What is the difference between cystitis and thrush

Classification

Vaginal candidiasis is classified depending on the exact location of the lesion, the nature of its course, the frequency of repeated exacerbations, damage to other organs and anatomical structures of the pelvis.
Depending on the frequency of exacerbations, vaginal candidiasis is divided into the following forms:

• Spicy. Episodes of thrush in the patient are rare, that is, there are no frequent relapses. The total number of registered cases over the past 12 months is 3 or less.
• Chronic, recurrent. More than 4 repeated episodes of vaginal thrush with severe symptoms within 1 year.

Based on the exact localization of the inflammatory process in the genital tract of women, pathology is divided into:

• Vaginitis is a local inflammation of the vaginal mucosa.
• Vulvovaginitis is a combination of lesions of the vagina and vulva.
• Cervicitis is an inflammation of the inner lining of the cervix.

Uncomplicated vaginal candidiasis

The diagnosis of an uncomplicated form of the disease is established when all the following criteria are met:

• The course of the disease is mild or moderate.
• The pathogen identified when taking a vaginal smear was C. albicans.
• There are no disorders of the immune system or diseases that reduce the body’s defenses.

Complicated vaginal candidiasis

A complicated form of the disease is indicated in the presence of at least one of the following factors:

• Clinically severe course of the disease.
• The causative agent of the disease, identified during bacteriological examination, is fungi of the genus Candida, distinct from C. albicans, for example: C. glabrata, C. tropicalis, C. parapsilosis, C. crusei, C. lusitaniae.
• Weakened immunity, for example due to long-term use of glucocorticosteroids, poorly controlled diabetes mellitus or during pregnancy.
• Concomitant damage to other pelvic organs.

Colpitis (vaginitis) - symptoms and treatment

The goals of treatment are to eliminate inflammation and restore vaginal microflora.

Treatment regimen for vaginitis

Treatment always consists of two stages. The first stage is the fight against inflammatory agents. This stage sometimes begins with a slight acidification of the vaginal environment (only if indicated). The second stage is the restoration of microflora in the vagina and intestines, followed by transition to preventive measures to reduce the risk of relapse.

Medicines

Treatment of specific and nonspecific vaginitis. Depending on the causative agent of the disease, systemic therapy with antibacterial drugs (amoxicillin, jazzomycin, clindamycin, ornidazole, metronidazole, tinidazole, etc.) may be required. Suppositories, capsules or vaginal tablets are prescribed locally, most often containing combination drugs (Poliginax, Macmiror complex, Terzhinan, Neo-penotran, etc.).

Treatment of candidal vaginitis (thrush). For thrush, antimycotic (antifungal) drugs of local and systemic action are prescribed.

Treatment of atrophic vaginitis. For atrophic vaginitis, the use of vaginal creams, tablets or rings with estrogen is indicated [13].

Lifestyle and aids

During treatment, sexual abstinence is recommended. After the main course of therapy, it is necessary to carry out a course of restoring the microflora in the vagina with preparations containing lactobacilli.

Physiotherapeutic procedures

In case of a chronic and often recurrent process, treatment should be comprehensive and include physiotherapeutic procedures (ultrasonic sanitation with the stage of restoration of vaginal biocinosis). It is important not only to eliminate inflammation, but also to restore damaged microflora, immune defense and remove the influence of the causative factor (sanitize foci of chronic infection, change personal hygiene products or contraception, compensate for diabetes with insulin).

It is also worth noting that there is an additional method of treating and restoring the vaginal microflora - this is low-frequency ultrasound sanitation with the Gineton-MM apparatus. Advantages of this treatment method:

• direct bactericidal effect of ultrasonic vibrations with a frequency of 22-44 kHz;
• effective hydrodynamic rehabilitation;
• increasing the concentration of the drug at the site of inflammation;
• vibration and hydromassage in sonified tissues, stimulation of microcirculation, improvement of trophism and tissue metabolism.

This method is used as an additional method to the main treatment [2][4][6][9][11].

Surgical operations

Surgery is not required to treat vaginitis.

