Treatment of vaginitis caused by non-albicans Candida species

ABSTRACT

Introduction

In the face of increased frequency of non-albicans Candida vulvovaginitis (VVC) reported worldwide, there is a paucity of effective oral and topical antifungal drugs available. Drug selection is further handicapped by an absence of data of clinical efficacy of available antifungal drugs for these infections.

Areas covered

In this review, attention is directed at the cause of drug shortage as well as increased frequency of non-albicans Candida (NAC) vulvovaginitis. There is widespread recognition of reduced in vitro azole drug susceptibility in NAC species. Moreover, antifungal susceptibility tests have not been standardized or validated for NAC isolates, hence clinicians rely on an element of empiricism especially given the absence of randomized controlled comparative studies targeting NAC species. Clinical spectrum of NAC species isolates is highly variable with ongoing difficulty in determining a causal role in symptomatic patients.

Expert opinion

We have entered the era of demand for Candida species-specific therapy and although consensus treatment guidelines are emerging, new antifungal agents that target these multiple-azole resistant or relatively resistant vaginal NAC species are urgently needed.

KEYWORDS:

• Vulvovaginal candidiasis
• Candida albicans
• non-albicans candida species
• C. glabrata
• C. krusei
• C. parapsilosis

Article highlights

• Increased frequency of non-albicans Candida NAC species reported.

• NACs are a heterogenous group that are less virulent and are less capable of severe vulvovaginitis.

• NACs are less susceptible to majority of available topical and oral antifungal agents and frequently persist in colonized patients.

• It is essential to establish a causal role of NAC species isolated in individual patients in contributing to patients’ vulvovaginal symptoms.

• Topical boric acid and nystatin play a primary and leading role in management when treatment is indicated.

• A persistent causal role in vulvovaginal symptoms requires antifungal therapy selected on the basis of in vitro antifungal susceptibility tests.

• The role of recently available potent therapeutic antifungal agents; ibrexafungerp and oteseconazole in management of NAC vaginitis have yet to be determined in spite of superior in vitro activity.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.