Guidelines for Nurse Practitioners in Gynecologic Settings 2016
Care Plan – Candiasis
B37.9 Candidiasis, unspecified
I. DEFINITION
Candidiasis, or monilia, is a microscopic, yeastlike fungal infection of the vagina usually caused by C. albicans (more than 90%). Candida tropicalis, Torulopsis glabrata, Candida krusei, Candida parapsilosis, and other lesser known Candida species are also clinically implicated.
II. ETIOLOGY
A. A fungus of the genus Candida, species C. albicans, C. tropicalis, or
T. glabrata; part of the normal flora of the mouth, gastrointestinal (GI) tract, and vagina; may become pathogenic under variable conditions, such as change in the vaginal pH, which encourage an overgrowth of the organism
B. Incubation period is about 96 hours
III. HISTORY
A. What the patient may present with
1. Vulvar pruritus, pain, redness
2. Vulvar and vaginal swelling, fissures
3. Vulvar excoriation
4. Vulvar burning and external dysuria with urination
5. Dyspareunia or burning during and/or after intercourse
B. Additional information to be considered
1. Previous vaginal infections or vaginosis; diagnosis, treatment, and compliance with treatment
2. Chronic illness (diabetes); immunocompromised patients
3. Sexual activity, including oral and anal sex
4. History of STI or PID
5. Last intercourse, changes in frequency, new partner
6. LMP
7. Method(s) of birth control
8. Other medications
a. Antibiotics
b. Steroids
c. Estrogens
9. Description of discharge
a. Color
b. Onset
c. Odor
d. Consistency
10. Constant versus intermittent
a. Relationship to sexual contact
b. Relationship to menses
c. Use of vaginal deodorant sprays; deodorant or scented tam- pons, panty liners, or pads; douches, perfumed toilet tissue
d. Change in laundry soaps, fabric softener, body soap (amount of soap used and application inside labia)
e. Clothing: consistent wearing of tight-crotched pants; wearing nylon underwear, panty hose under slacks; wearing under- wear to bed
11. “Jock” itch (partner); athlete’s foot (self or partner); itchy rash on thighs, buttocks, under breasts; oral candidiasis (thrush)
12. Diet high in refined sugar
IV. PHYSICAL EXAMINATION
A. External examination
Observe perineum for excoriation, erythema, edema, ulcerations, lesions
B. Vaginal examination (speculum)
1. Inspection of vaginal mucosa: may be erythematous, irritated, with white patches along side walls
2. Cervix
3. Discharge: characteristically thick, odorless, white, curdlike, resembling cottage cheese, with pH remaining in the normal range of 3.8 to 4.2 (nitrazine paper)
C. Bimanual examination
V. LABORATORY EXAMINATION
A. Wet prep microscopic examination to visualize hyphae, pseudohy- phae, spores, or buds
B. Affirm VPIII Microbial Identification Test
C. Consider vaginal or cervical culture
D. Consider fasting blood sugar and 2-hour postprandial blood sugar on women with chronic yeast infections
E. Further laboratory work as indicated by history, including HIV testing
VI. DIFFERENTIAL DIAGNOSIS
A. Herpes genitalis
B. Chemical vaginitis
C. Contact dermatitis
D. Normal physiologic discharge
E. Candidiasis secondary to diabetes, pregnancy, positive HIV status
F. T. glabrata or C. tropicalis or lesser known species (C. krusei,
C. parapsilosis, other Candida species)
G. Trichomonas, BV, Chlamydia, or gonococcal infection
VII. TREATMENT
A. Medications (some of these are now OTC)
1. Butoconazole 2% cream 5 g intravaginally for 3 days (Femstat 3) or
2. Clotrimazole (Gyne-Lotrimin, Lotrimin, Mycelex, Mycelex 7, Mycelex-G) 1% cream 5 g (one applicatorful) intravaginally at bed- time for 7 to 14 days
3. Clotrimazole (Femcare, Gyne-Lotrimin, Lotrimin, Mycelex, Mycelex-G) 2% cream 5 g (one applicatorful) intravaginally at bedtime for 3 days or
4. Miconazole 2% cream 5 g intravaginally for 7 days or
5. Miconazole 4% cream 5 g intravaginally for 3 days or