Diet for vaginitis

Nutrition does not have a significant effect on the course of vaginitis. When taking antibiotics, alcohol should be avoided.

Restoring and improving quality of life

If you follow the doctor's prescriptions, a complete cure and restoration of quality of life is possible.

Treatment of vaginitis during pregnancy

During pregnancy, careful monitoring of the microflora is necessary. This is due to the likelihood of infection spreading to the fetus and membranes, the threat of miscarriage and premature birth, miscarriage and pregnancy loss. The drugs are prescribed by the doctor individually depending on the test results and the timing of pregnancy.

How to treat vaginitis without potent drugs

Vaginitis caused by a bacterial infection cannot be cured without the use of antibiotics.

Is douching used for vaginitis?

Douching is not required to treat vaginitis.

How is a partner treated for vaginitis?

For specific vaginitis, the woman’s sexual partner is treated with antibacterial agents. For nonspecific vaginitis, the partner is not treated.

Traditional methods of treating vaginitis

The use of traditional medicine often not only does not lead to a cure, but also aggravates the situation.

Complications of vaginal candidiasis

The lack of proper treatment, recurrent course and disruption of the immune system contribute to the development of complications of candidiasis. In most cases, this causes the inflammatory process to spread to adjacent tissues and damage other pelvic organs.

Inflammatory lesions of other organs of the reproductive system

Endometritis is an inflammation of the inner lining of the uterus, the endometrium. This complication occurs in women after childbirth or instrumental methods for diagnosing the uterine cavity, which causes trauma to the endometrium. Most often it is one of the earliest complications, since the vagina directly communicates with the uterus through its cervix.

Clinically, the development of endometritis is accompanied by a progressive deterioration of the woman’s condition, an abundance of cheesy vaginal discharge, increased pain and its movement from the perineum to the pelvic region. General signs of the inflammatory process in the body also worsen: body temperature rises, headache, weakness, and sometimes nausea and vomiting may occur.

Salpingitis is an inflammation of the mucous membrane of the uterine (fallopian) tube, which connects the uterine cavity with the abdominal cavity and ovaries. It can be one- or two-sided (Fig. 1). It is often combined with oophoritis – inflammation of the ovaries, which is why the term “salpingoophoritis” is often used. Clinically, these conditions are not much different from endometritis, with the exception of pain that can spread to the iliac regions.

Figure 1. Salpingitis is inflammation of the fallopian tubes. Source: MedPortal

The danger of this group of complications is the disruption of reproductive function, namely, an increased risk of ectopic pregnancies and female infertility in the future. They can be caused either by direct damage to organs or by disruption of the patency of the fallopian tubes, which makes fertilization of the egg or its penetration into the uterus impossible.

A more rare complication is intrauterine infection of the fetus. In this case, spontaneous termination of pregnancy (spontaneous abortion) can occur, as well as the phenomenon of frozen pregnancy - cessation of fetal development and its death.

Also, against the background of vaginal candidiasis, it is possible to develop vaginal stenosis - deformation and narrowing of its lumen with loss of natural elasticity. The reason is the replacement of epithelial tissues with connective and scar tissue. The main symptoms are pain during sexual intercourse.

Damage to the urinary system

With vaginal thrush, the infection can also spread to the urethra (urethra) and bladder, causing inflammation - urethritis and cystitis, respectively.

Typical signs of urethritis are urinary disorders, namely: the appearance of pain or pain when emptying the bladder, an increased urge to urinate, the appearance of blood in the urine, and the symptom of “sticking together” of the edges of the urethra.

Characteristic features of cystitis are: severe pain, especially at the end of urination, pain in the pubic area, a feeling of an unemptied bladder immediately after urination, purulent or bloody impurities in the urine, visible to the naked eye. An increase in body temperature and moderate, constant dull pain in the pubic area are also often observed.

The development of one disease against the background of another

The need for differential diagnosis of one disease with another is especially necessary when cystitis occurs with thrush or thrush develops against the background of cystitis. Treatment methods for the two diseases will be different. To get rid of them, it is necessary to diagnose the disease in time and quickly begin treatment.

