Oral Treatment of Bacterial and/or Yeast Vaginal Infections
Frederick R. Jelovsek MD
"What oral medication would you recommend for bacterial and yeast infection?". Anonymous
This question does not clarify the intent of the request for oral medications. Both bacterial and yeast vaginitis are usually treated with vaginal topical medications. Some women prefer pills by mouth just because of the messiness of vaginal preparations. In other cases, the vaginal treatments may not have worked and the questioner is asking about 2nd choice therapeutic regimens to take by mouth.
It may also be that some oral medications are not tolerated due to side effects and the purpose of the question is to discover alternative oral medicines effective against the organisms. Finally the questioner may not be clear about the diagnosis since bacterial vaginosis and yeast vaginitis do not occur together very often. Thus it is mandatory to be sure of the diagnosis before initiating treatment.
How often is a vaginitis caused by both yeast and bacteria?
It is uncommon to have simultaneous infection with both candida (yeast) and bacteria giving a bacterial vaginosis. It is thought that some of the substances (amines) produced by bacterial vaginosis actually inhibit yeast growth and that is why they do not occur together very often (1). When women with active yeast infections are cultured for other bacteria, there are also much less of certain bacteria (peptostreptococcus species and anaerobic gram-positive cocci and/or bacilli) that would tend to be associated with bacterial vaginosis (2). Therefore the environments of yeast vaginitis and bacterial vaginitis are substantially different and thus they do not often occur together.
Nothing is an absolute in medicine however, and yeast vaginitis can occur along with bacterial vaginosis, especially recurrent bacterial infections (3). Even the situation of taking antibiotics for a bacterial vaginosis and a subsequent yeast vaginitis may be explained by the particular antibiotic used to treat bacterial vaginosis.
What is the best oral treatment for bacterial vaginitis?
The best treatment is metronidazole orally (Flagyl®) 500mg twice a day for 7 days. This has about a 95% cure. Metronidazole, 2000 mg orally as a single dose (4, 500mg tablets) has an 84% cure. Another pill by mouth is clindamycin (Cleocin®) 300 mg orally twice a day for 7 days which is 94% effective. Even though these oral medications have very high cure rates, metronidazole vaginal cream 0.75% (Metrogel®) 1 applicator intravaginal each day for 3 days (75% cure) is probably now the most commonly prescribed treatment for bacterial vaginosis because metronidazole occasionally produces nausea and clindamycin will sometimes swing a woman over into a yeast infection rather than a bacterial infection or it may also cause loose stools.
What is the best oral treatment for yeast vaginitis?
Oral treatment of yeast can use nystatin, amphotericin B or fluconazole(Diflucan®), although fluconazole is used most frequently for yeast vaginitis. Treating yeast vaginitis by oral medicine, however is not the first choice, recommended treatment. Topical vaginal treatment with butaconazole (Femstat® Nystatin ®) is the first choice treatment rather than oral fluconazole (Diflucan®) because it is non-prescription and very effective. Fluconazole is effective but non candida albicans species are becoming more resistant to it an requiring higher doses to eradicate the yeast (4, 5). Even C. albicans species may become more and more resistant to fluconazole as it is exposed more and more to the drug in clinical use (6). The scientific feeling is to save the systemic (oral) therapy for patients who have blood-borne yeast infections such as with AIDs or chemotherapy for cancer rather than inducing resistant organisms while treating only vaginal infections.
There can be resistances of the yeast species to commonly prescribed medications. One of the major causes of these resistances is due to the emergence of C. glabrata as the infectious agent rather than C. Albicans. C. glabrata is more resistance to many of the treatments (7).
What are other vaginitis treatments
Oral tablets with lactobacilli acidophillus that recolonize the gastrointestinal tract, and milk and yogurt with L. acidophilus can be effective in reducing the recurrence of bacterial vaginosis and yeast vaginitis although they are not very effective for primary treatment (8, 9). Vaginal tablets or suppositories containing lactobacillus can also recolonize the vagina and help prevent recurrence.
There are no other oral therapies that I am aware of for bacterial or yeast vaginitis. As far as other topical treatments for yeast infections, boric acid vaginal suppositories at 600 mg/day for 10 days is 80% effective for C. glabrata which has been resistant to other standard therapies (10). Essential oil therapy can also be used to treat yeast vaginitis. Tea tree oil has been shown to be effective against yeast in concentrations of 0.5% to 2% (11).
Does antibiotic treatment make you more likely to get a vaginitis?
Certain antibiotics seem to cause more yeast infections or overgrowth than others. Cephalosporins such as Keflex® permit more yeast overgrowth (12). Cipro® (ciprofloxacin), Augmentin® (amoxicillin/clavulanate potassium), and any other penicillin derivitives such as amoxicillin or ampicillin seem to destroy the normal vaginal lactobacillus and predispose to more yeast infections than do other antibiotics. Tetracycline, sulfa, metronidazole and even erythromycin do not cause yeast infections as often.
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