What is the treatment for bacterial vaginosis (BV) vs candidiasis?

Treatment for Bacterial Vaginosis vs Candidiasis

For bacterial vaginosis, metronidazole 500 mg orally twice daily for 7 days is the first-line treatment with a 95% cure rate, while vulvovaginal candidiasis is best treated with either topical azole preparations or oral fluconazole 150 mg as a single dose. 1

Bacterial Vaginosis (BV)

Diagnosis

• BV is diagnosed when at least 3 of 4 Amsel criteria are met:
  • Homogeneous, white discharge
  • Vaginal pH > 4.5
  • Positive "whiff test" (fishy odor when KOH applied to discharge)
  • Presence of clue cells on microscopy 1

Treatment Options

1. First-line treatment:

   • Metronidazole 500 mg orally twice daily for 7 days (95% cure rate) 1

2. Alternative treatments:

   • Metronidazole gel 0.75% intravaginally once daily for 5 days (95% cure rate)
   • Clindamycin cream 2% intravaginally at bedtime for 7 days
   • Metronidazole 2g orally in a single dose (84% cure rate) 1, 2

Special Considerations

• High recurrence rate (50-80% within one year) 1
• Pregnant women should receive treatment and follow-up evaluation one month after completion 1
• Avoid testing too soon after treatment (wait at least 3-4 weeks) 1

Vulvovaginal Candidiasis

Diagnosis

• Characterized by:
  • Intense vulvovaginal itching
  • White, thick discharge
  • Vaginal soreness
  • Normal vaginal pH (≤4.5) 1, 3
• Diagnosis confirmed by visualization of yeast or pseudohyphae in 10% KOH preparation 3

Treatment Options

1. Topical treatments:

   • Butoconazole 2% cream 5g intravaginally for 3 days
   • Clotrimazole 1% cream 5g intravaginally for 7-14 days
   • Miconazole 2% cream 5g intravaginally for 7 days
   • Terconazole 0.4% cream 5g intravaginally for 7 days 3, 1

2. Oral treatment:

   • Fluconazole 150 mg oral tablet, single dose 3, 1

Special Considerations

• For pregnancy: only topical azole therapies are recommended for 7 days 1
• For recurrent vulvovaginal candidiasis (≥4 episodes per year): maintenance therapy with weekly oral fluconazole for up to 6 months 4
• Self-medication with OTC preparations should only be advised for women previously diagnosed with candidiasis who have the same symptoms 3

Key Differences Between BV and Candidiasis

Feature	Bacterial Vaginosis	Vulvovaginal Candidiasis
Discharge	Homogeneous, white, thin	White, thick, "cottage cheese-like"
Odor	Fishy or musty	Usually minimal or none
pH	>4.5	≤4.5 (normal)
Key symptom	Discharge and odor	Intense itching
First-line treatment	Metronidazole 500mg BID x 7 days	Topical azoles or fluconazole 150mg single dose

Common Pitfalls to Avoid

• Misdiagnosing based on symptoms alone without microscopic confirmation 2
• Treating asymptomatic patients based solely on laboratory findings 5
• Inadequate treatment duration for recurrent cases 6
• Failing to consider treatment of sexual partners for BV recurrence 1
• Self-diagnosis and inappropriate self-medication with OTC preparations when symptoms persist beyond 7 days or recur within 2 months 1
• Douching, which increases the risk of bacterial vaginosis 1

For recurrent cases that don't respond to standard therapy, vaginal boric acid is likely the cheapest and easiest alternative option 6. Additionally, for recurrent BV, vaginal products containing Lactobacillus crispatus may be beneficial, though evidence for probiotics in vulvovaginal candidiasis prevention is limited 1, 6.