Vaginitis: Trichomoniasis, Candidiasis, Bacterial Vaginosis Management

Evaluation and Treatment of Sex Partners

Partners of Patients with Trichomoniasis

Sex partners of patients with T vaginalis infection may complain of clear or mucopurulent urethral discharge and dysuria and should be treated with a 7-day regimen of Metronidazole 500 mg twice a day or a single oral dose of Tinidazole 2 g. Partners within the last 60 days must be traced, checked, and treated. If the last sexual contact is >60 days ago, the most recent sex partner should be treated. Treatment of sex partners increases cure rates. Patients and their sex partners should avoid sex until they are cured (both partners have completed therapy and are asymptomatic). Patient-delivered partner therapy might be considered in managing partners for trichomoniasis.

Partners of Patients with Bacterial Vaginosis

Routine screening and treatment of sex partners were previously not recommended since these were thought to have no impact on possible relapse or recurrence or remission of bacterial vaginosis. However, based on a recent trial with 150 monogamous couples with confirmed bacterial vaginosis in the female, treatment of the partner for 1 week with an oral (Metronidazole) and topical (Clindamycin) antimicrobial in addition to standard treatment of the female patient reduced recurrences at 12 weeks compared with treating the female patient alone. Dual topical and oral antimicrobial male partner therapy for 7 days may be used to reduce bacterial vaginosis recurrence in female patients.

Partners of Patients with Vulvovaginal Candidiasis

Routine treatment of sex partners is not recommended, as it has no benefit in the therapeutic outcome of relapses but may be considered in women with recurrent infections. Male sex partners who are symptomatic will require treatment, and partners with balanitis may benefit from topical antifungal therapy.

Syndromic or empiric therapy may be given if the patient is at low risk for sexually transmitted infections or without symptoms of upper genital tract infection.

Trichomoniasis

Treatment is indicated in patients positive for trichomoniasis regardless of symptoms.

Recommended Regimen

Nitroimidazoles are the only class of drugs that are used for the oral or parenteral treatment of trichomoniasis. A single oral-dose regimen of Metronidazole or Tinidazole is preferred over a 7-day regimen because of reduced cost and increased compliance, though the 7-day course of Metronidazole has been shown in a randomized controlled trial to be more effective than the single dose. Studies have shown that oral Metronidazole has 90-95% cure rates and Tinidazole has 86-100% cure rates. Tinidazole is equivalent or superior to Metronidazole in achieving parasitologic cure and resolution of symptoms as suggested by some randomized controlled trials. Topical Metronidazole (eg Metronidazole gel) is generally not recommended because it is unlikely to achieve therapeutic levels in the urethra or perivaginal glands. Topical Metronidazole may only be used as a treatment option in special circumstances where oral nitroimidazoles are contraindicated. Secnidazole or Ornidazole may be used as a single-dose therapy as an alternative to Metronidazole therapy. Secnidazole offers an advantage over multiple-dose Metronidazole regimens.

Special Considerations

A repeat course of oral Metronidazole for 7 days may be considered in patients unresponsive to initial standard therapy. Treatment-resistant trichomoniasis may require higher doses of therapy. Extended doses of Tinidazole orally or intravaginally may be given if high-level Metronidazole resistance is reported. Concurrent intravaginal Paromomycin with oral Tinidazole may be considered if oral Tinidazole with intravaginal Tinidazole fails. In cases of 5-nitroimidazole derivative allergy, desensitization is recommended. Topical therapy of other drugs may be considered, but cure rates are <50%. Studies showed that patients treated with intravaginal Boric acid¹ exhibited clinical improvement.

A single dose of 2 g Metronidazole can be given to women at any stage of pregnancy, plus careful counseling about condom use and continued risk of sexual transmission. Preterm delivery is avoided with oral Metronidazole therapy in symptomatic pregnant patients. In asymptomatic pregnant patients, some specialists would postpone treatment until after 37 weeks of gestation. Tinidazole, Secnidazole and Ornidazole are not suggested as treatment during pregnancy. As treatment of trichomoniasis with Dequalinium Cl has an overall efficacy of 17-50%, a concomitant systemic trichomonacidal agent, eg Metronidazole, should be used. Breastfeeding should be discontinued during and for 12-24 hours after the last dose of Metronidazole or until 3 days after the last dose of Tinidazole. Intravaginal treatment may be considered; however, avoid high doses. In HIV-infected women, a multiple-dose regimen for trichomoniasis is recommended. Studies have shown that a single oral dose of Metronidazole 2 g is not as effective as the 7-day regimen using 500 mg twice a day.

