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How should you treat Candida vaginitis in patients on antibiotics?
EVIDENCE-BASED ANSWER

Oral and intravaginal antifungals for the treatment of uncomplicated vulvovaginal candidiasis (VVC) have similar effectiveness (strength of recommendation [SOR]: A, systematic review). However, no randomized controlled trials (RCTs) have addressed treatment options for patients taking antibiotics. Oral antifungals are contraindicated in pregnancy. While shorter courses of intravaginal therapy can be used by nonpregnant women, 7-day treatment may be necessary during pregnancy (SOR: A, systematic review). Products containing Lactobacillus species do not prevent postantibiotic vulvovaginitis (SOR: A, systematic review and RCT).

Clinical commentary

Most women would rather prevent than treat
Laura Kittinger-Aisenberg, MD
Chesterfield Family Medicine Residency Program, Virginia Commonwealth University

Many women complain about getting yeast infections after receiving antibiotics. Usually the patient will inform me of this while I’m writing the prescription for the antibiotic, asking for Diflucan “just in case.” Women prefer the convenience of the oral medicine over the hassle with topical applications. Some state that 1 dose of Diflucan does not cut it, and that they usually need 2. As a result, I find myself writing a prescription for Diflucan to be started along with the antibiotic, and then to be repeated as a second dose in 3 days. I have not heard any complaints from these patients about postantibiotic yeast infections.

Evidence summary

VVC is a common cause of vaginitis; Candida albicans accounts for 85% to 90% of cases. Risk factors include pregnancy, diabetes mellitus, and systemic antibiotics.1 Incidence increases with onset of sexual activity, but there is no direct evidence it is sexually transmitted.1 About 75% of women experience 1 VVC episode during their lifetime, 40% to 45% have 2 or more, and 5% to 8% have recurrent VVC (defined as 4 or more annually).1,2

The candidiasis/antibiotics link

A 2003 systematic review found the evidence supporting the association between antibiotics and VVC limited and contradictory.3 Most were case-control or cohort studies with small sample sizes. No RCTs compare the incidence of culture-confirmed VVC among women receiving antibiotics or placebo.

Nineteen reports of 18 original studies had sufficient data to calculate a relative risk or odds ratio for antibiotic-associated VVC. Thirteen of the 19 reports showed an increase (around twofold; range, 0.43–5) in vaginal Candida prevalence; however, 3 of the 13 reports had no mycological culture data. Six studies did not show significant association between antibiotics and vaginal yeast.3

 

Antibiotics are thought to increase risk of VVC by killing endogenous vaginal flora (particularly Lactobacillus), allowing microorganisms resistant to the antibiotics, like Candida, to flourish.1 Yet there is evidence that numbers of genital Lactobacillus are similar for women with and without symptomatic VVC.4 Further, decreasing Lactobacillus does not increase the risk of VVC.5

Topical and oral antifungals—both do the job

For the treatment of uncomplicated VVC, both topical and oral antifungals are clinically and mycologically effective, with comparable clinical cure rates >80%.6 No difference in persistent symptoms between single and multiple doses, or different durations of multiple dose regimens have been found, but samples may have been too small to detect clinically significant effects. An RCT found less nausea, headache, and abdominal pain with intravaginal imidazoles, but more vulvar irritation and vaginal discharge than oral fluconazole.6

For treatment of recurrent VVC, RCTs have shown the effectiveness of oral fluconazole and itraconazole maintenance therapy taken for 6 months after an initial regimen.7,8 Treating male sexual partners did not significantly improve resolution of the woman’s symptoms or reduce the rate of symptomatic relapse.9

Yogurt may not live up to its rep

Two poor-quality crossover RCTs provided insufficient evidence regarding effectiveness of a diet containing oral Lactobacillus yogurt to prevent recurrent VVC.9 A recent RCT of 278 women on short courses of antibiotics were randomized to oral lactobacilli or placebo and vaginal lactobacilli or placebo.10 The study was stopped early because there was no effect seen. Overall, 23% developed symptomatic vulvovaginitis.

