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gyn.vaginitis.core.v1PRODUCTION
gyn.vaginitis.core.v1

Vaginitis (bacterial vaginosis / candidiasis / trichomoniasis)

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12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Symptomatic vaginitis in an adult — empiric symptom-only treatment is wrong ~50% of the time; anchor on a structured point-of-care workup (pH → whiff → saline/KOH microscopy → NAAT) before naming a cause (CDC STI 2021; ACOG PB 215; PMID 28594779)

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scope confirmed: symptomatic adult with abnormal discharge/pruritus/odour

Patient inputs (20)

Reproductive-age vs postmenopausal reframes the differential — atrophic vaginitis / genitourinary syndrome of menopause dominates after menopause (ACOG PB 215)

Intense vulvar pruritus/burning favours VVC; erythema/excoriation severity grades uncomplicated vs severe VVC (ACOG PB 215; CDC STI 2021)

Trichomoniasis is an STI → partner therapy + STI co-testing; BV is sexually associated and male-partner treatment now reduces recurrence (StepUp Vodstrcil NEJM 2025)

Pregnancy makes VVC "complicated"; oral fluconazole avoided (use 7-d topical azole); symptomatic BV/trich are still treated (CDC STI 2021; ACOG PB 215)

≥ 3 VVC episodes/12 mo = recurrent VVC; recurrent BV (≥ 3/yr) drives suppressive/complicated regimens (CDC STI 2021; Sobel NEJM 2004)

Uncontrolled diabetes / HIV / immunosuppression / recent broad-spectrum antibiotics defines complicated VVC and predicts non-albicans / refractory disease (CDC STI 2021; ACOG PB 215)

Nitroimidazole allergy → metronidazole/tinidazole desensitisation for trichomoniasis (no cross-class cure); azole intolerance reroutes VVC therapy (CDC STI 2021)

Thin grey homogeneous → BV; thick white curd → VVC; frothy yellow-green → trichomoniasis (CDC STI 2021; ACOG PB 215) — sets pre-test prior

Fishy amine odour (± post-coital) is the hallmark of BV and a whiff-test correlate; absent in pure VVC (CDC STI 2021)

Point-of-care pivot: normal (≤ 4.5) → VVC/physiologic; elevated (> 4.5) → BV/trich/atrophic/DIV. Confounded by blood/semen/lubricant (CDC STI 2021; ACOG PB 215)

KOH amine "whiff" — Amsel criterion; positive favours BV (also trich) (Amsel; CDC STI 2021)

Clue cells (BV), motile trichomonads + PMNs (trich), parabasal cells (atrophic/DIV). Operator-/time-dependent sensitivity (CDC STI 2021; ACOG PB 215)

Pseudohyphae / budding yeast for VVC; 10% KOH lyses cells to improve yield (sens only ~50–70%) (ACOG PB 215; CDC STI 2021)

Nugent Gram-stain (0–10) is the BV REFERENCE standard (7–10 = BV; 4–6 intermediate) (CDC STI 2021; PMID 31748322)

Molecular NAAT/panel — most sensitive for trichomoniasis and multi-pathogen detection when microscopy negative or coinfection suspected (PMID 28594779; PMID 31748322)

Yeast culture + speciation/susceptibility for recurrent/refractory VVC — identifies azole-tolerant non-albicans (C. glabrata) (CDC STI 2021; ACOG PB 215)

Cervical/vaginal NAAT for N. gonorrhoeae & C. trachomatis — cervicitis is a separate pathway and trichomoniasis mandates STI co-testing (CDC STI 2021)

Recent antibiotics predispose to VVC; systemic/topical estrogen status drives the atrophic-vaginitis branch (ACOG PB 215; PMID 39771534)

Trichomoniasis is an STI — HIV + syphilis screen + repeat-infection 3-month retest are mandated (CDC STI 2021)

