Pharmacotherapy of Vulvovaginal Candidiasis
PST 06106
Basic Pharmacotherapy
Session 20: Pharmacotherapy of Vulvovaginal Candidiasis
Learning Objectives
By the end of this session students are expected to be able to:
Define vulvovaginal candidiasis
Explain pathophysiology of vulvovaginal candidiasis
Explain the clinical presentation of vulvovaginal candidiasis
Outline diagnosis of vulvovaginal candidiasis
Describe pharmacological treatment of vulvovaginal candidiasis
Describe the monitoring of vulvovaginal candidiasis therapy
Activity: Buzzing
What is Vulvovaginal
Candidiasis ?
Definition of Vulvovaginal Candidiasis
Vulvovaginal Candidiasis
Vulvovaginal candidiasis
(VVC) refers to infections in individuals with or without symptoms who have positive vaginal cultures for
Candida
species.
Depending on episodic frequency, VVC can be classified as either;
Sporadic or
Recurrent.
This classification is essential to understanding the pathophysiology, as well as
the
pharmacotherapy of
VVC.
Definition of Vulvovaginal
Candidiasis Cont.…
VVC may also be classified as;
uncomplicated, which refers to sporadic infections that are susceptible to all forms of antifungal therapy regardless of the duration of treatment, or
Complicated, in which consideration of factors affecting the host, microorganism, and pharmacotherapy all have an essential role in successful treatment.
Complicated VVC includes recurrent VVC, severe disease, non–
Candida albicans
candidiasis, and host factors, including diabetes mellitus, immunosuppression,
and pregnancy
Pathophysiology of Vulvovaginal Candidiasis
Candida albicans
is the major pathogen responsible for VVC, accounting for 80% to 92% of symptomatic episodes.
The remainders are caused by non–
species, with
Candida
glabrata
dominating.
The number of cases of non–
candidiasis appears to be increasing, possibly related to the use of nonprescription vaginal antifungal preparations and short-course therapy and/ or the increased use of long-term maintenance therapy in preventing recurrent infections.
Candida
species can act as commensal members of the vaginal flora.
Asymptomatic colonization with
Candida
species has been found in 10% to 20% of women of reproductive age.
Pathophysiology of Vulvovaginal
Candidiasis
Cont
…
Candida
organisms are dimorphic;
blastospores
are believed to be responsible for colonization (transmission and spread), whereas
Germinated Candida forms are associated with tissue invasion and symptomatic infections.
To colonize the vagina,
Candida
species must be able to attach to the mucosa. The attachment process is complex.
Not only are
candidal
surface structures important for attachment, but appropriate receptors for attachment must be present in the epithelial tissue.
Pathophysiology of Vulvovaginal Candidiasis
Cont.…
Not all women have the same range of receptors, which may explain variation in colonization.
Changes in the host’s vaginal environment or response are necessary to induce a symptomatic infection.
Unfortunately, in most cases of symptomatic VVC, no precipitating factor can be identified
C
linical presentation of Vulvovaginal candidiasis
General
Often involves both the vulva and the
vagina
Symptoms
Intense vulvar itching, soreness, irritation, burning on urination, and
dyspareunia
Signs
Erythema,
fissuring (crack),
curdy “cheese”-like discharge, satellite lesions,
edema
Laboratory tests
Vaginal pH—normal, saline and 10% KOH microscopy—
blastospores
or
pseudohyphae
Other diagnostic tests
Candida
cultures not recommended unless classic signs and symptoms with normal vaginal pH and microscopy are inconclusive or recurrence is suspected
Activity
: Small Group Discussion
What is the treatment of Vulvovaginal
Candidiasis ?
Treatment of Uncomplicated
Vulvovaginal candidiasis
Pharmacological Treatment of Vulvovaginal Candidiasis
Complicated Vulvovaginal Candidiasis
Complicated VVC occurs in patients who are immunocompromised or have uncontrolled diabetes mellitus and pregnant.
These
individuals need
a more aggressive treatment plan.
Current recommendations are to lengthen therapy to 10 to 14 days regardless of the
route of
administration.
Therapeutic options include those listed in Table
however
, regimens should be continued for 10 to 14 days.
Pharmacological Treatment of Vulvovaginal Candidiasis
Cont.….
Antifungal-Resistant Vulvovaginal Candidiasis
Resistance to azole antifungals should be considered in individuals who have persistently positive yeast cultures and fail to respond to therapy despite adherence to prescribed regimens.
These infections can be treated with;
intravaginal
twice weekly.
Boric acid should not be administered orally, as it is
toxic.
OR
Pharmacological Treatment of Vulvovaginal Candidiasis Cont.….
Monitoring of Vulvovaginal Candidiasis Therapy
Efficacy of the antifungal agent is partly influenced by patient adherence to the medication regimen.
Patients must be counseled on proper administration and dosing
Safety end points include monitoring for occurrence of the relevant drug side effects and drug interactions
It is still prudent to monitor for hypersensitivity reactions and side effects
that
might
occur with any medication.
Monitoring of Vulvovaginal Candidiasis
Therapy Cont.…..
GI intolerance is more associated with the oral azoles.
Hepatotoxicity can occur when azole therapy is prolonged beyond 7 to 10 days or high doses are used.
Periodic monitoring of liver enzymes (alanine transaminase and aspartate amino-transferase) should be considered, especially if prolonged therapy (longer than 21 days) is anticipated.
Patients who are receiving IV amphotericin B require daily monitoring by the pharmacist.
Key Points
Vulvovaginal
candidiasis
(VVC) refers to infections in individuals with or without symptoms who have positive vaginal cultures for
Candida
species
Symptoms include intense vulvar itching, soreness, irritation, burning on urination, and dyspareunia
Azole antifungals and other topical antifungals are drug of choice for
culvovaginal
candidiasis
Evaluation
What
is Vulvovaginal Candidiasis?
What is the pathophysiology of
Vulvovaginal Candidiasis?
What are the signs and symptoms of Vulvovaginal Candidiasis?
How is the treatment of Vulvovaginal Candidiasis?
References
Wells
BG,
DiPiro
J,
Schwinghammer
T (2013),
Pharmacotherapy Handbook
(6
th
Ed). New York, NY: McGraw-Hill.
DiPiro
JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey ML, (2008):
Pharmacotherapy: A Pathophysiologic Approach
(7
th
ed
): New York, NY: McGraw-Hill.
Katz M D., Matthias KR., Chisholm-Burns M A., Pharmacotherapy(2011)
Principles & Practice Study Guide: A Case-Based Care Plan Approach
: New York, NY: McGraw-Hill.
Schwinghammer
TL, Koehler JM (2009)
Pharmacotherapy Casebook: A Patient-Focused Approach
(7
th
ed
): New York, NY: McGraw-Hill.
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