¹Various combinations of Boric acid are available. Please see the latest MIMS for specific formulations and prescribing information.

Bacterial Vaginosis (BV)







Treatment is recommended in symptomatic patients, patients with positive direct microscopy with or without symptoms, pregnant women with a history of preterm birth or second-trimester miscarriage, and patients who will undergo surgical procedures. Treatment will help relieve signs and symptoms of bacterial vaginosis and lower the risk of acquiring sexually transmitted infections like C trachomatis, N gonorrhoeae, T vaginalis, herpes simplex type 2, or HIV. There is inconsistent evidence regarding the treatment of pregnant patients who have asymptomatic bacterial vaginosis who are at high risk for preterm deliveries.

Recommended Regimens

A seven-day regimen of oral Metronidazole, a single dose or 5-day regimen of intravaginal Metronidazole gel, or a 7-day regimen of intravaginal Clindamycin cream may be advised.

Alternative Regimens

Oral Metronidazole single dose, oral Secnidazole single dose, oral Tinidazole single dose or for 2-5 days, oral Clindamycin for 7 days, intravaginal Clindamycin ovules for 3 days, or intravaginal Dequalinium Cl for 6 days may be considered. Other options with limited data on efficacy include Metronidazole extended-release tablets for 7 days, single dose of Clindamycin intravaginal cream, nitroimidazole plus antifungal vaginal suppositories, dendrimer gel and adjunctive therapies such as intravaginal lactobacillus formulations, probiotics or vitamin C.

Special Considerations

Women with documented several recurrences (at least three documented separate episodes per year) are recommended to have longer courses of therapy (ie intravaginal Metronidazole gel for 16 weeks). In Metronidazole- or Tinidazole-allergic women, Clindamycin cream may be a substitute.

Symptomatic pregnant women should be treated to reduce the signs and symptoms of infection, to lower the risk for infectious complications, and to decrease other possible sexually transmitted infections. Oral Metronidazole or Clindamycin given for 7 days are the recommended regimens. Intravaginal Clindamycin cream should only be given in the first half of pregnancy due to possible adverse effects (eg low birth weight or neonatal infections). Treatment during pregnancy does not decrease the risk of a preterm delivery. In breastfeeding women, intravaginal treatment may be considered; however, avoid high doses.

Women who will undergo gynecological procedures may be given oral Metronidazole for 5 days or oral Clindamycin for 7 days. HIV-infected patients with bacterial vaginosis should receive the same treatment regimen as those who are HIV-negative. Bacterial vaginosis recurrence is higher in HIV-positive patients.

Vulvovaginal Candidiasis (VVC)

In non-pregnant women with uncomplicated vulvovaginal candidiasis, topical or intravaginal and oral antifungal azoles have similar efficacy. Asymptomatic candidiasis should only be treated during pregnancy due to perinatal transmission. Longer therapy may be required in infections with yeasts other than C albicans.

Recommended Regimens for Uncomplicated Vulvovaginal Candidiasis

Uncomplicated VVC is effectively and safely managed with oral and short-course topical regimens. Azoles are effective in relieving symptoms and providing negative cultures in 80-90% of patients after completion of treatment. Topically applied azole drugs require shorter therapies and appear to be more effective than Nystatin. Nystatin may be used in patients with an organism with reduced susceptibility to azole drugs. If symptoms persist after using over-the-counter preparations or if symptoms recur within 2 months, the patient should undergo further office-based evaluation.

