What is the treatment for vaginal infections?

Treatment for Vaginal Infections

The treatment for vaginal infections depends on the specific type of infection, with topical azole drugs being the first-line treatment for vulvovaginal candidiasis and metronidazole being the treatment of choice for trichomoniasis. 1

Types of Vaginal Infections and Their Treatments

1. Vulvovaginal Candidiasis (VVC)

Vulvovaginal candidiasis is caused primarily by Candida albicans and presents with symptoms including:

• Pruritus (itching)
• White vaginal discharge
• Vaginal soreness
• Vulvar burning
• Dyspareunia (painful intercourse)
• External dysuria

Treatment Options:

For uncomplicated VVC (mild-to-moderate, sporadic cases):

• Intravaginal azole preparations:

  • Clotrimazole 1% cream 5g intravaginally for 7-14 days 1, 2
  • Clotrimazole 100mg vaginal tablet for 7 days 1
  • Clotrimazole 100mg vaginal tablet, two tablets for 3 days 1
  • Clotrimazole 500mg vaginal tablet, single application 1
  • Miconazole 2% cream 5g intravaginally for 7 days 1
  • Miconazole 200mg vaginal suppository, one suppository for 3 days 1
  • Miconazole 100mg vaginal suppository, one suppository for 7 days 1
  • Terconazole 0.4% cream 5g intravaginally for 7 days 1
  • Terconazole 0.8% cream 5g intravaginally for 3 days 1
  • Terconazole 80mg vaginal suppository, one suppository for 3 days 1

• Oral agent:

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

Clinical efficacy: Topical azole drugs result in relief of symptoms and negative cultures in 80-90% of patients who complete therapy 1. Single-dose oral fluconazole has been shown to be as effective as 7-day intravaginal clotrimazole therapy 4.

Patient preference: Many patients (73%) prefer oral therapy over intravaginal applications 5.

2. Trichomoniasis

Treatment Options:

• First-line treatment:

  • Metronidazole 2g orally in a single dose 1

• Alternative regimen:

  • Metronidazole 500mg twice daily for 7 days 1

Management of sex partners: Sex partners should be treated, and patients should avoid sex until both they and their partners are cured and asymptomatic 1.

Special Considerations

Pregnancy

• For vulvovaginal candidiasis: Intravaginal azole preparations are recommended
• For trichomoniasis: Metronidazole 2g in a single dose 1

Recurrent Vulvovaginal Candidiasis

• Patients with recurrent infections (defined as 4 or more symptomatic episodes in a year) may require prolonged therapy for at least 6 months 6
• These patients are less likely to respond to standard treatments compared to those without a history of recurrent infections 4

HIV Infection

• Patients with trichomoniasis and HIV should receive the same treatment regimen as HIV-negative patients 1

Treatment Algorithm

1. Identify the type of infection:

   • Candidiasis: Normal vaginal pH (≤4.5), white discharge, presence of yeast/pseudohyphae on microscopy
   • Trichomoniasis: Elevated pH, frothy discharge, presence of motile trichomonads on microscopy

2. For vulvovaginal candidiasis:

   • First episode or uncomplicated: Choose either a single dose of oral fluconazole 150mg OR a topical azole for 1-7 days
   • Complicated (severe, recurrent, or in immunocompromised patients): Consider longer duration of therapy

3. For trichomoniasis:

   • Treat with metronidazole 2g as a single dose
   • Always treat sexual partners

4. Follow-up:

   • For persistent symptoms after treatment, rule out reinfection or presence of other conditions
   • Consider alternative diagnoses if symptoms persist despite appropriate therapy

Important Considerations

• Self-medication with OTC preparations should only be advised for women previously diagnosed with VVC who experience recurrence of the same symptoms 1
• Any woman whose symptoms persist after using an OTC preparation or who has a recurrence within 2 months should seek medical care 1
• Identifying Candida by culture in asymptomatic women should not lead to treatment, as 10-20% of women normally harbor Candida species in the vagina 1

By following this evidence-based approach to treating vaginal infections, clinicians can effectively manage these common conditions while minimizing recurrence and improving patient quality of life.