Patient handout

Vaginitis (bacterial vaginosis / candidiasis / trichomoniasis)

PRODUCTION

1. Your condition

This handout is for vaginitis (bacterial vaginosis / candidiasis / trichomoniasis). Your care team identified this based on: abnormal vaginal discharge — character/colour/consistency triages the differential (cdc sti 2021; acog pb 215).

Other reasons your team may use this plan: vulvovaginal itching / burning / irritation / dyspareunia (acog pb 215 — favours vvc; also atrophic/div); malodorous "fishy" discharge ± after intercourse (cdc sti 2021 — favours bv / trichomoniasis); positive vaginal naat/panel for t. vaginalis / bv / candida (cdc sti 2021 — most sensitive modality).

2. Your medications

Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.

Medication	Starting dose	How	When	What it does
metronidazole	500 mg PO BID × 7 d	PO	BID × 7 d	CDC STI 2021 first-line — ~80–90% short-term cure; safe in pregnancy (no longer requires later-trimester restriction); counsel alcohol avoidance
metronidazole vaginal gel 0.75%	one applicator (5 g) intravaginally	intravaginal	once daily × 5 d	CDC STI 2021 first-line topical — equivalent efficacy to oral, fewer systemic effects
clindamycin cream 2%	one applicator (5 g) intravaginally at bedtime	intravaginal	nightly × 7 d	CDC STI 2021 first-line alternative — oil-based, may weaken latex condoms ×5 d; preferred when nitroimidazole not tolerated
tinidazole	2 g PO daily × 2 d (or 1 g daily × 5 d)	PO	daily × 2–5 d	CDC STI 2021 alternative — longer half-life nitroimidazole; same alcohol counselling (RxCUI 10612 RxNav-verified, no in-repo precedent)
secnidazole	2 g PO single dose (oral granules)	PO	single dose	CDC STI 2021 alternative — single-dose nitroimidazole; rxcui omitted (no in-repo precedent, allowed at INTEGRATED)
clindamycin	300 mg PO BID × 7 d (or 100 mg ovule PV nightly × 3 d)	PO/intravaginal	BID × 7 d / nightly × 3 d	CDC STI 2021 alternative oral/ovule regimen; rxcui omitted for oral form (in-repo precedent is for cream; not invented)
metronidazole vaginal gel 0.75% (suppressive)	one applicator twice weekly	intravaginal	twice weekly × 3–6 months	Recurrent-BV suppression after induction cure — sustained reduction in recurrence (Sobel-class data; Surapaneni/Sobel PMID 34110746); monitor for secondary VVC
boric acid	600 mg intravaginally daily × ~21–30 d (adjunct in intractable RBV)	intravaginal	daily	Anti-biofilm adjunct in the prolonged combination RBV regimen (Surapaneni/Sobel PMID 34110746); TOXIC if ingested — counsel; rxcui omitted (no in-repo precedent)
L. crispatus CTV-05 live biotherapeutic (LACTIN-V)	intravaginal applicator: daily ×5 d week 1 then twice weekly ×10 wk (11-week course)	intravaginal	per 11-week regimen	CONDITIONAL adjuvant — reduces BV recurrence ONLY after post-antibiotic clinical cure: RR 0.56 (95% CI 0.35–0.77) by 12 wk if cured vs 1.34 (95% CI 0.47–2.23) if not (Hemmerling/Cohen PMID 38733973); sustains reduced genital IL-1α / soluble E-cadherin (Armstrong/Cohen PMID 35659905); post-CDC-2021 emerging evidence (not restated guideline standard); rxcui omitted (live biotherapeutic, no in-repo precedent, none invented)

Plan: Bacterial vaginosis — first-line cure → recurrent-BV suppression (CDC STI 2021; ACOG PB 215; Sobel/Surapaneni PMID 34110746; Vodstrcil NEJM 2025 PMID 40043236)

3. Your action plan

Use these zones to know what to do based on how you feel.

GREEN — Treated, improving / resolved

If you have:

Symptoms improving or resolved on the prescribed regimen
Completed full course as directed
Partner treated (if trichomoniasis)

Do this:

Finish the entire course even if you feel better (CDC STI 2021)
No alcohol during and for 72 h after metronidazole/tinidazole (CDC STI 2021)
No need for a re-test if symptoms have gone (except trichomoniasis — retest in 3 months) (CDC STI 2021)
Avoid douching and vaginal irritants; manage blood sugar if diabetic (ACOG PB 215)

YELLOW — Persistent, recurrent, or new symptoms

If you have:

Symptoms persist after completing treatment
Symptoms return within weeks, or ≥ 3 episodes in a year
New or different discharge / itch / odour

Do this:

Do NOT just repeat over-the-counter treatment — get re-examined with microscopy/culture (self-diagnosis is wrong ~50% of the time) (PMID 28594779)
Mention recurrences — you may need a longer suppressive plan or a culture for resistant/non-albicans yeast (Sobel NEJM 2004; ACOG PB 215)
For recurrent BV, ask about partner treatment options (Vodstrcil NEJM 2025)

Call your provider if:

Symptoms not improving after a full course
Three or more episodes in 12 months
You are pregnant and have symptoms

RED — Features beyond vaginitis — seek prompt care

If you have:

Pelvic or lower-abdominal pain, fever, pain with deep intercourse, or pain on cervical motion (possible pelvic infection) (CDC STI 2021)
Genital ulcers, severe swelling, or systemic illness
Pregnancy with significant symptoms

Do this:

Seek prompt medical evaluation — this may not be simple vaginitis (CDC STI 2021)
Bring details of any sexual partners and recent treatments

Call your provider if:

Always seek urgent care for fever + pelvic pain or systemic illness (CDC STI 2021; ACOG PB 215)

4. When to seek emergency care

Call 911 or go to the nearest emergency room right away if you have:

Cervical motion / uterine / adnexal tenderness, fever, or pelvic pain — points beyond vaginitis to PID / cervicitis (CDC STI 2021; ACOG PB 215)

5. Follow-up

Trichomoniasis: HIV + syphilis screen at diagnosis, partner treatment (expedited partner therapy where legal), pelvic rest until both treated + asymptomatic, 3-month repeat-infection retest. Recurrent VVC: ≥ 6-month maintenance plan, glycaemic optimisation, irritant avoidance. Recurrent BV: long-term suppression plan, condom/partner-treatment counselling, probiotic/vaginal-microbiome discussion (limited evidence). Education on trigger avoidance and accurate self-vs-clinician diagnosis limits (CDC STI 2021; ACOG PB 215; Vodstrcil NEJM 2025)

6. Sources

Guideline: CDC STI Treatment Guidelines 2021 (Workowski et al, MMWR Recomm Rep 2021;70(4):1-187) — BV / VVC / trichomoniasis sections; ACOG Practice Bulletin 215 "Vaginitis in Nonpregnant Patients" (2020); reconciled with IUSTI/BASHH-aligned 2021–2025 evidence