How do you treat positive Gardnerella vaginalis and positive Candida species?

Treatment of Positive Gardnerella vaginalis and Positive Candida species

For patients with both Gardnerella vaginalis and Candida species infections, treat the bacterial vaginosis with oral metronidazole 500 mg twice daily for 7 days AND simultaneously treat the vulvovaginal candidiasis with fluconazole 150 mg as a single oral dose.

Bacterial Vaginosis (Gardnerella vaginalis) Treatment

First-line Treatment:

• Oral metronidazole 500 mg twice daily for 7 days is the recommended regimen for bacterial vaginosis 1
• Patients should avoid alcohol during treatment with metronidazole and for 24 hours afterward 1

Alternative Regimens:

• Metronidazole 2 g orally in a single dose (note: this has lower efficacy with higher relapse rates) 1, 2
• Clindamycin cream 2%, one full applicator (5 g) intravaginally at bedtime for 7 days 1
• Metronidazole gel 0.75%, one full applicator (5 g) intravaginally twice daily for 5 days 1

Treatment Considerations:

• The 7-day oral metronidazole regimen has a higher cure rate (86-97%) compared to the single-dose regimen (46-86%) 2
• Oral metronidazole demonstrates excellent activity against anaerobic bacteria which play a major role in bacterial vaginosis 3
• If treatment failure occurs with the standard regimen, the patient should be retreated with metronidazole 500 mg twice daily for 7 days 1
• For repeated treatment failures, consider metronidazole 2 g once daily for 3-5 days 1

Vulvovaginal Candidiasis Treatment

First-line Treatment:

• Fluconazole 150 mg oral tablet as a single dose 1, 4
• This regimen provides therapeutic cure rates of approximately 55% 4

Alternative Regimens (Topical Options):

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

Treatment Considerations:

• Both oral fluconazole and topical azoles are equally effective for uncomplicated vulvovaginal candidiasis 5
• Topical and oral treatments achieve 80-90% relief of symptoms and negative cultures 1
• For non-albicans Candida species, azole therapy may be less reliable and alternative treatments may be needed 1

Special Considerations

Pregnancy:

• For bacterial vaginosis in pregnancy: metronidazole 2 g in a single dose after the first trimester 1
• For vulvovaginal candidiasis in pregnancy: topical azole treatments are preferred 1

HIV Infection:

• Patients with HIV should receive the same treatment regimens as those without HIV 1

Treatment of Sexual Partners:

• For bacterial vaginosis: Treatment of male sex partners has not been shown to reduce recurrence rates and is not recommended 1
• For trichomoniasis (if present): Sex partners should be treated simultaneously 6

Common Pitfalls and Caveats

• Failure to complete the full course of treatment may lead to recurrence or treatment failure 5
• Self-diagnosis of yeast vaginitis is unreliable and can lead to inappropriate treatment 1
• Treating only one infection when both are present can lead to persistent symptoms 5
• Oil-based creams and suppositories may weaken latex condoms and diaphragms 1
• Approximately 10-20% of women normally harbor Candida species in the vagina without symptoms, so treatment should be based on both symptoms and laboratory findings 1

Follow-up

• Follow-up is recommended if symptoms persist after completing treatment 1
• For recurrent vulvovaginal candidiasis (≥4 episodes/year), consider maintenance therapy with fluconazole 150 mg weekly for 6 months after initial induction therapy 1