Single oral dose fluconazole compared with conventional clotrimazole topical therapy of Candida vaginitis. Fluconazole Vaginitis Study Group

Pattern of Candida species isolated from patients with diabetes mellitus and vulvovaginal candidiasis and their response to single dose oral fluconazole therapy

OBJECTIVE

Patients with diabetes mellitus are at increased risk of vulvovaginal candidiasis (VVC). Besides Candida albicans, they often have infection due to non-C. albicans Candida species such as C. glabrata. Oral single dose fluconazole (150 mg) is commonly used to treat VVC in non-diabetic individuals with response rate varying from 70 to 90%. However, there is paucity of related information in diabetic women with VVC. Present study has been conducted to systematically assess the effect of fluconazole therapy among diabetic patients with clinically symptomatic VVC.

METHODS

Study subjects included 85 consecutive patients with diabetes mellitus (type 2=70 and type 1=15) and 62 non-diabetic women who had clinical signs and symptoms of VVC and in whom evidence of candidiasis was documented by presence of yeast on direct microscopy followed by culture. Single dose fluconazole (150 mg) was given orally to all the subjects in a supervised manner. Subjects were reassessed on 14th day after fluconazole therapy and a repeat high vaginal swab was taken for direct microscopy and fungal culture. Total glycosylated haemoglobin (HbA1) was measured to assess glycaemic control.

RESULTS

There were no significant differences in the frequency of pruritus (55.9 vs. 56.7%), vaginal discharge (63.8 vs. 69.0%), dyspareunia (25.0 vs. 20.0%), and percentage yeast positivity (67.5 vs. 54.7%) between diabetic and control groups before the start of fluconazole therapy. Following fluconazole therapy, vaginal discharge on examination and yeast positivity on direct microscopy continued to remain positive in higher percentage of subjects in the diabetic group as compared to non-diabetic subjects (52.5 vs. 36.4%; P =0.22 and 50.7 and 29.0%, respectively, P =0.07, respectively). Overall 67.1% of patients with diabetes and 47.3% of controls continued to show persistence of Candida growth on high vaginal swab culture following fluconazole treatment (P=0.042). Candida glabtara was the most common species isolated in patients with diabetes mellitus and its frequency was significantly higher in them when compared to control group (54.1 vs. 22.6%, P<0.001). C. albicans was the most common species isolated in controls. Species-specific response to fluconazole showed that 81.3% of patients in the diabetic group and 78.6% of the non-diabetic controls continued to show fungal growth when C. glabrata was the organism grown (P=0.99). However, in case of C. albicans, 45.4% of the patients in the diabetic group and only 21.5% of the controls had persistent Candida growth following fluconazole therapy (P=0.22).

CONCLUSION

Overall only one third of patients with diabetes mellitus and VVC respond to single dose 150 mg of fluconozole therapy. Limited response in the clinical symptoms and culture negativity following single dose fluconazole therapy in diabetic subjects with VVC is explained by the high prevalence of C. glabrata in them. The present study involved only 85 patients and majority of them had type-2 diabetes mellitus. There is need to perform similar study in large number of diabetics subjects including patients with type-1 diabetes mellitus and assess various alternative treatment protocol which are also effective in C. glabrata infection.

Antifungal activities and action mechanisms of compounds from Tribulus terrestris L

Antifungal activity of natural products is being studied widely. Saponins are known to be antifungal and antibacterial. We used bioassay-guided fractionation to have isolated eight steroid saponins from Tribulus terrestris L., which were identified as hecogenin-3-O-beta-D-glucopyranosyl (1-->4)-beta-D-galactopyranoside (TTS-8), tigogenin-3-O-beta-D-glucopyranosyl (1-->4)-beta-D-galactopyranoside (TTS-9), hecogenin-3-O-beta-D-glucopyranosyl (1-->2)-beta-D-glucopyranosyl (1-->4)-beta-D-galactopyranoside (TTS-10), hecogenin-3-O-beta-D-xylopyranosyl (1-->3)-beta-D-glucopyranosyl (1-->4)-beta-D-galactopyranoside (TTS-11), tigogenin-3-O-beta-D-xylopyranosyl (1-->2)-[beta-D-xylopyranosyl (1-->3)]-beta-D-glucopyranosyl (1-->4)-[alpha-L-rhamnopyranosyl (1-->2)]-beta-D-galactopyranoside (TTS-12), 3-O-[beta-D-xylopyranosyl (1-->2)-[beta-D-xylopyranosyl (1-->3)]-beta-D-glucopyranosyl (1-->4)-[alpha-L-rhamnopyranosyl (1-->2)]-beta-D-galactopyranosyl]-26-O-beta-D-glucopyranosyl-22-methoxy-(3beta,5alpha,25R)-furostan-3,26-diol (TTS-13), hecogenin-3-O-beta-D-glucopyranosyl (1-->2)-[beta-D-xylopyranosyl (1-->3)]-beta-D-glucopyranosyl (1-->4)-beta-D-galactopyranoside (TTS-14), tigogenin-3-O-beta-D-glucopyranosyl (1-->2)-[beta-D-xylopyranosyl (1-->3)]-beta-D-glucopyranosyl (1-->4)-beta-D-galactopyranoside (TTS-15). The in vitro antifungal activities of the eight saponins against five yeasts, Candida albicans, Candida glabrata, Candida parapsilosis, Candida tropicalis and Cryptococcus neoformans were studied using microbroth dilution assay. In vivo activity of TTS-12 in a Candida albicans vaginal infection model was studied in particular. The results showed that TTS-12 and TTS-15 were very effective against several pathogenic candidal species and Cryptococcus neoformans in vitro. It is noteworthy that TTS-12 and TTS-15 were very active against Candida albicans (MIC(80) = 10 and 2.3 microg/mL) and Cryptococcus neoformans (MIC(80) = 1.7 and 6.7 microg/mL). Phase contrast microscopy showed that TTS-12 inhibited hyphal formation, an important virulence factor of Candida albicans, and transmission electron microscopy showed that TTS-12 destroyed the cell membrane of Candida albicans. In conclusion, TTS-12 has significant in vitro and in vivo antifungal activity, weakening the virulence of Candida albicans and killing fungi through destroying the cell membrane.

