What medications are used to treat acute vaginitis in a woman of reproductive age?

Treatment of Acute Vaginitis

For uncomplicated vulvovaginal candidiasis in women of reproductive age, either a single oral dose of fluconazole 150 mg or short-course topical azole therapy (1-3 days) is highly effective and recommended as first-line treatment. 1, 2

Vulvovaginal Candidiasis (Most Common Acute Vaginitis)

First-Line Treatment Options

Oral therapy:

• Fluconazole 150 mg as a single oral dose - this is the most convenient option with 80-90% cure rates 1, 2, 3

Topical azole therapy (equally effective):

• Clotrimazole 1% cream 5g intravaginally for 7-14 days 1
• Clotrimazole 100 mg vaginal tablet for 7 days 1
• Clotrimazole 500 mg vaginal tablet as single application 1
• Miconazole 2% cream 5g intravaginally for 7 days 1
• Miconazole 200 mg vaginal suppository for 3 days 1
• Terconazole 0.4% cream 5g intravaginally for 7 days 1
• Terconazole 0.8% cream 5g intravaginally for 3 days 1
• Butoconazole 2% cream 5g intravaginally for 3 days 1
• Tioconazole 6.5% ointment 5g intravaginally as single application 1

Important Treatment Considerations

• Topical azoles are more effective than nystatin and should be preferred 1
• Single-dose and short-course (1-3 day) regimens are appropriate for uncomplicated mild-to-moderate cases 1, 2
• Multi-day regimens (7-14 days) are preferred for severe or complicated infections 1
• Oil-based creams and suppositories may weaken latex condoms and diaphragms 1, 2

Special Populations

Pregnancy:

• Only topical azole therapies should be used during pregnancy - oral fluconazole is contraindicated 2

Recurrent infections (≥4 episodes/year):

• Require longer initial therapy followed by maintenance regimen 2
• Evaluate for predisposing conditions including diabetes, immunosuppression, or HIV 2

Bacterial Vaginosis (If Diagnosed)

Recommended Treatment

• Metronidazole 500 mg orally twice daily for 7 days 1
• This achieves 95% cure rates 1

Alternative Regimens

• Metronidazole 2g orally as single dose (84% cure rate) 1
• Clindamycin cream 2%, one applicator (5g) intravaginally at bedtime for 7 days 1
• Metronidazole gel 0.75%, one applicator (5g) intravaginally twice daily for 5 days 1
• Clindamycin 300 mg orally twice daily for 7 days 1

Key Points

• Patients should avoid alcohol during metronidazole treatment and for 24 hours after 1
• Treatment of male partners is not recommended as it does not alter clinical course or recurrence rates 1

Common Pitfalls to Avoid

• Do not treat asymptomatic Candida colonization - 10-20% of women harbor Candida without symptoms 1, 2
• Misdiagnosis is the most common reason for treatment failure - less than 50% of patients clinically treated for vulvovaginal candidiasis actually have confirmed fungal infection 2
• Patients whose symptoms persist after OTC preparations or who experience recurrence within 2 months should seek medical evaluation 1, 2
• Consider non-albicans Candida species (particularly C. glabrata) if standard azole therapy fails - these may require boric acid 600mg in gelatin capsule vaginally daily for 14 days 2