Treatment of Yeast Infections and Bacterial Vaginosis
Yeast Infection (Vulvovaginal Candidiasis) Treatment
For uncomplicated yeast infections, use topical azole antifungals for 7 days as first-line therapy, with single-dose oral fluconazole 150 mg as an effective alternative. 1, 2
Recommended Topical Regimens (80-90% cure rate)
- Clotrimazole 1% cream 5g intravaginally for 7 days 1, 3
- Miconazole 2% cream 5g intravaginally for 7 days 1
- Terconazole 0.4% cream 5g intravaginally for 7 days 1
- Alternative shorter courses (3-day regimens) should be reserved only for mild-to-moderate cases; severe or complicated infections require the full 7-day course 1
Oral Alternative
- Fluconazole 150 mg orally as single dose achieves 55% therapeutic cure rate (clinical resolution plus negative culture) 2
- While convenient, oral therapy carries systemic toxicity risk that topical agents avoid 1
Over-the-Counter Considerations
- Miconazole and clotrimazole are available OTC for 7-day treatment 1
- Self-treatment should only be used by women previously diagnosed with VVC who recognize recurrent symptoms 1
- Any woman with persistent symptoms after OTC treatment or recurrence within 2 months must seek medical evaluation 1
Partner Management
- Do not treat sexual partners routinely - VVC is not sexually transmitted and partner treatment does not reduce recurrence 1
- Exception: Male partners with symptomatic balanitis (erythema and pruritus on glans) may benefit from topical antifungal treatment 1
Bacterial Vaginosis Treatment
For symptomatic BV, use metronidazole 500 mg orally twice daily for 7 days, which achieves 95% cure rate and is superior to single-dose regimens. 4, 5
First-Line Regimen
- Metronidazole 500 mg orally twice daily for 7 days (95% cure rate) 4, 5
- This 7-day regimen is significantly more effective than the single-dose alternative 4
Alternative Regimens
- Metronidazole 2g orally as single dose (84% cure rate - notably inferior to 7-day course) 4
- Metronidazole gel 0.75% intravaginally 5
- Clindamycin 2% vaginal cream 5
Critical Patient Instructions
- Patients must avoid all alcohol during metronidazole treatment and for 24 hours after completion to prevent disulfiram-like reactions 5
- This is a non-negotiable safety requirement 5
Treatment Indications
- Only treat symptomatic BV - the goal is symptom relief, not eradication of colonizing bacteria 1, 4, 5
- Asymptomatic women with BV findings should not be treated unless undergoing gynecologic procedures or pregnant with history of preterm delivery 4, 6
Partner Management
- Routine treatment of male partners is not recommended as it has not been shown to prevent recurrence in most cases 1, 5
- However, in truly recurrent BV (multiple episodes), partner treatment may be considered 5
Diagnostic Requirements Before Treatment
- Diagnosis requires 3 of 4 Amsel criteria: homogeneous white discharge, clue cells on microscopy, vaginal pH >4.5, and positive whiff test 4, 7, 5
- Do not diagnose BV without clue cells unless confirmed by Gram stain (Nugent criteria) 4, 7
- Use vaginal pool samples from posterior fornix, not cervical specimens 7
Follow-Up
- No routine follow-up needed if symptoms resolve 5
- Return only if symptoms persist after treatment completion or recur 5
- Recurrence rates are high (50-80% within one year) regardless of treatment approach 5
Common Pitfalls to Avoid
- Never diagnose vaginitis based on symptoms alone - pH testing and microscopy are essential to differentiate between the three common causes 7, 8, 9
- Do not use cervical Gram stain for diagnosing vaginal discharge - it has poor sensitivity and specificity for BV, candidiasis, and trichomoniasis 7
- Do not treat asymptomatic colonization - approximately 10-20% of women harbor Candida normally, and identifying yeast without symptoms should not trigger treatment 1
- Culture for Gardnerella vaginalis is not diagnostically useful as it can be isolated from 50% of normal women 5
- Wet mount misses trichomoniasis 30-50% of the time; consider NAAT testing if clinical suspicion remains high 7