Vaginitis: Diagnosis and Treatment

It may be associated with the following factors: I am unaware of any dietary regimen, so-called 'natural products' or lifestyle modification (other than prolongation of breastfeeding) which makes any significant difference to the incidence of this complaint. There are a number of reasons for treatment failure. Lancet 1984, 2: Presence of inflammatory signs is more commonly associated with vulvovaginal candidiasis (range of LRs, 2. )Success rate is estimated at 70%. What can cause vaginitis?

Over-the-counter treatments are safe and often effective in treating yeast infections. If symptoms recur, referral to a specialist is advised. Vulval oedema. In the second section, the panel poses questions regarding the management of candidiasis, evaluates applicable clinical trial and observational data, and makes recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework [2]. If this is the first time you have had vaginal symptoms, you should see your health care professional. Similar to the approach in nonneutropenic patients, the recommended duration of therapy for candidemia in neutropenic patients is for 14 days after resolution of attributable signs and symptoms and clearance of the bloodstream of Candida species, provided that there has been recovery from neutropenia. 13 Those who are nondiabetic but consume a diet high in refined sugars may be susceptible to VVC as well. Concentration-dependent toxicity results in bone marrow suppression and hepatitis.

  • Vaginal candidiasis is common, though more research is needed to understand how many women are affected.
  • Review at one month and repeat micro and culture if still symptoms.

Because many patients experience recurrences once prophylaxis is discontinued, long-term therapy may be warranted. Severity of disease was based upon a scoring system involving degree of pruritus and physical signs (erythema, edema, excoriation and fissures). This CKS topic does not cover the management of other causes of vaginal discharge and itching. Vaginal yeast infections, candidiasis can make a diaper rash worse, producing a reddening and sensitivity of the affected area and a raised red border in some cases. If nonalbicans candida is detected, the laboratory can perform sensitivity testing using disc diffusion methods to guide treatment.

31 Further research is needed before specific recommendations on its use can be made. Symptomatic women who remain culture-positive despite maintenance therapy should be managed in consultation with a specialist. Drugs that treat certain types of infections. J Womens Health Gend Based Med. Cotch MF, Hillier SL, Gibbs RS, Eschenbach DA:

To date, azole resistance among C. Signs of trichomoniasis may include a yellow-gray or green vaginal discharge. This type of discharge does not require any medication even when quite profuse, as is often the case in pregnancy. An infection that is spread by sexual contact, including chlamydia, gonorrhea, human papillomavirus (HPV), herpes, syphilis, and human immunodeficiency virus (HIV, the cause of acquired immunodeficiency syndrome [AIDS]). There may be a limitation of outcome from treatment variation, routes of administration, different doses and quality of the randomised trials used in the systematic review. (8 hours) and is ordinarily administered at a dosage of 25 mg/kg 4 times daily for patients with normal renal function.

Point-prevalence studies indicate that Candida spp.

Sources Of Randomized Controlled Trials

Patient information: Who gets vulvovaginal candidiasis? If there are vulval symptoms, consider a topical imidazole as well (eg, clotrimazole or miconazole). 5 mg in 2 mL 5% dextrose in water (weak recommendation; low-quality evidence). Our study aimed to see if previous observations were reproducible for the gene responsible for Candidalysin (ECE1). Goad JA, Hess KM. There is a need to treat C. 1% hydrocortisone/Clotrimazole cream or 1 % hydrocortisone ointment if severe vulvitis.

  • Vulvovaginal candidiasis often occurs during pregnancy and can be treated with topical azoles.
  • Accuracy of implementation of national guidance (in particular NICE guidelines).
  • Meis PJ, Goldenberg RL, Mercer B, et al.

HIV Infection

If effective initially but relapses occur, consider longer term treatment for some months. Systemic upset. Non-albicans Candida spp. Caspofungin and micafungin are approved by the US Food and Drug Administration (FDA) for use in children. Monistat product information. 14 Women who are already colonized may have a greater risk. Candidal vaginitis:

Antifungal therapy as detailed above for chorioretinitis without vitritis, PLUS intravitreal injection of either amphotericin B deoxycholate, 5–10 µg/0. Candida parapsilosis demonstrates innately higher MICs to the echinocandins than do most other Candida species, which raises the concern that C. A 1993 in vitro study examined more than 250 strains of C. But many women think that they have a yeast infection when they actually have another problem.