"Shotgun" versus sequential testing. Cost-effectiveness of diagnostic strategies for vaginitis

BACKGROUND

Although vaginitis is a common outpatient problem, only 60% of patients can be diagnosed at the initial office visit of a primary care provider using the office procedures of pH testing, whiff tests, normal saline, and potassium hydroxide preps.

OBJECTIVE

To determine the most cost-effective diagnostic and treatment approach for the medical management of vaginitis.

DESIGN

Decision and cost-effectiveness analyses.

PARTICIPANTS

Healthy women with symptoms of vaginitis undiagnosed after an initial pelvic exam, wet mount preparations, pH, and the four criteria to diagnose bacterial vaginosis.

SETTING

General office practice.

METHODS

We evaluated 28 diagnostic strategies comprised of combinations of pH testing, vaginal cultures for yeast and Trichomonas vaginalis, Gram's stain for bacterial vaginosis, and DNA probes for Neisseria gonorrhoeae and Chlamydia. Data sources for the study were confined to English language literature.

MEASUREMENT

The outcome measures were symptom-days and costs.

RESULTS

The least expensive strategy was to perform yeast culture, gonorrhoeae and Chlamydia probes at the initial visit, and Gram's stain and Trichomonas culture only when the vaginal pH exceeded 4.9 (330 dollars, 7.30 symptom days). Other strategies cost 8 dollars to 76 dollars more and increased duration of symptoms by up to 1.3 days. In probabilistic sensitivity analysis, this strategy was always the most effective strategy and was also least expensive 58% of the time.

CONCLUSIONS

For patients with vaginitis symptoms undiagnosed by pelvic examination, wet mount preparations and related office tests, a comprehensive, pH-guided testing strategy at the initial office visit is less expensive and more effective than ordering tests sequentially.

In Vitro and in Vivo Antifungal Activities of the Eight Steroid Saponins from Tribulus terrestris L. with Potent Activity against Fluconazole-Resistant Fungal

Antifungal activity of natural products is being studied widely. Saponins are known to be antifungal and antibacterial. We have isolated eight steroid saponins from Tribulus terrestris L., namely TTS-8, TTS-9, TTS-10, TTS-11, TTS-12, TTS-13, TTS-14 and TTS-15. TTS-12 and TTS-15 were identified as tigogenin-3-O-beta-D-xylopyranosyl(1-->2)-[beta-D-xylopyranosyl(1-->3)]-beta-D-glucopyranosyl(1-->4)-[alpha-L-rhamnopyranosyl(1-->2)]-beta-D-galactopyranoside and tigogenin-3-O-beta-D-glucopyranosyl(1-->2)-[beta-D-xylopyranosyl(1-->3)]-beta-D-glucopyranosyl(1-->4)-beta-D-galactopyranoside, respectively. The in vitro antifungal activities of the eight saponins against six fluconazole-resistant yeasts, Candida albicans, Candida glabrata, Candida parapsilosis, Candida tropicalis, Candida krusei, and Cryptococcus neoformans were studied using microbroth dilution assay. The results showed that TTS-12 and TTS-15 were very effective against several pathogenic candidal species and C. neoformans in vitro. It is noteworthy that TTS-12 and TTS-15 were very active against fluconazole-resistant C. albicans (MIC(80)=4.4, 9.4 microg/ml), C. neoformans (MIC(80)=10.7, 18.7 microg/ml) and inherently resistant C. krusei (MIC(80)=8.8, 18.4 microg/ml). So in vivo activity of TTS-12 in a vaginal infection model with fluconazole-resistant C. albicans was studied in particular. Our studies revealed TTS-12 also showed in vivo activities against fluconazole-resistant yeasts. In conclusion, steroid saponins TTS-12 and TTS-15 from Tribulus terrestris L. have significant in vitro antifungal activity against fluconazole-resistant fungi, especially TTS-12 also showed in vivo activity against fluconazole-resistant C. albicans.

Vulvovaginal candidiasis

VVC represents a spectrum of disease. Although there is a clear need for better use of diagnostic modalities and development of better treatment alternatives, most patients with VVC, even the complicated cases, at least have the perspective of achieving adequate control of their symptoms. Future advances, particularly in the area of home diagnostics, may help to optimize use of currently available medicines.