≥ 3 of 4 (discharge, pH > 4.5, whiff+, clue cells ≥ 20%) diagnoses BV at point of care (Amsel; CDC STI 2021)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (8)

8 need judgement
  • informationalsevereupper_tract_or_cervicitis_features
    Cervical motion / uterine / adnexal tenderness, fever, or pelvic pain — points beyond vaginitis to PID / cervicitis (CDC STI 2021; ACOG PB 215)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderaterecurrent_vvc_pathway
    ≥ 3 culture-confirmed VVC episodes in 12 months (recurrent VVC) (CDC STI 2021; Sobel NEJM 2004 PMID 15329425)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatenon_albicans_azole_tolerant_vvc
    Culture/speciation shows non-albicans Candida (esp. C. glabrata) or azole-refractory VVC (CDC STI 2021; ACOG PB 215)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatetrichomoniasis_sti_obligations
    Confirmed Trichomonas vaginalis — an STI requiring partner therapy, HIV/STI co-testing, and 3-month retest (CDC STI 2021)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatepregnancy_with_symptomatic_vaginitis
    Pregnant patient with symptomatic BV / VVC / trichomoniasis (CDC STI 2021; ACOG PB 215)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatenitroimidazole_allergy_with_trichomoniasis
    IgE-mediated nitroimidazole allergy in a patient with trichomoniasis — no effective cross-class alternative (CDC STI 2021)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatepostmenopausal_atrophic_vaginitis_gsm
    Postmenopausal/hypoestrogenic patient with vaginal symptoms, elevated pH, parabasal cells + PMNs and NO organism after the full pH→whiff→microscopy→NAAT/culture ladder — atrophic vaginitis / genitourinary syndrome of menopause (ACOG PB 215; PMID 39771534)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmildrecurrent_bv_adjuvant_live_biotherapeutic_conditional
    Recurrent BV considered for adjuvant L. crispatus live biotherapeutic (LACTIN-V) — efficacy is CONDITIONAL on documented post-antibiotic clinical cure before initiating the probiotic (PMID 38733973)
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