Cystitis with thrush can be suspected when the following symptoms appear:

• Increased pain or discomfort during sexual intercourse.
• The appearance of liquid brownish discharge on underwear in the absence of discharge from the vagina.
• The appearance of purulent discharge from the urethra.
• Increased body temperature.

The presence of an elevated temperature indicates the progression of the disease

• Burning sensation in the urethral area.
• The appearance of pain above the pubic bone.
• The appearance of a frequent urge to urinate.
• Discharge of 1-3 drops of blood after passing urine.
• The appearance or intensification of pain during urination.

These manifestations indicate the presence of inflammation of both the urethra and the bladder. To confirm the pathology, you need to make an appointment with a urologist and undergo the necessary diagnostics.

Cystitis due to thrush appears in women of any age. In the same way, thrush can occur against the background of cystitis. If cystitis has already been diagnosed, thrush can be suspected if the following symptoms appear:

• The appearance of white discharge of a thick consistency from the vagina (discharge may look like cottage cheese or cereal).
• Constant discomfort or pain during sexual intercourse.
• The appearance of a burning sensation in the vagina.

You can suspect thrush if you experience pain in the vagina during sex

• The presence of itching in the vagina, which intensifies during sexual intercourse, or during hygiene procedures.
• The appearance of a feeling of discomfort in the vagina during each urination.
• The appearance of an unusual odor from the vagina.
• Unpleasant odor from white discharge.

All of the above symptoms indicate the development of thrush during cystitis. To confirm the pathology, you need to visit a qualified gynecologist. He must make a smear from the vagina and isolate a culture of Candida fungi from there.

Causes

Vaginal yeast infections are caused by fungi of the genus Candida. The vagina normally contains a balanced combination of microflora, including candida and bacteria. Lactobacilli produce acid that prevents fungal overgrowth. This balance can be disrupted and can lead to candidiasis. A large amount of fungal microflora causes vaginal itching, burning and other classic signs of a yeast infection.

Fungal overgrowth can result from:

• the use of antibiotics that suppress vaginal lactobacilli and change the pH (acid-base balance) of the vagina;
• pregnancy;
• uncontrolled diabetes;
• weakened immune system;
• the use of oral contraceptives or hormonal therapy that increases estrogen concentrations.

Candida albicans is the most common type of fungus that causes yeast infections. Sometimes other candida are also the cause, but standard treatment is usually directed against Candida albicans. Infections caused by other types of fungi are more difficult to treat and require more aggressive treatment. Yeast infections can occur after some sexual activity, especially oral-genital sexual contact. However, candidiasis is not considered a sexually transmitted infection, since it can develop even in sexually inactive women.

Risk factors

Factors that increase your risk of developing a yeast infection include:

• Antibiotic therapy. Candidiasis is common among women taking antibacterial medications. Broad-spectrum antibiotics, which kill a number of bacteria, also destroy the normal microflora of the vagina, which leads to excessive growth of fungi.
• Increased estrogen levels. Yeast infections are more common among women with elevated concentrations of female hormones. This may be seen in pregnant women taking birth control pills or receiving estrogen hormone therapy.
• Uncontrolled diabetes mellitus. Women with diabetes who have poor blood sugar control are at greater risk of developing candidiasis than women who exercise self-control.
• Weakened immunity. Women with immune systems weakened by corticosteroid therapy or HIV infection are more likely to develop candidiasis.
• Sexual activity. Although candidiasis is not classified as a sexually transmitted infection, sexual contact can spread candida fungi.

Treatment of fungal infection

Treatment of candidiasis depends on the presence of complications.

