Management of Symptomatic Vaginitis Caused by Candida glabrata and Candida krusei

First‑Line Antifungal Therapy

Intravaginal boric acid 600 mg (gelatin capsule) taken daily for 14 days achieves clinical and mycological cure in the majority of patients with non‑albicans vaginitis. Infectious Diseases Society of America (IDSA) recommends this regimen for infections due to C. glabrata and C. krusei【1】【2】【5】.

Topical flucytosine 17 % cream, alone or combined with 3 % amphotericin B cream, can be used for refractory cases【3】.
Intravaginal nystatin suppositories (100 000 U) may provide benefit, although supporting evidence is limited【3】.
Intravenous amphotericin B deoxycholate 0.3–0.6 mg/kg daily for 1–7 days is reserved for severe or systemic disease【6】.
Amphotericin B bladder irrigation (50 mg/L sterile water daily for 5 days) may be considered when concurrent cystitis is present【6】.

A positive PCR for Candida does not automatically require treatment; 10–20 % of women harbor Candida species asymptomatically【7】.
Vaginal pH should be ≤ 4.5; an elevated pH suggests bacterial vaginosis or trichomoniasis rather than candidiasis【7】.
Mixed infections (e.g., co‑presence of sexually transmitted pathogens) are possible and warrant concurrent testing【7】.

Do not prescribe fluconazole for C. krusei—the species is intrinsically resistant, leading to treatment failure【1】【2】.
Short‑course azole regimens are unreliable for C. glabrata (MIC 16–32 µg/mL) and should be avoided【1】【2】.
Do not treat based solely on PCR results; therapy should be initiated only when typical symptoms (pruritus, discharge, irritation) are present【7】.
Recurrent vaginitis (≥ 3 episodes per year) warrants culture and antifungal susceptibility testing to guide therapy【7】.

Symptom improvement is typically observed within 48–72 hours after starting boric‑acid therapy【1】【2】.
Mycological cure should be confirmed 4–7 days after completing the 14‑day course【1】【2】.
Re‑evaluation is needed only if symptoms persist after therapy or recur within 2 months【4】.
Recurrence occurs in 40–50 % of patients after successful treatment, indicating a need for long‑term suppressive strategies【3】【4】.

Pregnancy: Oral azoles should be avoided due to teratogenic risk; use only topical non‑azole agents【3】【4】.
Immunocompromised (e.g., HIV‑positive) women: Apply the same regimens, but anticipate more frequent or severe episodes【7】.
Concurrent urinary‑tract involvement: Consider systemic amphotericin B or intravesical irrigation as adjunctive therapy【6】.

Routine treatment of sexual partners is not recommended, as vulvovaginal candidiasis is not a sexually transmitted infection【4】.