Diagnosis of VVC

As many as one third of women will have symptoms of vaginitis sometime during their lives. A detailed description of the methods, background, and evidence summaries that support each recommendation can be found in the full text of the guideline. Vaginal yeast infections, the bottom line:. β-D-glucan is a cell wall constituent of Candida species, Aspergillus species, Pneumocystis jiroveci, and several other fungi.


They include isoflavones (found in soybeans), coumestans (found in red clover and alfalfa sprouts), and lignans (found in oil seeds such as flaxseed). Patients are more likely to comply when antifungal therapy is administered orally, but oral treatment carries a greater potential for systemic toxicity and drug interactions. 45 The CDC (Table 413,32) recommends giving 2 g of metronidazole as a single dose, preferably after 37 weeks of gestation, and counseling patients about the potential risks and benefits of treatment.

The recommended oral dose is 9 mg/kg twice daily (maximum dose 350 mg) [95, 107]. Candida vaginitis is associated with a normal vaginal pH (<4. )Clinically important interactions can occur when oral azoles agents are administered with other drugs (722). Approximately 30 percent of symptomatic women remained undiagnosed after clinical evaluation. Pooling of results favored use of nonpolyenes to AmB-containing comparators. Removal of an indwelling bladder catheter, if feasible, is strongly recommended (strong recommendation; low-quality evidence).

Related Articles

Experts in the topic area. Single-dose miconazole nitrate vaginal ovule in the treatment of vulvovaginal candidiasis: Step-down therapy to fluconazole, 400–800 mg (6–12 mg/kg) daily, is recommended for patients who have susceptible Candida isolates, have demonstrated clinical stability, and have cleared Candida from the bloodstream (strong recommendation; low-quality evidence). Oral voriconazole, 200–300 mg (3–4 mg/kg) twice daily, or posaconazole tablets, 300 mg daily, can be used as step-down therapy for isolates that are susceptible to those agents but not susceptible to fluconazole (weak recommendation; very low-quality evidence). Irrigation through nephrostomy tubes, if present, with AmB deoxycholate, 25–50 mg in 200–500 mL sterile water, is recommended (strong recommendation; low-quality evidence). Symptoms tend to be exacerbated premenstrually and remit during menstruation.

  • Prospective assessment of pregnancy outcomes after first-trimester exposure to fluconazole.
  • Topical antifungal therapy has been ineffective in male sexual partners, probably because of the presence of reservoirs not reached by this treatment.
  • Vulvovaginal candidosis.
  • How the intervention might work Antifungal agents generally act as fungistatics and most often work by just destroying the cell wall.
  • How is trichomoniasis treated?
  • The susceptibility of Candida to the currently available antifungal agents is generally predictable if the species of the infecting isolate is known.
  • Premature discontinuation of antifungal therapy can lead to relapse (strong recommendation; low-quality evidence).

Non-albicans Species

Moreover, most studies have been carried out in sexually transmitted disease clinics, family planning or student health clinics, largely ignoring women seen by private practitioners, especially older women. Frequent antibiotic use decreases protective vaginal flora and allows colonization by Candida species. Treat with two doses of oral fluconazole (150 mg) three days apart. Prevotella species, Mobiluncus species Trichomoniasis Trichomonas vaginalis Green-yellow, frothy Pain with sexual intercourse, vaginal soreness, dysuria Not primary symptom Signs of inflammation, “strawberry cervix” Vestibular erythema may be present Vulvovaginal candidiasis Candida albicans, Candida krusei, Candida glabrata White, thick, lack of odor Burning, dysuria, dyspareunia Frequent Signs of inflammation, edema Excoriations Atrophic vaginitis Estrogen deficiency Yellow, greenish, lack of odor Vaginal dryness, pain with sexual intercourse Rare Vagina mildly erythematous, easily traumatized Vestibule thin and dry; labia majora lose their subcutaneous fat; labia minora irritated and friable Erosive lichen planus Etiology is unknown Yellow or gray Intense pain, dyspareunia, postcoital bleeding Intense Erythema with friable epithelium Erosions, white plaques Irritant or allergic contact dermatitis Contact irritation or allergic reaction with episodic flares Minimal Burning on acute contact, soreness More likely in allergic reactions Vulvar erythema possible Erythema with or without edema; vesicles or bullae rare Enlarge Print Table 2. The compound is available in the United States only as an oral formulation. 1,21 The pharmacist can assist patients in determining the most appropriate course of action by first obtaining pertinent information about their symptoms. 14 15 It was seen that women with RVVC with vulvar excoriation, longer disease time and family history of atopic disease are at greater risk of not responding to maintenance treatment with fluconazole.

