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Pharm 446 Final > Vaginal & Oral Candidiasis > Flashcards

Vaginal & Oral Candidiasis Flashcards

1
Q

What is the normal vaginal pH?

A

3.5-5.5
* pH normally acidic –> when outside this range, may see diff organisms.

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2
Q

Red flags for vaginal sx?

A

Red flags:
- Weird discharge (any color but not clear or whitish).
- fishy odor –> Yeast infections typically don’t cause any noticeable vaginal odors, which sets them apart from other vaginal infections.

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3
Q

What are the 3 most common causes of vaginal infections charcterized by discharge and Vulvovaginitis [inflammation or irritation of the vagina and vulva]?

A

Know there are other causes of vaginitis:
Bacterial Vaginosis, Trichomoniasis and Vulvovaginal candidiasis (yeast infeciton).

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4
Q

What sx differentiate Yeast infection from Lactobacillosis?

timing?
- mimicks what ?

A
  • ITCHY vagina/vulva, burning (mimicks uti), pH 3.5-5.5, discharge: whitish-yellow.
  • Timing: peaks shortly before period.
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5
Q

Waht is Lactobacilosis?

A

Lactobacillosis, also known as vaginal lactobacillosis or bacterial vaginosis, is a type of vaginal infection caused by an imbalance in the normal bacterial flora of the vagina.

Normally, the vagina is home to a mixture of bacteria, including lactobacilli, which help maintain a healthy pH and prevent overgrowth of harmful bacteria. However, in cases of lactobacillosis, the balance of these bacteria is disrupted, and there is an overgrowth of other types of bacteria, such as Gardnerella vaginalis and Mycoplasma hominis.

This imbalance can lead to symptoms such as vaginal discharge, itching, and a foul odor. Although the exact causes of lactobacillosis are not fully understood, factors such as sexual activity, the use of certain contraceptives, and douching may increase the risk of developing this condition.

Treatment for lactobacillosis typically involves antibiotics, such as metronidazole or clindamycin, to help restore the normal bacterial balance in the vagina.

NOte: Lactobacilli= normal in vaginal wall as well as candida. Only become problem when they become OVERGROWN.

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6
Q

What are the hallmark symptoms of a yeast infeciton? 3

A

○ ITCHING, BURNING (raw skin, irritation), and and COTTAGE CHEEESE discharge (Hallmark sign***)).

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7
Q

What sx differentiate Yeast infection from Bacterial Vaginosis?

  • pH?
  • odor?
  • discharge appearnace ?
  • most common cause?
A
  • pH: > 4.5 (more basic) [5-6
  • FISHY ODOR
  • DISCHARGE: creamy and yellow-grey*
  • polymicrobial inf.
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8
Q

What sx differentiate Yeast infection from Trichomoniaiss?

  • discharge appearance?
  • how transmited?
  • PH?
A
  • Frothy, wet discharge*.
  • **sexually transmitted
  • possibly itchy, pH > 6
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9
Q

What organism causes yeast infections?

A

Candida albicans most common (80-92%) but other species possible.

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10
Q

what percentage of women will get a yeast infeciton in their lifetime?

A

75% v common.

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11
Q

are yeast infections sexually transmitted?

A

no, but frequency incr sig after becoming sexually active, and doing oral sex.

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12
Q

What are the characterisitcs fo UNCOMPLICATED VVC?

  • frequency?
  • severity?
  • sp.?
  • medical conditions?
A
  • sporadic/infrequent
  • mild-mod sx
  • candida ALBICANS swabbed (not a funky sp.)
  • non immunocompromised .
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13
Q

What are the characterisitcs for COMPLICATED VVC?

  • frequency?
  • severity?
  • sp.?
  • medical conditions?
A
  • recurrent (4+ episodes/yr)
  • SEVERE sx (really bad, unbearable).
  • non albicans spp.
  • immunocomporomised.
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14
Q

What are predisposing factors for yeast infection?

  • what medical state? (3)
  • what meds/otcs? ( 3)
  • What 2 lifestyle factors?
  • diet?
  • what type of clothign? (2)
A

Pregnancy
● Diabetes mellitus
● Immunocompromised conditions

● Medications (antibiotics, corticosteroids, chemotherapy, hormone therapy,
oral contraceptives, levonorgestrel intrauterine systems, tamoxifen),
contraceptive agents (spermicides change pH, sponge, diaphragm)
● Chemical irritants (antiseptics, deodorants, sprays, soaps), douching–> DO NOT RECOMMEND VAGISIL**.

