Vaginitis medical therapy

Vaginitis Main Page
Patient Information
Overview
Classification Bacterial Vaginosis Candida vulvovaginitis Trichomonas infection Atrophic Vaginitis
Differential Diagnosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

The cause of the infection determines the appropriate treatment. It may include oral or topical antibiotics and/or antifungal creams, antibacterial creams, or similar medications. A cream containing cortisone may also be used to relieve some of the irritation. If an allergic reaction is involved, an antihistamine may also be prescribed. For women who have irritation and inflammation caused by low levels of estrogen (postmenopausal), a topical estrogen cream might be prescribed.

Bacterial Vaginosis

• Treatment is recommended for women with symptoms.
• The established benefits of therapy in nonpregnant women are to relieve vaginal symptoms and signs of infection. Other potential benefits to treatment include reduction in the risk for acquiring C. trachomatis or N. gonorrhoeae, HIV, and other viral STDs.
• Providers should consider patient preference, possible side-effects, drug interactions, and other coinfections when selecting a regimen.
• Women should be advised to refrain from intercourse or to use condoms consistently and correctly during the treatment regimen.
• Douching might increase the risk for relapse, and no data support the use of douching for treatment or relief of symptoms.

Bacterial Vaginosis Treatment Preferred Regimen ▸ Metronidazole 0.5 gm po bid x 7 days OR ▸ Metronidazolevaginal gel (1 applicator intravaginally) once daily x 5 days or 1 applicator contains 5 gm of gel with 37.5 mg Metronidazole OR ▸ Tinidazole 2 gm po once daily x 2 days or 1 gm po once daily x 5 days OR ▸ Clindamycin 2% vaginal cream 5 gm intravaginally at bedtime x 7 days Alternative Regimen ▸ Clindamycin 300 mg bid po x 7 days OR ▸ Clindamycin ovules 100 mg intravaginally at bedtime x 3 days Recurrent refractory BV ▸ Metronidazole 0.5 gm po bid x 7 days then Boric acid gelatin cap 600 mg, intravaginal hs x 21 days then Metronidazole vaginal gel, 1 applicator, 2 x/week for 16 weeks Pregnant women ▸ Metronidazole 500 mg po bid x 7 days OR ▸ Metronidazole 250 mg po tid x 7 days OR ▸ Clindamycin 300 mg po bid x 7 days

Follow-Up

Follow-up visits are unnecessary if symptoms resolve. Because recurrence of BV is common, women should be advised to

• return for evaluation if symptoms recur.* Detection of certain BV-associated organisms have been associated with antimicrobial resistance and might determine risk for subsequent treatment failure .
• Using a different treatment regimen might be an option in patients who have a recurrence; however, re-treatment with the same topical regimen is another acceptable approach for treating recurrent BV during the early stages of infection .
• Monthly oral metronidazole administered with fluconazole has also been evaluated as suppressive therapy.

Management of Sex Partners

The results of clinical trials indicate that a woman’s response to therapy and the likelihood of relapse or recurrence are not affected by treatment of her sex partner(s). Therefore, routine treatment of sex partners is not recommended.

Special Considerations

Allergy or Intolerance to the Recommended Therapy

Intravaginal clindamycin cream is preferred in case of allergy or intolerance to metronidazole or tinidazole. Intravaginal metronidazole gel can be considered for women who do not tolerate systemic metronidazole. Intravaginal metronidazole should not be administered to women allergic to metronidazole.

Pregnancy

• Treatment is recommended for all pregnant women with symptoms.
• Although BV is associated with adverse pregnancy outcomes, including premature rupture of membranes, preterm labor, preterm birth, intra-amniotic infection, and postpartum endometritis, the only established benefit of therapy for BV in pregnant women is the reduction of symptoms and signs of vaginal infection.
• Additional potential benefits include reducing the risk for infectious complications associated with BV during pregnancy and reducing the risk for other infections (other STDs or HIV).

