Treatment of Recurrent Bacterial Vaginosis and Recurrent Vulvovaginal Candidiasis

Initial Diagnostic Approach

The Centers for Disease Control and Prevention recommends confirming both diagnoses with appropriate testing, including Amsel's clinical criteria or Gram stain with objective scoring for bacterial vaginosis, and vaginal cultures to confirm diagnosis and identify non-albicans species for recurrent vulvovaginal candidiasis 2, 3
The American College of Obstetricians and Gynecologists suggests that culture is essential for diagnosing C. glabrata, which occurs in 10-20% of recurrent cases and responds poorly to standard azole therapy 2, 3

The Infectious Diseases Society of America recommends oral metronidazole 500 mg twice daily for 10-14 days, followed by maintenance therapy with metronidazole gel 0.75% twice weekly for 3-6 months if recurrence persists 1, 2, 3
The Centers for Disease Control and Prevention advises avoiding alcohol during treatment and for 24 hours after completion 4

The American College of Obstetricians and Gynecologists recommends extended initial therapy with 7-14 days of topical azole or fluconazole 150 mg repeated after 3 days, followed by maintenance fluconazole 100-150 mg weekly for 6 months 1, 2, 3
The Infectious Diseases Society of America suggests that maintenance therapy should be continued for 6 months to achieve complete mycologic remission 2, 3

The Centers for Disease Control and Prevention reports that recurrent vulvovaginal candidiasis affects 6 million U.S. women annually, causing $4.7 billion in lost productivity 5
The American College of Obstetricians and Gynecologists notes that maintenance fluconazole improves quality of life in 96% of women, though 63% continue to have infections after stopping maintenance therapy 5

The American College of Obstetricians and Gynecologists recommends using ONLY 7-day topical azole therapy for vulvovaginal candidiasis in pregnancy, as oral fluconazole is contraindicated 1
The Infectious Diseases Society of America advises treating HIV-infected patients with the same regimens as HIV-negative patients, with no dose adjustments needed 1, 2

The Centers for Disease Control and Prevention reports that 30-40% of women will have recurrent disease once maintenance therapy is discontinued 2, 3
The American College of Obstetricians and Gynecologists suggests reassessing for non-albicans species, considering boric acid, or referring to a specialist for vulvovaginal candidiasis 2