Recommendations from others

The Infectious Diseases Society of America11 recommends treating uncomplicated VVC with short-course of oral or topical antifungals; treating complicated VVC with antimycotic therapy for 7 days, either daily as topical therapy or as two 150-mg doses of fluconazole 72 hours apart; treating non-albicans species of Candida with topical boric acid (600 mg/day for 14 days) or topical flucytosine; and treating recurrent VVC with induction therapy with 2 weeks of a topical or oral azole followed by a maintenance regimen for 6 months (fluconazole once a week or itraconazole twice a week).11

References

1. Sobel JD, Faro S, Force RW, et al. Vulvovaginal candidiasis: epidemiologic, diagnostic, and therapeutic considerations. Am J Obstet Gynecol 1998;178:203-211.

2. Sobel JD. Vaginitis. N Engl J Med 1997;337:1896-1903.

3. Xu J, Sobel JD. Antibiotic-associated vulvovaginal candidiasis. Curr Infect Dis Rep 2003;5:481-487.

4. Sobel JD, Chaim W. Vaginal microbiology of women with acute recurrent vulvovaginal candidiasis. J Clin Microbiol 1996;34:2497-2499.

5. Hawes SE, Hillier SL, Benedetti J, et al. Hydrogen peroxide-producing lactobacilli and acquisition of vaginal infections. J Infect Dis 1996;174:1058-1063.

6. Watson MC, Grimshaw JM, Bond CM, Mollison J, Ludbrook A. Oral versus intra-vaginal imidazole and triazole antifungal treatment of uncomplicated vulvovaginal candidiasis (thrush). Cochrane Database Syst Rev 2001;(1):CD002845.-

7. Sobel JD, Wiesenfeld HC, Martens M, et al. Maintenance fluconazole therapy for recurrent vulvovaginal candidiasis. N Engl J Med 2004;351:876-883.

8. Spinillo A, Colonna L, Piazzi G, Baltaro F, Monaco A, Ferrari A. Managing recurrent vulvovaginal candidiasis. Intermittent prevention with itraconazole. J Reprod Med 1997;42:83-87.

9. Spence D. Candidiasis (vulvovaginal). Clin Evid 2006;15:1-8.

10. Pirotta M, Gunn J, Chondros P, et al. Effect of lactobacillus in preventing postantibiotic vulvovaginal candidiasis: a randomised controlled trial. BMJ 2004;329:548.-

11. Pappas PG, Rex JH, Sobel JD, et al. Guidelines for treatment of candidiasis. Clin Infect Dis 2004;38:161-189.

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Jinping Xu, MD, MS
Kendra Schwartz, MD, MSPH
Wayne State University, Detroit, Mich

Kristin Hitchcock, MSI
Department of Preventive Medicine, Northwestern University, Chicago, Ill

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The Journal of Family Practice - 56(8)
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671-672
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candida; albicans; yeast; infection; vagina; vaginitis; probiotics; yogurt; vulvovaginal; candidiasis; antifungal; lactobacillus; Jinping Xu MD; Kendra Schwartz MD; Kristin Hitchcock MSI; Laura Kittinger-Aisenberg MD
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Jinping Xu, MD, MS
Kendra Schwartz, MD, MSPH
Wayne State University, Detroit, Mich

Kristin Hitchcock, MSI
Department of Preventive Medicine, Northwestern University, Chicago, Ill

Author and Disclosure Information

Jinping Xu, MD, MS
Kendra Schwartz, MD, MSPH
Wayne State University, Detroit, Mich

Kristin Hitchcock, MSI
Department of Preventive Medicine, Northwestern University, Chicago, Ill

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EVIDENCE-BASED ANSWER

Oral and intravaginal antifungals for the treatment of uncomplicated vulvovaginal candidiasis (VVC) have similar effectiveness (strength of recommendation [SOR]: A, systematic review). However, no randomized controlled trials (RCTs) have addressed treatment options for patients taking antibiotics. Oral antifungals are contraindicated in pregnancy. While shorter courses of intravaginal therapy can be used by nonpregnant women, 7-day treatment may be necessary during pregnancy (SOR: A, systematic review). Products containing Lactobacillus species do not prevent postantibiotic vulvovaginitis (SOR: A, systematic review and RCT).

