Candidiasis | NZ STI Guidelines

Candidiasis is an infection with Candida species, caused by an overgrowth of the organisms often present in small amounts in the genital tract
Pathogenesis is unclear but there is likely to be a combination of genetic and immune factors
Asymptomatic people do not require treatment
Not considered to be a sexually transmitted infection (STI)
There is often no obvious cause, however risk factors include:
- Antibiotic use (within past 3 months)
- Poorly controlled diabetes
- Increase in oestrogen, either exogenous or endogenous (including pregnancy, menopausal hormone therapy and possibly combined oral contraception)
- Skin conditions e.g. eczema or dermatitis
- Immunosuppression
Although not specifically recognised as risk factors, people with recurrent candidiasis may benefit from avoidance of perfumed products and tight clothing that promotes excessive sweating e.g. wetsuits, synthetic underwear
Approximately 75% of women will experience at least one lifetime episode; less than 5% will have recurrent candidiasis (defined as 4 or more symptomatic episodes within 12 months)
Candida may cause balanitis, especially if uncircumcised

Site of infection	Signs and symptoms
Vulvovaginal	White ‘curd like’ vaginal discharge although discharge can appear normal Genital or vulval itch, discomfort Superficial dyspareunia External dysuria Excoriation, erythema, fissures, swelling
Penile	Red rash on genitals, especially under foreskin, may or may not be itchy Swelling of foreskin if severe Fissures Superficial erosions

Vulvovaginal

Examination is recommended for thorough assessment as symptoms of candidiasis are non-specific and may be due to other conditions such as dermatitis or genital herpes
Self-collected swabs can be obtained if examination is declined, but this is not recommended
STIs may cause symptoms similar to those of candidiasis. Unless STIs have been excluded, testing should occur as part of a full sexual health check
Recurrent candidiasis (4 or more symptomatic episodes in 12 months) should be confirmed by culture or microscopy on at least 2 occasions, before considering suppressive therapy

Test	Consideration
High vaginal swab for Candida and bacterial vaginosis (BV)	Clinical details must be included on laboratory form to ensure sample is processed appropriately BV is another common cause of unusual vaginal discharge
Consider
Vulvovaginal NAAT swab for chlamydia, gonorrhoea and trichomoniasis	If examined, vaginal swab should be taken before speculum insertion Symptoms and signs of candidiasis may be similar to other genital infections, including STIs
HIV and syphilis serology	If STI screening is indicated

NAAT – Nucleic Acid Amplification Test

Penile

Examination is recommended for thorough assessment as symptoms of candidiasis are non-specific and may be due to other conditions such as dermatitis or genital herpes
Usually diagnosed based on signs and symptoms
Unless STIs have been excluded, testing should occur as part of a full sexual health check
People with confirmed recurrent candida balanitis should be screened for diabetes, and the status of their sexual partner(s) should be discussed (often occurs in the context of untreated recurrent vulvovaginal candidiasis in the partner)

Test

Consideration

Culture swab

Culture for yeast

May be negative in cases that respond to empiric therapy

Treatment is indicated in symptomatic people only
Topical and oral azoles have a similar efficacy
Recurrent candidiasis (4 or more symptomatic episodes in 12 months) should be confirmed by culture or microscopy on at least 2 occasions, before considering suppressive therapy
If breakthrough symptoms on suppressive therapy occur, confirm ongoing candida before changing treatment regimen. Request culture swab for speciation and sensitivities, and write ‘breakthrough symptoms while on suppressive therapy’ on the request form

Situation	Recommended	Alternative
Acute candidiasis	Vulvovaginal
	Clotrimazole 2% vaginal cream, one vaginal applicator every night for 3 days OR Fluconazole 150 mg orally, as a single dose	Nystatin vaginal cream, one applicator 1-2 times daily for 2 weeks OR Miconazole 2% vaginal cream, one vaginal applicator every night for 7 days
	Penile
	Clotrimazole 1% topical cream twice daily for 5-7 days	Miconazole 2% topical cream twice daily for 5-7 days
Recurrent vulvovaginal candidiasis	Induction with fluconazole 150 mg orally, every 72 hours for 3 doses, followed by maintenance with fluconazole 150 mg orally, weekly for 6 months	Clotrimazole 2% vaginal cream one vaginal applicator every night for 3 days. Repeat every month for 6 months
Recurrent vulvovaginal candidiasis due to non-albicans species or resistant C. albicans	Seek specialist advice	Seek specialist advice

Other management

Avoid local irritants e.g. soaps, bath oils, body washes, bubble baths, spermicides, vaginal lubricants, vaginal hygiene products
Soap substitute for washing e.g. Sorbolene, Cetaphil, QV
Latex condoms, diaphragms and cervical caps can be damaged by antifungal vaginal creams
Sexual partners only require treatment if symptomatic
No strong evidence that specific diets or the use of probiotics influence the recurrence of candidiasis

Special Situations

Situation	Recommendation
Breastfeeding	As above
Pregnancy	Fluconazole contraindicated May need longer course of topical treatment
Allergy or contraindications	Try alternative treatment