Candida

Candidal Vaginitis

Infxn	Sx	Vag dc	whiff	micro	pH	%ID by direct microscopy
BV	foul smell, increased after intercourse	thin, homogenous, gray, white	+	>20% clue cells	>4.5	> 90%
Trich	frothery, foul smell, pruritis, discharge	purulent, profuses, irritating, frothy green yellow	+/-	incr WBCs, trichomonads	> 4.5, often >6	50-70%
Candida	pruritis, burning, dc	thick, adherent, white	neg	increased WBCs, budding yeast, pseudohyphae	4 to 4.5	50-60&

Recurrent vulvovaginal candidiasis

Several predisposing factors contribute to recurrent candidal vulvovaginal infections.

most common causes are recent antibiotic therapy (especially broad-spectrum antibiotics such as amoxicillin or tetracycline) and oral contraceptive use (particularly high-dose estrogen-containing preparations).
Other causes include diabetes mellitus, pregnancy, steroid use, immunosuppressive therapy, and infections that affect the immune system, such as human immunodeficiency virus (HIV).
A topical azole agent generally is recommended for the treatment of uncomplicated vulvovaginal candidiasis, with 3- and 7-day regimens believed to be superior to single-dose therapy. However, for many adolescents, single-dose therapy with oral fluconazole is preferable.
Recurrent vulvovaginal candidiasis occurs in fewer than 5% of women. The mainstay of therapy is elimination or reduction of risk factors, if possible, and the removal of any sources of reinfection.
- washing all underwear in hot water
- disposing of all diaphragms and obtaining new ones
- discontinuing oral-genital contact
- examining and treating the sexual partner.
- HIV testing also may be considered.
- Treatment with longer courses of topical agents or initiating therapy with an oral agent usually is necessary.
Long-term prophylaxis has been shown to decrease recurrences of Candida vulvovaginitis. Regimens include:
- standard oral dose of fluconazole once a month
- intravaginal dose of clotrimazole each month
- intra-vaginal miconazole twice a week
- Although an option, oral ketoconazole therapy is less preferred to fluconazole because of its higher potential for toxicity.
- There is no evidence to support placing the partner on long-term prophylaxis.
Switching the adolescent to an oral contraceptive agent containing a higher estrogen dose will increase her risk of recurrent candidal infections.

References:

Haward M, Shafer MA. Vaginitis and cervicitis. In: Neinstein LS, ed. Adolescent Health Care: A Practical Guide. 4th ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 2002:1014-1018
Ringdahl EN. Treatment of recurrent vulvovaginal candidiasis. Am Fam Physician. 2000;61:3306-3317
Abstract available online.