Uncomplicated candidiasis

If symptoms are mild or moderate, or in rare cases of fungal infection, your doctor may prescribe the following:

• A short course of vaginal medications. Antifungal therapy (butoconazole, clotrimazole, miconazole, terconazole) can be used in the form of creams, ointments, tablets and suppositories. The course of treatment lasts one, three or seven days. Side effects may include mild burning or irritation. The type of contraception during the treatment period must be changed to an alternative one, since suppositories and creams are oil-based, and they can weaken the protection of condoms and diaphragms.
• A single oral dose of an antifungal medication (fluconazole). Severe symptoms may require two single doses, 3 days apart.
• Over-the-counter vaginal antifungal suppositories and creams. They are effective in most cases and are safe during pregnancy. Treatment usually lasts for seven days. You should consult your doctor again if symptoms persist after treatment or return within 2 months.

Complicated candidiasis

Treatment for complicated vaginal yeast infections may include:

• Long course of vaginal medications. Yeast infection can be successfully treated with a course of azole for 7-14 days. Forms of release of azole: vaginal cream, ointment, tablets or suppositories.
• Oral medications in several dosages. The attending physician may prescribe 2-3 doses of fluconazole simultaneously with vaginal treatments. However, fluconazole is not recommended for pregnant women.
• Prophylactic use of fluconazole. Your doctor may prescribe regular use of fluconazole (once a week for 6 months) to prevent recurrent candidiasis. This decision can be made in case of frequent recurrences of fungal infection. Prevention begins only after a full course of treatment, which takes up to 14 days.

Usually the sexual partner does not need antifungal treatment, but may be required if he has signs of a fungal infection (inflammation of the glans penis - balanitis). As an alternative to treatment, a sexual partner can use a condom during sex.

Vaginitis is a widespread problem and one of the most common reasons for visiting an obstetrician-gynecologist. Among the various variants of vaginal infection, the undisputed leaders are considered to be vulvovaginal candidiasis (VVC) and bacterial vaginosis (BV), detected respectively in 17-39% and 22-50% of women with pathological discharge (leucorrhoea) from the vagina [5]. The prevalence of VVC and BV is extremely high. Approximately 75% of women of reproductive age experience VVC at least 1 time during their life, 40-45% experience 2 recurrences of the disease or more. Most cases of VVC are classified as uncomplicated candidiasis [8], but in approximately 10% of patients, VVC has a complicated course.

Bacterial vaginosis is considered the most common form of vaginal disease and occurs in approximately 30% of women [4]. Despite the indisputable infectious origin of VVC and BV, their infectiousness to a sexual partner has not been proven [4, 13], and they are not classified as sexually transmitted infections (STIs). However, a number of factors related to sexual behavior increase the risk of these diseases. These include: the beginning of sexual activity, the practice of orogenital sex, changing sexual partners, frequent vaginal douching [4].

Problems associated with VVC and BV cause patients a lot of inconvenience, associated not only with changes in the quantity and quality of vaginal discharge, but also with burning, skin irritation, a feeling of dryness, dyspareunia, and dysuria [5]. In addition to immediate discomfort, BV and VVC increase the risk of spontaneous abortion, premature birth, ante- and intrapartum infection of the fetus [12, 19, 22], postpartum endomyometritis, contribute to the development of cervicitis, inflammatory diseases of the pelvic organs involving the urinary system, the spread of viral infection, including HIV and genital herpes, gonorrhea, chlamydia, trichomoniasis, increase the risk of inflammatory postoperative complications [7, 33, 38].

According to the USA, Europe, and Canada, the most common causative agent of VVC is Candida albicans

(about 80-90% of cases).
The remaining fungi of the genus Candida
are collectively called non-
albicans

C. glabrata
is the most common [37].
According to the results of the epidemiological study ARTEMISK DISK in Russia, the main causative agent of candidiasis (various localizations, including VVC) was C. albicans
- 76.1%, in second place was
C. glabrata
- 5.3%, then
C. krusei
- 3 .4%,
C. parapsilosis
- 3.1%, which generally corresponds to the prevalence of certain types of fungi in North America and Europe [32].
Vulvovaginal candidiasis caused by Candida
non-
albicans
is regarded as a complicated disease. In addition, complicated forms of VVC include severe vaginitis, VVC in individuals with a reduced immune response, and recurrent VVC.

