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

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. Its prevalence is similar in both pregnant and non-pregnant women.

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 or corticosteroid use. Immunocompromised and diabetic women are also at risk.

Vaginitis--%20trichomoniasis,%20candidiasis,%20bacterial%20vaginosis Treatment

Pharmacotherapy

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

Trichomoniasis

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

Recommended Regimens

  • 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, though the 7-day course of Metronidazole has been shown in a randomized controlled trial to be more effective than the single dose
    • Studies have shown that oral 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; may only be used as a treatment option in special circumstances where oral nitroimidazoles are contraindicated
  • Secnidazole may be used as a single-dose therapy as an alternative to Metronidazole therapy
    • Secnidazole offers an advantage over multiple-dose Metronidazole regimens

Special Considerations

  • A repeat course of oral Metronidazole for 7 days may be considered in patients unresponsive to initial standard therapy 
  • 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
      • Concurrent intravaginal Paromomycin with oral Tinidazole may be considered if oral Tinidazole with intravaginal Tinidazole fails
  • In cases of 5-Nitroimidazole derivative allergy, desensitization is recommended
    • Topical therapy of other drugs may be considered but cure rates are <50%
    • Studies showed that patients treated with intravaginal Boric acid exhibited clinical improvement
      • Various combinations of Boric acid are available. Please see the latest MIMS for specific formulations and prescribing information
  • 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 HIV-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 (BV)

  • 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 BV, and lower the risk of acquiring STIs like C trachomatis, N gonorrhoeae, T vaginalis, herpes simplex type 2 or human immunodeficiency virus (HIV)
    • There are inconsistent evidences regarding treatment of pregnant patients who have asymptomatic BV 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 Secnidazole single dose, oral Tinidazole single dose or for 2-5 days, 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, nitroimidazole plus antifungal vaginal suppositories, dendrimer gel and adjunctive therapies such as intravaginal lactobacillus formulations, probiotics or vitamin C

Special Considerations

  • Women with documented several recurrences (at least 3 documented separate episodes per year) are recommended to have longer courses of therapy (ie intravaginal Metronidazole gel for 16 weeks)
  • 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 STIs
    • 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)
    • Treatment during pregnancy does not decrease the risk of a preterm delivery
  • 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
  • HIV-infected patients with BV should receive the same treatment regimen as those who are HIV-negative
    • BV recurrence is higher in HIV-positive patients

Vulvovaginal Candidiasis (VVC)

  • In non-pregnant women with uncomplicated VVC, topical/intravaginal and oral antifungal azoles have similar efficacy

Recommended Regimens for Uncomplicated VVC

  • Uncomplicated VVC is effectively and safely managed with oral and short-course topical regimens
  • Azoles (eg Butoconazole, Clotrimazole, Econazole, 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 VVC

  • Complicated cases include pregnancy, severe symptoms, recurrent disease (>4 episodes/year), presence of non-albicans species, and abnormal host factors [diabetic, debilitated, hyperestrogenemic, immunocompromised, immunosuppressed (eg corticosteroid therapy)]
  • To maintain clinical and fungal control, longer duration (ie 7-14 days) of initial intensive therapy prior to starting the maintenance antifungal regimen is recommended in patients with recurrent VVC     
    • Weekly oral Fluconazole for 6 months is the preferred agent used as maintenance regimen; however, 30-50% of VVC will recur once maintenance therapy is discontinued
  • For patients who are unwilling or unable to take Fluconazole, longer courses of therapy with topical azoles are options for the resolution of symptomatic recurrent VVC            
  • 10-14 days of topical azole or oral Fluconazole in 2-3 doses taken 3 days apart is recommended in patients with severe VVC
  • For non-albicans VVC, longer duration (ie 7-14 days) of oral or topical non-Fluconazole azole drug is the preferred regimen
    • If recurrence occurs, vaginal Boric acid given for 3 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 formulations and 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 
  • HIV-infected patients with VVC should receive the same treatment regimen as those who are HIV-negative
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