EUROP. J. OBSTET. GYNEC. REPROD. BIOL.

, 1979,9/4,253-259 0 Elsevier/North-Holland Biomedical Press

Treatment of vaginal candidiasis with ketoconazole,

a new, orally active, antimycotic

M.P.J.M.

Bisschop , J.M.W.M.

Merkus , H. Scheygrond

3, J. Van Cutsem 4 and A. van de Kuy *

1 Department of Obstetricsand Gynecology, * Department of ClinicalPharmacy, MariaHospital, Tilburg, The Netherlands and 3 Department of ClinicalResearch and 4 Department of Chemotherapy, Janssen Pharmaceutics, Beerse, Belgium

Accepted for publication 8 February 1979 BISSCHOP, M.P.J.M., MERKUS, J.M.W.M., SCHEYGROND, H., VAN CUTSEM, J. and VAN DE KUY,A. (1979): Treatment of vaginal candidiasis with ketoconazole, a new, orally active, antimycotic. Europ. J. Obstet. Gynec. reprod. Biol., 914, 253-259. The efficacy of a new, orally active antimycotic, ketoconazole, in the treatment of vaginal candidiasis was studied at different doses involving 63 patients. All patients had subjective complaints and were mycologically positive. There was no significant difference in the cure rates of the different doses. The oral treatment was successful in 55 out of 63 patients (87.3%). No correlation was found between the relapse rate of vaginal candidiasis and the dose regimen. There were no serious side-effects, and no significant changes were reported in hematological and biochemical parameters. Candida albicans; ketoconazole; vulvovaginitis

Introduction

Approximately one-third of women of child-bearing age currently have vulvovaginitis (Gardner, 1964). Candida albicans has now replaced Trichomonas vaginalis as the most common cause of vulvovaginitis in women. The ratio of cases of trichomonal vaginitis to cases of vaginal candidiasis is 1 : 3 (Catterall, 1971). According to some authors, an increase in the incidence of vaginal candidiasis is reported in non-pregnant women; this is probably caused by the increasing use of oral contraceptives (Francis, 1964; Tompkins, 1964; Grounds, 1965), although other authors cannot confirm this hypothesis (Morris and Morris, 1969; Rohatiner and Grimble, 1970). Figures concerning the incidence of vaginal candidiasis among women 253

treated with oral contraceptives vary widely; Jensen et al. (1970) report a 15% incidence in women using oral contraceptives, as compared to 5% in women not using oral contraceptives. The incidence of vaginal candidiasis in pregnant women is lo-20 times higher than in non-pregnant women (Gardner and Kaufman, 1969). The incidence of vaginal candidiasis in pregnant women has not significantly changed during the last 30 yr (Schnell et al., 1976). Gentian violet was used as the therapy of choice for many years, in spite of the irremovable staining of clothes and furniture (Hesseltine, 1959). In 1950, nystatin, a polyene antibiotic, produced from Streptomyces noursei, was made available for the treatment of Candida infections (Winner and Hurley, 1964). Since 1960, miconazole, econazole and

254

M.P.J.M. Bisschop et al.: Oral treatment of vaginal candidiasis

clotrimazole, imidazole derivatives, have been synthesized (Proost et al., 1972; Balmer, 1976; Spickhoff et al., 1976). Recently the orally active antimycotic, ketoconazole, also an imidazole derivative, was synthesized at Janssen Pharmaceutics research laboratories (Fig. 1). Ketoconazole is active in vitro against a large number of fungi, including the Candida species. It is effective by oral treatment in experimental crop candidiasis in turkeys, systemic candidiasis in guinea pigs and chickens, vaginal candidiasis in rats, skin candidiasis and dermatophytosis in guinea pigs (Van Cutsem and Thienpont, unpublished data, 1977) and pulmonary coccidioidomycosis in mice (Levine, in press). In the oral treatment of vaginal candidiasis in rats, complete cure at a dose of 10 mg/kg for 2 or 3 days and almost complete cure at a dose of 5 mg/kg for 5 days is achieved. In man, treatment with ketoconazole is also effective: in 30 patients with oral and intestinal mycoses the presence of Candida in the mouth was significantly reduced, while no Candida was isolated from the faeces after a 2-wk treatment with 200 mg ketoconazole b.i.d. Hematological and biochemical parameters did not show any deviation during and after 6 mth of treatment with ketoconazole (Broeckaert, unpublished data). The growth of Candida albicans, tested in Sabouraud medium t 10% inactivated bovine serum, was inhibited more than 75% at 1 pg/ml of ketoconazole after 14 days. The biologically determined antifungal plasma levels in man vary between 1 and 6 /_tg/mlduring the

first 8 h after oral administration of 200 mg ketoconazole. Therefore, a dose of 200 mg ketoconazole t.i.d. during 3 consecutive days seems indicated in women for the treatment of vaginal candidiasis. The present study was designed to evaluate the therapeufit efficacy and safety of ketoconazole in the treatment of vaginal candidiasis.