It is not entirely clear what exactly causes the frequent (4 times a year or more) repeated episodes of the disease. Systemic immunosuppression cannot serve as a sufficient justification for recurrent VVC. This is clearly demonstrated by observations of HIV-infected patients who have vaginal colonization with Candida

increases significantly, but the frequency of recurrent VVC increases moderately, far behind the increase in the frequency of episodes of oropharyngeal candidiasis [28]. It is more likely that relapses of VVC are caused by suppression or reduction of local protective immunoregulatory mechanisms with changes in the cytokine profile [18]. There is a version that the cause of symptomatic candidiasis is increased local sensitivity to fungi [15].

Diagnosis of VVC is based on the detection of budding yeast cells and/or pseudomycelium by light microscopy of native preparations or microscopy of Gram-stained smears. In case of complicated VVC, a cultural examination (inoculation on a nutrient medium) is recommended. Candida

spp.
- single-celled microorganisms measuring 6-10 microns. Many Candida
spp.
dimorphic, forming blastomycetes (bud cells), pseudomycelia (chains of budding yeast cells) and/or mycelium. Unlike mycelium, pseudomycelium does not have a common shell or partitions. The causative agents of Candida
non-
albicans,
especially
C. glabrata,
do not form pseudomycelium and are poorly recognized by light microscopy, and therefore the presence of VVC symptoms with negative microscopy results dictates the need to perform a culture test.

For BV, the etiological role of a specific microorganism as the sole cause of the disease has not yet been proven. Gardnerella vaginalis is most often associated with BV.

and
Mobiluncus curtisii,
but these microorganisms can also be detected in healthy women [16].
The advent of nucleic acid amplification methods (NAAT) and polymerase chain reaction, which make it possible to identify microorganisms that are difficult to cultivate, has expanded the microbial palette of BV. It turned out that, in contrast to the microbial spectrum of the vaginal contents of healthy women (from 1 to 6 species of bacteria with a predominance of lactobacilli), women with BV have a significantly greater diversity of microorganisms (from 9 to 17 per sample, on average 12.6), and in each sample, 58% of completely new clones were identified [11]. In total, 35 species of unique bacteria were identified in women with BV, including several species that did not have close relatives, and Atopobium vaginae
[11, 14 , 39].
In addition to A. vaginae,
the list of unculturable microorganisms was supplemented by BV-associated bacteria - BVAB 1, BVAB 2, BVAB 3,
Megasphera
spp.,
Eggerthella
spp.
and Leptotrichia
spp. [17, 20].

To assess the species diversity of the bacterial flora found in BV, a DNA biochip was developed [1], the use of which made it possible to identify 29 different types of microorganisms in 80 women with BV [2], with A. vaginae being most often identified.

It is important that
A. vaginae
was detected with the highest frequency during a long-term recurrent course of the disease, independently of other BV-associated microorganisms
(G. vaginalis, Mobiluncus
spp.,
Ureaplasma urealyticum, Mycoplasma hominis)
[2].
Although A. vaginae
has been detected in vaginal fluids not only in patients with BV but also in healthy women, the prevalence ratio of
A. vaginae
among patients with BV is clearly higher than among healthy women [1].

Whatever microorganisms the most advanced diagnostic techniques identify in women with impaired vaginal microbiocenosis, no one doubts that BV is characterized by the replacement of lactobacilli by opportunistic microorganisms, mainly anaerobic ones. Therefore, in clinical practice, the diagnosis of BV is based not on the identification of certain microorganisms, but on the basis of clinical and laboratory criteria. In this case, the criteria most often used are R. Amsel et al. (1983), when diagnosis requires identification of 3 out of 4 signs, only one of which (detection of “key” cells in Gram stain) is purely microbiological, and the rest are clinical. Less commonly used are the criteria of R. Nugent et al. [21], when Gram staining determines the corresponding bacterial morphotypes, based on the ratio of which the diagnosis is made.