Bacterial vaginosis — first-line cure → recurrent-BV suppression (CDC STI 2021; ACOG PB 215; Sobel/Surapaneni PMID 34110746; Vodstrcil NEJM 2025 PMID 40043236)
axis: bv_treatment_and_recurrence_suppression
Selected axis "Bacterial vaginosis — first-line cure → recurrent-BV suppression (CDC STI 2021; ACOG PB 215; Sobel/Surapaneni PMID 34110746; Vodstrcil NEJM 2025 PMID 40043236)" by default fallback (first axis)
  • metronidazole
    first line
    nitroimidazole
    500 mg PO BID × 7 d • PO • BID × 7 d
    triggers: symptomatic_BV, non_pregnant_or_pregnant_symptomatic
    CDC STI 2021 first-line — ~80–90% short-term cure; safe in pregnancy (no longer requires later-trimester restriction); counsel alcohol avoidance
    rxcui 6922
  • metronidazole vaginal gel 0.75%
    first line
    nitroimidazole_topical
    one applicator (5 g) intravaginally • intravaginal • once daily × 5 d
    triggers: symptomatic_BV, prefers_topical, GI_intolerance_to_oral
    CDC STI 2021 first-line topical — equivalent efficacy to oral, fewer systemic effects
    rxcui 6922
  • clindamycin cream 2%
    first line
    lincosamide_topical
    one applicator (5 g) intravaginally at bedtime • intravaginal • nightly × 7 d
    triggers: symptomatic_BV, nitroimidazole_intolerance_or_allergy
    CDC STI 2021 first-line alternative — oil-based, may weaken latex condoms ×5 d; preferred when nitroimidazole not tolerated
    rxcui 2582
  • tinidazole
    second line
    nitroimidazole
    2 g PO daily × 2 d (or 1 g daily × 5 d) • PO • daily × 2–5 d
    triggers: metronidazole_intolerance, alternative_regimen_needed
    CDC STI 2021 alternative — longer half-life nitroimidazole; same alcohol counselling (RxCUI 10612 RxNav-verified, no in-repo precedent)
    rxcui 10612
  • secnidazole
    second line
    nitroimidazole
    2 g PO single dose (oral granules) • PO • single dose
    triggers: adherence_concern, single_dose_preferred
    CDC STI 2021 alternative — single-dose nitroimidazole; rxcui omitted (no in-repo precedent, allowed at INTEGRATED)
    rxcui 36314
  • clindamycin
    second line
    lincosamide
    300 mg PO BID × 7 d (or 100 mg ovule PV nightly × 3 d) • PO/intravaginal • BID × 7 d / nightly × 3 d
    triggers: nitroimidazole_allergy, alternative_oral_or_ovule
    CDC STI 2021 alternative oral/ovule regimen; rxcui omitted for oral form (in-repo precedent is for cream; not invented)
    rxcui 2582
  • metronidazole vaginal gel 0.75% (suppressive)
    comorbidity specific
    nitroimidazole_topical
    one applicator twice weekly • intravaginal • twice weekly × 3–6 months
    triggers: recurrent_BV_>=3_episodes_per_year, post_induction_cure
    Recurrent-BV suppression after induction cure — sustained reduction in recurrence (Sobel-class data; Surapaneni/Sobel PMID 34110746); monitor for secondary VVC
    rxcui 6922
  • boric acid
    add on
    antiseptic_acidifier
    600 mg intravaginally daily × ~21–30 d (adjunct in intractable RBV) • intravaginal • daily
    triggers: intractable_recurrent_BV, biofilm_disruption_adjunct
    Anti-biofilm adjunct in the prolonged combination RBV regimen (Surapaneni/Sobel PMID 34110746); TOXIC if ingested — counsel; rxcui omitted (no in-repo precedent)
    rxcui 1700
  • L. crispatus CTV-05 live biotherapeutic (LACTIN-V)
    add on
    vaginal_live_biotherapeutic
    intravaginal applicator: daily ×5 d week 1 then twice weekly ×10 wk (11-week course) • intravaginal • per 11-week regimen
    triggers: recurrent_BV, DOCUMENTED_post_antibiotic_clinical_cure_required
    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)

outpatient playbook — drug actions (7)

  1. 1. metronidazole (BV)
    500 mg PO BID × 7 d (or 0.75% gel × 5 d, or 2% clindamycin cream × 7 d) • PO/intravaginal • 7 d / 5 d
    trigger: Amsel ≥ 3/4 or Nugent 7–10 (BV)
    CDC STI 2021 first-line BV
  2. 2. fluconazole (uncomplicated VVC)
    150 mg PO × 1 (or short-course topical azole) • PO/intravaginal • single / 1–7 d
    trigger: Pseudohyphae + normal pH + pruritus, immunocompetent non-pregnant
    CDC STI 2021 / ACOG PB 215 first-line uncomplicated VVC
  3. 3. fluconazole induction → weekly maintenance (recurrent VVC)
    150 mg q72h × 3 then 150 mg weekly × 6 mo • PO • q72h ×3 → weekly ×6 mo
    trigger: ≥ 3 culture-confirmed VVC episodes/12 mo
    Sobel NEJM 2004 (PMID 15329425) — 90.8% disease-free at 6 mo vs 35.9% placebo
  4. 4. boric acid (non-albicans VVC)
    600 mg intravaginally daily × 14 d • intravaginal • daily × 14 d
    trigger: Culture = C. glabrata / azole failure
    CDC STI 2021 / ACOG PB 215 — first-line non-albicans; fatal if ingested
  5. 5. metronidazole (trichomoniasis, women)
    500 mg PO BID × 7 d (men: 2 g × 1) • PO • BID × 7 d
    trigger: Motile trichomonads or positive NAAT
    CDC STI 2021 — Kissinger Lancet ID 2018 (PMID 30297322): 7-day superior to single 2 g in women
  6. 6. partner expedited therapy (trichomoniasis)
    Metronidazole 2 g PO × 1 to all partners • PO • single
    trigger: Trichomoniasis confirmed, partners within recency window
    CDC STI 2021 — partner treatment + pelvic rest reduces reinfection; EPT where legal
  7. 7. recurrent-BV suppression
    Metronidazole gel 0.75% twice weekly × 3–6 mo (± boric-acid-adjunct combination for intractable) • intravaginal • twice weekly
    trigger: ≥ 3 BV episodes/12 mo after induction cure
    Sobel/Surapaneni PMID 34110746; consider male-partner combination therapy (Vodstrcil NEJM 2025 PMID 40043236)

