Candida albicans vaginitis: the problem is diagnosis, the enigma is treatment. A randomized, comparative study of a single oral dose of fluconazole versus a single topical dose of clotrimazole in the treatment of vaginal candidosis among general practitioners and gynaecologists. Comparative study of fluconazole and clotrimazole for the treatment of vulvovaginal candidiasis. Comparative study of the effectiveness of oral fluconazole and intravaginal clotrimazole in the treatment of vaginal candidiasis. Treatment of candidal vaginitis. A prospective randomized investigator-blind multicenter study comparing topically applied econazole with oral fluconazole. A comparison of single-dose oral fluconazole with 3-day intravaginal clotrimazole in the treatment of vaginal candidiasis. Report of an international multicentre trial. Comparative study of fluconazole and clotrimazole in the treatment of vulvovaginal candidiasis. Educational strategies to promote evidence-based community pharmacy practice: a cluster randomized controlled trial (RCT). Single dose oral fluconazole vs intravaginal terconazole in treatment of Candida vaginitis. Comparison and pilot study. Prophylactic treatment with miconazole in patients highly predisposed to fungal infection. A placebo-controlled double-blind study. Comparison of clotrimazole, fluconazole and itraconazole in vaginal candidiasis. Single-dose oral fluconazole versus single-dose topical miconazole for the treatment of acute vulvovaginal candidosis. Treatment of vaginal candidosis: a comparative study of the efficacy and acceptability of itraconazole and clotrimazole. Evaluation of two self-care treatments for prevention of vaginal candidiasis in women with HIV. Comparison of vaginal flora after treatment with a clotrimazole 500 mg vaginal pessary or a fluconazole 150 mg capsule for vaginal candidosis.
At the UCLA Vulvovaginitis Clinic, 63 patients were diagnosed as having symptomatic Candida albicans vaginal infections. In a random select manner 3-day treatment with 200-mg clotrimazole suppositories was compared with 7-day treatment using 100-mg clotrimazole suppositories. 7- and 35-day follow-up of all patients entered revealed no statistical difference between the two groups, suggesting that short-term treatment is most efficacious and can be expected to work better since patient compliance is primarily a function of duration of treatment. In 50 cases of C. albicans patients treated with miconazole or clotrimazole in a random manner, the recurrence rate was 8 or 16. All patients in the study received perianal cultures for C. albicans before treatment and 7 and 35 days after treatment. 5 of the 8 patients with recurrence had perianal positive cultures at the 7- and 35-day check suggesting this as a source of recurrence. It is suggested that patients with persistently high perianal cultures after treatment be given an oral fungicide or fungistat to lower chronic recurrent C. albicans. To compare efficacy, acceptability and patient preference of a single oral dose of fluconazole with a single intravaginal dose of 500 mg clotrimazole (medication groups) in women with vaginal candidosis visiting gynaecologists or general practitioners (study groups).
                A comparative, randomized multicenter study. EVENTS: Baseline visit and treatment, short-term follow-up after 1 week and long-term follow-up after 4 weeks. At each visit, symptoms were graded and cultures were obtained.
                Symptomatic and mycological efficacy did not differ statistical significant in the medication groups or study groups. A complicated history regarding vaginal candidosis was more often found among gynaecologists, yielding poorer results of treatment. Patients preferred oral treatment over intra-vaginal treatment.
                No differences were found in the clinical and mycological efficacy of both drugs. Clinical results were related to parameters originating from the patients history, resulting in less favourable results in the study group of gynaecologists. The introduction of the triazole antifungal agent fluconazole, which can be used via an oral route and single dose, has had a significant impact on patient compliance.
                To compare the efficacy and safety of a single oral dose of 150 mg fluconazole with that of a 100-mg clotrimazole vaginal suppository twice a day in the morning and at bedtime for 3 days in the treatment of vulvovaginal candidiasis.
                A single-blind, randomized controlled trial was conducted at Ramathibodi Hospital between June 1 and September 30, 1993.
                There were 53 women in the group treated with fluconazole and 50 in the group treated with clotrimazole. There was no significant difference between the two groups regarding clinical characteristics (age and length of follow-up period). Mycological cure rates approximately 1 week after treatment were 79.2% in the fluconazole group and 80.0% in the clotrimazole group. Approximately 4 weeks after treatment, these rates were 60.4% and 66.0%, respectively. The side effects were minimal and did not warrant any treatment. The differences in the results were not statistically significant.