Despite the obvious difference between aerobic fungal and polymicrobial, predominantly anaerobic, infection, VVC and BV can be combined, creating additional difficulties in treatment. Diagnosis of such a mixed infection is based on microscopy of a Gram-stained smear and/or culture results. Microscopy of a vaginal smear reveals predominantly superficial epithelium and key cells. The leukocyte reaction reflects the presence of inflammation. With a large (massive) number of microorganisms, anaerobes and gardnerella dominate, yeast cells and/or fragments of pseudomycelium are present, lactobacilli are absent. Culture studies demonstrate a massive (more than 9 lg CFU/ml) number of microorganisms, but under aerobic conditions only Candida fungi are present.

Lactobacilli are absent or their titer is very low; Bacteroides, Gardnerella, anaerobic cocci, etc. dominate.

The combination of VVC and BV requires simultaneous treatment of both infections. But even in the absence of clinical and laboratory signs of VVC, treatment of BV with antibiotics can lead to the development of symptoms of candidiasis in cases of previous colonization of the vagina by fungi [30].

There are two effective ways to treat bacterial vaginosis. One of them is metronidazole or its derivatives from the group of 5-nitroimidazoles. True resistance of anaerobic microorganisms to nitroimidazoles is a rare phenomenon. As a rule, the effectiveness of metronidazole for BV in daily doses of 800 to 1200 mg for 1 week exceeds 90%, and the effect persists for 1 month in 80% of patients. Simultaneous treatment of BV with metronidazole at a dose of 2 g is effective in relieving symptoms, but the percentage of relapses is higher than when using a weekly course of the same drug. A significant disadvantage of oral administration of metronidazole is its poor tolerability, and tinidazole in a 5-day regimen, although better tolerated, has the same potential for side effects as metronidazole [23]. Local therapy with 2% clindamycin cream or metronidazole gel is as effective as systemic therapy [12, 27], while the clinical effectiveness of clindamycin has been demonstrated even in the presence of resistance of microorganisms detected in tests to this antibiotic [7, 27]. According to the US Centers for Disease Control (CDC), various forms of metronidazole (tablets and gel) and 2% clindamycin cream (suppositories) are the standard treatment for BV in the United States.

Metronidazole is prescribed at a dose of 500 mg 2 times a day for 7 days, or 0.75% metronidazole gel 5 g intravaginally once a day for 5 days, or 2% clindamycin cream 5 g intravaginally for 7 days. As an alternative, these recommendations suggest treatment with clindamycin 300 mg orally 2 times a day for 7 days or clindamycin suppositories 100 mg intravaginally at night for 3 days in a row. Undoubtedly, the shortest treatment regimen, which involves a 3-day course of clindamycin suppositories, is the most acceptable for women. As for the administration of single-stage treatment with metronidazole (orally at a dose of 2 g), the convenience of this regimen is offset by its relatively low effectiveness, and therefore it is currently not recommended by the CDC, even as an alternative option [12]. European recommendations [13] for the management of patients with vaginal discharge also indicate the low effectiveness of the simultaneous use of metronidazole at a dose of 2 g for BV. According to Russian recommendations [3], the preferred method is local (intravaginal) administration of metronidazole or clindamycin: clindamycin, cream 2% 5.0 g intravaginally at night, 6 days; Metronidazole, gel 0.75% 5.0 g intravaginally at night, 5 days. An alternative regimen involves the use of clindamycin suppositories (100 mg) for 3 days. Orally 5-nitroimidazoles or clindamycin are recommended to be prescribed only if intravaginal therapy is ineffective: metronidazole 500 mg orally 2 times a day for 7 days; clindamycin 300 mg 2 times a day for 7 days; ornidazole 500 mg orally for 5 days.

Treatment-resistant cases of BV pose a serious problem [40]. If standard therapy with metronidazole is ineffective, it can be repeated with an increase in duration, and if it fails again, another attempt at repetition is recommended with a preliminary course of antibiotic treatment in order to eliminate the accompanying aerobic microflora that can reduce the effectiveness of the nitro group of 5-nitroimidazoles on anaerobes [12, 13]. However, the feasibility of this approach is controversial for two reasons. First, long courses of oral metronidazole are poorly tolerated. Secondly, the reason for the lack of effect of therapy may not be aerobic microorganisms, but anaerobes associated with BV that are insensitive to nitroimidazoles.