Materials and methods

Fig. 1. cis-1acetyW/4-{[ 2_(2,4dichlorophenyl)2-(1H-imidazol-l-ylmethyl)-l,3dioxolan4-yl]methoxy}phenyl/-piperazine

This study consists of two parts: the pilot study to determine whether oral treatment with ketoconazole is effective in vaginal candidiasis, and a doseresponse study to investigate the optimal effective dose. In both studies non-pregnant patients, presenting with a clinical diagnosis of vaginal candidiasis and a positive microscopic KOH smear, were selected for treatment. Excluded from the study were patients in whom no confirmation by the isolation of yeasts on the Nickersons Medium was obtained, or who suffered mixed infection with Trichomonas. After obtaining informed consent of each patient, a relevant history was taken and physical examination was performed. In the pilot study 12 patients, in the doseresponse study 51 patients, were investigated. Afterwards, the results of the pilot study were included. Thus we analyzed the results of 63 patients. Treatment was started at selection and continued for 3 days. The sexual partner received no therapy; intercourse was not forbidden. On the third day of treatment a blood sample for plasma level determination of ketoconazole and in the dose-response study a cervical swab for determination of the antifungal activity of cervical mucus also were taken (1 or 2 h after the preceding intake of ketoconazole); the patients returned the questionnaire on the clinical response to treatment and on possible untoward sideeffects. In the pilot study, group blood samples for hematological and biochemical analyses (hematocrit, hemoglobin, red and white blood cell counts, sodium, potassium, chloride, calcium, inorganic phophorus, BUN, creatinine, alkaline phosphatase, SCOT, SGPT, SyGT, amylase, glucose, cholesterol, haptoglobin, bilirubin, total protein, albumin, globulin) were taken before treatmer,t, on the third day of treatment, and

M.P.J.M. Bisschop et al.: Oral treatment of vaginalcandidiasis TABLE I Patient characteristics of the pilot study group Age (median + range) yr Weight (median + range) kg No. with predisposing factors 8 Duration of signs (wk)

255

No.of
patients

was determined by bioassay. With the help of a calibration curve, the antifungal activity was expressed in pg/ml. Antifungal activity of the cervical swab was determined qualitatively in the same way.

12

31.5 (20-49)

62.5 (50-89)

4.8 (l-56)

Results Characteristics of the 12 patients of the pilot study are reported in Table I. The results of treatment (Table II) supplied convincing evidence of the efficacy of ketoconazole in vaginal candidiasis. All patients showed negative cultures of the vaginal smears on the fourth day after the end of treatment, and symptoms disappeared in many patients. Two patients reported slight nausea after swallowing the capsules. No other sideeffects were observed. Hematological and biochemical analysis of tlie blood samples did not reveal significant changes in any of the parameters. The patients tolerance of this type of therapy was good. Patient characteristics of the dose-response study are reported in Table III. Statistical analysis (x*-test, two-tailed probability) did not show differences

4 days after the end of treatment. Four and 25 days after the end of treatment the physical examination was repeated, including inoculation of a vaginal swab on Nickersons medium. In the pilot study patients were treated with 200 mg ketoconazole t.i.d.; in the dose-response study the effects of 100, 150 and 200 mg ketoconazole t.i.d. and of 200 mg b.i.d. were studied. The patients were divided at random between the 4 treatment groups. Of each inoculate in Nickersons medium, subcultures and identifications of the causal organisms were performed. Of each of the blood samples, taken on the third day of treatment, the antifungal activity

TABLE II

Positive clinical and mycological parameters in the pilot study Number of evaluated patients Vag. discharge (gynecologist) +28 0 +7 3112 25% +28 j/l1 45% 0 11112 92% +7 o/12 0% +28 o/12 0% 0 12112 100% +I 0112 0% +28 0112 0% 0 12/12 100% +7 o/12 0% +28 1112 8% Vaginitis (gynecologist) Pos. KOH smear (gynecologist) Pos. culture of Candida albicans

Pruritus (patients) 0 +71

9/12 75%

3112 25%

2112 16%

12112 100%

1 Days after start of treatment.

TABLE III

Patient characteristics in the 4 dose groups of the dose-response No. of patients Age (median + range) yr 29.5 31.5 31 33 (19-40) (23-42) (20-49) (21-60) Weight (median + range) kg 60 60.5 62 62 (37-65) (48-86) (50-89) (48-60)

study Patients with predisposing factors I 12 12 12 Duration of signs (wk) 5 22 5 5 (l-260) (l-104) (I- 56) (I-175)

Daily treatment for 3 consecutive days 100 mg t.i.d. 150 mg t.i.d. 200 mg t.i.d. 200 mg b.i.d.