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Abnormal vaginal discharge — character/colour/consistency triages the differential (CDC STI 2021; ACOG PB 215); Vulvovaginal itching / burning / irritation / dyspareunia (ACOG PB 215 — favours VVC; also atrophic/DIV); Malodorous "fishy" discharge ± after intercourse (CDC STI 2021 — favours BV / trichomoniasis).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Vaginitis (bacterial vaginosis / candidiasis / trichomoniasis)** (gyn.vaginitis.core.v1).
Phenotype framing: MECE four-way pivot — BV (clue cells, pH > 4.5, whiff+, no PMNs) vs VVC (pseudohyphae, pH ≤ 4.5, pruritus) vs trichomoniasis (motile trichomonads, pH > 4.5, PMNs, NAAT+) vs non-infective (atrophic/GSM: parabasal cells + high pH + low estrogen → route gyn.menopause-management.core.v1; DIV: purulent + parabasal + PMNs + no organism; contact/irritant; retained foreign body; physiologic). Cervicitis (GC/CT) is a SEPARATE pathway → gyn.pelvic-inflammatory-disease.core.v1. CONDITIONAL DEPENDENCES applied here, not naïve multiplication: (1) microscopy LR is operator/timing-conditioned — a negative trich saline mount (sens only ~50–70%) must NOT drop the posterior below the NAAT test-threshold; (2) pH LR+ is attenuated when blood/semen/cervical-mucus/lubricant present (confounded — not conditionally independent of whiff/clue cells); (3) Amsel and its individual components co-vary — never combined as independent (double-counting); (4) a confirmed cause does NOT zero a second cause — coinfection ~20–30% mandates explicit multi-pathogen testing when findings are mixed (clue cells + PMNs). Pre-test priors (symptomatic reproductive-age US outpatient): BV ≈ 0.45–0.50, VVC ≈ 0.20–0.30, trichomoniasis ≈ 0.04–0.10, non-infective ≈ 0.24 (CDC STI 2021; ACOG PB 215; PMID 28594779; PMID 31748322)
Scope: Symptomatic vaginitis in an adult — empiric symptom-only treatment is wrong ~50% of the time; anchor on a structured point-of-care workup (pH → whiff → saline/KOH microscopy → NAAT) before naming a cause (CDC STI 2021; ACOG PB 215; PMID 28594779)

No severity triggers fired against current inputs.

