  • Treat:
    • Give general advice about avoiding local irritants (such as soaps and shower gels) and tight-fitting synthetic clothes.
    • If non-compliance has been a problem with an intravaginal imidazole, prescribe a short course of an oral antifungal (e.g. fluconazole or itraconazole) as compliance is likely to be higher.
    • If symptoms are improving, consider treating with a longer course of an oral antifungal (e.g. itraconazole or fluconazole) or an intravaginal antifungal (e.g. clotrimazole, econazole, or miconazole).
      • For girls aged between 12 and 16 years oral antifungals (itraconazole or fluconazole) are generally preferred over intravaginal treatments. However, intravaginal antifungals may be considered if the girl is sexually active, if she uses tampons, or if there is no other alternative.
    • For vulval symptoms, consider prescribing a topical imidazole (e.g. clotrimazole or econazole) cream in addition to an oral or intravaginal antifungal.
  • Refer, or seek specialist advice, if:
      • Symptoms are not improving and treatment failure is unexplained.
      • Treatment fails again.
      • If diagnosis is unclear.
Basis for recommendation
  • CKS found no evidence or national guidelines specifically on treatment failure of uncomplicated vulvovaginal candidiasis, which usually responds well to treatment.
  • Review, investigation, referral:
  • Treatment:
    • The doses CKS has recommended for extended courses are estimates only, as published reviews and guidelines do not give details of what doses to use. Where possible CKS has recommended preparations that are licensed for extended use.
    • Intravaginal nystatin was recommended for non-albicans Candida species because experts believe (on the basis of laboratory evidence) that it is more effective than topical or oral azoles against Candida glabrata and other non-albicans Candida species [BASHH, 2002; FFPRHC and BASHH, 2006]. However, nystatin intravaginal cream is no longer available in the UK. The Centers for Disease Control recommend using any azole antifungal except fluconazole (but do not cite any supporting evidence) [CDC, 2006].
  • Girls aged 12–16 years:
    • Experts consider that oral antifungals are generally more appropriate than intravaginal antifungals in this age group. However, an intravaginal antifungal may be appropriate for girls who are sexually active or using tampons, or if there is no alternative [BNF for Children, 2007; Daniels, Personal Communication, 2007].
    • Oral itraconazole is licensed for use in girls over 12 years old.
    • Oral fluconazole is not licensed for use in children less than 16 years old, however experts suggest that it may be an appropriate option for girls between the ages of 12 and 16 years [Daniels, Personal Communication, 2007].
  • Adverse effects:
    • There is evidence from a number of randomized controlled trials that vulval burning and vaginal discharge are more common with intravaginal imidazoles, whilst nausea, headache, and abdominal pain are more common with oral imidazoles.
    • There is no evidence that antifungal treatments used appropriately have serious adverse effects.
  • Treatments not recommended:
    • Oral ketoconazole. The MHRA has advised that ketoconazole tablets should only be initiated by a physician who is experienced in the management of fungal infections because of the risk of serious hepatotoxicity. Oral ketoconazole should only be prescribed for the treatment of chronic mucocutaneous candidosis that cannot be treated topically because of the site, extent of the lesion, or deep infection of the skin, in people resistant to or intolerant of both fluconazole and itraconazole [MHRA, 2008].
    • Povidone-iodine is an antiseptic available in topical intravaginal formulations and is licensed for the treatment of candidal infections of the vagina. However, there is little published evidence to support its use.

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