12 16 19 16

TABLE IV Vag. discharge (gynecologist) +28 4112 33% 4115 21% 4119 21% o/13 0% 16/16 100% 3115 20% 3115 20% lo/16 63% O/16 0% 19/19 100% 9118 50% 11/18 61% 18/19 95% 0119 0% o/19 0% O/l5 0% 16116 100% 6116 38% 8115 53% 13116 81% O/16 0% 2115 13% 16/16 100% 19/19 100% 14116 88% 12112 100% 4110 40% 8/11 73% 5112 42% o/12 0% l/12 8% 11/12 92% 0 +I +28 0 +7 +28 0 +I l/11 9% 2116 13% o/19 0% l/16 6% Vaginitis (gynecologist) Pos. KOH smear (gynecologist) +28 3/11 21% S/15 33% l/19 5% o/14 0%

Positive clinical and mycological parameters in the dose-response study groups

Number of evaluated patients

Pruritus (patients)

Pos. culture of Candida albicans 0 +I +28

Dose during 3 consecutive days

+71

100 mg t.i.d. n=12

10/12 83%

3112 25%

12112 100% 16/16 100% 19119 100% 16/16 100%

2112 16% 4/16_ 25% l/19 5% l/16 6%

4112 33% 8115 53% 3119 16% 2114 14%

150 mg t.i.d. n=16

16/16 100%

l/16 6%

200 mg t .i.d. n= 19

16/19 84%

4114 26%

200 mg b.i.d. n= 16

14/16 88%

2116 13%

.S S? k G B z Q z ?

Days after start of treatment.

A4.P.J.M Bisschop et al.: Oral treatment of vaginalcandidiasis TABLE V Dose 100 mg t.i.d. 150 mg t.i.d. 200 mg t.i.d. 200 mg t.i.d. Total % n = 12 r n = 16 n = 19 2 n = 16 n=63 Initial improvement of signs and symptoms reported by the patients Day 1 3 4 0 2 9 15 Day 2 3 9 9 8 29 48 Day 3 1 2 6 2 11 18 Day 4-l 2 1 1 3 7 12 No improvement 2 1 1 4 7

251

1 One patient not evaluated. 2 Two patients not evaluated.

between the groups. The majority (65%) of the patients had a chronic candidiasis for more than 4 wk. Predisposing factors, such as diabetes mellitus, use of antibiotics or oral contraceptives, IUCD in situ, are also equally divided among the 4 dose groups. 29 Patients used oral contraceptives, 4 patients had diabetes mellitus, 5 patients chronically used antibiotics, 7 patients had an IUCD in situ. Table IV shows the clinical and mycological response to treatment. Before the treatment the severity of signs and symptoms between the treatment groups was not significantly different, except for vaginitis. Symptoms of vaginitis were less (P= 0.004) often present in the lowest dose group, compared to the 200 mg t.i.d. group. For each of the schedules vaginitis disappeared, pruritus was drastically reduced, and vaginal discharge was significantly less often present at the examination 4 days after the end of treatment. The clinical results are confirmed by the results of the mycological cul-

tures. Statistical analysis of the mycological results on the fourth and the 25th day after the end of treatment does not reveal differences in the 4 dose regimens. The clinical response to treatment was reported by 60 patients; their opinion is summarized in Table V. Only 4 patients experienced no improvement, but 81% reported improvement within the actual treatment period of 3 days. No significant differences exist between the 4 dose groups. The mean antifungal plasma levels were 3.34 /&ml for 100 mg t.i.d., 4.30 Is/ml for 150 mg t.i.d., 5.02 @g/ml for 200 mg b.i.d., and 5.72 @g/ml for 200 mg t.i.d. In 27 out of the 45 patients, antifungal activity in the cervical swab was demonstrated. No correlation could be found between the antifungal activity in the cervical swab and the plasma level of ketoconazole in the same patients. All patients answered the non-leading question about untoward side-effects. 14 Patients, equally

TABLE VI Side-effects

Incidence of untoward side-effects 100 mg t.i.d. 1 1 1 _ 9 150 mg t.i.d. _ 2 _ 3 1 11 200 mg t.i.d. 3 12 12 15 200 mg b.i.d. 1 _ 1 14 Total 1 7 1 4 2 1 49

Dry mouth Nausea Perspiration Headache Abdominal distress Dizziness None

r One patient reported dizziness and nausea. One patient reported headache and abdominal distress.

