What is the recommended treatment for a 17-year-old female with a 3-point Bacterial Vaginosis (BV) score and positive Candida on an Aptima (nucleic acid amplification test) swab, presenting with mild vaginal discharge and no other symptoms?

Treatment for 17-Year-Old Female with BV and Candida Co-infection

For a 17-year-old female with a 3-point BV score and positive Candida on Aptima swab presenting with mild discharge and no other symptoms, the recommended treatment is oral metronidazole 500 mg twice daily for 7 days for BV plus fluconazole 150 mg as a single oral dose for candidiasis. 1

Diagnosis Confirmation

The patient's presentation aligns with a dual infection:

• 3-point BV score (consistent with bacterial vaginosis)
• Positive Candida on Aptima swab (nucleic acid amplification test)
• Mild vaginal discharge
• No other symptoms reported

Treatment Plan

For Bacterial Vaginosis:

• First-line treatment: Metronidazole 500 mg orally twice daily for 7 days 1
  • Expected cure rate: approximately 95%
  • Important patient education: Must avoid alcohol during treatment and for 24 hours afterward 1

For Candidiasis:

• First-line treatment: Fluconazole 150 mg orally as a single dose 1, 2
  • Convenient single-dose therapy
  • Clinical cure rates of approximately 69% for acute vaginitis 2

Alternative Options for BV:

• Metronidazole gel 0.75% intravaginally once daily for 5 days
• Clindamycin cream 2% intravaginally at bedtime for 7 days 1

Alternative Options for Candidiasis:

If oral fluconazole is contraindicated, topical options include:

• Clotrimazole 1% cream: 5g intravaginally daily for 7-14 days
• Miconazole 2% cream: 5g intravaginally daily for 7 days
• Other topical azoles with varying treatment durations 1

Important Considerations

Potential Side Effects:

• Fluconazole: Headache (13%), nausea (7%), and abdominal pain (6%) are most common 2
• Metronidazole: May cause metallic taste, gastrointestinal upset, and disulfiram-like reaction with alcohol 1

Follow-up Recommendations:

• Follow-up visits are generally not necessary if symptoms resolve 1
• Patient should return if symptoms persist or recur 1
• No routine testing for cure is recommended 3

Treatment Efficacy:

• The combination of treatments addresses both infections simultaneously
• Studies show that proper treatment of both conditions is essential for symptom resolution 1
• Therapeutic cure rates for fluconazole in vaginal candidiasis are approximately 55% 2

Special Considerations for Adolescents

• The recommended treatment regimen is the same for adolescents as for adult women 1
• Ensure appropriate counseling regarding medication adherence
• Discuss potential side effects and importance of completing the full course of metronidazole

Prevention of Recurrence

• Consider probiotics as an adjunct treatment, as they show promising results for BV management 1
• Educate patient on preventive measures:
  • Avoid douching
  • Use mild, unscented soap for genital hygiene
  • Wear cotton underwear
  • Avoid tight-fitting clothing

Common Pitfalls to Avoid

1. Treating only one infection: Failing to treat both BV and candidiasis can lead to persistent symptoms 1
2. Alcohol consumption: Remind patient to avoid alcohol during metronidazole treatment and for 24 hours afterward to prevent disulfiram-like reaction 1
3. Incomplete treatment: Emphasize the importance of completing the full 7-day course of metronidazole even if symptoms improve 1
4. Self-medication: Advise that self-medication with over-the-counter preparations should only be used for recurrence of previously diagnosed symptoms 1