Treatment of vaginitis caused by Candida glabrata: use of topical boric acid and flucytosine

OBJECTIVE

The purpose of this study was to review the treatment outcome and safety of topical therapy with boric acid and flucytosine in women with Candida glabrata vaginitis.

STUDY DESIGN

This was a retrospective review of case records of 141 women with positive vaginal cultures of C glabrata at two sites, Wayne State University School of Medicine and Ben Gurion University.

RESULTS

The boric acid regimen, 600 mg daily for 2 to 3 weeks, achieved clinical and mycologic success in 47 of 73 symptomatic women (64%) in Detroit and 27 of 38 symptomatic women (71%) in Beer Sheba. No advantage was observed in extending therapy for 14 to 21 days. Topical flucytosine cream administered nightly for 14 days was associated with a successful outcome in 27 of 30 of women (90%) whose condition had failed to respond to boric acid and azole therapy. Local side effects were uncommon with both regimens.

CONCLUSIONS

Topical boric acid and flucytosine are useful additions to therapy for women with azole-refractory C glabrata vaginitis.

Fluconazole susceptibility of vaginal isolates obtained from women with complicated Candida vaginitis: clinical implications

Despite considerable evidence of azole resistance in oral candidiasis due to Candida species, little is known about the azole susceptibilities of the genital tract isolates responsible for vaginitis. The fluconazole susceptibilities of vaginal isolates obtained during a multicenter study of 556 women with complicated Candida vaginitis were determined by evaluating two fluconazole treatment regimens. Of 393 baseline isolates of Candida albicans, 377 (96%) were highly susceptible to fluconazole (MICs, <8 microg/ml) and 14 (3.6%) were resistant (MICs, >or=64 microg/ml). Following fluconazole therapy, one case of in vitro resistance developed during 6 weeks of monitoring. In accordance with the NCCLS definition, in vitro fluconazole resistance correlated poorly with the clinical response, although a trend of a higher mycological failure rate was found (41 versus 19.6% on day 14). By using an alternative breakpoint of 1 micro g/ml, based upon the concentrations of fluconazole achievable in vaginal tissue, no significant differences in the clinical and mycological responses were observed when isolates (n = 250) for which MICs were <or=1 microg/ml were compared with isolates (n = 30) for which MICs were >1 microg/ml, although a trend toward an improved clinical outcome was noted on day 14 (odds ratio, >2.7; 95% confidence interval, 0.91, 8.30). Although clinical failure was uncommon, symptomatic recurrence or mycological relapse almost invariably occurred with highly sensitive strains (MICs, <1.0 microg/ml). In vitro fluconazole resistance developed in 2 of 18 initially susceptible C. glabrata isolates following fluconazole exposure. Susceptibility testing for women with complicated Candida vaginitis appears to be unjustified.

Mucosal candidiasis

This article examines the ecology and epidemiology of gastrointestinal candidiasis, esophageal candidiasis, chronic mucocutaneous candidiasis, urinary tract candidiasis, and vulvovaginal candidiasis. Such issues as pathogenesis and host defenses, clinical manifestations, diagnosis, and treatment are discussed.

High rate of vaginal infections caused by non-C. albicans Candida species among asymptomatic women

A prospective observational study of patients attending a gynecological clinic and those referred to a clinic for genitourinary infections was undertaken with the purpose of evaluating the relative prevalence of non-C. albicans Candida species among Candida isolates from the vagina in different clinical settings in an area with high occurrence of vulvovaginal candidiasis. The rate of non-C. albicans Candida species was 44.5% among asymptomatic women, 19.4% among those with sporadic vaginitis and 21% among patients with chronic vaginal symptoms (p < 0.001 for asymptomatic vs. pooled symptomatic women). No increase in the rate of non-C. albicans Candida was observed during a period of 4 years (1995-1998) despite a 1.57-fold increase in the sales of azole antifungal agents. Unlike some previous reports we could not document an association of non-C. albicans Candida species with chronic vaginal symptoms or increased use of azole antifungal agents. The significantly higher rate of these yeasts in asymptomatic women is in accord with the known tendency of non-C. albicans Candida species to cause mild symptoms.

Treatment of vaginal Candida infections

Candida vaginitis is most commonly caused by Candida albicans (> 85%) with little evidence of an increase in vaginitis due to non-C. albicans species. Epidemiological studies are no longer possible in the US in the era of self-diagnosis and -treatment by women empowered by the availability of over-the-counter antimycotics. A new classification of vulvovaginal candidiasis into uncomplicated and complicated vaginitis has simplified choice and duration of antifungal therapy. Vaginitis due to C. albicans responds well to available therapy. In contrast, vaginitis due to Candida glabrata is associated with a high treatment failure rate. Candida vaginitis infection rates in HIV-positive women remain undetermined and reports of refractory fungal vaginitis have not been substantiated. In spite of the wide array of antifungal agents currently available, considerable limitations in available therapy exist in the effective management of complicated vaginitis.