● Diet (excess refined carbohydrates) –> NO SOLID LINK, but can consider.

● Stress
● Active* Menses

● Synthetic undergarments (recommend cotton).
● Tight-fitting clothing

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15
Q

What are the red flags for referral for vaginal sx? (6)

  • ____ women.
  • below what age?
  • presenting for ___ ….
  • recurrence ?
  • udnerlying conditions (2)?
  • risk of after ______ hx?
A
  • Pregnant individuals
    ● Prepubertal: < 12 cuz VVC not common.
    ● **PRESENTING with vaginal symptoms for FIRST TIME–> send to a GP for TESTING to make sure we’re treating the right thing. Know which clinics to refer to (i.e. walk in, sti clinic).
    ○ If they have been DX IN THE PAST, and those sx align with what they had last time (2 yrs ago), you have the go ahead to treat with self-care. But if they havent seen a doc, REFER!

● Recurrence of VVC within **2 months of last episode
● Immunosuppressed
● Underlying illness such as diabetes –> incr risk with SGLT2 I –> don’t need to refer these ppl all the time. Use judgement.

● Risk of STI (e.g., history of unprotected intercourse, multiple
partners, casual sexual encounters) –> After sexual hx, if you think they could be at risk for an STI, REFER to rule out any other infection.

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16
Q

What are the TRX options for yeast infecitons?

  • Brand name and dosage form for:
  • clotrimazole
  • miconazol
  • fluconazol
  • terconazole
  • boric acid come sin what form only?
A

1) AZOLE Antifungals (PO or topical): eg/ Clotrimazole (Canesten), miconazole (monistat- Vaginal only (vag ovule or cream), fluconazole (Diflucan or CanesORal), terconazole.

2) OTC Antifungal creams: eg/ Clotrimazole (Canesten topical) and Miconazole (Monistat).

3) Rx antifungals: Terconazole (Terazole - vaginal cream)

4) Vaignal supositories: borica acid (vaginal capsule ONLY).

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17
Q
A

CanesOral: Fluconazole 150 mg

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18
Q

What are the goals of trx for yeast inf?

A

● Relieve symptoms
● Cure the infection
● Prevent recurrence
● Prevent misdiagnosis and delayed treatment

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19
Q

What are some non pharm counselling points for yeast infections?

  • what is the main purpose of non pharm in yest inf?

● Good _____
● Avoid what products?
● Avoid what type of clothing?
● ?Dietary modifications have any effect?

A
  • to PREVENT RECURRENCE rather than trx.

● Good hygiene
● Avoid vaginal deodorants, douches, harsh soaps and perfumed
products
● Avoid tight clothing and synthetic underwear
● not rlly, but no harm. ?Dietary modifications (ie. yogurt with lactobacillus - inconsistent
results in studies, yeast or sugar free diets - no data)

19
Q

What are some non pharm counselling points for yeast infections?

  • what is the main purpose of non pharm in yest inf?

● Good _____
● Avoid what products?
● Avoid what type of clothing?
● ?Dietary modifications have any effect?

A
  • to PREVENT RECURRENCE rather than trx.

● Good hygiene
● Avoid vaginal deodorants, douches, harsh soaps and perfumed
products
● Avoid tight clothing and synthetic underwear
● not rlly, but no harm. ?Dietary modifications (ie. yogurt with lactobacillus - inconsistent
results in studies, yeast or sugar free diets - no data)

20
Q

Is there any diff btnw PO vs Vaginal/topical Antifungal trx for VVC? what abotu btwn azole agents?

A

nope! both equally effective, and PO does not speed cure. only convenience. Should resolve in max 7 days. May consider topical for pregnant pts.

  • no diff btwn azoles.
21
Q

What are the 2 IMIDAZOLES available as NON-RX trx in Canada?

A

Clotrimazole (Canesoral (fluconazole), vaginal cream (Clotrimazole)) and Miconazole ( Monistat (Vaginal only - cream or ovule).

22
Q

What is the only TOPICAL PRESCRIPTION PRODUCT?

A

TERCONAZOLE (0.4 % vaginal cream).

23
Q

What is hte one non-Rx PO option?

