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Cited by 48Reproductive tract infections researchAntifungal resistance and susceptibilityUrinary Tract Infections Management

Treatment for recurrent vulvovaginal candidiasis (thrush)

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Cooke, Georga, Watson, Cathy, Deckx, Laura, Pirotta, Marie, Smith, Jane, van Driel, Mieke L·2022·Cochrane Database of Systematic Reviews
DOI 10.1002/14651858.cd009151.pub2PMC PMC8744138
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Abstract

BACKGROUND: Recurrent vulvovaginal candidiasis (RVVC) affects up to 5% of women. No comprehensive systematic review of treatments for RVVC has been published. OBJECTIVES: The primary objective was to assess the effectiveness and safety of pharmacological and non-pharmacological treatments for RVVC. The secondary objective was to assess patient preference of treatment options. SEARCH METHODS: We conducted electronic searches of bibliographic databases, including CENTRAL, MEDLINE, Embase, and CINAHL (search date 6 October 2021). We also handsearched reference lists of identified trials and contacted authors of identified trials, experts in RVVC, and manufacturers of products for vulvovaginal candidiasis. SELECTION CRITERIA: We considered all published and unpublished randomised controlled trials evaluating RVVC treatments for at least six months, in women with four or more symptomatic episodes of vulvovaginal candidiasis in the past year. We excluded women with immunosuppressive disorders or taking immunosuppressant medication. We included women with diabetes mellitus and pregnant women. Diagnosis of RVVC must have been confirmed by presence of symptoms and a positive culture and/or microscopy. We included all drug and non-drug therapies and partner treatment, assessing the following primary outcomes: • number of clinical recurrences per participant per year (recurrence defined as clinical signs and positive culture/microscopy); • proportion of participants with at least one clinical recurrence during the treatment and follow-up period; and • adverse events. DATA COLLECTION AND ANALYSIS: 40-70%). We used the GRADE tool to assess overall certainty of the evidence for the pooled primary outcomes. MAIN RESULTS: Studies: Twenty-three studies involving 2212 women aged 17 to 67 years met the inclusion criteria. Most studies excluded pregnant women and women with diabetes or immunosuppression. The predominant species found on culture at study entry was Candida albicans. Overall, the included studies were small (<100 participants). Six studies compared antifungal treatment with placebo (607 participants); four studies compared oral versus topical antifungals (543 participants); one study compared different oral antifungals (45 participants); two studies compared different dosing regimens for antifungals (100 participants); one study compared two different dosing regimens of the same topical agent (23 participants); one study compared short versus longer treatment duration (26 participants); two studies assessed the effect of partner treatment (98 participants); one study compared a complementary treatment (Lactobacillus vaginal tablets and probiotic oral tablets) with placebo (34 participants); three studies compared complementary medicine with antifungals (354 participants); two studies compared 'dermasilk' briefs with cotton briefs (130 participants); one study examined Lactobacillus vaccination versus heliotherapy versus ciclopyroxolamine (90 participants); one study compared CAM treatments to an antifungal treatment combined with CAM treatments (68 participants). We did not find any studies comparing different topical antifungals. Nine studies reported industry funding, three were funded by an independent source and eleven did not report their funding source. Risk of bias: Overall, the risk of bias was high or unclear due to insufficient blinding of allocation and participants and poor reporting. Primary outcomes: Meta-analyses comparing drug treatments (oral and topical) with placebo or no treatment showed there may be a clinically relevant reduction in clinical recurrence at 6 months (RR 0.36, 95% CI 0.21 to 0.63; number needed to treat for an additional beneficial outcome (NNTB) = 2; participants = 607; studies = 6; I² = 82%; low-certainty evidence) and 12 months (RR 0.80, 95% CI 0.72 to 0.89; NNTB = 6; participants = 585; studies = 6; I² = 21%; low-certainty evidence). No study reported on the number of clinical recurrences per participant per year. We are very uncertain whether oral drug treatment compared to topical treatment increases the risk of clinical recurrence at 6 months (RR 1.66, 95% CI 0.83 to 3.31; participants = 206; studies = 3; I² = 0%; very low-certainty evidence) and reduces the risk of clinical recurrence at 12 months (RR 0.95, 95% CI 0.71 to 1.27; participants = 206; studies = 3; I² = 10%; very low-certainty evidence). No study reported on the number of clinical recurrences per participant per year. Adverse events were scarce across both treatment and control groups in both comparisons. The reporting of adverse events varied amongst studies, was generally of very low quality and could not be pooled. Overall the adverse event rate was low for both placebo and treatment arms and ranged from less than 5% to no side effects or complications. AUTHORS' CONCLUSIONS: In women with RVVC, treatment with oral or topical antifungals may reduce symptomatic clinical recurrences when compared to placebo

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Research works printed but not linked: 10

