3-49
homogenous, thin appearance; fishy odor with the addition of 10% KOH; presence of clue cells (vaginal
epithelial cells with their cell borders obscured by bacteria). In bacterial vaginosis, 2-50% of epithelial cells
will be clue cells.
Differential Diagnosis: Candida vaginitis or trichomonas (see Vaginitis chart), GC/chlamydia (see STD
section), PID (may have fever, chills, abdominal/pelvic pain as well as vaginitis complaints).
Plan:
Treatment
Primary: Metronidazole 500 mg po bid x 7 days
Alternative: Clindamycin 300 mg po bid x 7 days or ampicillin 500 mg po qid x 7 days (cure rate only
60%)
NOTE: If patient is breastfeeding or in 1st trimester of pregnancy, give clindamycin. Alternatively, use
vaginal clindamycin gel or metronidazole gel in the first trimester of pregnancy.
Patient Education
General: Take medications as prescribed, abstain from intercourse during treatment period.
Activity: Regular
Diet: As tolerated
Medications: No alcohol consumption (including mouthwash or topical alcohol-containing products) during
treatment with Metronidazole due to Antabuse-like effect (extreme fatigue, vomiting, anxiety, etc.).
Prevention and Hygiene: None
No Improvement/Deterioration: Return immediately
Follow-up Actions
Return evaluation: If symptoms do not resolve, the most likely cause of persistent disease is noncompliance
with medical therapy. If patient has been compliant, may re-treat with metronidazole 500 mg po bid x 14
days. Consider that patient may have trichomonas and be reinfected from a sexual partner. Treat the partner
as well with metronidazole 500 mg po bid x 7 days. The couple must abstain from intercourse during the
treatment period. If the patient has any suggestion of STD/PID treat immediately.
Consultation Criteria: Worsening/possible PID.
Symptom: GYN Problems: Candida Vaginitis/Vulvitis
MAJ Ann Friedmann, MC, USAIntroduction: Candida vaginitis and vulvitis are inflammatory conditions caused by Candida yeast. At least
25% of women with vaginitis will be diagnosed with candida infections. Other than the localized symptoms
there are no long-term or immediate sequelae of vaginal/vulvar candidiasis although a small percentage
of females will have frequent recurrence requiring prolonged treatment. Risk factors include pregnancy,
diabetes, immunosuppression (includes HIV) and antibiotic use.
Subjective: Symptoms
Vulvar and vaginal itching are the most common complaints; thick, curdy white discharge - increased from
baseline; external irritation and occasionally dysuria and pain with intercourse; no systemic symptoms (i.e.,
fever or abdominal pain) unless there is another illness; no foul-smelling vaginal discharge.
Focused History: Have you had this before? (may be “exactly like” her last infection). Do you have a new
partner? (Increased intercourse can change vaginal pH and predispose to candida vaginitis and bacterial
vaginosis. Consider STD screening- see PID section.)
Objective: Signs
See pelvic exam procedure and KOH prep lab procedure sections.