IID 14: Vaginal Infections Flashcards
Vaginal Discharge
- normal: thick/thin, white/clear
- BV: thin, copious amounts, grey/milky
- VVC: curd-like, clumpy, white
- trichomoniasis: frothy, yellow-green or off-white
- PMAV: possible, usually vaginal dryness
Dysuria/Dyspareunia
- normal: none
- BV: possible
- VVC: possible
- trichomoniasis: possible
- PMAV: possible
Pruritus
- normal: none
- BV: usually none
- VVC: yes
- trichomoniasis: yes
- PMAV: possible
Abnormal Odour
- normal: no
- BV: yes, fishy
- VVC: no
- trichomoniasis: yes, very fishy
- PMAV: no
Erythema Swelling
- normal: none
- BV: none to mild
- VVC: yes
- trichomoniasis: yes
- PMAV: no
pH
- normal: 3.8-4.5
- BV: 5-6
- VVC: 4-5
- trichomoniasis: ≥ 6
- PMAV: ~7
Sexual Transmission
- BV: no
- VVC: no
- trichomoniasis: yes
- PMAV: no
Organism
- BV: Gardnerella vaginalis
- VVC: C. albicans (> 90%), C. glabrata (5-10%), C. tropicalis (5%), C. krusei (1%)
- trichomoniasis: Trichomonas vaginalis
- PMAV: none
Microscopy
- normal: Lactobacilli, negative whiff test
- BV: clue cells, positive whiff test
- VVC: Candida species, negative whiff test
- trichomoniasis: motile trichomonads, + or – whiff
- PMAV: typically ↓ in Lactobacillus spp.
Serious Complication (Untreated)
- BV: 2x increase in miscarriage, pelvic inflamm disease (PID)
- VVC: none
- trichomoniasis: pre-term birth, low birth weight
- PMAV: none
Refer to MD
- BV: yes
- VVC: 1st time, other complications
- trichomoniasis: yes
- PMAV: yes
What is the pathogenesis of VVC?
- adhesion of single yeast cells triggered by change in environment (ie. pH or hormones)
- cells proliferate then form elongated projections that continue to grow into filamentous hyphal form
- hyphae filaments stick to mucous layer and form biofilm, non-adherent yeast cells are released from biofilm into surroundings where they can colonize other surfaces
Usual Treatment
- BV: Rx antibiotics (metronidazole, clindamycin)
- VVC: OTC oral, topical antifungals (fluconazole, miconazole, clotrimazole)
- trichomoniasis: Rx antibiotics (metronidazole)
- PMAV: Rx topical estrogen, or OTC vaginal moisturizers
Does the partner of someone who has VCC need to be treated?
not necessary to treat partner unless symptomatic
What are the predisposing factors for VVC?
- often absent
- sexually active
- poorly controlled diabetes
- immunocompromised (corticosteroids, chemotherapy, HIV)
- current or recent antibiotic use, some diabetic drugs
- hormonal (pregnancy, oral contraceptives, hormone replacement)
- smoking may decrease Lactobacilli species
What are the characteristics of uncomplicated VVC?
patient must have all:
- symptoms: mild or moderate
- frequency: sporadic or infrequent
- organism: C. albicans
- host factors: normal immune function, non-pregnant
What are the characteristics of complicated VVC?
patient must have 1 or more:
- symptoms: severe
- frequency: recurrent
- organism: C. non-albicans
- host factors: abnormal immune function, pregnant
What are the patient-specific factors that indicate a need for a referral?
- age: pre-pubertal or post-menopausal patient
- STI: considered at risk
- pregnant: first yeast infection while pregnant OR having multiple yeast infections
- concurrent predisposing medical conditions (ie. diabetes)
What are the symptoms that indicate a need for a referral?
- no prior diagnosis of VVC
- symptoms not consistent with VVC
- less than 2 months since previous occurrence
- ≥ 2 VVC episodes in past 6 months
- symptoms have not improved after 3 days of treatment
What are the antifungals used to treat VVC?
- imidazoles (azoles)
- triazoles
- polyene antifungal
What are the antiseptics used to treat VVC?
boric acid (pv) – compounded 600 mg vaginal capsules
Imidazoles (Azoles) for VVC
- sched 3: miconazole (pv)
- sched 3: clotrimazole (pv)
Triazoles for VVC
- sched 3: fluconazole (po) – sold as single 150 mg tablet for VVC
- sched 1: terconazole (pv) – Taro-Terconazole© vaginal cream 0.4%
Polyene Antifungal for VVC
- sched 1: nystatin (pv) – Nyaderm© or Teva-Nystatin© vaginal cream 25 000 units/g
What are the side effects of imidazoles?