Plan

Regimen axis: **Bacterial vaginosis — first-line cure → recurrent-BV suppression (CDC STI 2021; ACOG PB 215; Sobel/Surapaneni PMID 34110746; Vodstrcil NEJM 2025 PMID 40043236)**.
1. metronidazole 500 mg PO BID × 7 d PO BID × 7 d (nitroimidazole, first line) — CDC STI 2021 first-line — ~80–90% short-term cure; safe in pregnancy (no longer requires later-trimester restriction); counsel alcohol avoidance
2. metronidazole vaginal gel 0.75% one applicator (5 g) intravaginally intravaginal once daily × 5 d (nitroimidazole_topical, first line) — CDC STI 2021 first-line topical — equivalent efficacy to oral, fewer systemic effects
3. clindamycin cream 2% one applicator (5 g) intravaginally at bedtime intravaginal nightly × 7 d (lincosamide_topical, first line) — CDC STI 2021 first-line alternative — oil-based, may weaken latex condoms ×5 d; preferred when nitroimidazole not tolerated
4. tinidazole 2 g PO daily × 2 d (or 1 g daily × 5 d) PO daily × 2–5 d (nitroimidazole, second line) — CDC STI 2021 alternative — longer half-life nitroimidazole; same alcohol counselling (RxCUI 10612 RxNav-verified, no in-repo precedent)
5. secnidazole 2 g PO single dose (oral granules) PO single dose (nitroimidazole, second line) — CDC STI 2021 alternative — single-dose nitroimidazole; rxcui omitted (no in-repo precedent, allowed at INTEGRATED)
6. clindamycin 300 mg PO BID × 7 d (or 100 mg ovule PV nightly × 3 d) PO/intravaginal BID × 7 d / nightly × 3 d (lincosamide, second line) — CDC STI 2021 alternative oral/ovule regimen; rxcui omitted for oral form (in-repo precedent is for cream; not invented)
7. metronidazole vaginal gel 0.75% (suppressive) one applicator twice weekly intravaginal twice weekly × 3–6 months (nitroimidazole_topical, comorbidity specific) — Recurrent-BV suppression after induction cure — sustained reduction in recurrence (Sobel-class data; Surapaneni/Sobel PMID 34110746); monitor for secondary VVC
8. boric acid 600 mg intravaginally daily × ~21–30 d (adjunct in intractable RBV) intravaginal daily (antiseptic_acidifier, add on) — Anti-biofilm adjunct in the prolonged combination RBV regimen (Surapaneni/Sobel PMID 34110746); TOXIC if ingested — counsel; rxcui omitted (no in-repo precedent)
9. 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 (vaginal_live_biotherapeutic, add on) — 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)

Setting playbook (outpatient) — Diagnose the specific cause with a structured point-of-care workup (pH → whiff → saline/KOH microscopy → Amsel/Nugent → NAAT/culture as needed), give cause-specific therapy, classify complicated/recurrent VVC and recurrent BV, treat trichomoniasis as an STI (partner + co-testing + retest), and avoid empiric-only mistreatment (CDC STI 2021; ACOG PB 215; PMID 28594779)
10. metronidazole (BV) 500 mg PO BID × 7 d (or 0.75% gel × 5 d, or 2% clindamycin cream × 7 d) PO/intravaginal 7 d / 5 d — Amsel ≥ 3/4 or Nugent 7–10 (BV) (CDC STI 2021 first-line BV)
11. fluconazole (uncomplicated VVC) 150 mg PO × 1 (or short-course topical azole) PO/intravaginal single / 1–7 d — Pseudohyphae + normal pH + pruritus, immunocompetent non-pregnant (CDC STI 2021 / ACOG PB 215 first-line uncomplicated VVC)
12. fluconazole induction → weekly maintenance (recurrent VVC) 150 mg q72h × 3 then 150 mg weekly × 6 mo PO q72h ×3 → weekly ×6 mo — ≥ 3 culture-confirmed VVC episodes/12 mo (Sobel NEJM 2004 (PMID 15329425) — 90.8% disease-free at 6 mo vs 35.9% placebo)
13. boric acid (non-albicans VVC) 600 mg intravaginally daily × 14 d intravaginal daily × 14 d — Culture = C. glabrata / azole failure (CDC STI 2021 / ACOG PB 215 — first-line non-albicans; fatal if ingested)
14. metronidazole (trichomoniasis, women) 500 mg PO BID × 7 d (men: 2 g × 1) PO BID × 7 d — Motile trichomonads or positive NAAT (CDC STI 2021 — Kissinger Lancet ID 2018 (PMID 30297322): 7-day superior to single 2 g in women)
15. partner expedited therapy (trichomoniasis) Metronidazole 2 g PO × 1 to all partners PO single — Trichomoniasis confirmed, partners within recency window (CDC STI 2021 — partner treatment + pelvic rest reduces reinfection; EPT where legal)
16. recurrent-BV suppression Metronidazole gel 0.75% twice weekly × 3–6 mo (± boric-acid-adjunct combination for intractable) intravaginal twice weekly — ≥ 3 BV episodes/12 mo after induction cure (Sobel/Surapaneni PMID 34110746; consider male-partner combination therapy (Vodstrcil NEJM 2025 PMID 40043236))