Oral versus intra-vaginal imidazole and triazole anti-fungal agents for the treatment of uncomplicated vulvovaginal candidiasis (thrush): a systematic review

OBJECTIVES

To compare the relative effectiveness, cost effectiveness and safety of oral versus intra-vaginal anti-fungal treatments for uncomplicated vulvovaginal candidiasis (thrush) and establish patient preference for the route of anti-fungal administration.

DESIGN

A systematic review of studies comparing oral and intra-vaginal anti-fungal treatments for uncomplicated vulvovaginal candidiasis. Standard Cochrane Collaboration methods were used.

DATA SOURCES

The following sources were searched: the Cochrane Controlled Trials Register; the Cochrane Sexually Transmitted Disease review group Specialised Register of Controlled Trials; EMBASE (January 1980 to January 2000); and MEDLINE (January 1985 to May 2000). The reference list of each trial was checked for additional references. The manufacturers of anti-fungal treatments in the UK were asked for information on trials fulfilling the inclusion criteria.

METHODS

There was duplicate, independent examination and selection of the electronic search results followed by duplicate data abstraction. Disagreements regarding inclusion status and data abstraction were resolved by discussion between reviewers and the editor of the Cochrane Sexually Transmitted Disease group. Randomised controlled trials conducted worldwide and published in any language were included. The primary outcome measure was clinical cure. Mycological cure, patient preference and safety were secondary outcome measures.

RESULTS

Seventeen trials were included in the review, reporting 19 oral versus intra-vaginal anti-fungal treatment comparisons. No statistically significant differences were shown between oral and intra-vaginal anti-fungal treatment for clinical or mycological cure. All 10 trials that reported a preference favoured oral treatment (compared with intra-vaginal or no preference). No trials presented cost data.

CONCLUSIONS

There is no difference between the relativeeffectiveness of oral and intra-vaginal anti-fungal treatment for thrush.

Treatment of complicated Candida vaginitis: comparison of single and sequential doses of fluconazole

OBJECTIVE

An attempt was made to validate recent recommendations that women with complicated Candida vaginitis (severe or recurrent, non-albicans Candida spp or abnormal host) require longer-duration antifungal therapy to achieve clinical cure and mycologic eradication.

STUDY DESIGN

A prospective, multicenter, randomized, double-blind study was performed comparing a single dose of 150 mg of fluconazole with 2 sequential 150-mg doses of fluconazole given 3 days apart.

RESULTS

Five hundred fifty-six women with severe or recurrent Candida vaginitis were enrolled, and 398 had at least one postbaseline evaluation (intent to treat) and of these 309 were fully evaluable (efficacy-valid). At baseline, 92% of vaginal isolates were Candida albicans. The 2-dose fluconazole regimen achieved significantly higher clinical cure rates in women with severe vaginitis when evaluated on day 14 (P =.015) and higher clinical and mycologic responses persisted at day 35. Women with recurrent but not severe vaginitis did not benefit clinically short term by the additional fluconazole dose. Multivariate logistic regression analysis showed that being infected with non-albicans Candida predicted significantly reduced clinical and mycologic response regardless of duration of therapy. Fluconazole therapy was well tolerated and free of serious adverse effects.

CONCLUSION

Treatment of Candida vaginitis requires individualization, and women with severe Candida vaginitis achieve superior clinical and mycologic eradication with a 2-dose fluconazole regimen.

Vaginitis: meeting the clinical challenge

Vaginitis is a common gynecologic disorder that is responsible for 10 million office visits to physicians each year. Infectious vaginitis is the most common cause of a vaginal discharge, but other important diagnostic considerations include infectious cervicitis, a physiologic discharge, atrophic vaginitis, and allergic or irritant vaginitis. Although the history and gynecologic examination may suggest the diagnosis, laboratory confirmation should be routinely sought by performance of the vaginal pool wet mount examination, the amine whiff test, determination of the vaginal pH, and the Q-tip test. Once a precise diagnosis is made, effective therapy can then be prescribed. For patients with Candida vaginitis, therapeutic options include either the vaginal administration of a number of available imidazole or triazole antifungal agents or the prescription of the oral triazole agent fluconazole. Oral metronidazole remains the only effective treatment for trichomoniasis in the United States. Bacterial vaginosis, which has been linked to a number of obstetric and gynecologic complications, is effectively treated with oral metronidazole, although vaginal metronidazole gel and oral and vaginal clindamycin formulations are available as well.

Oral versus intra-vaginal imidazole and triazole anti-fungal treatment of uncomplicated vulvovaginal candidiasis (thrush)

BACKGROUND

Anti-fungals are available for oral and intra-vaginal treatment of vulvovaginal candidiasis (thrush).

OBJECTIVES

The primary objective of this review was to assess the relative effectiveness of oral versus intra-vaginal anti-fungals for the treatment of uncomplicated vulvovaginal candidiasis. The secondary objectives of the review were to assess the cost-effectiveness, safety and patient preference of oral versus intra-vaginal anti-fungals.

SEARCH STRATEGY

The following sources were searched: The Cochrane Library (Issue 4, 1999), MEDLINE (January 1985 to May 2000), EMBASE (January 1980 to January 2000) and the Cochrane Collaboration Sexually Transmitted Disease Group Specialised Register of Controlled Trials. The reference lists of retrieved articles were reviewed manually. The manufacturers of anti-fungals available in the UK were contacted.