- stinging, burning (itching if sensitive), allergy, headache, abdominal cramps
- clotrimazole reported to cause less stinging than miconazole
- if stinging occurs with higher dose product, try switching to lower dose for longer duration
What are the drug interactions with imidazoles?
topical miconazole may increase serum concentration of warfarin
What are the side effects for a single 150 mg dose of fluconazole?
headache (13%), nausea (7%), abdominal pain (6%), diarrhea (3%), dyspepsia (1%), dizziness (1%), taste perversion (1%), rare cases of anaphylaxis
What are the interactions with fluconazole?
- strong inhibitor of CYP2C9, moderate inhibitor of CYP3A4 and 2C19 – but interactions with single dose likely minimal
- monitor warfarin, phenytoin, blood sugars with some oral diabetes agents
- absorption not affected by food, gastric pH
What are the side effects of boric acid?
- ~10% vaginal burning and irritation
- erythema
- watery discharge
What are the interactions with boric acid?
- pregnancy – teratogenic, lack of safety data
- not recommended in lactating women
What is the primary therapy for uncomplicated VVC?
- topical antifungal agents, with no one superior agent (strong rec – high-quality evidence)
- alternative: single 150-mg oral dose of fluconazole (strong rec – high-quality evidence)
- duration of therapy: start with shorter course (1-3 days) – more convenient and still > 90% effective
What is the speed of symptom resolution for uncomplicated VVC?
- conflicting results for time to symptom relief (oral vs. vaginal)
- should be some relief by 2-3 days, full resolution within 7 day (regardless of whether 1 or 7 day treat)
What are severe symptoms of complicated VVC?
extensive vulvar erythema, edema, excoriations, fissures
What is the therapy for complicated VVC (severe symptoms)?
- fluconazole 150 mg po q72h (3 days) for 2 or 3 doses
- miconazole 7 day or clotrimazole 6 day pv regimens (and repeat once if needed)
- (maybe) clotrimazole 500 mg pv x 2 doses (days 1 and 4)
- longer duration of therapy
What is recurrent VVC?
≥ 4 episodes in 12 months of symptomatic VVC
- usually azole-susceptible C. albicans
- reason for it unknown, but possibly due to localized vaginal allergic response, impaired Candida-specific cell-mediated immunity
Do partners have to be treated for recurrent VVC?
if male partner is symptomatic, apply azole cream BID to penis x 7 days
What is the therapy for recurrent VVC (complicated)?
10-14 days of induction therapy with vaginal agent or oral fluconazole, followed by fluconazole 150 mg po weekly for 6 months
induction:
- fluconazole 150 mg po q72h x 3 doses (day 1, 4, 7) OR
- azole pv for 12-14 days (6 or 7 day pv, repeated once)
THEN maintenance:
- fluconazole 150 mg capsule po once weekly x 6 months (preferred)
- clotrimazole 500 mg tablet pv once weekly x 6 months
- clotrimazole 200 mg tablet pv twice weekly x 6 months
- boric acid 600 mg capsule pv once weekly x 6 months
What is the causative organism for VVC in patients with diabetes?
- C. glabrata (60%)
- C. albicans (40%)
What is the causative organism for VVC in patients with abnormal immune function (other than diabetes)?
- C. tropicalis
- C. parapsilosis
- C. krusei (1%)
Describe the susceptibility of C. glabrata, C. tropicalis, and C. krusei to azoles.
- C. glabrata responds poorly to azoles
- C. tropicalis may not respond to azoles
- C. krusei unresponsive to oral azoles, but responds well to vaginal azoles
What is the treatment for complicated VVC caused by other organisms?
