Examining the Evidence
Weekly fluconazole reduces recurrent candidiasis
To evaluate weekly fluconazole (150 mg orally for 6 months) to prevent recurrent vulvovaginal candidiasis.
Immediately before randomization, all patients had a culture-proven episode of candidiasis, which was successfully treated with 3 doses of fluconazole (150 mg each) given orally at 72-hour intervals. Six months of weekly maintenance followed, with 150 mg fluconazole or placebo.
At the end of 6 months, 13/141 (9%) of the fluconazole group and 91/142 (64%) of the placebo group had suffered recurrent candidiasis (P<.001). However, of the 126 fluconazole-treated patients who were disease-free after 6 months of maintenance fluconazole, 72 (57%) developed a recurrence over the next 6 months.
For the gynecologist, recurrent candidiasis is one of those niggling, but pervasive, challenges of practice. But for the woman subject to repeated outbreaks, it is a major obstacle to quality of life, even though episodic antifungal treatment is readily available with or without a visit to the office. As physicians, we just don’t appreciate the negative impact that recurrent candidiasis has on a woman’s daily functioning.
Although prolonged (6-month) antifungal therapy has proven effective against recurrent candidiasis, some women object to the extended use of topical antifungals, and oral therapy with ketoconazole is associated with hepatotoxicity. This study showed that weekly oral fluconazole for 6 months is an effective and acceptably safe way to suppress recurrences. It also leads to a prolonged disease-free interval after treatment in almost half of treated women.
Good study design, but applies mainly to Candida albicans
The strengths of this study lie in the randomized, double-blind, placebo-controlled design and the use of culture to identify and speciate fungal isolates.
However, it should be stressed that the initial treatment to clear active infection (three 150-mg doses of fluconazole every 72 hours) was more intensive than the norm.
Furthermore, since most of these women (94%) had Candida albicans infections, the applicability of these results to non-albicans species is unclear.
Despite frequent recurrences after stopping treatment, maintenance fluconazole prevented most symptomatic episodes of recurrent vulvovaginal candidiasis caused by C. albicans.