Infectious Disease Compendium

Vaginitis

Diagnosis

Vaginal discharge. Usually three forms:

1) Bacterial Vaginosis. Clinical criteria require three of the following symptoms or signs:

a) a homogeneous, white, noninflammatory discharge that smoothly coats the vaginal walls;

b) the presence of clue cells on microscopic examination; a pH of vaginal fluid > 4.5; and

c) a fishy odor of vaginal discharge before or after addition of 10% KOH (i.e., the whiff test, also used to determine who plays t-ball).

2) Candida.

3) Trichomoniasis.

4) Occ. reported is recurrent Grp A streptococci vulvovaginitis/cellulitis, where the 'husband' can be a rectal carrier and source of recurrence.

Epidemiologic Risks

An STD.

Microbiology

Three forms, not mutually exclusive:

1) BV: anaerobic microorganisms, mycoplasmas, and Gardnerella vaginalis. Non culture techniques have revealed a host of hither to unknown anaerobes (PubMed). This is more an overgrowth syndrome due to abnormal flora.

b) Candida albicans.

III) T. vaginalis. They can coexist together.

Empiric Therapy

BV:

Recommended Regimens

Metronidazole 500 mg po twice a day for 7 days OR metronidazole gel 0.75%, one full applicator (5 g) intravaginally, once a day for 5 days OR clindamycin cream 2%, one full applicator (5 g) intravaginally at bedtime for 7 days. Relapse likely.

Alternative Regimens (not as good)

Metronidazole 2 g po in a single dose OR clindamycin 300 mg po twice a day for 7 days OR clindamycin ovules 100 g intravaginally once at bedtime for 3 days.

Candida (from the CDC guidelines)

Recommended Regimens

Intravaginal Agents: Butoconazole 2% cream 5 g intravaginally for 3 days. Butoconazole 2% cream 5 g (Butaconazole1-sustained release), single intravaginal application. Clotrimazole 1% cream 5 g intravaginally for 7 to 14 days. Clotrimazole 100 mg vaginal tablet for 7 days. Clotrimazole 100 mg vaginal tablet, two tablets for 3 days. Clotrimazole 500 mg vaginal tablet, one tablet in a single application. Miconazole 2% cream 5 g intravaginally for 7 days. Miconazole 100 mg vaginal suppository, one suppository for 7 days. Miconazole 200 mg vaginal suppository, one suppository for 3 days. Nystatin 100,000-unit vaginal tablet, one tablet for 14 days. Tioconazole 6.5% ointment 5 g intravaginally in a single application. Terconazole 0.4% cream 5 g intravaginally for 7 days. Terconazole 0.8% cream 5 g intravaginally for 3 days. Terconazole 80 mg vaginal suppository, one suppository for 3 days.

Oral Agent: fluconazole 150 mg oral tablet, one tablet in single dose. For recurrent disease, 150 mg fluconazole a week therapy works (PubMed).

The use of probiotics (as compared, I suppose to the amateur biotics) is still not clear, but may have some benefit (PubMed).

Trichomoniasis: A single 2 gm po dose of metronidazole or 500 mg po bid x 7 d or tinidazole 2 gm po one time.

Pearls

Do not need to treat male partners.

Rants