SELECTION CRITERIA

~Bullet~Randomised controlled trials published in any language. ~Bullet~Trials had to compare at least one oral anti-fungal with one intra-vaginal anti-fungal. ~Bullet~Women (aged 16 years or over) with uncomplicated vulvovaginal candidiasis. ~Bullet~The diagnosis of vulvovaginal candidiasis to be made mycologically (i.e. a positive culture and / or microscopy for yeast). ~Bullet~Trials were excluded if they solely involved subjects who were HIV positive, immunocompromised, pregnant, breastfeeding or diabetic. ~Bullet~The primary outcome measure was clinical cure.

DATA COLLECTION AND ANALYSIS

Duplicate scrutiny was performed of the titles and abstracts of the electronic search results. Full article formats of all selected abstracts were retrieved and independently assessed by two reviewers. Independent duplicate abstraction was performed by four reviewers. Disagreements regarding trial inclusion or data abstraction were resolved by discussion between the reviewers. Odds ratios were pooled using the random effects model. Chi-squared tests with a p-value of less than 0.1 indicated heterogeneity in the results.

MAIN RESULTS

Seventeen trials are included in the review, reporting 19 oral versus intra-vaginal anti-fungal comparisons. No statistically significant differences were shown between oral and intra-vaginal anti-fungal treatment for clinical cure at short term (OR 1.00 (95% CI, 0.72 to 1.40)) and long term (OR 1.03 (95% CI, 0.72 to 1.49)) follow-up. No statistically significant differences for mycological cure were observed between oral and intra-vaginal treatment at short term (OR 1.20(95% CI, 0.87 to 1.65)) or long term follow-up (OR 1.30 (95% CI, 0.99 to 1.71)). Two trials each reported one withdrawal from treatment due to an adverse reaction. Treatment preference data were poorly reported.

REVIEWER'S CONCLUSIONS

No differences exist in terms of the relative effectiveness (measured as clinical and mycological cure) of anti-fungals administered by the oral and intra-vaginal routes for the treatment of uncomplicated vaginal candidiasis. No definitive conclusion can be made regarding the relative safety of oral and intra-vaginal anti-fungals for uncomplicated vaginal candidiasis. The oral route of administration is the preferred route for anti-fungals for the treatment of vulvovaginal candidiasis. The decision to prescribe or recommend the purchase of an anti-fungal for oral or intra-vaginal administration should take into consideration: safety, cost and treatment preference. Unless there is a previous history of adverse reaction to one route of administration or contraindications: if women are purchasing their own treatment, they should be given full information about the characteristics and costs of treatment to make their own decision. If health services are paying the treatment cost, decision-makers should consider whether the higher cost of oral anti-fungal administration is worth the gain in convenience, if this is the patient's preference.

Double-blind randomized dose-finding study in acute vulvovaginal candidosis. Comparison of flutrimazole site-release cream (1, 2 and 4%) with placebo site-release vaginal cream

A double-blind randomized comparative phase II study of flutrimazole site-release vaginal cream (1, 2 and 4%) with placebo site-release vaginal cream was undertaken in patients with acute vulvovaginal candidosis. Vaginitis was demonstrated by both positive findings on microscopic examination of vaginal smears and positive culture as well as by the presence of clinical signs and symptoms. The vaginal monodose treatment was inserted in the evening at bedtime using a vaginal applicator and, in addition, all four groups of patients received additional topical external cream for application to the vulva twice-daily for 7 days; the placebo group received a placebo cream and the active therapy groups all received a 2% flutrimazole cream. A total of 133 patients who were seen over a 10-month period were screened and randomized: five patients did not take the allocated medication, and four patients whose menstrual period began shortly after study entry were excluded from the study, leaving 124 patients who were randomly allocated to receive a monodose vaginal 1% cream (regimen A, 28 patients), a monodose vaginal 2% cream (regimen B, 32 patients), a monodose vaginal 4% cream (regimen C, 31 patients) or a monodose vaginal placebo cream (regimen D, 33 patients). At the assessment 9 days after the end of therapy the proportion of patients who were cured was 82% in group A, 87.4% in group B, 83.8% in group C and 63.5% in group D. Three patients (10.7%) in group A, four (12.5%) in group B, one (3.2%) in group C and 12 (36.36%) in group D did not respond to the treatment. One patient (3.5%) in group A, and two patients (6.4%) in group C terminated the treatment prematurely due to intolerance. There was a significant association between Candida glabrata and treatment failure (P < 0.04) and C. glabrata and carrier state (P = 0.01) in vagina (chi 2 test, P = 0.01) and vulvovagina (chi 2 test, P = 0.00001). At the assessment 4 weeks after the end of therapy the proportion of cured patients was 60.6% in group A, 78% in group B, 80.6% in group C and 48.4% in group D. Group D (placebo) versus group B (2%) and group C (4%) showed a significant difference (P = 0.01 and P = 0.007, respectively). Although there were no significant differences in clinical and mycological activity between the three active groups, group B (flutrimazole 2% site-release vaginal cream) was chosen for clinical use due to its tolerance profile. Seven patients (25%) in group A, three (9.3%) in group B, two (6.4%) in group C and five (15.1%) in group D relapsed 4 weeks after the end of therapy; the relapse rate was not significantly associated with positive culture results 9 days after treatment. There was a significant association between C. glabrata and the carrier state (P < 0.01). The overall ineffective treatment (includes failures at control 1, relapses at control 2 and premature terminations) was 39% in group A, 21.7% in group B, 16% in group C and 51.3% in group D. There was a significant difference in the overall ineffective treatment when C and D groups were compared with placebo (P = 0.01 and P = 0.003, respectively).

