The most appropriate recommendation for this patient is extended-course antifungal treatment to decrease the risk of recurrent vulvovaginal candidiasis (VVC). Although VVC is common, complicated VVC is recurrent (defined as four or more episodes in 1 year), characterized by more severe symptoms, or may be due to non-albicans candida such as Candida glabrata. Complicated infection may develop in women who are pregnant, have uncontrolled diabetes mellitus, or are immunosuppressed but may also occur in patients without associated medical issues, such as this one. In women with complicated VVC, more sustained treatment of a recurrent infection may be needed to achieve symptom relief and cure. Extended-course antifungal therapy appears to decrease the risk of recurrence, and there is minimal evidence suggesting that more prolonged treatment increases the level of fungal resistance to antimicrobial agents. However, the optimal antifungal regimen and time frame have not been defined.
The role of sexual activity in recurrent VVC is unclear, and there is equivocal evidence that treatment of a sexual partner for Candida is of benefit in decreasing the risk of recurrent infection. Therefore, treating this patient's partner in the absence of symptoms is not recommended.
The probiotic Lactobacillus is sometimes taken by patients, either orally or intravaginally, in an attempt to decrease the colonization of the vagina with Candida, thereby reducing the risk of recurrent VVC. However, there are few data suggesting that women with VVC are deficient in lactobacilli or that attempting to reduce vaginal Candida colonization by this method is effective in decreasing recurrent VVC. It is therefore not recommended as a method of preventing recurrent infection.
Although indwelling contraceptive methods (such as vaginal sponges, diaphragms, and intrauterine devices) have been inconsistently associated with Candida colonization, switching to an alternative contraceptive method would not be expected to be of benefit in reducing infections in this patient.