Vaginal Candidiasis - Management of Infection Guidance for Primary Care

Publication: 30/09/2010  
Next review: 01/02/2019  
Clinical Guideline
CURRENT 
ID: 2244 
Approved By:  
Copyright© Leeds Teaching Hospitals NHS Trust 2016  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Vaginal Candidiasis

Illness

Comments

Preferred options

Vaginal Candidiasis
BASHH
PHE
CKS

All topical and oral azoles give 75% cure1A+
Pregnancy:
Avoid oral azoles 2B-
Use intra-vaginal for 7 days 3A+  4 B-

For relapsing infection please send High Vaginal Swab for Fungal Culture and Sensitivity.

Clotrimazole electronic Medicines Compendium information on Clotrimazole 1A+
500mg pessary OR 10% cream single dose
OR
Fluconazole electronic Medicines Compendium information on Fluconazole 1A+
150mg orally single dose
OR
Clotrimazole electronic Medicines Compendium information on Clotrimazole 3A+
100mg pessary nocté, 6 nights5C
OR
Miconazole electronic Medicines Compendium information on Miconazole
2% cream,  5 g intra-vaginally BD, 7 days3A+

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Principles of Treatment

  1. This guidance is based on the best available evidence but its application must be modified by professional judgement.
  2. A dose and duration of treatment is suggested. In severe or recurrent cases consider a larger dose or longer course
  3. Choices are given as Preferred option or Alternative for patients intolerant of the preferred option and 2nd Line for when an alternative is required because of treatment failure
  4. Only send microbiology specimens if there is a clinical suspicion of infection. Inappropriate specimens (e.g. routine ulcer swab or routine catheter specimen of urine) lead to inappropriate antibiotic prescribing.
  5. Limit prescribing over the telephone to exceptional cases.
  6. Where a ‘best guess’ therapy has failed or special circumstances exist, microbiological advice can be obtained from LTHT Microbiology (Mon-Fri 9am-5pm and Sat and Sun 9am-1pm: 0113 39 23962/28580; Otherwise via LTHT switchboard - ask for the On call Microbiology Registrar)

Note
Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information.
Letters indicate strength of evidence:
A+ = systematic review: D = informal opinion

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Provenance

Record: 2244
Objective:
  • to provide a simple, empirical approach to the treatment of common infections
  • to promote the safe, effective and economic use of antibiotics
  • to minimise the emergence of bacterial resistance and reduce the incidence of Healthcare Associated Infections in the community
Clinical condition:

Vaginal Candidiasis
Target patient group:
Target professional group(s): Primary Care Doctors
Pharmacists
Adapted from:

This guidance was initially developed in 1999 by practitioners in South Devon, as part of the S&W Devon Joint Formulary Initiative, and Cheltenham & Tewkesbury Prescribing Group and modified by the PHLS South West Antibiotic Guidelines Project Team, PHLS Primary Care Co-ordinators and members of the Clinical Prescribing Sub-group of the Standing Medical Advisory Committee on Antibiotic Resistance. It was further modified following comments from Internet users. The guidance has been updated annually as significant research papers, systematic reviews and guidance have been published. The Health Protection Agency works closely with the authors of the Clinical Knowledge Summaries.

Evidence base

Grading of guidance recommendations

The strength of each recommendation is qualified by a letter in parenthesis.


Study design

Recommendation
grade

Good recent systematic review of studies

A+

One or more rigorous studies, not combined

A-

One or more prospective studies

B+

One or more retrospective studies

B-

Formal combination of expert opinion

C

Informal opinion, other information

D

A+ = systematic review: D = informal opinion

STI screening

  1. National Chlamydia Screening Programme here
  2. BASHH and MedFASH. Standards for the management of sexually transmitted infections (STIs). British Association of Sexual Health and HIV and the Medical Foundation for AIDs and Sexual Health. 2010. www.medfash.org.uk

Vaginal Candidiasis

  1. Nurbhai M, Grimshaw J, Watson M, Bond CM, Mollison JA, Ludbrook A. Oral versus intravaginal imidazole and triazole anti-fungal treatment of uncomplicated vulvovaginal candidiasis (thrush). Cochrane Database of Systematic Reviews 2007, Issue 4. http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD002845/frame.html Accessed 23.09.14. RATIONALE: No statistically significant differences were observed in clinical cure rates of antifungals administered by the oral or the intravaginal route. At short-term follow-up, 74% cure was achieved with oral treatment and 73% cure with intra-vaginal treatment (OR 0.94, 95% CI 0.75 to 1.17).
  2. UKTIS. Use of fluconazole in pregnancy. The UK Teratology Information Service. 2008. (Tel: 0844 892 0909, RATIONALE: Fluconazole is a triazole antifungal commonly used in the treatment of candidiasis. Data on the outcomes of over 1,700 pregnancies exposed to low dose fluconazole (150mg as a single dose) show no increased incidence of spontaneous abortions or malformations and no pattern of defects. However, there may be an increased risk of malformations associated with high dose chronic therapy (>400mg/day). First-line treatment of candidal infection in pregnancy is with a topical imidazole such as clotrimazole. Fluconazole (150mg as a single dose) may be a suitable second-line treatment if clotrimazole is ineffective.
  3. Young GL, Jewell D. Topical treatment for vaginal candidiasis (thrush) in pregnancy. Cochrane Database of Systematic Reviews 2001, Issue 4. http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD000225/frame.html Accessed 23.09.14. RATIONALE: This Cochrane review found that topical imidazole appears more effective than nystatin at treating vaginal candidiasis in pregnancy. In addition, treatment for only four days was less effective than treatment for seven days (OR 11.7, 95% CI 4.21 to 29.15).
  4. Schaefer C, Peters P, Miller RK. Drugs during pregnancy and lactation: treatment options and risk assessment. Academic Press 2007. RATIONALE: Clotrimazole and miconazole are the topical antifungals of choice during pregnancy. There is no evidence of an increased risk of spontaneous abortions or malformations with use of clotrimazole or miconazole during pregnancy.
  5. Public Health England and the British Infection Association recommend 6 nights treatment with clotrimazole 100mg pessaries during pregnancy because this is the quantity in one original pack of clotrimazole 100mg pessaries.

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Document history

LHP version 1.0

Related information

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