Vaginitis in the adolescent patient

For any clinician involved in the health care of women, vaginitis remains an unavoidable problem. Vaginitis accounts for an estimated 10 million office visits each year, and it remains the most common reason for patient visits to obstetrician-gynecologists. Despite extensive self-diagnosis and self-treatment for vaginal symptoms in all age groups, important questions persist about the accuracy of such an approach. This article addresses these questions and approaches.

Vulvovaginitis in healthy women

Vulvovaginal symptoms are extremely common and result in millions of visits to practitioners' offices, STD clinics and emergency rooms. Vaginal infections or infectious vaginitis is responsible for only a minority of symptoms and is readily diagnosed. Epidemiology, diagnosis and therapy of vaginitis is reviewed.

Limitations of antifungal agents in the treatment of Candida vaginitis: future challenges

The availability of several potent antifungal agents, systemic or topical, over the counter or prescription would suggest that therapeutic needs for Candida vaginitis are minimal or absent. Unfortunately, unmet needs still exist. Moreover, the pharmaceutical industry has abandoned Candida vaginitis and no new agents or studies are imminent. Perhaps the most important advance in the last decade has been the recognition that therapy must be individualized and that not all forms of Candida vaginitis are equal. A critical factor is duration of therapy and the need for maintenance therapy in recurrent candidiasis. In addition, serious deficiencies exist in the therapy of C. glabrata vaginitis, an emerging problem. Azole therapy for C. glabrata frequently fails, depleting the therapeutic armamentarium of successful options. Additional therapeutic challenges remain for women who can be easily controlled but not cured with intensive azole therapy in spite of absence of in vitro antifungal resistance. Any advance in non-drug related therapy will require a better understanding of the immunopathogenesis of VVC and effective naturally occurring host protective mechanisms. Copyright 1999 Harcourt Publishers Ltd.

Current evaluation and management of vulvovaginitis

There are many problems in the diagnosis and treatment of vaginitis. Often, the patient is not examined (telephone treatment) or examined improperly with lack of attention to the wet prep. In patients with recurrent vaginitis, it should not be assumed that the current infection is the same as a previous infection without a thorough examination. At times, there is an overuse of topical steroids for all vulvar symptoms or use of antifungals for all vulvar symptoms. The various abnormalities in vulvovaginitis have unique physical findings, laboratory tests, and treatments. It should be remembered that unusual conditions of the vagina and vulva may resemble vulvovaginitis. Many vulvar conditions must be considered when a patient reports discharge and itching. It is important to remember that if the treatment is not working, reconsider the diagnosis.

Current and emerging azole antifungal agents

Major developments in research into the azole class of antifungal agents during the 1990s have provided expanded options for the treatment of many opportunistic and endemic fungal infections. Fluconazole and itraconazole have proved to be safer than both amphotericin B and ketoconazole. Despite these advances, serious fungal infections remain difficult to treat, and resistance to the available drugs is emerging. This review describes present and future uses of the currently available azole antifungal agents in the treatment of systemic and superficial fungal infections and provides a brief overview of the current status of in vitro susceptibility testing and the growing problem of clinical resistance to the azoles. Use of the currently available azoles in combination with other antifungal agents with different mechanisms of action is likely to provide enhanced efficacy. Detailed information on some of the second-generation triazoles being developed to provide extended coverage of opportunistic, endemic, and emerging fungal pathogens, as well as those in which resistance to older agents is becoming problematic, is provided.

Clinical, cellular, and molecular factors that contribute to antifungal drug resistance

In the past decade, the frequency of diagnosed fungal infections has risen sharply due to several factors, including the increase in the number of immunosuppressed patients resulting from the AIDS epidemic and treatments during and after organ and bone marrow transplants. Linked with the increase in fungal infections is a recent increase in the frequency with which these infections are recalcitrant to standard antifungal therapy. This review summarizes the factors that contribute to antifungal drug resistance on three levels: (i) clinical factors that result in the inability to successfully treat refractory disease; (ii) cellular factors associated with a resistant fungal strain; and (iii) molecular factors that are ultimately responsible for the resistance phenotype in the cell. Many of the clinical factors that contribute to resistance are associated with the immune status of the patient, with the pharmacology of the drugs, or with the degree or type of fungal infection present. At a cellular level, antifungal drug resistance can be the result of replacement of a susceptible strain with a more resistant strain or species or the alteration of an endogenous strain (by mutation or gene expression) to a resistant phenotype. The molecular mechanisms of resistance that have been identified to date in Candida albicans include overexpression of two types of efflux pumps, overexpression or mutation of the target enzyme, and alteration of other enzymes in the same biosynthetic pathway as the target enzyme. Since the study of antifungal drug resistance is relatively new, other factors that may also contribute to resistance are discussed.