Recommended Regimens for Complicated Vulvovaginal Candidiasis

Complicated cases, which include pregnancy, severe symptoms (eg extensive vulvovaginal involvement, skin fissures, and/or tissue edema), recurrent disease (3 test-confirmed episodes/year), infection with non-albicans species, and abnormal host factors (diabetic, debilitated, hyperestrogenemic, immunocompromised, or immunosuppressed [eg corticosteroid therapy]) generally require longer courses of antimycotic drugs. To maintain clinical and fungal control, a longer duration (ie 7-14 days) of initial intensive therapy prior to starting the maintenance antifungal regimen is recommended in patients with recurrent vulvovaginal candidiasis. Weekly oral Fluconazole for 6 months is the preferred agent used as a maintenance regimen; however, 30-50% of vulvovaginal candidiasis will recur once maintenance therapy is discontinued. For patients who are unwilling or unable to take Fluconazole, longer courses of therapy with topical azoles are options for the resolution of symptomatic recurrent vulvovaginal candidiasis. Ten to fourteen days of topical azole or oral Fluconazole in 2-3 doses taken 3 days apart is recommended in patients with severe vulvovaginal candidiasis. For patients with recurrent vulvovaginal candidiasis, Oteseconazole may be considered only in patients who are not of reproductive potential.

For non-albicans (eg C glabrata, C krusei, C tropicalis, S cerevisiae, C parapsilosis) vulvovaginal candidiasis, a longer duration (ie 7-14 days) of an oral or topical non-Fluconazole azole drug is recommended as the preferred regimen. Vaginal Boric acid¹ is the preferred initial therapy for C glabrata; alternative treatments include topical Flucytosine, topical Amphotericin B deoxycholate and Nystatin. If recurrence occurs, vaginal Boric acid¹ given for 3 weeks is advised, which has 70% clinical and mycological eradication rates.

Special Considerations

Women with immunodeficiency, uncontrolled diabetes, or those taking corticosteroids should receive prolonged conventional antifungal treatment. Only topical azoles (eg Clotrimazole, Miconazole, Nystatin) applied for 7 days are advised for use in pregnant patients. Some pregnant patients may require longer treatment duration (10-14 days) for symptoms to resolve. Maintain daily use of topical azoles until delivery in relapses occurring from the 34th week of pregnancy. Oral anticandidal therapy and Boric acid should not be used during pregnancy. In patients with severe Candida vulvar inflammation, topical corticosteroids can be applied to the vulva for 48 hours until antifungals exert their effect. Intravaginal Dequalinium Cl may be used during pregnancy and lactation, if necessary, due to its negligible systemic absorption. HIV-infected patients with vulvovaginal candidiasis should receive the same treatment regimen as those who are HIV-negative.

¹Various combinations of Boric acid are available. Please see the latest MIMS for specific formulations and prescribing information.

Patient Education 

The patient needs to be informed about the nature of the infection and the importance of taking the full course of the medication. Counsel patients with possible complications of vaginitis and therapy. Bacterial vaginosis is associated with post-procedure pelvic inflammatory disease (PID), intrauterine device insertion or other instrumentation, vaginal cuff cellulitis, and pregnancy-related problems (eg late miscarriage, preterm birth, premature rupture of membranes, chorioamnionitis, and postpartum endometritis). Patients with bacterial vaginosis are also at increased risk of HIV, chlamydia, gonorrhea, and herpes infections. Trichomoniasis can potentially cause cervicitis and PID and is associated with increased HIV transmission and adverse pregnancy outcomes (eg preterm delivery, premature rupture of membranes, and low birth weight). Inform patients with bacterial vaginosis to avoid vaginal douching, use of shower gel and antiseptic agents, or shampoo in the bathtub. Advise patients with vulvovaginal candidiasis to avoid tight-fitting synthetic clothes and use of local irritants. Antifungal vaginal creams used for vulvovaginal candidiasis treatment can damage latex condoms, cervical caps, and diaphragms.

Consider alternative contraceptive methods in women with recurrent vulvovaginal candidiasis who are utilizing combined hormonal contraception. Advise trichomoniasis and bacterial vaginosis patients on how to lower their risk of acquiring STIs. Tailor counseling to the patient’s specific risk factors. Abstinence and condom use may be done. A careful selection of partners should be advised. Dual antibiotic partner therapy for bacterial vaginosis should be prescribed in combination with patient or partner education on sexual transmission and discussion of consistent condom use to reduce transmission.