vaginitis--%20trichomoniasis,%20candidiasis,%20bacterial%20vaginosis
VAGINITIS: TRICHOMONIASIS, CANDIDIASIS, BACTERIAL VAGINOSIS

Trichomoniasis is caused by a flagellated protozoan, Trichomonas vaginalis. It is always sexually transmitted.

Bacterial vaginosis is the most common cause of vaginitis, vaginal discharge or malodor. It results from overgrowth of anaerobic bacteria.

Vulvovaginal candidiasis is caused by overgrowth of yeasts where 70-90% of cases are secondary to Candida albicans. It most commonly occurs when the vagina is exposed to estrogen (ie, reproductive years, pregnancy) and may be precipitated by antibiotic use.

Pharmacotherapy

  • Syndromic or empiric therapy may be given if patient is low risk for sexually transmitted infections or without symptoms of upper genital tract infection

Trichomoniasis

  • Treatment is indicated in patients positive for trichomoniasis regardless of symptoms

Recommended Regimen

  • Nitroimidazoles are the only class of drugs that are used for the oral or parenteral treatment of trichomoniasis
  • Single oral dose regimen of Metronidazole or Tinidazole is preferred over 7-day regimen because of reduced cost and increased compliance
    • Studies have shown that Metronidazole have 90-95% cure rates and Tinidazole have 86-100% cure rates
    • Tinidazole is equivalent or superior to Metronidazole in achieving parasitologic cure and resolution of symptoms as suggested by some randomized controlled trials
  • Topical Metronidazole (eg Metronidazole gel) is generally not recommended because it is unlikely to achieve therapeutic levels in the urethra or perivaginal glands

Special Considerations

  • Treatment-resistant trichomoniasis may require higher doses of therapy
    • Extended doses of Tinidazole orally or intravaginally may be given if high-level Metronidazole resistance is reported  
  • In cases of 5-Nitroimidazole derivative allergy, desensitization is recommended
    • Topical therapy of other drugs may be considered but cure rates are <50%
  • Single dose of 2 g Metronidazole can be given to women at any stage of pregnancy plus careful counseling about condom use and continued risk of sexual transmission
    • Preterm delivery is avoided with oral Metronidazole therapy in symptomatic pregnant patient 
    • In asymptomatic pregnant patient, some specialists would postpone treatment until after 37 weeks of gestation
    • Tinidazole’s safety during pregnancy has not been well-studied
  • As treatment of trichomoniasis with Dequalinium Cl has an overall efficacy of 17-50%, a concomitant systemic trichomonacidal agent, eg Metronidazole, should be used 
  • Breastfeeding should be discontinued during and for 12-24 hr after the last dose of Metronidazole or until 3 days after the last dose of Tinidazole
    • Intravaginal treatment may be considered, however, avoid high doses
  • In human immunodeficiency virus-infected women, multiple-dose regimen for trichomoniasis is recommended
    • Studies have shown that single oral dose of Metronidazole 2 g is not as effective as the 7-day regimen using 500 mg twice a day

Bacterial Vaginosis

  • Treatment is recommended in symptomatic patients, patients with positive direct microscopy with or without symptoms, in pregnant women with history of preterm birth or 2nd trimester miscarriage, and in patients who will undergo surgical procedure
    • Treatment will help relieve signs and symptoms of bacterial vaginosis, and lower the risk of acquiring sexually transmitted infections like C trachomatis, N gonorrhoeae, T vaginalis, herpes simplex type 2 or human immunodeficiency virus
    • There are inconsistent evidences regarding treatment of pregnant patients who have asymptomatic bacterial vaginosis who are at high risk for preterm deliveries

Recommended Regimens

  • 7-day regimen of oral Metronidazole, 5-day regimen of intravaginal Metronidazole gel, or 7-day regimen of intravaginal Clindamycin cream may be advised