Uncultivable or difficult to cultivate microorganisms may be resistant to metronidazole, and they also provide a persistent relapsing course of BV. Repeated episodes of vaginitis are observed in 30% of women within 3 months after treatment [40]. A series of studies conducted in Australia showed that after oral administration of metronidazole, relapses of BV within 1 year of observation were observed in 58% of patients [9]. Risk factors for relapse were associated with a previous history of BV, regular sexual activity with a regular partner, and lesbianism. Condom use did not affect the risk, and hormonal contraception had a protective effect. In a molecular analysis of noncultured organisms, the study authors found that failure of long-term response to metronidazole therapy was significantly more likely to be associated with the detection of A. vaginae

[10].

The inability to identify unculturable microorganisms in routine practice before the start of therapy becomes the key to its ineffectiveness [7, 11]. Resistance of A. vaginae

to metronidazole has been demonstrated repeatedly [14].
A number of publications [7, 41] have shown that A. vaginae

is more sensitive to clindamycin than to metronidazole
in
in vitro Clinical studies confirm a significantly higher effectiveness of standard intravaginal therapy for BV associated with A. vaginae,
clindamycin (2% cream, 5 g intravaginally for 6 days) compared to metronidazole (0.75% gel, 5 g intravaginally for 5 days, at night) .
Similar results were obtained in studies comparing topical therapy with metronidazole and clindamycin for BV, presumably associated with Mobiluncus
[26].

Apparently, the sensitivity characteristics of microorganisms involved in the development of BV are the leading factor in the failure of treatment or the increased frequency of relapses. Strategies for treating sexual partners and recolonizing the vagina with lactobacilli have not demonstrated a significant effect in reducing the frequency of relapses and normalizing the vaginal microbiota [6, 40], although individual studies on the use of eubiotics and probiotics provide encouraging results [24]. At the same time, the participation of aerobic microorganisms, including fungi, in worsening the prognosis of treatment for BV cannot be discounted. A comparison of metronidazole gel and vaginal tablets containing metronidazole with nystatin found a reduction in relapse rates with the combination drug [27], even in the absence of data on the underlying fungal infection.

Thus, despite the comparable effectiveness of metronidazole and clindamycin, the latter has obvious advantages in the treatment of recurrent BV due to a wider range of effects on microorganisms, including unculturable or difficult to cultivate forms. The use of a 3-day course of vaginal clindamycin tablets is comparable in effectiveness to other courses of therapy, but the short duration of treatment makes the method more acceptable to patients. However, the use of clindamycin is fraught with the occurrence of VVC, which requires preventive measures.

Several groups of drugs with local and systemic action have been proposed for the treatment of VVC. Their effectiveness was equivalent, as demonstrated in a systematic review of 19 randomized controlled trials (RCTs) comparing topical and oral antifungal therapy [25], although the review authors noted a trend towards better long-term outcomes of oral therapy, associated with lower relapse rates [35]. . The undisputed leader of oral therapy with a good safety and efficacy profile is fluconazole, which is used in a single dose of 150 mg for uncomplicated candidiasis [34].

The presence of recurrent VVC requires long-term treatment regimens. Of these, the most popular in the world is the use of fluconazole at a dose of 150 mg once a week for 6 months after the initial relief of the next acute episode with three doses of 150 mg of fluconazole with an interval of 72 hours. According to the results of an RCT, 6-month use of fluconazole was accompanied by a significantly lower number of relapses after its completion (9%) compared with placebo (64%), and none of the patients stopped treatment due to side effects [37]. Despite the fact that in some patients the symptoms of VVC return several months after the end of treatment, the suppressive therapy regimen with fluconazole is currently the only method that has an evidence base of effectiveness. To control the symptoms of VVC in the absence of a sufficient effect of a six-month course, the possibility of its prolongation to a year is being considered. Other treatment approaches, including the use of yogurt, lactobacilli, Candida antigen desensitization,

low-carbohydrate diet has not yet confirmed its effectiveness in clinical studies [31].

