Treatment of Vaginitis

Transcription

1 Treatment of Vaginitis Dr Wong Ying Grace 黃凝醫生 OG specialist MBBS MRCOG DCH(Ireland) FHKAM (O&G) FHKCOG June 23, 2013

2 Diseases characterized by vaginal discharge Careful history Sexual behaviors Gender of sex partners Menses Vaginal hygiene practices (douching) Other medications

3 3 diseases most frequently associated with vaginal discharge 1. Bacterial Vaginosis 細菌性陰道炎 2. Trichomoniasis 陰道滴蟲 3. Candidiasis Albicans 念珠菌

4 Bacterial vaginosis 細菌性陰道炎 陰道内正常菌群失調所致, 陰道内有大量的細菌 伴有陰道分泌物性質改變的一組症候群 Lactobacillus ( ph) Mixed growth of anaerobic bacteria (bacterial floral imbalance)

5 Bacterial Vaginosis 細菌性陰道炎 BV is a polymicrobial clinical syndrome represents a complex change in the vaginal flora characterized by a reduction in concentration of the normally dominant hydrogen peroxide producing lactobacilli, and an increase in the concentration of anaerobic Gram negative bacteria eg Prevotella sp, Mobiluncus sp, Gardnerella vaginalis, Ureaplasma, Mycoplasma.

6 Bacterial vaginosis 細菌性陰道炎 Loss of lactobacilli ph rises Massive overgrowth of vaginal anaerobes These anaerobes produce large amounts of proteolytic carboxylase enzymes, which break down vaginal peptides into a variety of amines that are volatile, malodorous with vaginal squamous cells exfoliation.

7 Bacterial Vaginosis (BV) 細菌性陰道炎 BV is the most prevalent cause of vaginal discharge or malodor (CDC guideline 2010) About 50 to 75 % of women with BV are symptomatic When symptomatic, the symptoms are off white, thin, homogenous fishy smelling discharge which is more noticeable after coitus and during menses In US, National survey (self collected vaginal swabs of over 3700 women) the prevalence of BV was 29 percent in the general population of women aged 14 to 49 yo

8 Bacterial Vaginosis 細菌性陰道炎 BV is associated with: 1 having multiple sex partner 2 a new sex partner 3 Douching 4 lack of condom 5 lack of vaginal lactobacilli (most experts believe that BV does not occur in women who have never had vaginal intercourse)

9 Bacterial Vaginosis 細菌性陰道炎 Women with BV are at increased risk: 1 acquiring STD s (HIV, gonorrhea, Chlamydia, HSV2) 2 complications of pregnancy (preterm labour)/gynaecological surgery

10 Bacterial Vaginosis Diagnostic criteria: BV can be diagnosed 1 by Gram stain: relative concentrations of lactobacilli vs Gram negative/gramvariable rods and cocci and curved Gram negative rods 2 by clinical criteria

11 Bacterial Vaginosis Clinical criteria (amsel criteria) at least 3 criteria must be present: 1. homogenous thin grayish white discharge that smoothly coats the vaginal walls 2. presence of clue cells (ie epithelial cells with borders obscured by small bacteria) on microscopic exam 3. ph of vaginal fluid > A fishy odor of vaginal discharge before or after addition of 10% KOH (the whiff test)

12 Bacterial Vaginosis DNA probe based test for high concentrations of Gardnerella vaginalis has been acceptable test. (CDC guideline 2010) Pap smear is not reliable for diagnosis of BV Vaginal culture has no role in diagnosis because BV reprsents complex changes in the vaginal flora.

13 Bacterial Vaginosis Treatment BV can resolve spontaneously in up to 1/3 of women. Therefore, treatment is not necessary for asymtomatic women (CDC recommendation) Aim is to relieve vaginal symptoms and reduce in the risk for acquiring Chlamydia or Neisseria, HIV and other viral STD s.

14 Bacterial Vaginosis Recommended regimen: Metronidazole 500mg BD oral for 7 days (Consuming alcohol should be avoided during treatment and for 24 hours thereafter) Metronidazole gel 0.75%one full applicator 5 gram intravaginally once a day for 5 days Clindamycin cream 2% one full applicator 5 gram intravaginal at bedtime for 7 days Alternative regimen: Tinidazole 2 gram orally once daily for 2 days Or Tinidazole 1 gram orally once daily for 5 days Or Clindamycin 300mg oral twice daily for 7 days (CDC guideline 2010)

15 Bacterial Vaginosis Douching may increase the risk of relapse Women should refrain from intercourse or use condoms consistently during treatment period

16 Bacterial Vaginosis Follow up visits are unnecessary if symptoms resolve Recurrence of BV is common, so women should be advised to return if symptoms recur Monthly oral metronidazole administered with fluconazole has been evaluated as suppressive therapy. Routine treatment of sex partner is not recommended

17 Bacterial Vaginosis Special considerations Allergy: Intravaginal clindamycin cream is preferred in case of allergy or intolerance to metronidazole or tinidazole.