- boric acid 600 mg pv QHS x 14 days (cures 70% C. glabrata infections)
- nystatin vaginal cream 25 000 unit/g: 5g pv BID x 14 days (reasonable activity against C. glabrata)
What is the drug of choice to treat pregnant patients with VVC (complicated)?
vaginal azole antifungals
- recommend minimal systemic exposure, therefore little risk of harm to baby
- increased efficacy with 7-day therapy over shorter durations
- no greater benefit from longer durations (ie. > 14 days)
What drug is used to treat pregnant patients with VVC (complicated)?
nystatin
- considered safe in all trimesters
- may be less effective than vaginal imidazoles
What drug are NOT recommended to treat pregnant patients with VVC (complicated)?
oral fluconazole
- safety concerns – MSK/conotruncal/cardiac malformations, oral clefts
- single dose of oral fluconazole 150 mg is second-line option
boric acid
- association with major malformations
- > 2x increased risk of birth defects with use during first 4 months of pregnancy
What is the therapy for complicated VVC in patients with abnormal immune function?
if C. albicans still suspected, suggest longer duration:
- fluconazole 150 mg q72 h x 3 doses
- 6 or 7 day vaginal azole regimens (may repeat)
What drugs for VVC are compatible in lactation?
- clotrimazole
- nystatin
- fluconazole
What drugs for VVC are probably compatible in lactation?
miconazole
What are the 2 monitoring points for VVC?
symptoms of VVC
- endpoint: eradication of symptoms (itching, burning, dysuria, dyspareunia, lumpy white discharge)
- action: if symptoms still present after 7 days, confirm correct use of product or consult physician
side effects of drug
- endpoint: no increased irritation, common side effects of specific drug
- action: D/C product if necessary, consider 3 or 7 day treatment if appropriate, refer to physician if severe irritation
What is trichomoniasis?
anaerobic parasitic protozoan Trichomonas vaginalis
- most common non-viral STI
- lasts for months to years
What is the treatment for trichomoniasis?
- metronidazole 2 g po single dose, whether symptomatic or not
- metronidazole 500 mg po BID x 7 days
What is the treatment for trichomoniasis if persistent/recurrent infection?
- metronidazole 500 mg po BID x 7 days
- metronidazole 2 g po daily x 5 - 7 days
What is the treatment for trichomoniasis if pregnant and symptomatic?
- infection associated with pre-term delivery
- metronidazole 500 mg po BID x 7 days
- metronidazole 2 g po single dose
What are the interactions in the treatment of trichomoniasis?
- avoid alcohol – disulfiram-like reaction, vaginal treatment is not effective
- stop breastfeeding during treatment with metronidazole and for 12-24 hours after last dose (pump and dump)
What is bacterial vaginosis (BV)?
polymicrobial syndrome with replacement of normal Lactobacillus with high concentrations of anaerobic bacteria (Gardnerella vaginalis, and Mobiluncus, Mycoplasma, Prevotella, and Bacteroides species)
What are the risk factors for BV?
multiple sex partners, copper IUD), prior pregnancy, smoking, vaginal douches or intravaginal products
Is BV sexually transmitted?
maybe, but not considered STI
- no treatment necessary for sexual partner
Treatment of BV is reserved for patients with…
bothersome symptoms or special consideration (ie. pregnancy, IUD insertion, gynecologic surgery, etc.)
What is the treatment for BV?
- metronidazole 500 mg po bid x 7 days
- metronidazole 0.75 % gel (5 g applicator of gel) pv daily x 5 days
- clindamycin 2 % cream (5 g applicator of cream) pv daily x 7 days
What are the alternative treatments for BV?
- metronidazole 2g po single dose
- clindamycin 300mg capsule po bid x 7 days
What is the treatment for BV if pregnant?
oral metronidazole or clindamycin preferred
- do NOT recommend vaginal therapy
What is the treatment for BV if recurrent infection?
- refer to physician to reconfirm diagnosis
- metronidazole 500 mg po BID x 10-14 days
- if not effective: metronidazole 0.75% gel (5 g app) pv daily x 10 days, then continue twice weekly for 3-6 months, also suggest regular condom use
What is post-menopausal atrophic vaginitis (PMAV)?
- tissue/organ becoming smaller, thinner, or weaker
- low estrogen levels after menopause may result in: thinning of vaginal tissues, loss of vaginal elasticity, dryness, irritation, itching, burning, pain during intercourse
What are the risk factors for PMAV?
hypoestrogenism, cigarette smoking, low androgen levels, non-vaginal childbirth
What is the treatment for PMAV?
- vaginal moisturizers and/or vaginal estrogen depending on severity
- PMAV does not improve over time without treatment
- like VVC, trichomoniasis, and BV, medical history alone is not adequate for making accurate diagnosis because symptoms overlap and more than one cause may be present – pelvic exam may also be needed