Non-pharmacologic actions:
- Counsel alcohol avoidance during + 72 h after metronidazole/tinidazole (CDC STI 2021)
- Pelvic rest until partner treated + asymptomatic (trichomoniasis) (CDC STI 2021)
- No test-of-cure if asymptomatic resolution; retest trichomoniasis at 3 months (CDC STI 2021)
- Glycaemic optimisation, stop unnecessary antibiotics, avoid douching/irritants for recurrent VVC (ACOG PB 215)
- Discuss male-partner combination therapy for recurrent BV (Vodstrcil NEJM 2025 PMID 40043236)
- Boric acid / oteseconazole are NOT for use in pregnancy or planned pregnancy — counsel (CDC STI 2021; PMID 38319878)

AVOID / contraindication checks:
- Metronidazole tinidazole alcohol disulfiram reaction counsel (CDC STI 2021)
- Clindamycin cream oil based weakens latex condoms and diaphragms x5d (CDC STI 2021)
- Clindamycin c difficile colitis counsel (IDSA cross reference)
- Boric acid intravaginal only fatal if ingested keep from children and not in pregnancy (CDC STI 2021)
- Metronidazole safe in pregnancy treat symptomatic BV (CDC STI 2021; ACOG PB 215)

Monitoring

Regimen monitoring:
- no test of cure if asymptomatic resolution (CDC STI 2021)
- re-evaluate if symptoms persist or recur within weeks (CDC STI 2021)
- recurrent BV suppression monitor for secondary VVC (PMID 34110746)
- consider male partner combination therapy to reduce recurrence (Vodstrcil NEJM 2025 PMID 40043236)
- adjuvant L crispatus CTV05 LACTIN-V ONLY after documented post antibiotic clinical cure RR 0.56 vs 1.34 conditional (PMID 38733973; PMID 35659905)

Setting (outpatient) monitoring:
- Symptom resolution; re-examine + culture/NAAT if persistent/recurrent (CDC STI 2021)
- Trichomoniasis 3-month repeat-infection retest (CDC STI 2021)
- LFTs if prolonged oral azole maintenance; watch breakthrough/relapse off suppression (PMID 15329425)
- Secondary VVC during recurrent-BV metronidazole-gel suppression (PMID 34110746)

Follow-up plan: 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)
- Close-out criterion: partner/STI plan, suppression plan, retest schedule, and education documented

Monitoring phase: No test-of-cure if asymptomatic resolution (BV/uncomplicated VVC). Reassess if symptoms persist/recur — re-examine + culture/NAAT, consider non-albicans or alternative diagnosis (incl. atrophic/GSM route-out in postmenopausal). Trichomoniasis: retest 3 months after treatment (high reinfection — CDC STI 2021). Recurrent VVC on fluconazole suppression: monitor LFTs if prolonged, watch breakthrough; recurrent BV on metronidazole gel: monitor for secondary VVC (PMID 34110746). Adjuvant L. crispatus live biotherapeutic (LACTIN-V) for recurrent BV is CONDITIONALLY effective — only after documented post-antibiotic clinical cure (RR 0.56, 95% CI 0.35–0.77 if cured vs 1.34, 95% CI 0.47–2.23 if not — PMID 38733973); LACTIN-V also sustains reduced genital inflammation post-treatment (PMID 35659905) (CDC STI 2021; Sobel NEJM 2004)