  1. Fardyazar Z, Habibzadeh S. Long term vaginal azoles versus prophylactic oral fluconazole in treatment of recurrent vulvovaginal candidiasis. Research Journal of Biological Sciences 2007;2(6):663-6.
  2. Lopez-Olmos 2000 {published and unpublished data} Lopez-Olmos J, Lerma E. Treatment of recurring vulvo-vaginal candidiasis: a comparative prospective study during six months of three anti-mycotic preparations of a single dosis. Clinica e Investigacion en Ginecologia y Obstetricia 2000;27:366-75.
  3. Mendling 2011 {published data only} Mendling W, Birkner V. Vaccination with inactivated lactobacilli or heliotherapy can improve the quality-of-life of women with chronic recurrent vulvovaginal candidosis a prospective randomized study [Die Vakzination mit inaktivierten Laktobazillen oder mit Heliotherapie kann die Lebensqualitat von Frauen mit rezidivierender vulvovaginaler Kandidose verbessern -Eine prospektive 3-armige randomisierte Studie]. Geburtshilfe und Frauenheilkunde 2011;71(9):767-72.
  4. Metts J, Famula TR, Trenev N, Clemens RA. Lactobacillus acidophilus, strain NAS (H2O2 positive), in reduction of recurrent candidal vulvovaginitis. Journal of Applied Research 2003;3:340-8.
  5. Roth AC, Milsom I, Forssman L, Wahlen P. Intermittent prophylactic treatment of recurrent vaginal candidiasis by postmenstrual application of a 500 mg clotrimazole vaginal tablet. Genitourinary Medicine 1990;66:357-60.
  6. Deeks JJ, Higgins JPT, Altman DG, editor(s). Chapter 9: Analysing data and undertaking metaanalyses. In: Higgins JPT, Churchill R, Chandler J, Cumpston MS, editor(s). Cochrane Handbook for Systematic Reviews of Interventions Version 5.2.0 (updated June 2017). Cochrane, 2017. Available from www.training.cochrane.org/handbook.
  7. Lopez JEM. Candidiasis (vulvovaginal). BMJ Clin Evid 2013;3:0815.
  8. Review Manager 2014 [Computer program] Nordic Cochrane Centre, The Cochrane Collaboration Review Manager 5 (RevMan 5). Version 5.3. Copenhagen: Nordic Cochrane Centre, The Cochrane Collaboration, 2014.
  9. controlled NEAR/7 (study OR design OR trial)):ti,ab 391,000 37. volunteer:ti,ab OR volunteers:ti,ab 262,747 38. trial:ti 346,345 39. human experiment'/de 557,732 (Continued) Treatment for recurrent vulvovaginal candidiasis (thrush) (Review) Copyright © 2022 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. Search strategy (results) 1. exp Candidiasis, Vulvovaginal/ (333) 2. exp Candida/ (444) 3. exp Candidiasis/ (958) 4. candid*.tw. (20077)
  10. exp Secondary Prevention/ (20479) Treatment for recurrent vulvovaginal candidiasis (thrush) (Review) Copyright © 2022 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. Cochrane Database of Systematic Reviews 20. exp Chemoprevention/ (20280)

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Authors
Cooke, G., Watson, C., Deckx, L., Pirotta, M., Smith, J., & van Driel, M. L.
Affiliations
  • The University of Queensland (AU)
  • The University of Melbourne (AU)
  • Bond University (AU)
  • Primary Care Clinical Unit, Faculty of Medicine; The University of Queensland; Brisbane Australia
ORCID
Venue
Cochrane Database of Systematic Reviews
Publisher
Wiley
Published
2022-01-10
Volume
2022
Issue
1
Pages
CD009151-CD009151
ISSN
  • 1361-6137 (ISSN-L)
  • 1465-1858
DOI
10.1002/14651858.cd009151.pub2
PMC
PMC8744138
OpenAlex
W4205691527
Cited by
48
References
86
Citations by year
2026: 6 · 2025: 7 · 2024: 18 · 2023: 11 · 2022: 6
FWCI
1.38
Type
journal article
Language
en
Open access
Locations
  • Cochrane Database of Systematic Reviews (publishedVersion)
  • PubMed Central (publishedVersion)
  • PubMed (publishedVersion)
  • Bond University Research Portal (Bond University) (submittedVersion)
  • Minerva Access (University of Melbourne) (submittedVersion)
Topics
  • Life Sciences › Immunology and Microbiology › Microbiology › Reproductive tract infections research
  • Health Sciences › Medicine › Infectious Diseases › Antifungal resistance and susceptibility
  • Health Sciences › Medicine › Epidemiology › Urinary Tract Infections Management
Keywords
recurrent vulvovaginal candidiasis, candidiasis, antifungal therapy, oral antifungal agents, topical antifungal agents, partner treatment, probiotics, recurrence prevention, treatment safety, patient preferences, Candida albicans, non-pharmacological treatment, treatment duration, dosing regimen, pregnancy, diabetes mellitus
MeSH terms
Antifungal Agents, Candidiasis, Oral, Candidiasis, Vulvovaginal, Female, Humans, Immunosuppressive Agents, Pregnancy

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