The likely cause of VVC relapses and/or resistance to therapy is the characteristics of the infectious agent. It is known that C. albicans is sensitive to azole antimycotics,

the most common causative agent of VVC.
Candida
non-
albicans
is resistant to most antifungal drugs, and the treatment of such patients is always a big challenge.
In the USA and Europe, this problem is resolved with the help of a 2-week course of gelatin vaginal capsules containing 600 mg of boric acid; C. glabrata,
the most common non-
albicans
pathogen, is sensitive to this type of therapy [36]. Another method of therapy suggests the topical use of amphotericin B (50 mg suppositories) alone or in combination with flucytosine for 14 days [29]. Unfortunately, these treatment methods are not available in Russia, therefore, in domestic clinical practice, the task of eliminating resistant pathogens can only be solved by increasing the dose of azole antimycotics.

Treatment planning for VVC and BV, as well as mixed infections, should be based on evidence of the effectiveness of treatment regimens. Metronidazole and clindamycin for BV, oral and topical antimycotics for VVC have proven comparable effectiveness and can be prescribed as equal first-line therapy. But with repeated episodes of vaginitis or mixed infections, one should remember the characteristics of the pathogens of BV and VVC, which predispose to the formation of chronic forms of the disease. Considering the difficulties in diagnosing the cause of BV and prognosis of the course of VVC, in such situations the optimal treatment regimen may be the administration of clindamycin, which covers a wide range of unculturable anaerobes, in the form of local therapy and fluconazole as a means of preventing and treating VVC. A three-day course of clindamycin with a single dose of fluconazole can certainly be considered the most acceptable treatment option for patients.

Sources

• Denison HJ., Worswick J., Bond CM., Grimshaw JM., Mayhew A., Gnani Ramadoss S., Robertson C., Schaafsma ME., Watson MC. Oral versus intra-vaginal imidazole and triazole anti-fungal treatment of uncomplicated vulvovaginal candidiasis (thrush). // Cochrane Database Syst Rev - 2021 - Vol8 - NNULL - p.CD002845; PMID:32845024
• Yeh SJ., Yeh CC., Lan CY., Chen BS. Investigating Common Pathogenic Mechanisms between Homo sapiens and Different Strains of Candida albicans for Drug Design: Systems Biology Approach via Two-Sided NGS Data Identification. // Toxins (Basel) - 2021 - Vol11 - N2 - p.; PMID:30769958
• Tulasidas S., Rao P., Bhat S., Manipura R. A study on biofilm production and antifungal drug resistance among Candida species from vulvovaginal and bloodstream infections. // Infect Drug Resist - 2021 - Vol11 - NNULL - p.2443-2448; PMID:30538510
• St Clair-Brown TT., Schwerer KE., Dogbey GY. Neonatal Thrush Is Not Associated with Mode of Delivery. // J Am Board Fam Med - 2019 - Vol31 - N4 - p.537-541; PMID:29986979
• Pidwill GR., Rego S., Jenkinson HF., Lamont RJ., Nobbs AH. Coassociation between Group B Streptococcus and Candida albicans Promotes Interactions with Vaginal Epithelium. // Infect Immun - 2018 - Vol86 - N4 - p.; PMID:29339458
• Gow NAR., Yadav B. Microbe Profile: Candida albicans: a shape-changing, opportunistic pathogenic fungus of humans. // Microbiology (Reading) - 2021 - Vol163 - N8 - p.1145-1147; PMID:28809155
• Gamaletsou MN., Drogari-Apiranthitou M., Denning DW., Sipsas NV. An estimate of the burden of serious fungal diseases in Greece. // Eur J Clin Microbiol Infect Dis - 2021 - Vol35 - N7 - p.1115-20; PMID:27086365
• Osmanov A., Denning DW. Burden of serious fungal infections in Ukraine. // Mycoses - 2015 - Vol58 Suppl 5 - NNULL - p.94-100; PMID:26449513