That is, earlier intervention with appropriate antifungal therapy and removal of a contaminated central venous catheter (CVC) or drainage of infected material is generally associated with better overall outcomes [14–19]. Longitudinal studies indicate that most women will be found to be colonized with Candida, often transiently, with up to 90% of women being colonized at one time or another [12,13]. Studies comparing different medications are not available.

What Is Trichomoniasis?

PCR testing for yeast is not FDA-cleared; culture for yeast remains the gold standard for diagnosis. In suspected bacterial/resistant or complicated infection, take swabs from the anterior fornix or lateral vaginal wall and send for microscopy, culture and sensitivity. The majority prefer the convenience of oral therapy, although relief may occur sooner with topical agents. Always look carefully for a predisposing factor. The major route of elimination is nonenzymatic degradation. However, recent case series have described treatment failure associated with resistant strains of C. Caspofungin, anidulafungin, and micafungin are available only as parenteral preparations [82–84]. Vaginal pH is maintained between 3.

Fever, right upper quadrant discomfort, nausea, and elevation of liver enzymes occur following return of neutrophils and persist for months unless treatment is initiated. Atrophic vaginitis is treated with estrogen, which can be applied as a vaginal cream, ring, or tablet. 24 In addition, long-term treatments are expensive, and approximately 50% of women experience recurrence of symptoms a few months after treatment completion. As such, blood cultures should be positive during the vast majority of active Candida bloodstream infections. Perspiration associated with tightly fitted clothes or poorly ventilated underwear increases local temperature and moisture. Fluconazole is readily absorbed, with oral bioavailability resulting in concentrations equal to approximately 90% of those achieved by intravenous administration [55].

For example, if the infection is a different kind, such as bacterial vaginosis (the most common cause of abnormal vaginal discharge), rather than thrush. It should be emphasized that azole-resistant strains of C. The data are largely derived from single-arm studies, small subsets of randomized controlled studies that have enrolled mostly nonneutropenic patients, and pooled outcomes from randomized trials [205, 206]. What is the treatment for chronic disseminated (hepatosplenic) candidiasis?

Tea Tree Oil (and Other Essential Oils)

Bacterial vaginosis is caused by overgrowth of the bacteria that occur natually in the vagina. Broad-spectrum antibiotic use alters the bacterial microflora, allowing for the overgrowth of Candida organisms. These include miconazole (Monistat), tioconazole (Vagistat), and clotrimazole (Gyne-Lotrimin). 12,13 The normal vaginal environment protects women against vaginal infections. PCR has potential advantages over β-D-glucan or antigen-antibody assays, including the capacity for species identification, detection of molecular markers for drug resistance, and multiplex formatting. Several factors are associated with increased rates of asymptomatic vaginal colonization with Candida spp. Most experience with AmB is with the deoxycholate preparation. Sex partners should be treated simultaneously.

