#179 Recurrent Vulvovaginal Candidiasis: Can the yeast be beat?

CLINICAL QUESTION

QUESTION CLINIQUE

What is the most effective management for women with recurrent vulvovaginal candidiasis (four or more episodes within one year)?

BOTTOM LINE

RÉSULTAT FINAL

Prophylaxis with six months of azole therapy (like fluconazole) will result in relapse in 9-19% of women compared to 50-64% on placebo (one fewer woman would relapse for every 2-4 treated). Efficacy, however, declines after therapy cessation and clinical cure remains elusive. Limited evidence suggests women may prefer episodic over maintenance therapy.

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EVIDENCE

DONNÉES PROBANTES

Two double blind, Randomized Controlled Trials (RCTs) of 373¹ and 64 women² with symptoms and culture confirmed recurrent vulvovaginitis, compared fluconazole 150 mg PO weekly for six months (after initial fluconazole 150 mg PO every 72 hours for 3 days) versus placebo:
- Significant difference in clinical relapse rate:
  - Following six months treatment:^1,2 9-19% versus 50-64%, Number Needed to Treat (NNT)=2-4.
  - 12 month follow-up:¹ 57% versus 78%, NNT=5.
    - Smaller study: No significant difference.
    - No increase in resistance.^1,2
- Adverse events:
  - “Mild” elevation of liver enzymes in one patient, did not require discontinuation.¹
- Limitations: Analysis only included compliant women.¹
Two RCTs examined monthly itraconazole 400 mg PO (114 women)³ or clotrimazole 500 mg vaginal suppository (62 women)⁴ versus placebo for six months:
- Significant difference in clinical relapse rate: 30-36% versus 64-79%, NNT=3-4.
- No longer significant at 12 month follow-up.^3,4
One observational study, 136 women, individualized decreasing dose (200 mg fluconazole three times/week, weekly x 2 months, biweekly x 4 months, then monthly x 6 months) based on clinical symptoms:⁵
- Clinical relapse during 12 months treatment: 30%.
- 18 month follow-up: 45%.

Context:

Studies of alternative therapies such as probiotics or homeopathy, are poor quality, and/or with mixed results.^6-8
Limited evidence suggests no significant difference between different azoles in Candida albicans acute or recurrent vulvovaginitis.^9,10
Candida albicans is responsible for 90% of vulvovaginal candidiasis; followed by Candida glabrata, which is azole-resistant.¹¹
One small trial (54 participants) demonstrated that treating male partner with antifungals does not reduce relapse rate.¹²
A randomized cross-over trial of 23 women reported 74% versus 14% prefer to treat each episode empirically versus maintenance therapy.¹³