A

Fluconazole (Diflucan One, Canes Oral, generics)

24
Q

What are the 3 dosing regimens for Canesten?

  • for 1% cream?
  • 2% cream? 200 mg PO?
  • 10% cream? 500 mg PO?
  • days of admin? (3)
A

Dosing options:

  • 1% cream x 6 nights (admin b/o bed!!!!)
  • 2% cream or 200 mg tabas x 3 nights
  • 10% cream or 500 mg tab x 1 night.
  • topical cream (1%) - use prn.
  • Canesten options: 1,3, or 6 days.
25
Q

Vaginal antifungals shoudl be taken when?

A

right before bed.

26
Q

What are the 3 dosing regimens for Monistat?

  • for 2% cream/1000 mg ovule?
  • 4% cream/ 400 mg ovule?
  • 12oo mg ovule?
  • days of admin? (3)
A

2% cream/100 mh ovule x 7 nights
4% cream / 400 mg ovule x 3 nights
1200 mg ovule x 1 night

Monistate 3/7 dual pack : includes PV ovule and cram.

  • options: 1,3 or 7.
27
Q

What are some common AE FROM TOPICAL antifungals?

  • strategy to alleviate?
A

Common = burning, redness, irritation, stinging and itching

Switching brands may alleviate this side effect

28
Q

What is the BBW for Terconazole?

A

Anaphylaxis and
toxic epidermal necrolysis (TEN). Therapy should be discontinued if anaphylaxis
or TEN develops

{think: TER for TEN}

29
Q

What are some possible interactions with TOPICAL AZOLES?

  • possible interaction with miconazole and what?
  • TOPICAL azoles should not be combined with what 2 things? (vag. med, non pharm).

-

A
  • Possible interaction w/ miconazole and warfarin–> May increase INR (monitor for bleeding or switch to
    clotrimazole)

● Topical Imidazoles + vagainal progesterone capsule –> may diminish effects of vaginal progesterone -avoid concomitant use

● Ovules diminish effectiveness of condoms & diaphragms (ovulees degrade condoms).

30
Q

What pt education should you provide REGARDING TOPICAL ANTIFUNGALS?

  • specify what most importantly (freuqency)?
  • can they take while on their period?
  • avoid ?
  • Educate on?
  • Vulva sx?
  • apply WHEN?
A

● Must be used for the specified number of days, consecutively (SPECIFY WHETHER ITS A 1, 3 OR 7 DYA TRX).

● If on period, CONTINUE TO TAKE.

●AOVID TAMPONS w/ topical treatment
○ Potentially absorbs medication
○ Provides a hospitable environmental medium for fungus to grow on\

● Educate how to use Applicator for intravaginal creams/tabs/ovules

● If vulvar symptoms significant – can apply to vulva and outer areas. if vulva fine, don’t need to apply cream thee.

● Applied at bedtime to increase contact time

31
Q

What is the usual does of Fluconazole/Canesoral?

  • most common AE? know for osce
A

150 mg PO x 1 dose.
- AE: N/V, diarrhea, cramping, headache.

  • yes, avialble as singel tbalet or combo packate iwth clotrimazole crema.
32
Q

Why is TOPICAL FLUCONAZOLE preffered over PO in pregnancy?

A

Cuz assoc with incr risk of SPONTANEOUS ABORPTION, cardiac septal closure abnormalities. Hence recommend topical.
But note, there’s still mixed messaging.

33
Q

How is SEVERE yeast infections treated differnetly?

  • for both po and topical trx?
A
  • fluconazole 150 mg BID x 2 doses instead 1.
  • vaginal product –> duration extends to 10-14 days.
  • basically duration is doubled*
34
Q

When should sx be gone for VVC?

A

max 7 days. If sx persist or get worse, refer.

35
Q

Is conventional antifgunal therapy as effecfive on non-albicans candida spp>

A

no! need something else.

36
Q

what is INDUCTION TRX for RECURRENT VVC? (2 meds)

  • key is adding what med?
  • Is BORIC ACID safe in PRGNANCY?
A

Fluconazole or intravaginal azole + boric acid** (main difff) .

● Fluconazole 150 mg po once every 72 hours x 3 doses
○ Efficacy 92%
○ Should be avoided in pregnancy where possible

OR

● Topic azole x 10-14 days
○ Ex - clotrimazole × 7–14 days to achieve mycologic remission

PLUS
Boric acid 300-600 mg gelatin capsule intravaginally once daily
for 14 days.

