VAGINITIDES

I. Bacterial Vaginosis

  1. May be associated with Salpingitisthough this is controversial
  2. Diagnosis
    1. Traditional clinical diagnosis-3 of the following
      1. Gray-white vaginal discharge
      2. "Clue" cells on microscopic exam of vaginal discharge
      3. "Whiff" test ("amine" odor with application of KOH to vaginal discharge)
      4. Vaginal pH > 4.4
    2. DNA probe testing for gardnerella vaginalis
  3. Also associated with RR of about 2.0 for first-trimester spontaneous abortion (BMJ 319:220, 1999--JW)
  4. Most common treatment = metronidazole 2g PO x 1
  5. BV in Pregnancy
    1. BV is established as a risk factor for preterm delivery, odds ratio 1.8 for preterm delivery in one study (Am J Obstet Gynecol 1995 Oct;173(4):1231-5)
    2. Impact on treatment of BV on outcomes esp. preterm birth--Data are mixed.
      1. 1,919 pregnant women with asymptomatic BV randomized to metronidazole 2g PO Q48h x 2 vs. placebo between 16-23wks gestation and again between 24-29wks. Incidence of delivery at < 31wks was no different in metronidazole vs. placebo groups (12.2% vs. 12.5%)--also no diff. among the subgroup of women who either had had a preterm delivery or were tx'd at < 20wks (Klebanoff et al., presentation at Soc. for Mat-Fetal Med 1999 cited in "Family Practice News" 5/1/99 p.50)
      2. 404 pregnant women with BV dx'd at 13-20wks randomized to Clindamycin 2% vaginal cream 5g QD x 3d vs. placebo, repeated for 7d course 3wks later if BV persisted. Risk of delivery < 37wks in Clindamycin and placebo groups was 4.1% vs. 9%; greater differences seen among those pts first tx'd < 16wks (Lamont et al., presentation at Soc. for Gyn. Investig. 1999 cited in "Family Practice News" 5/1/99 p.51)
      3. One study (NEJM 333:1732, 1995) used abx in 2nd TM and found a lower rate of preterm delivery in a population of 258 women with BV plus other risk factors for preterm delivery (31% vs. 49%, p = 0.006). The tx was metronidazole 250 PO TID x 7d + erythromycin 333mg TID x 14d given first at 23wks and then repeat wet mount & done and if still present, BV was re-tx'd with same regimen at 28wks.
      4. Another study used metronidazole 2g PO x 2, 48h apart, vs. placebo in 1953 women from a "general" OB-GYN practice, i.e. unselected for risk of preterm delivery, at 16-24wks with asymptomatic BV; re-tx given to those who failed test-of-cure at 24-30wks. Risk of delivery at < 37wks was no different between the two groups; ditto for risk of delivery at < 32wks. (NEJM 342:534, 2000)
      5. 409 pregnant women w/BV at 13-20wks' gestation randomized to 2% clindamycin vaginal cream x 3d vs. placebo; re-tested 3wks later and if still w/BV, received 7d of same.  Sig. fewer preterm deliveries in active-tx group (4% vs. 10%) (Obs. Gyn. 101:516, 2003--JW)
      6. 494 pregnant women w/BV at 12-22wks' gestation to clindamycin 300mg PO BID x 5d vs. placebo.  Incidence of pregnancy loss at 13-37wks was 5% in clindamycin group vs. 16% in placebo group (sig.). (Lancet 361:983, 2003-JW)
      7. Other studies I didn't review:
  1. Am J Obstet Gynecol 1994;171:345
  2. Br J Obstet Gynaecol 1997;104:1391
  3. Am J Obstet Gynecol 1995;173
  4. Am J Obstet Gynecol 1994

II. Trichomoniasis

  1. Caused by Trichomonas vaginalis
  2. Diagnosis
    1. Traditional diagnosis is by vaginal wet mount, but sensitivity is only 60-80% compared with culture
    2. Observation of spun urine for trichomonads had slightly lower sensitivity than vaginal wet mount in a study of 75 pts presenting to an adolescent clinic with vaginitis symptoms, but did identify some cases of infection (using culture as gold standard) that wet mount missed (Arch. Pediat. Adol. Med. 153:1222, 1999--AFP)
    3. DNA probe for T. vaginalis
  3. Associated with Premature Rupture of Membranes in pregnancy
    1. However, in a randomized trial of 617 asymptomatic women with trich on routine wet mount at 16-23wks randomized to metronidazole 2g Q48h x 2 vs. placebo, the metronidazole pts had sig. higher risk of preterm birth (19% vs. 10.7%) and nonsig. increased risk of delivery before 32wks (5.1% vs. 3.8%) (Study presented by C. Carey at Soc. for Mat-Fet Med, 2000, FP News 4/15/00)
  4. Treatment
    1. Single-dose metronidazole
    2. Single-dose tinidazole

III. Vaginal candidiasis ("yeast" infection)

  1. Pathophysiology
    1. Usually Candida albicans; sometimes C. glabrata (aka Torulopsis glabrata?)
  2. Treatment
    1. "-Azole" antifungals are mainstay of treatment (both oral and topical)
      1. Nystatin has less clinical effectiveness than the azoles (Med. Lett. 43:3, 2001)
    2. Boric Acid
    3. Lactobacillus
      1. In a randomized trial in 235 nonpregnant women 18-50yo requiring 6d or fewer of oral antibiotics, randomized to oral or vaginal lactobacillus, both, or double placebo, from start of tx until 4d after tx completed, incidence of culture-positive vaginal candidiasis was not sig. different in any of the active-tx groups c/w placebo (BMJ 329:548, 2004--JW)
    4. Resistance
      1. In a nonrandomized study of 40 pts with refractory fungal vaginitis with Torulopsis glabrata treated with oral or topical azoles, nystatin suppositories, or topical boric acid (600mg powder in a gelatin capsule intravag QD x 14d), the latter tx cured or improved 81% of the episodes for which it was prescribed, in contrast to the 50% success rate of the other treatments. Side effects limited to local irritation (Clin. Inf. Dis 24:649, 1997-JW)
  3. Risk factors 
    1. Pregnancy
    2. Oral contraceptives
    3. Antibiotic use
    4. Systemic corticosteroid use
    5. Immunocompromise
    6. Diabetes mellitus
  4. Prevention of antibiotic-induced yeast vaginitis
    1. 278 women 18-50yo undergoing antibiotic use x 6d for non-gyn infctions randomized to lactobacillus PO, lactobacillus intravaginal, both, or double-placebo; incidence of yeast vaginitis was not sig. diff. among any of the groups (BMJ 329:548, 2004--JW)
  5. Recurrent yeast vaginitis
    1. Consider secondary causes, including DM and immunosuppression (including HIV), though prevalence of the latter will be low.
    2. Suppression with chronic fluconazole
      1. In a study of 387 immunocompetent women with recurrent vulvovaginal candidiasis (> 3 episodes/yr) randomized to fluconazole 150mg Qwk vs. placebo x 6mos, recurrence rates were 9.2% at 6mos, 26.8% at 9mos, and 57.1% at 12mos w/fluconazole vs. 64.1% at 6mos, 72.2% at 9mos, and 78.1% at 12mos w/placebo.  No resistant strains were observed to develop (NEJM 351:876, 2004--JW)