Clinical commentary

Most women would rather prevent than treat
Laura Kittinger-Aisenberg, MD
Chesterfield Family Medicine Residency Program, Virginia Commonwealth University

Many women complain about getting yeast infections after receiving antibiotics. Usually the patient will inform me of this while I’m writing the prescription for the antibiotic, asking for Diflucan “just in case.” Women prefer the convenience of the oral medicine over the hassle with topical applications. Some state that 1 dose of Diflucan does not cut it, and that they usually need 2. As a result, I find myself writing a prescription for Diflucan to be started along with the antibiotic, and then to be repeated as a second dose in 3 days. I have not heard any complaints from these patients about postantibiotic yeast infections.

Evidence summary

VVC is a common cause of vaginitis; Candida albicans accounts for 85% to 90% of cases. Risk factors include pregnancy, diabetes mellitus, and systemic antibiotics.1 Incidence increases with onset of sexual activity, but there is no direct evidence it is sexually transmitted.1 About 75% of women experience 1 VVC episode during their lifetime, 40% to 45% have 2 or more, and 5% to 8% have recurrent VVC (defined as 4 or more annually).1,2

The candidiasis/antibiotics link

A 2003 systematic review found the evidence supporting the association between antibiotics and VVC limited and contradictory.3 Most were case-control or cohort studies with small sample sizes. No RCTs compare the incidence of culture-confirmed VVC among women receiving antibiotics or placebo.

Nineteen reports of 18 original studies had sufficient data to calculate a relative risk or odds ratio for antibiotic-associated VVC. Thirteen of the 19 reports showed an increase (around twofold; range, 0.43–5) in vaginal Candida prevalence; however, 3 of the 13 reports had no mycological culture data. Six studies did not show significant association between antibiotics and vaginal yeast.3

 

Antibiotics are thought to increase risk of VVC by killing endogenous vaginal flora (particularly Lactobacillus), allowing microorganisms resistant to the antibiotics, like Candida, to flourish.1 Yet there is evidence that numbers of genital Lactobacillus are similar for women with and without symptomatic VVC.4 Further, decreasing Lactobacillus does not increase the risk of VVC.5

Topical and oral antifungals—both do the job

For the treatment of uncomplicated VVC, both topical and oral antifungals are clinically and mycologically effective, with comparable clinical cure rates >80%.6 No difference in persistent symptoms between single and multiple doses, or different durations of multiple dose regimens have been found, but samples may have been too small to detect clinically significant effects. An RCT found less nausea, headache, and abdominal pain with intravaginal imidazoles, but more vulvar irritation and vaginal discharge than oral fluconazole.6

For treatment of recurrent VVC, RCTs have shown the effectiveness of oral fluconazole and itraconazole maintenance therapy taken for 6 months after an initial regimen.7,8 Treating male sexual partners did not significantly improve resolution of the woman’s symptoms or reduce the rate of symptomatic relapse.9

Yogurt may not live up to its rep

Two poor-quality crossover RCTs provided insufficient evidence regarding effectiveness of a diet containing oral Lactobacillus yogurt to prevent recurrent VVC.9 A recent RCT of 278 women on short courses of antibiotics were randomized to oral lactobacilli or placebo and vaginal lactobacilli or placebo.10 The study was stopped early because there was no effect seen. Overall, 23% developed symptomatic vulvovaginitis.

Recommendations from others

The Infectious Diseases Society of America11 recommends treating uncomplicated VVC with short-course of oral or topical antifungals; treating complicated VVC with antimycotic therapy for 7 days, either daily as topical therapy or as two 150-mg doses of fluconazole 72 hours apart; treating non-albicans species of Candida with topical boric acid (600 mg/day for 14 days) or topical flucytosine; and treating recurrent VVC with induction therapy with 2 weeks of a topical or oral azole followed by a maintenance regimen for 6 months (fluconazole once a week or itraconazole twice a week).11

EVIDENCE-BASED ANSWER

Oral and intravaginal antifungals for the treatment of uncomplicated vulvovaginal candidiasis (VVC) have similar effectiveness (strength of recommendation [SOR]: A, systematic review). However, no randomized controlled trials (RCTs) have addressed treatment options for patients taking antibiotics. Oral antifungals are contraindicated in pregnancy. While shorter courses of intravaginal therapy can be used by nonpregnant women, 7-day treatment may be necessary during pregnancy (SOR: A, systematic review). Products containing Lactobacillus species do not prevent postantibiotic vulvovaginitis (SOR: A, systematic review and RCT).