M.P.J.M. Bisschop et al.: Oral treatment of vaginalcandidiasis

divided among the 4 dose groups, reported untoward side-effects, which were of a non-disturbing nature. Side-effects are mentioned in Table VI.

Discussion

Ketoconazole is an efficacious agent for the oral treatment of vaginal candidiasis. At the dose of 200 mg t.i.d. for 3 consecutive days, 95% of the patients had a negative culture of the vaginal swab 4 days after the end of treatment. The differences in the results of the 4 dose regimen groups are not significant. It may be expected that in a larger study a significant proof of an optimal efficacious dose of 200 mg t.i.d. or b.i.d. for 3 consecutive days will be found. Reviewing the results of the entire study oral treatment with ketoconazole was successful in 55 out of 63 patients; this is a cure rate of 87.3%. In topical treatment with imidazole derivatives, miconazole, econazole and clotrimazole, cure rates of 82-93% were obtained (Proost et al., 1972; Peeters et al., 1973; Obolensky and Maire, 1975; Balmer, 1976; Masterton et al., 1976; Spickhoff et al., 1976; Wallenburg and Wladimiroff, 1976), and with the polyene antibiotic, nystatin, cure rates of 65-68% (Culbertson, 1974; Wallenburg and Wladimiroff, 1976). Twelve patients, with a reinfection at 28 days, were then treated with the next highest dose regimen, but in 6 patients this produced no better result. Four of these 6 patients were subsequently treated with 200 mg o.d. for 1 mth. During and shortly after treatment no Candida could be isolated, but a positive culture occurred in all 4 within 3 wk of termination of treatment. In one patient no negative cultures were obtained at all. In this patient the antifungal activity of the cervical swab was negative or poor, although the antifungal plasma levels were 5.0 pg/ml or unexpectedly high at 9.0 pg/ml. Sensitivity tests with the culture isolation of this patient with an IUCD in situ demonstrated no resistance to ketoconazole. No correlation could be demonstrated between the results and the use of oral contraceptives. Also Pasquale et al. (1977) found no significant difference in the cure rates in oral contraceptive users as compared to the cure rates in non-users, when treated with miconazole. Pruritus, reported by the

patients, showed to be the most reliable complaint. Vaginal discharge, reported by the patients, varied considerably; often patients realized that they had suffered excessive discharge only after successful treatment had restored the normal secretions. Vulvitis, dyspareunia and dysuria were also hardly reliable complaints. A relatively objective parameter seemed to be the neutral clinical opinion of the experienced gynecologist. The KOH smears were microscopically examined by the same gynecologist. In no instance was a positive KOH smear obtained, while the culture was negative. The sensitivity of this method for diagnosing the presence of Candida species is rather low: of 37 positive cultures the candidiasis was diagnosed microscopically in 22 patients (59%). This is confirmed in the literature (OBrien, 1964; Burgess et al., 1970). The reading of the Nickersons medium by the gynecologist showed a higher reliability. In 224 out of 228 positive cultures on Nickersons medium Candida albicans and, in 3 of the cases, Torulopsis glabrata were isolated. In all cases in which the Nickersons cultures were negative, no Candida was isolated. Nickersons medium is prepared with bismuth hydroxysultite, on which Candida grows in black or brown colonies, appearing on the surface after 28-48 h of aerobic culture at room temperature (OBrien, 1964). The absence of a correlation between the antifungal activity of the cervical swab and the plasma may be caused by differences in the quality and quantity of the cervical mucus. A number of patients do suffer from recurrent candidiasis shortly following this treatment. However, most probably there is no difference in results, if the treatment is prolonged. It might be possible that the reason for the recurrent candidiasis can be found in the patients themselves. In the literature it is generally accepted that diabetes melhtus, the chronic use of broad spectrum antibiotics, gravidity and the use of oral contraceptives are predisposing factors. In our patients the influence of these factors on the treatment results was not evident. An extensive study of the genesis of recurrent vaginal candidiasis and the real nature of the predisposing factors would be of great interest.

M.P.J.M. Bisschop et al.: Oral treatment of vaginalcandidiasis Conclusion

259

Ketoconazole is successful in the oral treatment of vaginal candidiasis. No intergroup statistical difference exists between the responses to treatment of 4 dose regimens. Without serious sideeffects and without significant changes in hematological and biochemical parameters 87.3% of the patients with vaginal candidiasis were successfully treated: i.e., no yeast could be isolated on the fourth day after the end of treatment from the vaginal swab. No higher cure rate was achieved with a higher dose regimen. The aid of Nickersons medium in the diagnosing of vaginal candidiasis is indispensable.

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