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The management of persistent thrush in primary care

 

One of the common problems that nurses in primary care have to deal with in sexual health or triage is that of recurrent or persistent thrush. This condition is one which causes women a great deal of discomfort and embarrassment, leading them to self-manage the condition with

over-the-counter products or alternative treatments.1 The result may be poorly-managed thrush, resulting in persistent or recurring infections. It is thought that uncomplicated vulvovaginal candidiasis or thrush affects 75% of women at least once during their lifetime.2,3 The Health Protection Agency (HPA) suggest the figure is slightly higher at 80%.4 Of this number, 10-20% of women are thought to be asymptomatic.5

Causative factors

Thrush is caused by a fungal infection. There are thought to be at least 100 different species of candida fungi and at least 200 strains but the main causative organism for vaginal thrush is candida albicans. Other common causative organisms are C glabrata, C trophicalis, C keyr, C guillermondi and sacharomyces cerevisiae.6

Signs and symptoms

Thrush has a variety of key symptoms. The commonest of these may include vulval itching, burning and soreness that can occur more at night, and a thick white/cheese-like purulent discharge which can be described to have a cottage-cheese like consistency.

severe symPtoms

In addition to the above symptoms, patients may also experience inflammation (erythema) of the vagina and vulva that may extend to the labia minora or majora and perineum. The tissue may crack and bleed resulting in sores in the surrounding area that can eventually lead to fissuring. The trauma to the vagina and surrounding areas can result in superficial dyspareunia, which is pain during or after intercourse in the vaginal area. Patients can also experience external dyspareunia or dysuria, which is pain on micturition. Although we are aware of these physical signs and symptoms,

the psychological impact of thrush is often overlooked. Women have reported that it can make them feel upset, unable to work, embarrassed, or even stigmatised.7 Two-thirds of the women interviewed in Chapple et al's study7 stated the vaginal symptoms associated to thrush made them miserable, uncomfortable, and embarrassed. Some individuals even reported feeling frightened. The role of the nurse in primary care should therefore be to reassure women that thrush is a commonly occurring condition and that it is not generally regarded as sexually transmitted.

Differential diagnosis

As part of the diagnosis and management of this condition, the nurse must first rule out other causative factors for the key symptoms that the patient has presented with. Infections can be identified by the nurse by obtaining an accurate history of the patient's health, sexual history and the presenting complaint. Accurate diagnosis may include a clinical examination and swabs, or further tests such as a litmus test for bacterial vaginosis. Taking an accurate history of the patient's presenting problem may also help the nurse identify whether this is a one-off episode of thrush or if there is persistent thrush.

Questions should be focused and include questions about any change or increase in discharge, the nature and position of the pain, and any precipitating factors. This should also include questions about the woman's usual menstrual cycle and sexual health history.

Risk factors

If you speak to the women presenting with this condition they will often be able to tell you what they believe are the risk factors for this condition. These can range from a high sugar diet, tight fitting clothes or persistent hot baths. The evidence is conflicting and there is a need for more robust studies.1 It is known however that broad-spectrum antibiotics/systemic corticosteroids, allergies, the use of high dose oral contraceptives and a compromised immune system do increase risk.8,9 It is most common in women aged 20-30 and in pregnancy, as the hormone oestrogen promotes the growth and colonisation of the organism.4

Recurrent vulvovaginal candidiasis is therefore thought to be due to the problematic host rather than the specific organism. An example would be a woman with poorly controlled diabetes or who is HIV positive.10 Identifying the organism and ensuring the patient's health is not compromised are the key components of managing this condition.

Management

The treatment aims are to eradicate the infective organism and allow maintenance of a healthy vaginal tract. If the woman has persistent thrush they require a vaginal examination and swab for fungal culture and speciation. This swab ideally should be taken from the anterior fornix but this will only detect 65-68% of symptomatic cases on microscopy.11,12

The risk factors for persistent thrush also need to be considered. In the case of hormonal risk, the use of high-oestrogen contracep- tives should be avoided. An alternative treatment that has been suggested is Depo-Provera, although the research in this area is somewhat dated.13

General advice

The general advice you can give women would include suggesting that they avoid local irritants and tight-fitting synthetic clothing.14 There is also no evidence to suggest that the woman's sexual partner need to be treated if they are asymptomatic, but it is best avoiding intercourse until they themselves are clear.15

Treatment

All topical and oral azole therapies have a clinical and mycological cure rate of over 80% in uncomplicated acute vulvovaginal candidiasis.14 The nurse should therefore refer to his/her local guidelines taking this into consideration.