Clinical commentary

Most women would rather prevent than treat
Laura Kittinger-Aisenberg, MD
Chesterfield Family Medicine Residency Program, Virginia Commonwealth University

Many women complain about getting yeast infections after receiving antibiotics. Usually the patient will inform me of this while I’m writing the prescription for the antibiotic, asking for Diflucan “just in case.” Women prefer the convenience of the oral medicine over the hassle with topical applications. Some state that 1 dose of Diflucan does not cut it, and that they usually need 2. As a result, I find myself writing a prescription for Diflucan to be started along with the antibiotic, and then to be repeated as a second dose in 3 days. I have not heard any complaints from these patients about postantibiotic yeast infections.

Evidence summary

VVC is a common cause of vaginitis; Candida albicans accounts for 85% to 90% of cases. Risk factors include pregnancy, diabetes mellitus, and systemic antibiotics.1 Incidence increases with onset of sexual activity, but there is no direct evidence it is sexually transmitted.1 About 75% of women experience 1 VVC episode during their lifetime, 40% to 45% have 2 or more, and 5% to 8% have recurrent VVC (defined as 4 or more annually).1,2

The candidiasis/antibiotics link

A 2003 systematic review found the evidence supporting the association between antibiotics and VVC limited and contradictory.3 Most were case-control or cohort studies with small sample sizes. No RCTs compare the incidence of culture-confirmed VVC among women receiving antibiotics or placebo.

Nineteen reports of 18 original studies had sufficient data to calculate a relative risk or odds ratio for antibiotic-associated VVC. Thirteen of the 19 reports showed an increase (around twofold; range, 0.43–5) in vaginal Candida prevalence; however, 3 of the 13 reports had no mycological culture data. Six studies did not show significant association between antibiotics and vaginal yeast.3

 

Antibiotics are thought to increase risk of VVC by killing endogenous vaginal flora (particularly Lactobacillus), allowing microorganisms resistant to the antibiotics, like Candida, to flourish.1 Yet there is evidence that numbers of genital Lactobacillus are similar for women with and without symptomatic VVC.4 Further, decreasing Lactobacillus does not increase the risk of VVC.5

Topical and oral antifungals—both do the job

For the treatment of uncomplicated VVC, both topical and oral antifungals are clinically and mycologically effective, with comparable clinical cure rates >80%.6 No difference in persistent symptoms between single and multiple doses, or different durations of multiple dose regimens have been found, but samples may have been too small to detect clinically significant effects. An RCT found less nausea, headache, and abdominal pain with intravaginal imidazoles, but more vulvar irritation and vaginal discharge than oral fluconazole.6

For treatment of recurrent VVC, RCTs have shown the effectiveness of oral fluconazole and itraconazole maintenance therapy taken for 6 months after an initial regimen.7,8 Treating male sexual partners did not significantly improve resolution of the woman’s symptoms or reduce the rate of symptomatic relapse.9

Yogurt may not live up to its rep

Two poor-quality crossover RCTs provided insufficient evidence regarding effectiveness of a diet containing oral Lactobacillus yogurt to prevent recurrent VVC.9 A recent RCT of 278 women on short courses of antibiotics were randomized to oral lactobacilli or placebo and vaginal lactobacilli or placebo.10 The study was stopped early because there was no effect seen. Overall, 23% developed symptomatic vulvovaginitis.

Recommendations from others

The Infectious Diseases Society of America11 recommends treating uncomplicated VVC with short-course of oral or topical antifungals; treating complicated VVC with antimycotic therapy for 7 days, either daily as topical therapy or as two 150-mg doses of fluconazole 72 hours apart; treating non-albicans species of Candida with topical boric acid (600 mg/day for 14 days) or topical flucytosine; and treating recurrent VVC with induction therapy with 2 weeks of a topical or oral azole followed by a maintenance regimen for 6 months (fluconazole once a week or itraconazole twice a week).11

References

1. Sobel JD, Faro S, Force RW, et al. Vulvovaginal candidiasis: epidemiologic, diagnostic, and therapeutic considerations. Am J Obstet Gynecol 1998;178:203-211.

2. Sobel JD. Vaginitis. N Engl J Med 1997;337:1896-1903.

3. Xu J, Sobel JD. Antibiotic-associated vulvovaginal candidiasis. Curr Infect Dis Rep 2003;5:481-487.

4. Sobel JD, Chaim W. Vaginal microbiology of women with acute recurrent vulvovaginal candidiasis. J Clin Microbiol 1996;34:2497-2499.