                We recommend that a single oral dose of 150 mg of fluconazole be given as an alternative method of treating vulvovaginal candidiasis, but the cost is higher than for clotrimazole. A study was carried out to compare 3 treatment regimens for vaginal candidiasis.
                A total of 150 women with clinical and mycological evidence of vaginal candidiasis were randomized to receive 50 mg of oral fluconazole daily for 6 days (50 women), a single oral 150 mg dose of fluconazole (50 women), or 100 mg of intravaginal clotrimazole daily for 6 days (50 women). They were assessed at 5-15 days (short-term assessment) and again at 30-60 days (long-term assessment) after the completion of treatment.
                Candida species were completely eradicated from the vagina in 88% or 80% in the 6-day oral fluconzaole group, 76% or 70% in the single oral fluconazole group, and 72% or 60% in the intravaginal clotrimazole group at short-term or long-term assessment, respectively. The rates of clinical effectiveness were 92% or 88% in the 6-day oral fluconzaole group, 80% or 76% in the single oral fluconazole group, and 72% or 58% in the intravaginal clotrimazole group at the short-term or long-term assessment, respectively. Treatment-related side effects were not found in any group.
                This study suggests that the treatment of vaginal candidiasis with oral fluconazole is effective and that a single oral fluconazole dose might be one choice in the treatment of vaginal candidiasis. Two hundred and thirty-five women with clinically and microbiologically proven candidal vaginitis were randomly allocated for treatment with either one topically applied vaginal tablet of 150 mg econazole (114 women) or one orally administered capsule of 150 mg fluconazole (121 women). The women returned for follow-up visits 7-10, 28-35, and 80-100 days after the recruitment visit. Women with clinical and/or mycological failures and/or a recurrence were successively excluded from the follow-up. At the 28-35-day follow-up visit, the women treated with fluconazole had a significantly higher clinical/microbiological cure rate than those given econazole (P = 0.022; Fisher's exact 2-tail test). No significant such differences were observed at the 7-10 and the 80-100-day follow-up visits, although fluconazole tended to be more efficacious. Nine women administered fluconazole, and 2 women given econazole reported minor systemic side effects of the treatment. Three women out of 4 preferred oral to local therapy of candidal vaginitis. A total of 369 women with clinical and mycological evidence of vaginal candidiasis received treatment, after random allocation, with either a single oral 150-mg dose of fluconazole (188 women) or 200 mg of intravaginal clotrimazole given daily for 3 consecutive days (181 women). They were assessed at 5-16 days and again at 27-62 days after treatment. Candida species were completely eradicated from the vagina in 72% of the fluconazole group and in 62% of the clotrimazole group at the long-term assessment (P = 0.07). Favourable clinical responses were obtained in 99% of the fluconazole group and in 97% of the clotrimazole group at the short-term assessment and in 93% and 84% respectively at the long-term assessment when there was a significant advantage for fluconazole treatment (P = 0.02). Symptoms in patients receiving fluconazole were relieved more rapidly (P less than 0.001). Treatment-related side-effects were few and minor in both groups. It is concluded that treatment of vaginal candidiasis with fluconazole, as a single oral dose, was more effective in the long term, relieved symptoms more rapidly, and was as safe as treatment with intravaginal clotrimazole. Fluconazole is a new oral triazole antifungal with good activity against Candida spp. In this study, we investigated the effectiveness and tolerability of a three-day course of treatment with fluconazole compared with clotrimazole vaginal tablets in nonpregnant women with acute Candida vaginitis. Of the 90 evaluable patients who received fluconazole, 76 (84 percent) were asymptomatic seven to ten days after treatment compared with 84 of 95 (88 percent) treated with clotrimazole. An additional ten patients in the fluconazole group (11 percent) and seven in the clotrimazole group (7 percent) had improvement in their signs and symptoms. Only four patients in each group (4 percent) were considered treatment failures. Mycological cures were obtained in 89 and 93 percent of patients treated with fluconazole and clotrimazole, respectively, seven to ten days posttreatment. Clinical cure rates remained high one month posttreatment: 79 percent in the fluconazole group and 83 percent in the clotrimazole group. Both therapies were well tolerated. One patient discontinued treatment after she developed diarrhea while receiving fluconazole. The most common adverse effects associated with fluconazole use were nausea (six percent) and diarrhea (three percent). No clinically significant laboratory abnormalities were observed. In this investigation, oral fluconazole therapy was found to be as safe and effective as clotrimazole vaginal tablets in women with acute vulvovaginal candidiasis. Community pharmacists have increasing involvement in the self-management of minor illness as a result of the availability of a wider range of over-the-counter (OTC) medicines. We undertook a randomized controlled trial (RCT) to assess the effectiveness and efficiency of educational strategies to implement evidence-based guidelines for the sale of OTC anti-fungals in the community pharmacy setting.