6. Miconazole 100-mg vaginal suppository, one suppository daily intravaginally for 7 days or
7. Miconazole 200-mg vaginal suppository, one suppository daily intravaginally for 3 days or
8. Miconazole 1,200-mg vaginal suppository, one suppository intravaginally for 1 day or
9. Tioconazole (Vagistat-1) 6.5% ointment 5 g intravaginally in a single application or prescription intravaginal agents
10. Nystatin 100,000 unit vaginal tablet, one tablet once a day for 14 days or
11. Terconazole (Terazol) 0.4% cream 5 g (one applicatorful) intravagi- nally for 7 days or
12. Terconazole 0.8% cream 5 g (one applicatorful) intravaginally for 3 days or
13. Terconazole 80-mg vaginal suppository, one suppository for 3 days
14. Oral agent: fluconazole (Diflucan) 150-mg oral tablet, one tablet in a single dose (pregnancy category C)
15. In pregnancy: use only topical azole therapies; most effective in pregnancy are butoconazole, clotrimazole, micon- azole, and terconazole; CDC STDTG of 2014 recommend 7-day therapy.
16. Miconazole cream (Monistat-Derm) or clotrimazole cream (Mycelex) can be used for external irritation.
17. If treatment is unsuccessful, may refill script once; if still unsuccessful, consider treating partner and/or fasting blood sugar and 2-hour postprandial blood sugar; review history carefully with the woman
18. If fasting blood sugar and 2-hour postprandial blood sugar are within normal limits, several options may be considered.
a. Clotrimazole 1 applicatorful intravaginally every other week for 2 months. If patient remains symptom free, reduce treatment to every month, the week prior to menses.
b. If the first option is not successful, consider non-C. albicans species: T. glabrata or C. tropicalis. If laboratory result confirms diagnosis, treat with gentian violet one tampon at bedtime for 12 days; triazole compounds have also been found to be effective (Terazol, terconazole; Noxafil, posaconazole; ravuconazole; voriconazole; itraconazole).
c. Boric acid capsules: 600 mg one capsule twice a week intravagi- nally for recurrent C. vaginitis (four or more episodes per year) as
organism may be T. glabrata (less sensitive to fluconazole or imidazoles)
d. Clove of garlic in gauze placed in vagina for 10 to 12 hours; other complementary therapies (see Complementary and Alternative Therapies, Chapter 3; and Bibliographies)
B. General measures
1. No intercourse until symptoms subside; then use condoms until end of treatment
2. No douching
3. Stress the importance of continuing medication even if menses begin
4. Do not use tampons during treatment
5. Stress hygiene, cotton underwear, loose clothing, no underpants while sleeping, wipe front first and then back
6. Do not use feminine hygiene sprays, deodorants, and so forth
7. Treat athlete’s foot, jock itch, or rash with OTC antifungals (such as Lotrimin, Tinactin) or prescription dual-action Lotrisone
8. Consider the use of vitamin C 500 mg twice to four times a day to increase acidity of vaginal secretions or oral acidophilus tablets 40 million to 1 billion units daily (one tablet); eat live culture yogurt several times a week
VIII. COMPLICATIONS
A. Drug interactions; adverse reactions to treatment
B. Need for maintenance regimens: oral fluconazole 100-, 150-, or 200-mg dose weekly for 6 months
C. Severe vulvovaginitis: extensive vulvar erythema, edema, excoriation, fissure formation: 7 to 14 days of topical azole or 150 mg of fluconazole in two sequential doses: initial dose and second dose 72 hours after initial dose
IX. CONSULTATION/REFERRAL
A. No response to treatment as outlined previously
B. Elevated fasting blood sugar or 2-hour postprandial blood sugar
C. Presence of concurrent systemic disease
X. FOLLOW-UP
A. None necessary unless
1. Symptoms persist after treatment
2. Symptoms recur or exacerbate
Appendix I has information on candidiasis that you may wish to photocopy or adapt for your patients.
See Bibliographies.