Transactions from the 71st Annual Meeting of the Pacific Coast Obstetrical and Gynecological Society
Treatment of non-albicans Candida vaginitis with amphotericin B vaginal suppositories

https://doi.org/10.1016/j.ajog.2005.03.034Get rights and content

Objective

This study was undertaken to investigate whether amphotericin B vaginal suppositories would be effective in the treatment of non-albicans Candida vaginitis in women who failed conventional therapy.

Study design

Thirty-two patients were identified with non-albicans Candida vaginitis. These patients were treated with conventional antifungal agents. Ten patients had persistence of the non-albicans Candida infection after treatment. Amphotericin B 50-mg vaginal suppositories were given nightly for 14 days to this subgroup of treatment failures.

Results

Of 10 women, 8 (80%) who were treated with amphotericin B vaginally initially showed no further infection. One of the treatment successes had 2 recurrences and responded to a second course of amphotericin B but failed a third course. If this patient is considered a treatment failure, then amphotericin B vaginal suppositories were successful in 70% of patients. The medication was well tolerated and local side effects were minimal.

Conclusion

Amphotericin B vaginal suppositories are a viable treatment option for refractory vaginitis caused by non-albicans Candida.

Section snippets

Materials and methods

With approval of Saint John's Hospital Health Center/John Wayne Cancer Institute Joint Institutional Review Board, a review of the author's private practice patients with non-albicans Candida vaginitis was conducted. Between 1995 and 2004, 465 patients were seen with symptoms of Candida vaginitis (pruritus, vulvar burning, discharge) and had a diagnosis of Candida vaginitis. From within this group, were 32 patients (7%) found to have non-albicans Candida vaginitis. These patients were not

Results

Ten patients (9 with C glabrata; 1 with C tropicalis) of the original 32 patients with non-albicans Candida, continued to demonstrate infection after treatment with a topical azole, followed by systemic azole treatment with either fluconazole or ketoconazole. These patients were prescribed amphotericin B 50-mg suppositories nightly for 14 days. The MIC levels for amphotericin B of the group was in the sensitive range (between 0.5 and ≤0.06). All patients returned for follow-up after treatment

Comment

Over the course of practice, the physician will encounter patients who have from recurrent vaginal Candida infections. This can be related to conditions that predispose the patient to candidiasis, including diabetes, immunosuppression, estrogens, and antibiotic use. Chronic infection can also be due to patients with non-albicans Candida, who have resistance to treatment with conventional azole agents. The incidence of vaginal infections with non-albicans Candida and specifically C glabrata is

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      Flucytosine is the second line treatment, compounded into a 15.5% vaginal cream, 5 g daily for 14 days, but access to this medication is limited by cost.37 Amphotericin B suppositories have been reported and could be another option for patients.38 A case series published by Nyirjesy and colleagues39 described 17 of 19 patients with C parapsilosis who had negative cultures after fluconazole 200 mg twice weekly for 4 weeks and 6 of 6 patients who received boric acid vaginal capsules 600 mg twice daily for 2 weeks.

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      Standard treatments for C. albicans are minimally effective for C. glabrata. Several therapeutic protocols have been described: vaginal suppositories of boric acid (600 mg/day, 14 days) or amphotericin B (50 mg daily, 14 days) [39]; vaginal application of 17% flucytosine (once daily, 14 days); and oral fluconazole (800 mg/day, 14–21 days). Recurrent vaginal candidiasis, defined as at least four symptomatic episodes per year, remains a challenging clinical situation.

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    Presented at the 71st Annual Meeting of the Pacific Coast Obstetrical and Gynecological Society, October 19-24, 2004, Phoenix, Ariz.

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