Disposition

Current setting: outpatient — Diagnose the specific cause with a structured point-of-care workup (pH → whiff → saline/KOH microscopy → Amsel/Nugent → NAAT/culture as needed), give cause-specific therapy, classify complicated/recurrent VVC and recurrent BV, treat trichomoniasis as an STI (partner + co-testing + retest), and avoid empiric-only mistreatment (CDC STI 2021; ACOG PB 215; PMID 28594779)

Disposition criteria:
- Outpatient management for essentially all vaginitis (CDC STI 2021; ACOG PB 215)
- Specialist referral for refractory/recurrent/non-albicans or diagnostic uncertainty after full workup (ACOG PB 215)

Escalation triggers (move to higher acuity):
- Cervical motion/uterine/adnexal tenderness, fever, pelvic pain → pelvic inflammatory disease pathway (CDC STI 2021)
- Pregnancy with symptomatic infection → obstetric coordination; topical-only azole for VVC (ACOG PB 215)
- Refractory/recurrent disease or non-albicans needing compounded therapy → vulvovaginal-disorders specialist (ACOG PB 215)
- True nitroimidazole allergy with trichomoniasis → allergy/ID for desensitisation (CDC STI 2021)

Patient Action Plan

**Vaginitis self-management + recurrence-prevention plan**
Personalised values: confirmed_cause, regimen_and_duration, partner_treatment_status, recurrence_tier, pregnancy_status.

**Treated, improving / resolved** (green):
Triggers:
- Symptoms improving or resolved on the prescribed regimen
- Completed full course as directed
- Partner treated (if trichomoniasis)
Actions:
- 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)

**Persistent, recurrent, or new symptoms** (yellow):
Triggers:
- Symptoms persist after completing treatment
- Symptoms return within weeks, or ≥ 3 episodes in a year
- New or different discharge / itch / odour
Actions:
- 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)
Contact provider when:
- Symptoms not improving after a full course
- Three or more episodes in 12 months
- You are pregnant and have symptoms

**Features beyond vaginitis — seek prompt care** (red):
Triggers:
- 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
Actions:
- Seek prompt medical evaluation — this may not be simple vaginitis (CDC STI 2021)
- Bring details of any sexual partners and recent treatments
Contact provider when:
- Always seek urgent care for fever + pelvic pain or systemic illness (CDC STI 2021; ACOG PB 215)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [SEVERE] Cervical motion / uterine / adnexal tenderness, fever, or pelvic pain — points beyond vaginitis to PID / cervicitis (CDC STI 2021; ACOG PB 215)
- [MODERATE] ≥ 3 culture-confirmed VVC episodes in 12 months (recurrent VVC) (CDC STI 2021; Sobel NEJM 2004 PMID 15329425)
- [MODERATE] Culture/speciation shows non-albicans Candida (esp. C. glabrata) or azole-refractory VVC (CDC STI 2021; ACOG PB 215)

Citations

- 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 [PMID:34292926](https://pubmed.ncbi.nlm.nih.gov/34292926/)
- Cited evidence (PMID 32332401) [PMID:32332401](https://pubmed.ncbi.nlm.nih.gov/32332401/)
- Cited evidence (PMID 31856118) [PMID:31856118](https://pubmed.ncbi.nlm.nih.gov/31856118/)
- Cited evidence (PMID 30297322) [PMID:30297322](https://pubmed.ncbi.nlm.nih.gov/30297322/)
- Cited evidence (PMID 37921835) [PMID:37921835](https://pubmed.ncbi.nlm.nih.gov/37921835/)

Last reconciled with current guidelines: 2026-05-17.
References
  • 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 — PMID:34292926
  • Cited evidence (PMID 32332401) — PMID:32332401
  • Cited evidence (PMID 31856118) — PMID:31856118
  • Cited evidence (PMID 30297322) — PMID:30297322
  • Cited evidence (PMID 37921835) — PMID:37921835