Clinical resistance of recurrent Candida albicans vulvovaginitis to fluconazole in the presence and absence of in vitro resistance

OBJECTIVE: To determine if failure of recurrent Candida albicans vulvovaginitis to respond clinically to fluconazole is related to in vitro mycologic resistance. STUDY DESIGN: We compared clinical response to fluconazole with culture and sensitivity data in all cases of recurrent C albicans vulvovaginitis referred to our clinic over an 18-month period. RESULTS: Of 52 patients referred to us with recurring vulvovaginitis, 10 were C albicans culture positive. All 10 had previously responded to fluconazole but subsequently failed fluconazole therapy. All were euglycemic and HIV negative. In 3 of the 10 isolates, the mean inhibitory concentration for fluconazole was > 64 μg/mL. The history of response to fluconazole in the 7 patients with susceptible isolates was indistinguishable from that of the 3 with resistant isolates. Five of the 10 patients were given multiagent antifungal therapy. Of 4 patients available for long-term follow-up in this group, all had negative fungal cultures. In contrast, 4 evaluable patients who received maintenance azole therapy were C albicans culture positive at long-term follow-up. CONCLUSION: Recurrent C albicans vulvovaginitis can display clinical resistance to fluconazole that correlates with in vitro resistance in only some cases. We postulate that aberrant host response may play a role in the failure to control fungal colonization with a single fungistatic agent.