Chapter 56: Vaginitis – Antifungal & Antibacterial Treatments

The diagnostic criteria for Bacterial Vaginosis (BV) hinge on findings like thin homogeneous discharge, a positive whiff test, elevated pH above 4.5, and the presence of clue cells, commonly referred to as the Amsel criteria. First-line treatments for BV include oral or topical nitroimidazoles, specifically metronidazole or tinidazole, as well as clindamycin formulations. For Vulvovaginal Candidiasis (VVC), therapy selection is based on classification as uncomplicated or complicated, with uncomplicated cases typically managed by short-course topical azole antifungals like clotrimazole or miconazole, or a single oral dose of fluconazole. Recurrent VVC mandates more aggressive management, requiring induction therapy followed by a six-month maintenance regimen, usually with oral fluconazole. The chapter highlights that non-albicans species, such as Candida glabrata, often show azole resistance and necessitate alternative treatments, including boric acid or nystatin suppositories. Trichomoniasis diagnosis relies on highly accurate molecular assays (NAATs), and treatment is achieved using systemic metronidazole or tinidazole, often requiring specialist consultation if resistance is suspected. Important patient education includes counseling against alcohol consumption during and shortly after metronidazole or tinidazole therapy due to the risk of a disulfiram-like reaction, and advising that oil-based vaginal formulations (azoles and clindamycin) can damage latex contraceptive devices. Special attention is given to managing vaginitis during pregnancy, limiting VVC treatment to topical azoles and utilizing metronidazole for symptomatic BV and Trichomoniasis, while hormone replacement therapy is indicated for atrophic vaginitis in postmenopausal women.