● Contraindicated in pregnancy
● Efficacy 80%
● Local irritation, vaginal burning; more pronounced with
higher dose.
Compounded product - boric acid in gelatin capsule

37
Q

what is MAINTENANCE TRX for RECURRENT VVC?

  • what is min duration? of trx?
A

● Fluconazole 150 mg po once weekly. Recurrence occurred in 10%
while receiving therapy.

● Clotrimazole 500 mg intravaginally once a month.

● Boric acid 300 mg capsule intravaginally for 5 days each month; start
1st day of cycle. Recurrence 30%

Maintenance therapy duration: minimum 6 months

38
Q

Are probiotics improve clinical cure or reduce occurance?

A

not really- evidence says no, but no harm.

39
Q

What are the MEDICATION-realted RFs for ORAL THRUSH?

A

○ Broad spec abx
○ Chemo
- Inhaled ICS inhalers
- immunosuppresive durgs.

40
Q

How does thrush presnt?

  • What is the classic marker for thrush? Is the white stuff easily wiped away?
A

Classic presentation – white plaque on tongue,
buccal mucosa, hard palate, soft palate and
oropharynx

● Typically asymptomatic

● Symptomatic patients may have burning sensation or changes in taste

● Classic marker – easy to wipe off plaques leaving
behind erythematous surface
Clin Dermatol. 2016

41
Q

What is first line therapy for thrush?

  • how is nystatin adminsitered?
A

Topical nystatin oral suspension:

○ Adults: 400 000-600 000 (~4-6 mL of 100,000 unit suspension) units 4 times daily
(swish and swallow) x 7-14 days

○ Infant thrush: 100 000 units (1mL) in each side of mouth QID x 7–14 days

■ In breastfeeding infant, consider topical treatment of nipple (clotrimazole,
nystatin, miconazole - but lacks safety data. Refer for assessment of latching
and possible dual therapy.

○ Used commonly for initial episodes and mild cases
○ Well tolerated, no clinically significant interactions (minimal absorption from GI tract)

42
Q

What is second line therapy for thrush?

  • why is it 2nf line?
A

Fluconazole 100-200 mg PO daily x 7-14 days

○ 2nd line due to azole-resistant Candida strains
○ For moderate to severe disease

○ Preventive therapy for recurrent infections.
■ 100mg 3x/wk PO * HIV-infected patients
■ 100mg daily or 3x/weekly PO (Drug of choice

43
Q

How Would you counsel on NYSTATIN SUSPENSION? oSCKE.

  • step 1?
  • swallow?
  • do not eat/drink for how long after?
  • when can they brush their teeth affter taking and why?
  • avoid concomittent use with wht product?
A

Shake the bottle well before you measure each dose.

● Swish nystatin around your mouth and then swallow the liquid. Retain in mouth for as long as possible (ie. several
minutes if possible)

● Do not eat or drink anything for 5-10+ minutes after each
dose.

● Try to brush your teeth 20 to 30 minutes after taking
nystatin, as it contains sugar. Brush your teeth at least twice a day, especially before going to bed.

● Avoid concomitant topical use with chlorhexidine (exdenture wearers) as will negate effect of nystatin –> MUST space!!

44
Q

What Monitoring advicce to give for oral thrush?

  • when should sx improve?
  • monitor daily for how long?
A

Improvement in signs and symptoms within 48-72 hours

● Monitor patients at risk of recurrence (e.g., antibiotic use, etc)

● Once antifungal treatment is initiated, advise the patient to
monitor symptoms on a daily basis during treatment and for
up to 2 weeks after clearing of symptoms to ensure the
infection has completely resolved.

45
Q

Vaginal Candidiasis monitoring:

Efficacy:
- When should symptoms resolve after starting treatment?

safety:
- most common a/e with topical azole?
- 3-4 commone a/es with oral fluconazole?

A
  • 7 days since beginning treatment. Refer if no improvement or worsening within those 7 days.

Safety:
- most common a/es with topical azole: local hypersensitivity (redness, irritation)
- a/es w/ oral fluconazole: headache, nausea, abdominal pain, diarrhea

46
Q
A

Pharm 446 Final (9 decks)

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