Fluconazole treatment sub-optimal for recurrent thrush

Current treatment regimes have high relapse rates and there is a need for more effective alternatives, say GP researchers

Recurrent vulvovaginal candidiasis (aka “thrush”) is a challenging gynaecological infection that many women and healthcare practitioners struggle with, say the authors of a new review article in the Australian and New Zealand Journal of Obstetrics & Gynaecology.

Affecting 5-8% of women of reproductive age, recurrent thrush (defined as four or more episodes in 12 months) can affect quality of life, causing symptoms such as itching and soreness, painful sexual intercourse, discomfort when urinating, and abnormal discharge.

It can be associated with frequent use of antibiotics, use of the oral contraceptive pill, immunocompromised states and hyperglycaemia. 

Professor Danielle Mazza and Alexia Matheson from the Department of General Practice at Monash University conducted a review of the current guidelines, in order to develop a summary of recommendations to assist in the management of women with this condition.

They found the regimen suggested by most guidelines (fluconazole weekly for six months) is not particularly effective – only 42.9% of patients are disease free after 12 months.

Some guidelines stated that results were comparable between fluconazole, clotrimazole and ketoconazole.

Another offered boric acid inserts as an appropriate maintenance alternative, with rates of relapse up to 54.5% after six months.

An alternative regimen put forward by one of the guidelines cites a 77% cure rate after 12 months, however this involved a year-long process of gradually weaning down oral fluconazole to provide remission.

A 2011 RACGP survey also found fluconazole was the most common medication prescribed in the sample of health professionals.

However, the doses prescribed varied widely – for example, some clinicians prescribed 50 mg per week, others 150 mg per day for up to 3 weeks. Others treated with longer term doses, either weekly or monthly, and some used decreasing doses.

The difficulty in management of recurrent thrush is reflected in the wide variation of practice of health professionals surveyed, concluded the RACGP study.

The Monash researchers also found that, in general, most guidelines they studied lacked specific recommendations and were of mixed quality.

“The current most recommended treatment of recurrent vulvovaginal candidiasis is sub-optimal,” the researchers argue.

“International guidelines for the treatment of recurrent thrush are consistent. However, the suggested treatments are not particularly effective and a majority of women relapse following the prescribed therapy.

“Despite most guidelines agreeing on six months of oral anti-fungals as the appropriate treatment, the results from this regimen are disappointing.

“Studies performed on a larger scale are required to identify more effective treatments.”

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