Trichomoniasis

Trichomoniasis Treatment Preferred Regimen ▸ Metronidazole 2 g po single dose OR ▸ Tinidazole 2 g po single dose Alternative Regimen ▸ Metronidazole 500 mg bid for 7 days Pregnancy ▸ Metronidazole 2 g single dose

• Topically applied antimicrobials (e.g., metronidazole gel) are unlikely to achieve therapeutic levels in the urethra or perivaginal glands; therefore, use of this gel is not recommended.
• Several other topically applied antimicrobials occasionally have been used for treatment of trichomoniasis; however, these preparations likely are no more effective than metronidazole gel.

Follow-Up

• Because of the high rate of reinfection among patients in whom trichomoniasis was diagnosed (17% were reinfected within 3 months in one study), rescreening for T. vaginalis at 3 months following initial infection can be considered for sexually active women with trichomoniasis.
• No data support rescreening in men diagnosed with T. vaginalis.
• While most recurrent T. vaginalis infections are thought to result from having sex with an untreated partner (i.e., reinfection), some recurrent cases can be attributed to diminished susceptibility to metronidazole.

Management of Sex Partners

• Sex partners of patients with T. vaginalis should be treated. Patients should be instructed to abstain from sex until they and their sex partners are cured (i.e., when therapy has been completed and patient and partner[s] are asymptomatic).

• Male partners should be evaluated and treated with either tinidazole in a single dose of 2 g orally or metronidazole twice a day at 500 mg orally for 7 days.

Special Considerations

Allergy, Intolerance, and Adverse Reactions

• Metronidazole and tinidazole are both nitroimidazoles. Patients with an immediate-type allergy to a nitroimidazole can be managed by metronidazole desensitization in consultation with a specialist .*Topical therapy with drugs other than nitroimidazoles can be attempted, but cure rates are low (<50%).

Pregnancy

Vaginal trichomoniasis has been associated with adverse pregnancy outcomes, particularly premature rupture of membranes, preterm delivery, and low birth weight. *However, metronidazole treatment has not been shown to reduce perinatal morbidity.

• Treatment of T. vaginalis might relieve symptoms of vaginal discharge in pregnant women and might prevent respiratory or genital infection of the newborn and further sexual transmission.

• In lactating women who are administered metronidazole, withholding breastfeeding during treatment and for 12–24 hours after the last dose will reduce the exposure of the infant to metronidazole.
• For women treated with tinidazole, interruption of breastfeeding is recommended during treatment and for 3 days after the last dose.

HIV Infection

• There is increasing evidence for epidemiologic and biologic interaction between HIV and T. vaginalis .

• T. vaginalis infection in HIV-infected women might enhance HIV transmission by increasing genital shedding of the virus, and treatment for T. vaginalis has been shown to reduce HIV shedding .

• For sexually active women who are HIV-positive, screening for trichomoniasis at entry into care with subsequent screening performed at least annually is recommended based on the reported prevalence of T. vaginalis, the effect of treatment at reducing vaginal HIV shedding, and the potential complications of upper-genital-tract infections among women who are left untreated.

• Rescreening 3 months after completion of therapy should be considered among HIV-positive women with trichomoniasis, a recommendation based on the high proportion of recurrent or persistent infection and the association between HIV and T. vaginalis infection.

• A multi-dose treatment regimen for T. vaginalis, like 500 mg twice daily for 7 days can be considered in HIV-infected women.

Candida

Candida Vaginitis Treatment Preferred Regimen Oral ▸ Fluconazole 150 mg po x 1 dose OR ▸ Itraconazole 200 mg po bid x 1 day Intravaginal ▸ Any of the following topical antifungals x 7-14 days clotrimazole butoconazole miconazole tioconazole as creams or vaginal suppositories Alternative Regimen ▸ Fluconazole 150 mg po q week x 6 months OR ▸ Itraconazole 100 mg po q24h x 6 months OR ▸ Clotrimazole vaginal suppositories 500 mg q week x 6 months