Should a patient who tests positive for bacterial vaginosis (BV), Trichomonas vaginalis infection (trichomoniasis), and vulvovaginal candidiasis (VVC) be treated for all three infections?

Treatment of Co-Infection with BV, Trichomonas, and Candidiasis

Yes, treat all three infections simultaneously when laboratory testing confirms bacterial vaginosis, trichomoniasis, and vulvovaginal candidiasis. Each represents a distinct pathophysiologic process requiring specific antimicrobial therapy, and treating only one or two will leave the patient symptomatic and at risk for complications. 1

Treatment Regimen

Bacterial Vaginosis

• Metronidazole 500 mg orally twice daily for 7 days is the first-line treatment, achieving 95% cure rates. 2, 3
• Alternative: Clindamycin 2% cream (5g intravaginally at bedtime for 7 days) if oral therapy is contraindicated. 2
• Critical caveat: Instruct the patient to avoid alcohol during treatment and for 24 hours afterward to prevent disulfiram-like reactions. 2

Trichomoniasis

• Metronidazole 2g orally as a single dose is the standard treatment, with cure rates of 88-95%. 3, 4, 1
• Alternative: Metronidazole 500 mg orally twice daily for 7 days if single-dose therapy fails. 1
• Partner treatment is mandatory: The sexual partner must receive metronidazole 2g single dose simultaneously to prevent reinfection, even without testing. 1, 4

Vulvovaginal Candidiasis

• Clotrimazole 1% cream 5g intravaginally for 7-14 days is first-line topical therapy. 5, 1
• Alternative oral option: Fluconazole 150mg as a single oral dose for patients who prefer systemic therapy. 5
• Multi-day topical courses (7-14 days) are preferred when treating concurrent infections to ensure adequate coverage. 1

Timing and Coordination

The metronidazole regimen for BV (500mg twice daily for 7 days) will simultaneously treat trichomoniasis, simplifying the treatment protocol. 3, 2 Administer the antifungal therapy concurrently—there is no contraindication to treating all three conditions at once. 1

Common Pitfalls to Avoid

• Do not treat BV organisms separately: BV is a polymicrobial syndrome requiring single-agent therapy targeting the entire dysbiotic flora, not individual pathogens like Gardnerella or Mycoplasma. 2
• Do not skip partner treatment for trichomoniasis: Failure to treat the sexual partner leads to immediate reinfection and treatment failure. 1, 4
• Do not treat asymptomatic candidal colonization: 10-20% of women harbor Candida asymptomatically; only treat when symptoms are present. 5, 1
• Complete the full 7-day metronidazole course: Premature discontinuation leads to treatment failure and recurrence. 2

Special Considerations in Pregnancy

If the patient is pregnant, modify the regimen:

• BV: Metronidazole 250mg orally three times daily for 7 days (second/third trimester) or clindamycin vaginal cream (first trimester preferred). 2
• Trichomoniasis: Metronidazole 2g single dose is safe and reduces preterm birth risk. 4, 3
• Candidiasis: Use topical azoles only; avoid oral fluconazole in pregnancy. 1

Follow-Up

• Re-evaluate only if symptoms persist after completing therapy or recur within 2 months. 5, 1
• Test-of-cure is not routinely recommended for trichomoniasis after metronidazole treatment. 4
• Confirm both patient and partner completed trichomoniasis therapy to prevent reinfection. 1