Vulvovaginal candidiasis: epidemiologic, diagnostic, and therapeutic considerations

Although it is the second most common vaginal infection in North America, vulvovaginal candidiasis is a non-notifiable disease and has been excluded from the ranks of sexually transmitted diseases. Not surprisingly, vulvovaginal candidiasis has received scant attention by public health authorities, funding agencies, and researchers. Epidemiologic data on risk factors and pathogenic mechanisms remain inadequately studied. Most important, standards of care, including diagnosis and therapy, remain undefined. A conference was held in April 1996 to define and summarize what is known and supported by scientific data in the areas of epidemiology, diagnosis, and treatment of vulvovaginal candidiasis; but, more important, the conference aimed at defining what is not known, poorly studied, and controversial. Guidelines for the treatment and diagnosis of the different forms of vulvovaginal candidiasis are suggested.

Treatment of vaginal infections: candidiasis, bacterial vaginosis, and trichomoniasis

OBJECTIVE

To describe the signs and symptoms of and recommend treatments for Candida vulvovaginitis, bacterial vaginosis, and Trichomonas vaginitis.

DATA SOURCES

Current clinical literature.

DATA SYNTHESIS

Patients with candidal vulvovaginitis often present with itching, burning, white discharge, vulvar or vaginal erythema, painful intercourse, and stinging on urination. It is treated with oral or topical antifungal agents. Bacterial vaginosis is characterized by a musty or fishy vaginal odor and a thin, white vaginal discharge. It is treated with oral or topical metronidazole or clindamycin. Patients with trichomoniasis usually complain of profuse, yellow-green discharge and vaginal or vulvar irritation. The standard treatment is a single 2 gram dose of oral metronidazole for both the patient and sexual partners.

CONCLUSION

Given the potential adverse effects of the drugs used to treat these conditions, pharmacists are in a unique position to recommend appropriate therapies and to refer patients to other health care providers as needed.

Clinical pharmacokinetics of fluconazole in superficial and systemic mycoses

The bis triazole agent fluconazole is used widely in the treatment of superficial and deep mycoses. A single oral dose of fluconazole 150 mg gives a mean long term clinical cure rate of 84 +/- 5% and is considered a valuable alternative to other topical antifungal drugs for vaginal candidiasis. A clinical cure rate of 90.4% for oropharyngeal candidiasis was obtained with 100mg daily for a minimum of 14 days; however, as for the other azoles the rate of relapse was large (40%) in immunocompromised patients. A daily dose of 100mg for at last 3 weeks gave satisfying outcomes for oesophageal candidiasis. Most patients (71 to 86%) with signs and symptoms of urinary tract candidiasis show beneficial clinical results when given oral fluconazole 50mg for several weeks. Fluconazole 50 to 150 mg given for weeks or months results in over 90% clinical cure or improvement for cutaneous mycosis including tinea, pityriasis, cryptococcosis and candidiasis. Prolonged (6 to 12 months) fluconazole 150 mg once a week is needed to treat onychomycosis successfully. Higher oral doses (200 to 400 mg daily) for long periods are generally used to treat deep mycoses such as meningitis, ophthalmitis, pneumonia, hepatosplenic mycosis and endocarditis. Fluconazole is effective for treating the fungal peritonitis which can complicate continuous ambulatory peritoneal dialysis (CAPD). A regimen of 50 mg intraperitoneally or 100 mg orally was used in these patients with impaired renal function. The dosage schedules used to treat disseminated fungal infections due to systemic mycoses with different or multiple foci of infections vary widely, with doses of 50 to 400 mg given orally or intravenously for between 1 week and several months. The most recent clinical reports have investigated the use of prophylaxis with fluconazole 100 to 400 mg daily, in immunocompromised patients. Fluconazole is found in body fluids such as vaginal secretions, breast milk, saliva, sputum and cerebrospinal fluid at concentrations comparable with those determined in blood after single or multiple doses. There is an excellent linear plasma concentration-dose relationship, but the mycological and clinical responses do not appear to be well correlated with the dose. A total maximum daily dose of 1600 mg is recommended to avoid neurological toxicity. Data from pharmacokinetic studies conducted in patients, mainly those with AIDS, and using a 1-compartment model give very constant parameters similar to those obtained in healthy individuals. Bioavailability, measured in HIV-positive patients and those with AIDS, exceeded 93% for tablets, suspension and suppositories. The time to reach peak plasma concentrations (tmax) was 2.4 to 3.7 hours. The peak plasma drug concentration (Cmax) obtained after a 100 mg oral dose was 2 mg/L. Areas under the concentration-time curve (AUC) obtained in different studies all correlate well with the dose (r = 0.926). The AUC determined after 200 and 25 mg suppositories were similarly well correlated. Hypochlorhydria does not affect the absorption of fluconazole, neither does food intake, race (Japanese or Caucasian) or gastrointestinal resection. Binding to plasma protein is low (11.14%) and is increased to 23% in cancer patients. Fluconazole is rapidly distributed to the tissue, where it accumulates. Tissues fall into 1 of 4 groups of increasing drug concentration: blood, bone and brain have the lowest concentrations, and spleen has the highest. The volume of distribution (Vd) remains stable at 46.3 +/- 7.9L and is considered to be an 'invariant' parameter across species. Fluconazole is poorly metabolised and is mainly eliminated unchanged in the urine. The percentage of the dose recovered in the urine in 48 hours is close to 60%. Concentrations in the urine are high and the half-life (t1/2) is long (37.2 +/- 5.5h) in patients, mainly those with AIDS, which is not significantly different from the t1/2 (31.4 +/- 4.7 hours) in healthy individuals. (ABSTRACT TRUN

Single-dose systemic oral fluconazole for the treatment of vaginal candidiasis

OBJECTIVES

To evaluate the acceptance of fluconazole given in a single oral dose, for the safe, effective treatment of vaginal candidiasis.