The imidazole drugs such as (clotrimazole, econazole, fenticona- zole, and miconazole) are effective against candida in short courses of one to two weeks (see Box 2).16 The usual regime for recurrent candida (with the exception of pregnancy) is to prescribe a single dose of the 150mg fluconazole capsule every 72 hours for three doses. This should then be followed by a 150mg capsule once a week for at least six months.14 This regime will result in 90% of women being disease-free in six months. Symptomatic candidosis in pregnancy should be treated with topical azoles.16.

Complementary methods

As previously mentioned women do try to self-manage this embarrassing condition. Part of the nurse's role in primary care is to educate women about current treatments. One example of this is the use of tea tree oil, which is still widely used despite the fact that there is evidence to show that tea tree oil is not effective as an anti-fungal agent.17 Women should also be advised to avoid douching and perfumed vaginal products that may act as irritants. Another common treatment is the use of natural yoghurt contain- ing lactobacillus acidophilus or garlic; both these treatments are also inconclusive, although there is more evidence to suggest that lactobacillus may aid treatment.6

Summary

Persistent and recurring thrush can both be debilitating conditions affecting the woman's physical and mental state. The role of the nurse working in primary care should be to educate women how to effectively manage this condition and to dispel any associated myths.

Resources

Management and laboratory diagnosis of abnormal vaginal discharge: quick reference guide for primary care

BNf information on prescribing

References

1. Watson C, Calabretto H. Comprehensive review of conventional and non-conventional methods of management of recurrent vulvovaginal candidiasis. Aust N Z J Obstet Gynaecol 2007;47(4):262-72.

52 Nursing in Practice March/April 2013

2. Ferrer J. Vaginal candidosis: epidemiological and etiological factors. Int J Gynaecol Obstet 2000;71(Suppl 1):S21-7.

3. Saporiti AM, Gomez D, Levalle S et al. Vaginal candidiasis: Etiology and sensitivity profile to antifungal agents in clinical use. Rev Argent Microbiol 2001;33:217-22.

4. HPA. Management of abnormal vaginal discharge in women. Quick reference guide for primary care for consultation and adaptation. Health Protection Agency. 2007. Available at: www.hpa.org.uk.

5. Holland J, Young ML, Lee O, Chen S. Vulvovaginal carriage of yeasts other than Candida albicans. Sexually transmitted infections 2003;79(3):249-50.

6. Clinical evidence. Yoghurt containing Lactobacillus acidophilus (oral or vaginal). 2012. Available at: http://clinicalevidence.bmj.com/x/systematic-review/0815/intervention/ sr-0815-i24.html

7. Chapple K, Hassell K, Nicolson M, Cantrill J. You don't really feel you can function normally: Women's perceptions and personal manage- ment of vaginal thrush. Journal of Reproductive and Infant Psychology 2000;18:(4)

8. Duncan D. Managing persistent thrush, Independent Nurse, 2012:18-21

9, Sheary B, Dayan L. Clinical practice. Recurrent vulvovaginal candidiasis. Aust Fam Physician 2005;34:147-50.

10. Nwokolo NC, Boag FC. Chronic vaginal candidiasis. Management in the postmenopausal patient. Drugs Aging 2000;16(5):335-9.

11. Sonnex C, Lefort W. Microscopic features of vaginal candidiasis and their relation to symptomatology. Sex Transm Infect 1999;75:417-9.

12. Zdolsek B, Hellberg D, Froman G, Nilsson S, Mardh PA. Culture and wet smear microscopy in the diagnosis of low-symptomatic vulvovaginal candidosis. European Journal of Obstetrics, Gynecology & Reproductive Biology 1995;58(1):47-51.

13. Dennerstein GJ. Depo-Provera in the treatment of recurrent vulvovaginal candidiasis. J Reprod Med 1986;31(9):801-3.

14. BASHH. United Kingdom National Guideline on the Management of Vulvovaginal Candidiasis. UK: Bash; 2007. Available at: www.bashh. org/documents/50/50.pdf.

15. Bisschop MP, Merkus JM, Scheygrond H, van Cutsen J. Co-treatment of the male partner in vaginal candidosis: a double blind randomized control study. Br J Obstet Gynecol 1986;93:79-81.

16. BNF.Fungalinfections.2013.Availableat:www.medicinescomplete. com/mc/bnf/current/PHP4823-fungal-infections.htm.

17. Ernst E, Huntley A. Tea tree oil: A systematic review of randomised clinical trials. Forsch Komplementarmed, Klass Naturheilked. Research in Complementary Medicine 2000;7:17-20.