What is the treatment for a female patient with vaginal candidiasis and bacterial vaginosis (BV) presenting with irritation and creamy, smelly discharge?

Treatment of Vaginal Candidiasis with Concurrent Bacterial Vaginosis

For a patient presenting with both vaginal candidiasis and bacterial vaginosis with irritation and creamy, smelly discharge, treat both infections simultaneously: oral metronidazole 500 mg twice daily for 7 days for the bacterial vaginosis AND either a single dose of oral fluconazole 150 mg or a 7-day course of topical azole therapy for the candidiasis. 1, 2

Diagnostic Confirmation

Before initiating treatment, confirm both diagnoses:

• Measure vaginal pH using narrow-range pH paper: pH >4.5 suggests bacterial vaginosis (the "smelly discharge" component), while candidiasis typically presents with pH ≤4.5 3, 4
• Perform saline wet mount microscopy to identify clue cells characteristic of bacterial vaginosis and assess for inflammatory cells 1, 3
• Perform 10% KOH preparation to visualize yeast or pseudohyphae confirming candidiasis, and simultaneously conduct the whiff test (fishy odor indicates bacterial vaginosis) 1, 3
• The combination of creamy, smelly discharge with irritation strongly suggests concurrent infections, as candidiasis alone produces white, thick discharge with normal pH, while bacterial vaginosis produces malodorous discharge with elevated pH 1, 4

Treatment Protocol for Concurrent Infections

For Bacterial Vaginosis (Primary Treatment for Smelly Discharge):

• Oral metronidazole 500 mg twice daily for 7 days is the first-line treatment 1, 2, 5
• Alternative options include metronidazole vaginal gel 0.75% (5 g twice daily for 5 days) or clindamycin vaginal cream 2% (5 g once daily for 7 days), though cure rates are equivalent at 75-86% 5
• The oral route is preferred when treating concurrent infections to avoid potential interference between intravaginal medications 2, 5

For Vulvovaginal Candidiasis (Treating the Irritation Component):

• For uncomplicated candidiasis: Single-dose oral fluconazole 150 mg achieves 55% therapeutic cure rate and is highly convenient 1, 6, 2
• For complicated candidiasis (severe symptoms, recurrent disease, or immunocompromised host): Use topical azole therapy for 7-14 days OR fluconazole 150 mg every 72 hours for 3 doses 1, 4
• Topical azole options include: clotrimazole 1% cream (5 g intravaginally for 7-14 days), miconazole 2% cream (5 g intravaginally for 7 days), or terconazole 0.4% cream (5 g intravaginally for 7 days) 1

Critical Treatment Considerations

• Timing of antifungal therapy: Since metronidazole treatment can precipitate vulvovaginal candidiasis in 12.5-30% of patients, initiating concurrent antifungal therapy is essential 5
• Treatment of sexual partners: Not routinely recommended for candidiasis, but consider if male partner has symptomatic balanitis 1
• For bacterial vaginosis: Partner treatment has not been shown to reduce recurrence rates 1

Common Pitfalls to Avoid

• Do not treat based on symptoms alone without microscopic confirmation, as symptoms overlap significantly between different causes of vaginitis 1, 3
• Do not use single-dose or short-course (3-day) azole therapy if symptoms are severe or if this represents complicated candidiasis 1, 4
• Do not prescribe only one agent when clinical presentation suggests concurrent infections—the smelly discharge indicates bacterial vaginosis while irritation suggests candidiasis 3, 4
• Avoid self-medication with OTC preparations unless the patient has been previously diagnosed and is experiencing identical recurrent symptoms 1

Follow-Up Protocol

• Instruct patients to return only if symptoms persist or recur within 2 months 1, 3
• Routine test-of-cure is unnecessary if symptoms resolve completely 3
• If symptoms persist after treatment: Reclassify as complicated infection, extend treatment duration to 7-14 days of topical azoles, and consider maintenance therapy with fluconazole 150 mg weekly for 6 months 1, 4, 2
• Verify compliance with the full 7-day metronidazole course, as incomplete treatment is a common cause of bacterial vaginosis recurrence 4

Special Populations

• Pregnant women: Use only 7-day topical azole therapy for candidiasis (never oral fluconazole) and oral metronidazole for bacterial vaginosis 4, 2
• HIV-infected patients: Receive identical treatment regimens as HIV-negative patients with equivalent expected cure rates 1, 4
• Recurrent infections (≥4 episodes per year): After achieving initial cure, maintain with fluconazole 150 mg weekly for 6 months 1, 2