METHODS

A total of 428 patients who had a first or recurrent episode of vaginal candidiasis diagnosed clinically or by culture, were offered treatment with fluconazole by 40 primary care gynecologists who were unfamiliar with fluconazole treatment of vaginal candidiasis. The efficacy of this treatment was evaluated by both physicians and patients.

RESULTS

Most of the physicians (72%) and most of the patients (69%) found the drug effective in relieving or at least alleviating the signs and symptoms of the disease. The majority of patients (83.5%) rated it better than other drugs they had received for vaginitis in the past. No recurrences were noted at the 6-week follow-up.

CONCLUSIONS

Fluconazole has been found effective by physicians and patients. Both physician willingness to use it and patient compliance are satisfactory.

Antibiotic use in the emergency department. IV: Single-dose therapy and parenteral-loading dose therapy

There are a number of infectious diseases that can be treated efficaciously with a single dose of an antimicrobial agent. Other infections that can be treated with oral antibiotics on an outpatient basis may resolve more quickly if a parenteral loading dose is given in the emergency department (ED) prior to discharge. This article reviews the supporting literature and indications for single-dose and parenteral first-dose-loading antimicrobial therapy in the ED. This approach may be appropriate for such diverse infections as streptococcal pharyngotonsillitis, otitis media, urinary tract infections, chlamydial genital infections, vaginitis due to yeast, bacteria, or trichomoniasis, pneumonia, gonorrhea and pelvic inflammatory disease, and pediatric fever without a source.

Short-course itraconazole in the treatment of candida vulvovaginitis: A multicentre Canadian study

OBJECTIVE

To determine the clinical and mycological effectiveness of oral itraconazole in the treatment of acute candida vulvovaginitis.

DESIGN

A prospective, randomized and single-blinded, multicentre trial of 221 women, comparing a one-day course of oral itraconazole 200 mg bid with vaginal clotrimazole 500 mg single-dose therapy.

MAIN OUTCOME MEASURES

Symptoms, signs and mycological results were assessed up to two months following treatment. Adverse events were recorded and evidence of hepatotoxicity sought.

RESULTS

At 10 and 30 days post-treatment, clinical and mycological cure rates were similar (61.3% clinical and 88.6% mycological 10 days after, and 67.7% clinical and 79.5 mycological 30 days after itraconazole; 64.0 clinical and 85.9% mycological 10 days after, and 62.1% clinical and 78.6 mycological 30 days after clotrimazole) with the majority of both treatment groups free from infection. A total of 69 patients reported adverse events, which were generally transient and mild. Itraconazole was more often associated with gastrointestinal or central nervous system complaints, while clotrimazole recipients more often had genitourinary symptoms. No evidence of hepatotoxicity was found. A higher incidence of relapse was noted among women on the birth control pill and among those who were symptomatic for longer than 10 days before treatment.

CONCLUSIONS

A one-day course of oral itraconazole is as effective as intravaginal clotrimazole in the treatment of acute yeast vulvovaginitis. The number of patients reporting adverse events was similar for the treatment groups, although the side effect profile differed. No hepatotoxicity was observed.

Fluconazole. An update of its antimicrobial activity, pharmacokinetic properties, and therapeutic use in vaginal candidiasis

Fluconazole is a bis-triazole antifungal drug which has a pharmacokinetic profile characterised by its high water solubility, low affinity for plasma proteins, and metabolic stability. After a single 150 mg oral dose, therapeutic concentrations in vaginal secretions are rapidly achieved and are sustained for a duration sufficient to produce high clinical and mycological responses in nonimmunocompromised patients with vaginal candidiasis (candidosis). At this dosage, clinical and mycological responses have compared favourably with responses achieved after multiple dose regimens of other oral and intravaginal antifungal agents. Clinical efficacy rates have ranged between 92 and 99% at short term evaluation (5 days post-treatment). At 80 to 100 days post-treatment clinical efficacy rates of 91% have been reported. In addition, limited data indicate that fluconazole is more effective than placebo as prophylactic treatment of frequently recurring vaginal candidiasis. Single oral doses of fluconazole 150 mg are well tolerated. Most frequently observed adverse events are gastrointestinal symptoms, which are generally mild and transient in nature. Thus, fluconazole is a valuable alternative to established systemic and intravaginal azole antifungal drugs which are used to treat vaginal candidiasis. Moreover, in view of its favourable patient acceptability and compliance profile compared with alternative treatments, single-dose oral fluconazole should be considered as a first-line therapeutic choice for the treatment of women with vaginal candidiasis.