title: Fluconazole-resistant Candida albicans vulvovaginitis.
abstract: OBJECTIVE
  As a result of high recurrence rates of Candida albicans vaginitis, successful suppressive fluconazole is widely used, and drug resistance is considered rare. We report increased occurrence of secondary fluconazole resistance, analysis of risk factors thereof, and describe management of fluconazole-refractory vaginitis.
  
  
  METHODS
  Patients referred to the Vaginitis Clinic at Wayne State University with clinically refractory fluconazole-resistant (minimum inhibitory concentration [MIC] 2 micrograms/mL or greater) C albicans vaginitis from 2000 to 2010 were enrolled. Patients completed a questionnaire pertaining to demographics, comorbidities, behavioral characteristics, exposure to antimicrobials and antifungals, fluconazole consumption in defined daily doses in the previous 6 months, management received, and outcomes. With patients not located, data were extracted from charts. Susceptibilities to antifungals were determined by broth microdilution.
  
  
  RESULTS
  Twenty-five women with fluconazole-resistant recurrent C albicans vaginitis were identified, and 16 returned filled questionnaires. Study cohort consisted mainly of married, insured white women with more than 12 years of formal education and average or above average socioeconomic status. Median fluconazole MIC was 8 micrograms/mL (range 2-128 micrograms/mL). Risk factors for mycologic failure included increased fluconazole consumption (P=.03) with 16 of 25 women exposed to low-dose weekly fluconazole maintenance therapy. All patients were clinically controlled successfully, although treatment was difficult and often prolonged.
  
  
  CONCLUSIONS
  Fluconazole-resistant C albicans vaginitis was previously considered rare. We report 25 cases over an 11-year period, indicating an emerging problem. All patients had fluconazole consumption in the previous 6 months. Management of fluconazole refractory disease is extremely difficult with limited options, and new therapeutic modalities are needed.
authors.affiliation: Division of Infectious Diseases, Detroit Medical Center, Wayne State University School of Medicine, Detroit, Michigan, USA.
authors.forename: Dror
authors.initials: D
authors.lastname: Marchaim
authors.forename: Leslie
authors.initials: L
authors.lastname: Lemanek
authors.forename: Suchitha
authors.initials: S
authors.lastname: Bheemreddy
authors.forename: Keith S
authors.initials: KS
authors.lastname: Kaye
authors.forename: Jack D
authors.initials: JD
authors.lastname: Sobel
mesh_terms: D000328:Adult; D000935:Antifungal Agents / Q000627:therapeutic use*; D002176:Candida albicans / Q000187:drug effects*; D002181:Candidiasis, Vulvovaginal / Q000175:diagnosis / Q000188:drug therapy* / Q000382:microbiology; D025141:Drug Resistance, Fungal; D005260:Female; D015725:Fluconazole / Q000627:therapeutic use*; D006801:Humans; D015994:Incidence; D008826:Microbial Sensitivity Tests; D008875:Middle Aged; D015995:Prevalence; D016896:Treatment Outcome
chemical_list: D000935:Antifungal Agents; D015725:Fluconazole