The development of evidence-based guidelines for over-the-counter treatment of vulvovaginal candidiasis

Objective: The purpose of this study was to develop evidence-based guidelines for over-the-counter (OTC) treatment of vulvovaginal candidiasis with non-prescription anti-fungal medicines purchased from community pharmacies.
Method: A multidisciplinary guideline development group was recruited from the locality where the guidelines were to be tested. A Nominal Group Technique (NGT) was used to achieve formal consensus within the group regarding the issues that the guidelines would address. Guideline recommendations were developed from the results of two systematic literature reviews that assessed which symptoms were predictive of vulvovaginal candidiasis ( using data from epidemiological studies) and estimated the relative effectiveness of oral and intra-vaginal anti-fungals using data from randomised controlled trials.
Main outcome measures: Evidence-based guideline recommendations. The guideline statements were linked to the evidence using a standard hierarchy.
Results: The guideline development group met four times. The use of NGT was an effective way of achieving consensus on guideline content. Two systematic reviews carried out as part of the guideline development process identified evidence for the guidelines on the efficacy of OTC treatments and symptoms suggestive of vulvovaginal candidiasis. The guideline recommendations were presented as a booklet and a laminated algorithm. In summary, the guidelines highlighted symptoms suggestive of vulvovaginal candidiasis, and symptoms associated with other vaginal conditions that should be referred to the GP. The guidelines stated that oral treatment and intra-vaginal treatment are equally effective, and that selection of an anti-fungal should be based upon safety, cost and patient preference. Many of the recommendations were influenced by OTC licence restrictions of each antifungal product. Contra-indications to, and special precautions with, antifungals were also listed. In addition, the guidelines stated that the male sexual partner does not require treatment unless symptomatic.
Conclusion: There is sufficient evidence available to develop evidence-based guidelines for the treatment of vulvovaginal candidiasis in the community pharmacy setting. The NGT is a useful component in the guideline development process.