5. Hawes SE, Hillier SL, Benedetti J, et al. Hydrogen peroxide-producing lactobacilli and acquisition of vaginal infections. J Infect Dis 1996;174:1058-1063.

6. Watson MC, Grimshaw JM, Bond CM, Mollison J, Ludbrook A. Oral versus intra-vaginal imidazole and triazole antifungal treatment of uncomplicated vulvovaginal candidiasis (thrush). Cochrane Database Syst Rev 2001;(1):CD002845.-

7. Sobel JD, Wiesenfeld HC, Martens M, et al. Maintenance fluconazole therapy for recurrent vulvovaginal candidiasis. N Engl J Med 2004;351:876-883.

8. Spinillo A, Colonna L, Piazzi G, Baltaro F, Monaco A, Ferrari A. Managing recurrent vulvovaginal candidiasis. Intermittent prevention with itraconazole. J Reprod Med 1997;42:83-87.

9. Spence D. Candidiasis (vulvovaginal). Clin Evid 2006;15:1-8.

10. Pirotta M, Gunn J, Chondros P, et al. Effect of lactobacillus in preventing postantibiotic vulvovaginal candidiasis: a randomised controlled trial. BMJ 2004;329:548.-

11. Pappas PG, Rex JH, Sobel JD, et al. Guidelines for treatment of candidiasis. Clin Infect Dis 2004;38:161-189.

References

1. Sobel JD, Faro S, Force RW, et al. Vulvovaginal candidiasis: epidemiologic, diagnostic, and therapeutic considerations. Am J Obstet Gynecol 1998;178:203-211.

2. Sobel JD. Vaginitis. N Engl J Med 1997;337:1896-1903.

3. Xu J, Sobel JD. Antibiotic-associated vulvovaginal candidiasis. Curr Infect Dis Rep 2003;5:481-487.

4. Sobel JD, Chaim W. Vaginal microbiology of women with acute recurrent vulvovaginal candidiasis. J Clin Microbiol 1996;34:2497-2499.

5. Hawes SE, Hillier SL, Benedetti J, et al. Hydrogen peroxide-producing lactobacilli and acquisition of vaginal infections. J Infect Dis 1996;174:1058-1063.

6. Watson MC, Grimshaw JM, Bond CM, Mollison J, Ludbrook A. Oral versus intra-vaginal imidazole and triazole antifungal treatment of uncomplicated vulvovaginal candidiasis (thrush). Cochrane Database Syst Rev 2001;(1):CD002845.-

7. Sobel JD, Wiesenfeld HC, Martens M, et al. Maintenance fluconazole therapy for recurrent vulvovaginal candidiasis. N Engl J Med 2004;351:876-883.

8. Spinillo A, Colonna L, Piazzi G, Baltaro F, Monaco A, Ferrari A. Managing recurrent vulvovaginal candidiasis. Intermittent prevention with itraconazole. J Reprod Med 1997;42:83-87.

9. Spence D. Candidiasis (vulvovaginal). Clin Evid 2006;15:1-8.

10. Pirotta M, Gunn J, Chondros P, et al. Effect of lactobacillus in preventing postantibiotic vulvovaginal candidiasis: a randomised controlled trial. BMJ 2004;329:548.-

11. Pappas PG, Rex JH, Sobel JD, et al. Guidelines for treatment of candidiasis. Clin Infect Dis 2004;38:161-189.

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The Journal of Family Practice - 56(8)
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The Journal of Family Practice - 56(8)
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671-672
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How should you treat Candida vaginitis in patients on antibiotics?
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How should you treat Candida vaginitis in patients on antibiotics?
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candida; albicans; yeast; infection; vagina; vaginitis; probiotics; yogurt; vulvovaginal; candidiasis; antifungal; lactobacillus; Jinping Xu MD; Kendra Schwartz MD; Kristin Hitchcock MSI; Laura Kittinger-Aisenberg MD
Legacy Keywords
candida; albicans; yeast; infection; vagina; vaginitis; probiotics; yogurt; vulvovaginal; candidiasis; antifungal; lactobacillus; Jinping Xu MD; Kendra Schwartz MD; Kristin Hitchcock MSI; Laura Kittinger-Aisenberg MD
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