                The aim of the study was to compare the effectiveness and efficiency of two guideline dissemination strategies in community pharmacy settings.
                A 2 x 2 factorial, cluster RCT was conducted with 60 community pharmacies in the Grampian region of Scotland. The interventions included dissemination of an evidence-based guideline for OTC management of vulvovaginal candidiasis (thrush) by postal dissemination (control), educational outreach visit or attendance at a continuing professional education session. Pre- and post-intervention simulated patient visits were made to participating pharmacies. The simulated patients completed assessment forms following each visit. The primary outcome was the appropriateness (based upon the guidelines) of sale or no sale of OTC anti-fungals.
                There were no significant differences in the proportion of appropriate outcomes following educational outreach [odds ratio (OR) = 1.1; 95% confidence interval (CI) 0.52 to 2.45] or continuing professional education (OR = 0.88; 95% CI 0.41 to 1.91).
                Neither strategy was effective in improving the appropriateness of OTC management of vulvovaginal candidiasis by community pharmacy staff. Further research is needed to identify barriers to guideline implementation and evidence-based practice in this setting. Candida vaginitis develops in approximately one-fourth of women in their childbearing years. Conventional management consists of antifungal creams or tablets/suppositories administered intravaginally. Many patients have stated preferences for oral therapy. A randomized, double-blind placebo trial compared the efficacy of a single oral 200 mg dose of fluconazole with the application of terconazole 80 mg vaginal suppository daily for 3 days. Twenty-two patients (fluconazole = 12, terconazole = 10) were evaluated during a four-month period and favorable clinical responses were observed at both early and late evaluations. Mycologic cure was attained by 75% of the fluconazole group and 50% of the terconazole group at the early evaluation. At the late evaluation, mycologic cure was 75% and 100% respectively. The mean time to onset of symptom relief was 2.4 (1.7) days for the fluconazole group and 1.8 (1.8) days for the terconazole group. The mean time to complete relief of symptoms was 6.08 (2.84) and 6.6 (2.95) days respectively. A statistically significant difference did not exist for any of these measures. Seventy-three percent of the patients preferred oral therapy. In a placebo-controlled double-blind study the prophylactic value of oral systemic treatment with the antimycotic agent miconazole was assessed in 30 highly predisposed patients receiving intensive cytostatic chemotherapy because of haematological malignancies. Patients colonized with Candida before treatment were not freed from this micro-organism by miconazole treatment. However, only 3 out of 6 initially non-colonized miconazole-treated patients became colonized during the study, against 10 out of 10 placebo-treated patients (p = 0.036). Seven out of 15 patients in the placebo group developed clinical mycosis, against only two out of 15 in the miconazole group. The miconazole-treated patients remained clinically free of mycosis for 252 out of 264 treatment days, while the placebo-treated patients remained free of mycosis for only 263 out or 338 treatment days (p = 0.0001). The results indicate that systemic miconazole treatment protects highly predisposed patients from colonization with Candida and prevents or postpones clinically established candidosis. Women attending a genitourinary medicine clinic (n = 229) with mycologically confirmed acute vulvovaginal candidiasis were randomised to receive either clotrimazole (500 mg pessary and 1% cream), fluconazole (150 mg single oral dose) or itraconazole (200 mg bd oral dose for 1 day). Mycological cure rates were 96% in the itraconazole group, 95% in the clotrimazole group, and 83% in the fluconazole group (P = 0.008). The proportion of patients who were clinically cured showed a similar pattern (itraconazole 80%, clotrimazole 80%, fluconazole 62%). This suggests that itraconazole or clotrimazole are more effective than fluconazole in the treatment of acute vaginal candidiasis. To compare efficacy, safety and patient preference of a single oral dose of 150 mg fluconazole with a single intravaginal dose of 1200 mg miconazole in vaginal candidosis. To investigate the effect of treatment on Candida colonization of throat and rectum.
                Double-blind, double-dummy, parallel, randomized trial. Ninety-nine patients with symptomatic and mycologically verified candidosis were given 150 mg fluconazole with an intravaginal dummy, or 1200 mg miconazole with an oral dummy. Patients with an inadequate short-term response were given a second dose.
