Clinical Manual for Management of the HIV-Infected Adult
2006 Edition

Section 6: Disease-Specific Treatment

Candidiasis, Vulvovaginal

Background

Vulvovaginal candidiasis is a yeast infection caused by several types of Candida, typically Candida albicans. This disease is common in all women, but may occur more frequently and more severely in immunocompromised women.

Although refractory vaginal Candida infections by themselves should not be considered indicators of HIV infection, they may be the first clinical manifestation of HIV infection, and can occur early in the course of disease (at CD4 counts >500 cells/µL). The frequency of vaginal candidiasis tends to increase as CD4 counts decrease; this may, however, be due in part to increased antibiotic use among women with advanced HIV infection.

Risk factors for candidiasis include diabetes mellitus and the use of oral contraceptives, corticosteroids, or antibiotics.

S: Subjective

The patient may complain of itching, burning, or swelling of the labia and vulva; a thick white or yellowish vaginal discharge; painful intercourse; and pain and burning on urination.

The most important elements in the history include:

• Type and duration of symptoms
• Previous vaginal yeast infection
• Oral contraceptive use
• Recent or ongoing broad-spectrum antibiotic therapy
• Recent corticosteroid therapy
• Sexual exposures (to evaluate for sexually transmitted infections)
• Diabetes history
• Cushing syndrome
• Obesity
• Hypothyroidism
• Pregnancy
• Use of douches, vaginal deodorants, or bath additives

O: Objective

A focused physical examination of the external genitalia may reveal inflammation of the vulva with evidence of discharge on the labial folds and vaginal opening. Speculum examination usually reveals a thick, white discharge with plaques adhering to the vaginal walls and cervix. Bimanual examination should not elicit pain or tenderness and otherwise should be normal.

A: Assessment

Rule out other causes of vaginal discharge and pruritus:

• Bacterial vaginosis
• Atrophic vaginitis
• Pediculosis
• Chemical or mechanical causes
• Trichomoniasis
• Gonorrhea, chlamydia, and other sexually transmitted infections
• Scabies
• Pediculosis

P: Plan

Diagnostic Evaluation

A presumptive diagnosis is made on the basis of the clinical presentation and potassium hydroxide (KOH) preparation:

• Perform microscopic examination of a KOH preparation of vaginal secretions. This exam usually reveals pseudohyphae and Candida spores (presumptive diagnosis).
• Definitive diagnosis is rarely needed, but may be made by a culture of vaginal secretions.
• In the presence of urinary tract symptoms (beyond external vulvar burning), perform urinalysis, culture, or both on a clean-catch urine specimen.
• Consider testing for gonorrhea and chlamydia in patients with a history of possible sexual exposure.

Treatment

Uncomplicated infections

Topical medications

• Prescribe topical vaginal antifungal agents in the form of cream or suppositories: miconazole (Monistat), clotrimazole (Gyne-Lotrimin), terconazole (Terazol). Treat for 3-7 days and offer refills depending on the time to the next scheduled clinic visit. The creams may also be used on the vulva for pruritus.
• Nystatin vaginal pastilles 100,000 units; insert 1 daily for 14 days

Note that the mineral-oil base in topical vaginal antifungal preparations may erode the latex in condoms, diaphragms, and dental dams. Advise the patient to use alternative methods to prevent HIV transmission or conception, or to discontinue intercourse while using these medications. Nonlatex condoms (plastic and polyethylene only) or "female" condoms (polyurethane) can be used.

Oral medications

• Fluconazole 150 mg orally, 1 dose (see "Treatment notes" below)
• Itraconazole 200 mg orally twice daily for 1 day, or 200 mg orally once daily for 3 days (see Treatment notes below)

Complicated infections

Severe or recurrent candidiasis

Severe or recurrent candidiasis is defined as 4 or more episodes within 1 year. Consider the following treatments:

• Topical therapy as above, for 7-14 days
• Fluconazole 150 mg orally in a single dose; repeat in 72 hours (see "Treatment notes" below)

For severe cases that recur repeatedly, secondary prophylaxis can be considered, eg, clotrimazole vaginal suppository (500 mg once weekly) or fluconazole.

