Classification System Aids Vaginitis Treatment

OB/GYN News, Oct 1, 2001 by Bruce Jancin

DURBAN, SOUTH AFRICA - Treatment of candidal vaginitis has been made much easier by introduction of the Infectious Diseases Society of America disease classification system, Dr. Jack D. Sobel said.

The IDSA classification system, of which Dr. Sobel was a coauthor (Clin. Infect. Dis. 30[4]:662-78, 2000), divides patients into those having uncomplicated or complicated disease. (See chart.)

At least 90% of women with vulvovaginal candidiasis fall into the "uncomplicated" category. The important implication of assigning a woman to this category is that she has a greater than 90% likelihood of responding to a very brief course of azole therapy he said at an industry-sponsored symposium held in conjunction with WONCA 2001, the conference of the World Organization of Family Doctors.

"In fact, the placebo response of uncomplicated candidal vaginitis is 60%," according to Dr. Sobel, professor of medicine at Wayne State University, Detroit.

Uncomplicated candidal vaginitis responds to any of numerous intravaginal preparations of clotrimazole, miconazole, tioconazole, and butaconazole available over the counter. Regimens of 1,3,7, and 14 days all work very well.

Alternatively, oral therapy is both highly effective and convenient. Regimens include a single 150-mg dose of fluconazole or, off label, 200 mg of itraconazole b.i.d. for 1 day. Resolution of signs and symptoms occurs in 48-72 hours, with mycologic cure seen in 4-7 days.

Recurrent or otherwise complicated candidal vaginitis is another matter entirely. The therapeutic strategy here is to employ maintenance therapy to prevent recolonization, thereby preventing clinical relapse. Start with 10-14 days of intensive induction therapy with any topical or oral azole, then follow with 6 months of maintenance therapy.

Maintenance regimens that have demonstrated effectiveness in published studies include 150 mg of oral fluconazole once per week, oral ketoconazole at 100 mg once daily, oral itraconazole at 100 mg once daily, a single 500-mg tablet of clotrimazole administered intravaginally once weekly, or a daily azole cream.

Unfortunately, once maintenance therapy is stopped after 6 attack-free months, 30%-40% of women will return to their prior pattern of frequent recurrences. "You have no alternative then but to restart this whole process," Dr. Sobel said.

His wish list for candidal vaginitis centers on new, more effective antifungal agents and better diagnostic tests. "Every single drug we use to treat candidal vaginitis is fungistatic. That's why we have a high recurrence rate after stopping maintenance therapy. We need fungicidal action," the infectious disease specialist stressed.

With regard to diagnostic studies, he continued, the sensitivity of microscopy is no more than 50% in most physicians' hands. Even in expert hands its sensitivity is only 60%-70%.

"We have a crisis in the diagnosis of candidal vaginitis. Physicians of good intentions, specialists and otherwise, are having difficulty in making the diagnosis. We have a massive problem with over- and underdiagnosis, and no new diagnostic tests in sight," Dr. Sobel said.

The "best kept secret" regarding women with vulvovaginal symptoms is that most affected women don't have an infection at all.

"Probably no more than one out of four or five actually has an infection," according to Dr. Sobel.

Classifying Candidal Vaginitis Into Complicated vs. Uncomplicated Cases
(*)

                  Uncomplicated              Complicated

Severity         Mild to moderate  Severe
Frequency        Sporadic          Recurrent (at least four
                                   episodes per year)
Organism         Candida albicans  Non-albicans species of
                                   Candida
Host immunology  Normal            Abnormal (uncontrolled diabetes
                                   mellitus, corticosteroid
                                   therapy, pregnancy, etc.)

(*)Women are classified as having uncomplicated candidal vaginitis under
this system developed by the Infectious Diseases Society of America only
if they possess all four listed features of uncomplicated disease. Women
having any of the features of complicated disease are considered as
having a complicated case.

Source: Dr. Jack D. Sobel