Alternative Regimens

  • Oral Metronidazole single dose, oral Tinidazole for 2-5 days, oral Tinidazole single dose, oral Clindamycin for 7 days, intravaginal Clindamycin ovules for 3 days or intravaginal Dequalinium Cl for 6 days may be considered
  • Other options with limited data on efficacy include Metronidazole extended release tablets for 7 days or single dose of Clindamycin intravaginal cream, and adjunctive therapies such as intravaginal lactobacillus formulations, probiotics or vit C

Special Considerations

  • Women with documented several recurrences are recommended to have longer courses of therapy  
  • In Metronidazole- or Tinidazole-allergic women, Clindamycin cream may be a substitute
  • Symptomatic pregnant women should be treated to reduce the signs and symptoms of infection, to lower the risk for infectious complications, and to decrease other possible sexually transmitted infections
    • Oral Metronidazole or Clindamycin given for 7 days are the recommended regimens
    • Intravaginal Clindamycin cream should only be given in the 1st half of pregnancy due to possible adverse effects (eg low birth weight or neonatal infections)
  •  In breastfeeding women, intravaginal treatment may be considered, however, avoid high doses  
  • Women who will undergo gynecological procedures may be given oral Metronidazole for 5 days or oral Clindamycin for 7 days
  • Human immunodeficiency virus-infected patients with bacterial vaginosis should receive the same treatment regimen as those who are human immunodeficiency virus-negative
    • Bacterial vaginosis recurrence is higher in human immunodeficiency virus-positive patients

Vulvovaginal Candidiasis

  • Topical/intravaginal and oral antifungal azoles have similar efficacy

Recommended Regimens for Uncomplicated Vulvovaginal Candidiasis

  • Uncomplicated vulvovaginal candidiasis is effectively managed with single dose and short-course topical regimens
  • Azoles (eg Butoconazole, Clotrimazole, Fluconazole, Itraconazole, Miconazole, Tioconazole, Terconazole) are effective in relieving symptoms and providing negative cultures in 80-90% of patients after completion of treatment
  • Topically applied azole drugs require shorter therapies and appear to be more effective than Nystatin
    • Nystatin may be used in patients with an organism with reduced susceptibility to azole drugs
  • If symptoms persist after using over-the-counter preparations or if symptoms recur within 2 months, patient should undergo further office-based evaluation

Recommended Regimens for Complicated Vulvovaginal Candidiasis

  • Complicated cases include pregnancy, severe symptoms, recurrent disease (>4 episodes/year), presence of non-albicans species, and abnormal host factors (diabetic, hyperestrogenemic, immunosuppressed)
  • To maintain clinical and fungal control, longer duration of initial therapy prior to starting the maintenance antifungal regimen is recommended in patients with recurrent vulvovaginal candidiasis
    • Weekly oral Fluconazole for 6 months is the preferred agent used as maintenance regimen; however, 30-50% of vulvovaginal candidiasis will recur once maintenance therapy is discontinued
  • Longer courses of therapy with topical azoles may be needed for the resolution of symptomatic VVC  
    • 7-14 days of topical azole or oral Fluconazole is recommended in patients with severe vulvovaginal candidiasis
  • For non-albicans vulvovaginal candidiasis, longer duration of oral or topical non-Fluconazole azole drug is the preferred regimen
    • If recurrence occurs, vaginal Boric acid given for 2 weeks is advised which has 70% clinical and mycological eradication rates
  • Various combinations of Boric acid are available. Please see the latest MIMS for specific prescribing information

Special Considerations

  • Women with immunodeficiency, uncontrolled diabetes or those taking corticosteroids should receive prolonged conventional antifungal treatment
  • Only topical azoles applied for 7 days are advised for use in pregnant patients
    • Oral anti-candidal therapy should not be used during pregnancy
  • Intravaginal Dequalinium Cl may be used during pregnancy and lactation, if necessary, due to its negligible systemic absorption 
  • Human immunodeficiency virus-infected patients with vulvovaginal candidiasis should receive the same treatment regimen as those who are human immunodeficiency virus-negative
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