Vaginal azoles versus oral fluconazole in treatment of ... - Journals

18 Treatment of recurrent vulvovaginal candidiasisby the persistence of a single yeast genotype thatundergoes morphological and behavioral changesin the presence of antifungal agents (3). Associatedsymptoms and signs include pruritus, burning,soreness, abnormal vaginal discharge, dysparonia,and vaginal and vulvar erythema and edema (4).Known predisposing host factors which includeuncontrolled diabetes mellitus,immunosuppression, pregnancy, and hormonereplacement therapy, could partly explain RVVC.Broad spectrum antibiotic use has been suggestedas a risk factor for both acute and recurrent VVC.Frequent recurrences of symptomaticvulvovaginitis result in considerable suffering andhave a markedly negative influence on sexualrelation (5).The diagnosis should be confirmed by physicalexamination, direct microscopy of the vaginalsecretions and, of course, fungal culture.Characteristic budding mycelia are seen in fewerthan 30% of positive candida cultures (6).The optimal treatment of VVC has not yet beendefined (7). Consequently, treatment must beindividualized based on a comparison ofeffectiveness, convenience, potential side effects,and costs. Treatment of the acute episode usuallyinvolves topical application of Azoles drugs ornystatin or systemic oral antifungal agents.However, for recurrent VVC, after treatment of theacute episode, subsequent prophylaxis(maintenance therapy) is essential (7). Severalmaintenance regimens have been proposed, likeketoconazole 100 mg/day or fluconazole 150mgweekly for 6 months (7). Oral treatment carries agreater potential for systemic toxicity and druginteraction for pregnant women, diabetic patients,and for whom it is contraindicated (such as thosewith renal or hepatic insufficiency).The present study was designed to compare theefficacy and safety of a single oral dose offluconazole (150mg) weekly with clotrimazolevaginal cream 150 mg twice weekly for 6 monthsas the treatment of choice for recurrent VVC.PATIENTS and METHODSWe conducted a clinical trial study on 124women with RVVC. Cases were recruited frompatients presenting to the Gynecology andObstetrics Clinic at Tabriz Medical Universitybetween 2002–2004.Patients with signs and symptoms of candidiavulvovaginitis (pruritus, irritation, burning,discharge, erythema and edema) and a history ofmore than 4 episodes of VVC during the past year(at least one of the previous episodes must havebeen diagnosed by physician) were included. Thefollowing exclusion criteria were applied atbaseline: severe chronic disease, use of oralhypoglycemic drugs, chronic dermatologic disease.All subjects were requested to sign an informedconsent, then, social, demographic and medicalfeatures as well as the present complaint of thepatient were inquired and vaginal examination wasperformed.Sampling of vaginal discharge was achieved forclinically suspected patients, then, observed withKOH for vaginal candidiasis. Sample culture wasperformed for cases in whom the result of directexamination was negative but there was highclinical suspicion of the disease. For laboratoryexamination, swab specimens were placed onsabourauds agar plus chloramphenicol andcyclohexamide with natural PH. The specimenswere stored at 37°C and subsequently identified bysmooth white colony formation. FBS (fasting bloodsugar) test was requested to confirm the unknowndiabetes mellitus, and Pap smear was alsoperformed to rule out pre-cancer lesion of thecervix.For treatment, patients were randomizedsystematically in 2 groups with 62 cases in each.The first group received clotrimazole vaginalcream 5g/day for 7 days for acute episode and 5gtwice a week for 6 months as a prophylaxis. Thesecond group was prescribed single oral dose offluconazole capsule 150 mg for acute episodeIranian Journal of Clinical Infectious Disease 2007;2(1):17-22