What is the treatment for recurrent bacterial vaginosis (BV) and candida?

From the Guidelines

The treatment for recurrent bacterial vaginosis (BV) and candida infections typically involves extended antimicrobial therapy and maintenance regimens, with the most recent and highest quality study recommending fluconazole 150 mg orally as a single dose, followed by weekly fluconazole 150 mg for 6 months for recurrent candidiasis 1. For recurrent BV, the standard approach includes metronidazole 500 mg orally twice daily for 7-14 days, followed by maintenance therapy with metronidazole gel 0.75% intravaginally twice weekly for 3-6 months. Alternative options for BV include oral tinidazole 2 g once daily for 5 days or clindamycin cream 2% intravaginally for 7 days. Topical options for candidiasis include clotrimazole, miconazole, or terconazole vaginal creams or suppositories for 7-14 days. Lifestyle modifications are also important, including avoiding douching, wearing breathable cotton underwear, and limiting sugar intake. For patients with both conditions, sequential treatment is recommended, typically treating BV first with metronidazole followed by antifungal therapy for candida. This approach works because BV involves an overgrowth of anaerobic bacteria and loss of protective lactobacilli, while candidiasis is caused by overgrowth of Candida species, usually Candida albicans. The extended treatment regimens help restore normal vaginal flora and prevent recurrence. Some key points to consider in the treatment of recurrent VVC include the use of maintenance fluconazole, which has been shown to improve quality of life in 96% of women, but is uncommonly curative and recurrence occurs more frequently than was previously thought 1. New treatment approaches, such as oteseconazole, a novel oral highly-selective inhibitor of fungal lanosterol demethylase, and a vaccine targeting a hyphal virulence factor of Candida albicans, are being evaluated for the treatment of RVVC 1.

Some of the key considerations for the treatment of recurrent BV and candida include:

• The importance of sequential treatment, with BV typically being treated first with metronidazole, followed by antifungal therapy for candida
• The use of extended antimicrobial therapy and maintenance regimens to restore normal vaginal flora and prevent recurrence
• The importance of lifestyle modifications, such as avoiding douching, wearing breathable cotton underwear, and limiting sugar intake
• The need for new treatment approaches, such as oteseconazole and a vaccine targeting a hyphal virulence factor of Candida albicans, to improve outcomes for women with recurrent VVC.

In terms of the evidence, the most recent and highest quality study recommends fluconazole 150 mg orally as a single dose, followed by weekly fluconazole 150 mg for 6 months for recurrent candidiasis 1. This study also highlights the importance of maintenance fluconazole in improving quality of life for women with recurrent VVC, but notes that it is uncommonly curative and recurrence occurs more frequently than was previously thought 1. Overall, the treatment of recurrent BV and candida requires a comprehensive approach that includes extended antimicrobial therapy, maintenance regimens, and lifestyle modifications, as well as consideration of new treatment approaches to improve outcomes for women with these conditions.

From the FDA Drug Label

Tinidazole is indicated for the treatment of bacterial vaginosis (formerly referred to as Haemophilus vaginitis, Gardnerella vaginitis, nonspecific vaginitis, or anaerobic vaginosis) in adult women [see Use in Specific Populations ( 8.1) and Clinical Studies ( 14.5)]. Other pathogens commonly associated with vulvovaginitis such as Trichomonas vaginalis, Chlamydia trachomatis, Neisseria gonorrhoeae, Candida albicans and Herpes simplex virus should be ruled out.

The treatment for recurrent bacterial vaginosis (BV) is tinidazole, given as either 2 g once daily for 2 days or 1 g once daily for 5 days. However, for Candida, the provided drug labels do not directly support the use of tinidazole as a treatment. Key points:

• Tinidazole is effective for treating bacterial vaginosis.
• The drug labels do not provide information on the treatment of Candida with tinidazole.
• Other treatments may be necessary for Candida, but this information is not provided in the drug labels 2, 2.

From the Research

Treatment of Recurrent Bacterial Vaginosis (BV) and Candida

The treatment for recurrent bacterial vaginosis (BV) and candida involves a combination of antimicrobial therapies and other approaches.

• For recurrent BV, extended courses of metronidazole treatment (500 mg twice daily for 10-14 days) are recommended 3.
• If metronidazole is ineffective, metronidazole vaginal gel 0.75% for 10 days, followed by two times per week for 3-6 months, is an alternate treatment regimen 3.
• For recurrent vulvovaginal candidiasis (RVVC), a combined scheme using both systemic antimicrobial drug therapy with oral fluconazole 200 mg and topical drug therapy using the association metronidazole 500 mg and clotrimazole 100 mg (vaginal ovules) with adjuvant oral probiotic therapy has been proposed 4.
• Vaginal boric acid is also considered a cheap and easy alternative option for recurrent cases 5.
• Probiotics, specifically vaginal products containing Lactobacillus crispatus, may have promise for recurrent bacterial vaginosis 5, 6.

Approaches to Prevention and Treatment

Several approaches are being explored for the prevention and treatment of recurrent BV and candida, including:

• Probiotics and prebiotics 3, 6
• Biofilm disruption 3, 6
• pH modulation 6
• Vaginal microbiome transplantation 6
• Behavioral modifications, such as smoking cessation, condom use, and hormonal contraception 6
• Dietary modification and non-medical vaginally applied products 6

Considerations for Treatment

When choosing a treatment, factors such as risk of recurrence and side effect profile should be considered 7.

• Single-dose clindamycin vaginal cream (2%) may be a good alternative to oral metronidazole for the treatment of BV, given the low rates of recurrence and subsequent VVC demonstrated in some studies 7.