                At each visit a patient self assessment and an investigators' global assessment were recorded, and cultures were set up. Adverse events were recorded and laboratory tests were performed. Clinical cure or improvement (investigators' assessment) was obtained in 100% (short-term) and 95% (long term) of the fluconazole group and in 94% and 90%, respectively, of the miconazole group. Patients considered the treatment excellent or good in 81% (short-term) and 88% (long-term) in the fluconazole group and in 84% and 76%, respectively, of the miconazole group. Mycological cure was achieved in 98% (short-term) and 73% (long-term) of the fluconazole group and in 96% and 82% respectively in the miconazole group. The differences in results were not significant. Both treatments significantly reduced the number of positive rectal cultures: neither treatment had a significant effect on throat cultures. Four percent of the patients preferred intravaginal therapy.
                A single dose fluconazole is as safe and effective as a single dose of miconazole. To compare the clinical and mycological efficacy and patient acceptability of the oral antifungal itraconazole with vaginal clotrimazole in the treatment of vaginal candidosis.
                A multicentre, single-blind, randomised, parallel group comparison of itraconazole and clotrimazole.
                17 Genito Urinary Medicine clinics in UK hospitals.
                Women with symptomatic, culture positive vaginal candidosis.
                Patients were randomly allocated 2 x 100 mg itraconazole capsules to be taken twice in a 24 hour period, or a 500 mg clotrimazole vaginal tablet. Clinical and mycological assessments were made at entry and after approximately seven and 35 days.
                Cure rate was defined in terms of mycological results, and patients were questioned on their opinion of treatment.
                Of 214 patients, 109 received itraconazole and 105 clotrimazole with similar improvement in clinical signs and symptoms. Mycological cure rates one week after treatment were obtained in 72 of 97 patients (74%) in the itraconazole group and 64 of 89 patients (72%) in the clotrimazole group. Identical mycological cure rates six weeks after treatment were obtained with 40 of 79 patients (51%) receiving itraconazole and 39 of 78 patients (50%) receiving clotrimazole.
                Clotrimazole and itraconazole were found to be equally effective. A majority of patients receiving the latter preferred it to previous treatments. Vaginal candidiasis (VC) is a common concern for women living with HIV infection. The authors evaluated the effectiveness of two self-care approaches to prophylaxis of VC among HIV-infected women, weekly intravaginal application of Lactobacillus acidophilus or weekly intravaginal application of clotrimazole tablets, in a randomized, double-blind, placebo-controlled trial. VC was defined as a vaginal swab positive for Candida species in the presence of signs/symptoms of vaginitis and the absence of a diagnosis of Trichomonas vaginalis or bacterial vaginosis. Thirty-four episodes of VC occurred among 164 women followed for a median of 21 months. The relative risk of experiencing an episode of VC was 0.4 (95% CI = 0.2, 0.9) in the clotrimazole arm and 0.5 (95% CI = 0.2, 1.1) in the Lactobacillus acidophilus arm. The estimated median time to first episode VC was longer for clotrimazole (p = .03, log rank test) and Lactobacillus acidophilus (p = .09, log rank test) compared with placebo. Vaginal yeast infections can be prevented with local therapy. Education about self-care for prophylaxis of VC should be offered to HIV-infected women. The effect of antifungal therapy on the vaginal microbial flora was studied in 23 patients suffering from culture-positive, symptomatic vaginal candidosis. They were randomly allocated to receive either a 500 mg clotrimazole vaginal pessary or a 150 mg fluconazole capsule. Quantitative microbiological examination was carried out on samples of vaginal secretions obtained prior, and at intervals up to 10 days after, treatment. No significant difference was found in the vaginal flora before or after therapy in individual patients or between the treatment groups. In patients with C glabrata or C krusei, the yeasts persisted longer in the vagina with poorer response to either of the medications.
No statistically significant differences were observed in clinical cure rates of anti-fungals administered by the oral and intra-vaginal routes for the treatment of uncomplicated vaginal candidiasis. No definitive conclusion can be made regarding the relative safety of oral and intra-vaginal anti-fungals for uncomplicated vaginal candidiasis.
The decision to prescribe or recommend the purchase of an anti-fungal for oral or intra-vaginal administration should take into consideration: safety, cost and treatment preference. Unless there is a previous history of adverse reaction to one route of administration or contraindications, women who are purchasing their own treatment should be given full information about the characteristics and costs of treatment to make their own decision. If health services are paying the treatment cost, decision-makers should consider whether the higher cost of some oral anti-fungals is worth the gain in convenience, if this is the patient's preference.