What's the Best Route for Treating Vaginal Candidiasis? --- HealthandAge

December 1, 2008


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What's the Best Route for Treating Vaginal Candidiasis?

Robert W. Griffith, MD
March 20, 2002 (Reviewed: March 7, 2004)

Introduction

Vulvovaginal candidiasis (thrush) is a common affliction in women before the menopause - 75% will have at least one episode. Antifungal treatment directed at Candida albicans (the most frequent pathogen), C. glabrata, or C. krusei is effective, whether given locally (intravaginally) or systemically (by mouth). There has been uncertainly about the relative efficiency of these two routes (efficacy, safety, cost, convenience), which should be largely removed by a recent meta-analysis conducted for the Cochrane Collaboration.

Method

All published randomized controlled studies of antifungals (imidazole and/or triazole derivatives) were included in the analysis if they compared oral vs. intra-vaginal treatment in women over 16 with uncomplicated thrush. Uncomplicated meant that they were not pregnant, breast-feeding, diabetic, HIV positive, or immuno-compromised. Ketoconazole studies were excluded because of this drug's recognized toxicity.

The diagnosis of candidiasis was confirmed by microscopy and/or culture. However, mycology was not used as a primary outcome measure, as C. albicans occurs routinely in symptomless women. The primary outcome measures were short-term (5 to 15 days) and long-term (2 to 12 weeks) clinical cure. Secondary variables recorded were mycological cure, safety, side effects, and patient preference.

Studies were assessed for quality based on standard methodology. Statistical analyses compared any oral with any intra-vaginal therapy. Sub-group analyses included individual drug analyses and different frequencies of administration.

Results

Seventeen randomized controlled studies met the inclusion criteria; they yielded 19 comparisons of oral vs. intra-vaginal medications. Oral fluconazole was studied vs. clotrimazole vaginal tablets in 11 trials, vs. miconazole pessaries in 2 trials, and vs. local terconazole or econazole in one trial each. Oral itraconazole was studied vs. clotrimazole tablets in 3 trials and vs. local econazole in one trial.

In 12 trials, fluconazole was given orally as a single dose of 150 mg. In three trials, different dosage regimens were used - 200 mg once, 50 mg daily for 3 days, and 50 mg for 6 days. Itraconazole was given orally at doses of 200 mg daily for 3 days (2 trials), 200 mg BD for 3 days, and 200 mg BD for one day.

Local treatment in these studies was usually given for 3 or 7 days (clotrimazole 200 mg or 100 mg tablets, respectively, or econazole 150 mg for 3 days), but in some case single administrations were tested - clotrimazole 500 mg, econazole 150 mg, miconazole 1,200 mg.

There was no statistically significant difference between oral and intra-vaginal treatment for short-term cure; the odds ratio (OR) was 1.00 (95% confidence interval [CI] 0.72-1.40). Similarly, there was no difference between the two routes of administration for long-term follow-up - the OR was 1.03 (95% CI 0.72-1.49). The results were practically similar when oral fluconazole was compared with local clotrimazole.

Mycological cure results mirrored those for clinical cure. Safety (measured by withdrawals for side effects) and the adverse effects reported did not allow adequate analysis to detect any differences between treatments. However, in all trials that reported a preference for one treatment over another, oral therapy was favored more than local therapy. Cost-efficacy evaluations were not made in any of the trials.

Conclusions

Both routes of antifungals administration provided short-term clinical and mycological cure in over 80% of the subjects. Treatment failures may have been due to undiagnosed concomitant chlamydia or trichomonas infections. The absence of differences between oral and intra-vaginal routes with regard to efficacy and safety in this population means that the choice must be based on other considerations - e.g. cost and preference. In general, oral antifungals are more expensive than formulations for local application.

It should be noted that vaginal candidiasis is not uncommon in pregnant women. In such cases, intra-vaginal treatment may be preferred, in order to avoid exposing the fetus to any possible systemic drug (or its metabolites) circulating in the mother.

Oral antifungals may be excreted in maternal milk, so breast-feeding mothers should also be given local therapy.

Source

Oral versus intra-vaginal imidazole and triazole anti-fungal agents for the treatment of uncomplicated vuvlovaginal candidiasis (thrush): a systematic review. MC. Watson, JM. Grimshaw, CM. Bond, et al., BJOG, 2002, vol. 109, pp. 85--95