Non-albicans candidiasis

• Non-fluconazole azole for 10-14 days (see "Treatment notes" below)
• Boric acid 600 mg intravaginal gelatin capsules once daily for 2 weeks for refractory cases
• Consult with a specialist

Treatment notes

• Systemic azole drugs are not recommended during pregnancy, and women taking azoles should use effective contraception. Topical azoles are recommended or the treatment of pregnant women.
• Itraconazole interacts with some antiretroviral medications; check for adverse drug interactions before prescribing. Itraconazole should not be used by pregnant women or women considering pregnancy.
• Resistance to azole medications may develop, especially with prolonged use of oral agents.
• Avoid ketoconazole: Case reports have associated ketoconazole with a risk of fulminant hepatitis (1 in 12,000 courses of treatment with oral ketoconazole). Experts agree that the risks may outweigh the benefits in women with vulvovaginal candidiasis. Ketoconazole also interacts with many other drugs, including some antiretroviral drugs.

Patient Education

• Advise women to wash external genitals daily with a fresh washcloth or water-soaked cotton balls and to wipe the vulva and perirectal area from front to back after toileting. Women should not use baby wipes on inflamed vulval tissue because they may increase irritation.
• Women should avoid the use of perfumed soaps, bubble baths, feminine hygiene or vaginal deodorant products, and bath powders.
• Advise women not to douche.
• Women should wear cotton underwear and avoid tight, constrictive clothing, particularly pantyhose.
• If women are prescribed medication for vaginal candidiasis, they should take the medication exactly as prescribed and finish the medicine even during a menstrual period.
• Women who continue to have symptoms, can purchase Monistat or Gyne-Lotrimin medication over the counter. Advise patients to start using these as soon as symptoms come back, and to call the clinic if symptoms get worse while they are taking these medicines.
• Women taking fluconazole or ketoconazole must avoid pregnancy. Some birth defects have been reported.
• The mineral-oil base in topical vaginal antifungal preparations may erode the latex in condoms, diaphragms, and dental dams. Advise patients to use alternative methods to prevent HIV transmission or conception or to discontinue intercourse while using these medications. Nonlatex condoms (plastic and polyethylene only) or "female" condoms (polyurethane) can be used.
• Sex toys, douche nozzles, diaphragms, cervical caps, and other items can reinfect patients if not properly cleaned and thoroughly dried after use.
• Some studies have suggested that eating yogurt with live cultures (check labels) can reduce the occurrence of vaginal yeast infections.

References

• Abularach S, Anderson J. Gynecologic Problems. In: Anderson JR, ed. A Guide to the Clinical Management of Women with HIV. Rockville, MD: Health Resources and Services Administration, HIV/AIDS Bureau; 2005. Available online at hab.hrsa.gov/publications/womencare05/. Accessed May 19, 2006.
• Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines 2002. MMWR Recomm Rep. 2002 May 10;51(RR-6):1-78.
• U.S. Public Health Service, Infectious Diseases Society of America. Guidelines for preventing opportunistic infections among HIV-infected persons--2002. MMWR Recomm Rep. 2002 Jun 14;51(RR08);1-46. Available online at aidsinfo.nih.gov/Guidelines/. Accessed May 19, 2006.
• Cohn SE, Clark RA. Sexually transmitted diseases, HIV, and AIDS in women. In: The Medical Clinics of North America, Vol. 87; 2003:971-995.
• Hatcher RA, Stewart FH, Trussell J, et al. Contraceptive Technology, 15th ed. New York: Ardent Media; 1999:123-5.
• Sande MA, Eliopoulos GM, Moellering RC, et al. The Sanford Guide to HIV/AIDS Therapy, 14th ed. Hyde Park, VT: Antimicrobial Therapy, Inc.; 2005.
• Spence D. Candidiasis (vulvovaginal). Clin Evid. 2004 Dec;(12):2493-511.