  • The recent emergence of multidrug-resistant Candida species further complicates the selection of antifungal therapy for the immediate future [10, 12, 35–38] as there are no good prospective data to guide therapy.
  • In addition, it is still important to recognise that the excessive use and overuse of such topical agents have had other adverse consequences such as oedema, irritability of the skin and maybe even chronic vulvar pain condition (vulvodynia).
  • Hormonal contraception, vitamin A deficiency, and other risk factors for shedding of HIV-1 infected cells from the cervix and vagina.
  • Another pooled analysis that summarized results of treating with micafungin or comparators (liposomal AmB or caspofungin) for candidemia in the setting of malignancy-associated neutropenia from 2 randomized trials demonstrated success rates ranging from 53% to 85%, but no significant differences among treatment groups [206].
  • If no treatment was started at the first visit, information on treatments will be offered to woman and preferences will be asked.
  • For initial treatment, liposomal AmB, 5 mg/kg daily, with or without oral flucytosine, 25 mg/kg 4 times daily is recommended (strong recommendation; low-quality evidence).
  • Published studies have shown conflicting results, but Lactobacillus rhamnosus GR-1, Lactobacillus fermentum RC-14, and L acidophilus have been shown to be somewhat effective; eating 8 oz of yogurt with live cultures daily may also provide some benefit.

Alternative Treatments

Yeast infection also is known as candidiasis. Topical clotrimazole or miconazole may also be used for vulval symptoms. For patients who have recurrent esophagitis, chronic suppressive therapy with fluconazole, 100–200 mg 3 times weekly, is recommended (strong recommendation; high-quality evidence). Treatment usually entails the use of topical vaginal estrogen for 1-2 weeks to alleviate symptoms. Treatment with fresh garlic extract and pure allicin (an active compound produced in cut garlic) resulted in a decrease in SIR2 expression in all strains. Am J Perinatol 1986, 3: All are more or less equally effective. Contact your healthcare provider if you have any of these symptoms.

2 17–19 A previous Cochrane review aimed to compare the clinical cure rate of topical versus oral treatment for the treatment of VVC20 and found no difference in the efficacy of oral and vaginal treatment but found that women generally preferred oral treatment. PubMed, which includes Medline (1946 to present), was searched to identify relevant studies for the Candida guideline PICO (population/patient, intervention/indicator, comparator/control, outcome) questions. 3 mg/kg daily, are other alternatives for refractory disease (weak recommendation; moderate-quality evidence). Chemicals (creams, gels, foams) that inactivate sperm. Thrush treatments, symptoms, causes & home remedies, for adults who have recurring cases of oral thrush with no known cause, their healthcare provider will evaluate them for underlying medical conditions that might be contributing to thrush. Hurley R, De Louvois J: Lipid formulation AmB, 3–5 mg/kg daily, for 2 weeks, followed by fluconazole, 400 mg (6 mg/kg) daily, for at least 4 weeks is a less attractive alternative (weak recommendation; low-quality evidence). 6 Although antifungal resistance can cause treatment failure, other factors may contribute to recurrent vulvovaginal candidiasis (Table 1).

Books About Skin Diseases

A type of vaginal infection caused by a one-celled organism that is usually transmitted through sex. Refer to condom product labeling for further information. Use of some types of antibiotics increase your risk of a yeast infection. The information provided to women has been developed taking into account the results of a discussion group of women with candidal vaginitis and primary health care physicians working on different formats and content. With macular involvement, antifungal agents as noted above PLUS intravitreal injection of either AmB deoxycholate, 5–10 µg/0. What is the cause of vulvovaginal candidiasis? For step-down therapy after the patient has responded to initial treatment, fluconazole, 400–800 mg (6–12 mg/kg) daily, is recommended (strong recommendation; low-quality evidence).

Therapy should continue until all signs, symptoms, and cerebrospinal fluid (CSF) and radiological abnormalities, if present, have resolved (strong recommendation; low-quality evidence). Bacterial vaginosis vs. yeast infection: how to tell the difference, either of the EcoVag® strains, L. Add antiviral if suspect coexistent HSV. Species-specific prevalence of vaginal candidiasis among patients with diabetes mellitus and its relation to their glycaemic status. The recent combined analysis of 7 candidemia trials observed a survival benefit among those who underwent CVC removal at some time during treatment for candidemia [19]. 30 DIAGNOSIS In clinical practice, bacterial vaginosis is diagnosed by the presence of three out of four Amsel criteria31: McDonald HM, O’Loughlin JA, Jolley P, et al.

When vaginal wet-mount preparation is promptly examined, motile trichomonads with flagella slightly larger than a leukocyte may be seen (arrow). The development of reliable nonculture assays is critical to providing the opportunity for earlier intervention and more targeted antifungal therapy among large numbers of patients in whom traditional blood cultures are insensitive or provide untimely results [20]. Use of oral corticosteroids or immunosuppressants in the last week.

  • In the same study, women with severe vaginitis found short-course therapy (single-dose fluconazole) less effective than more prolonged therapy with 7 days of clotrimazole.
  • Having had sex without use of barrier methods in the previous 24 hours.
  • The vast majority of these patients will not be diabetic.


Thousands of women carry the label of recurrent yeast infections when, in fact, recurrent symptoms are due to noninfectious etiologies such as allergic and hypersensitivity vulvitis. Other tests include culture in Sabouraud chloramphenicol agar or chromagar, the germ tube test, DNA probe testing by polymerase chain reaction (PCR), and spectrometry to identify the specific species of candida. Many women in Europe and the United States have used dong quai, a traditional Chinese herb extracted from the Angelica sinensis root, for menopausal symptoms. Systemic antifungal therapy is always required. However, vulvovaginal candidiasis does occur more frequently and is more likely to persist in HIV-positive women and longer courses of treatment may be required. Other infrequent causes of VVC include C.

Certainly, no major morbidity or serious complications have been reported, although high-dose regimens of terconazole were associated with fever and flu-like symptoms that resulted in the withdrawal of this topical agent in these concentrations [25]. For the most part, once a correct diagnosis is obtained and the patient placed in the correct category of complicated or uncomplicated VVC, more than 90% of episodes of VVC can be effectively handled using existing agents for the recommended duration. Pain syndromes, can mimic symptoms of candidiasis. Fungal sensitivities can be requested if there is treatment failure for candida. CMAJ Can Med Assoc J. Unfortunately, these drugs are not soluble and hence not available orally, and stability issues have precluded their topical use.

Fluconazole, 800-mg (12 mg/kg) loading dose, then 400 mg (6 mg/kg) daily, is an acceptable alternative for patients who have had no recent azole exposure and are not colonized with azole-resistant Candida species (strong recommendation; moderate-quality evidence). Patients undergoing urologic procedures should be treated with oral fluconazole, 400 mg (6 mg/kg) daily, OR AmB deoxycholate, 0. For patients in whom a ventricular device cannot be removed, AmB deoxycholate could be administered through the device into the ventricle at a dosage ranging from 0. This causes the lining of the vagina to become inflamed. Some women with yeast infections notice an increase or change in discharge. Although not structurally defined, longer duration may be defined as the presence of therapeutic concentrations of the antifungal drug in the vagina for at least 7 days. Yeast infection during pregnancy, also, over-the-counter medicine should not be used by anyone younger than 12 or girls who might be pregnant without talking to a doctor first. This recommendation is based on expert opinion in a review article, which states that after alternative diagnoses have been excluded and risk factors removed (where possible), the investigation and treatment of vulvovaginal candidiasis in older women should be the same as for younger women.


Pirotta MV, Garland SM. Complicated VVC due to non-albicans Candida spp. The symptoms of VVC are usually nonspecific and can be due to a variety of causes. Eight home remedies for a yeast infection, airy, cotton undies:. Among women with bacterial vaginosis, no overall increased risk of developing pelvic inflammatory disease has been found. Although long-term prophylactic therapy with fluconazole at a dose of 200 mg weekly has been effective in reducing C. To fully realize the benefits of combining culture and nonculture tests, however, clinicians must carefully consider the types of invasive candidiasis, understand the strengths and limitations of each assay, and interpret test results in the context of the clinical setting.


The distribution of these entities is likely to differ among centers; on balance, data suggest that the groups are approximately equal in size [129]. Earlier epidemiologic studies found that almost all women diagnosed with fluconazole-resistant C albicans had experienced previous exposure to fluconazole. Loose-fitting clothing — avoid occlusive nylon pantyhose. The fishy odor caused by production of amines from anaerobic bacteria found in many of these patients is predictive of bacterial vaginosis. Relationship between cell surface composition of Candida albicans and adherence to acrylic after growth on different carbon sources. Mendling W, Schlegelmilch R. In vitro studies have shown that imidazole antifungal agents such as miconazole and clotrimazole are not as effective against non– C.