18 Bacterial Vaginosis in pregnancy ACOG and CDC recommends not to routinely screen and test all pregnant women with asymptomatic BV to prevent preterm birth. There may be benefits to early screening and treatment of asymptomatic pregnant women who have previous history of preterm delivery. Recommended dose for pregnant women Metronidazole 500mg BD oral for 7 days Or 250mg oral three times daily for 7 days Or Clindamycin 300mg oral BD for 7 days

19 Bacterial Vaginosis Women undergoing pregnancy termination who have asymptomatic BV should be given flagyl to prevent post op infectious complications (up to date 2013)

20 Bacterial Vaginosis Use of probiotics (intravaginal lactobacillus formulations) to treat BV no sufficient evidence for or against efficacy.

21 Trichomoniasis 陰道滴蟲 Men may not have symptoms, some may have urethritis Women have diffuse malodrous, yellow green discharge with vulva irritation. Many women do not have symptoms Diagnosis microscopy wet preparation slides

22 Trichomoniasis Culture test is sensitive and highly specific Recommended treatment Metronidazole 2 gram orally in a single dose Tinidazole 2 gram orally in single dose Alternative treatment Metronidazole 500mg orally twice a day for 7 days Use of metronidazole gel is not recommended because less efficacious

23 Trichomoniasis High rate of reinfection. Therefore rescreening for trichomoniasis at 3 months following initial infection can be considered for sexually active women with trichomoniasis (CDC guideline 2010) Sexual partner should be treated

24 Trichomoniasis Vaginal trichomoniasis has been associated with adverse pregnancy outcomes premature rupture of membranes preterm labour, low birth weight. Women can be treated with 2 gram metronidazole in a single dose at any stage of pregnancy. Multiple studies and meta analyses have not demonstrated an association between metronidazole use during pregnancy and teratogenic effects.

25 Trichomoniasis Lactating women if administer metronidazole, withhold breastfeed during treatment and for hours after the last dose will reduce exposure of metronidazole to infants.

26 Vulvocandidiasis 念珠菌 Candida Albicans Pruritus vaginal soreness, beancurd like discharge Diagnosis gram stain, wet preparation, culture

27 Vulvocandidiasis Clotrimazole cream, Butoconazole cream, miconazole cream, Ticonazole cream Nystatin vaginal tablet 100,000unit one tablet 14 days Terconazole 80mg vaginal suppository one suppository for 3 days Fluconazole 150mg oral tablet single dose Itraconazole 200mg BD for a single day

28 Recurrent Vulvovaginal Candidiasis Longer duration of initial therapy E.g days of topical therapy or 100mg, 150mg, 200mg oral dose of fluconazole (Diflucan) every third day for a total of 3 doses to attempt mycologic remission (CDC guideline 2000)

29 Recurrent Vulvovaginal Candidiasis Oral fluconazole 100mg, 150mg or 200mg dose weekly for 6 months is the first line of treatment. (CDC guideline 2000)

30 Pregnant women with Vulval Candidiasis Only topical therapies can be used

31 Vulval Candidiasis Sporonox (itraconazole) 200mg BD po Vs oral Fluconazole (Diflucan) 150mg QD po for once Similar efficacy Itraconazole vs fluconazole for the treatment of uncomplicated acute vaginal and vulvovaginal candidiasis in nonpregnant women: a metaanalysis of randomized controlled trials. Pitsouni E, Iavazzo C, Falagas ME. Am J Obstet Gynecol Feb;198(2):

32 Zalain sertraconazole Safe to use. Effective Drugs. 2009;69(3): Sertaconazole: a review of its use in the management of superficial mycoses in dermatology and gynaecology. Croxtall JD, Plosker GL.

33 Conclusion 1 Bacterial vaginosis, trichomoniasis and vulvovaginal candidiasis are the most common infectious causes of vaginitis. 2. Bacterial vaginosis is a polymicrobial clinical syndrome resulting from replacement of lactobacillus in the vagina with high concentrations of anerobic bacteria. 3. Bacterial vaginosis is associated with having multiple sexual partners, a new sexual partner, vaginal douching and lack of condom use. 4. Women with bacterial vaginosis are at increased risk of acquiring sexually transmitted diseases, complications of pregnancy and complications after gynaecological surgery. 5. Women with trichomoniasis have symptoms characterized by a diffuse, malodorous, yellow green vaginal discharge.

34 Thank you

35 Management of PID RCOG guideline 2008 Oral Ofloxacin 400mg BD daily +oral metronidazole 400mg BD for 14 days IM Ceftriaxone (Rocephin) 250mg single dose +oral doxycycline 100mg BD daily +metronidazole 400mg BD for 14 days

36 Management of acute PID RCOG guideline 2008 Ceftrizxone 2g (Rocephin) by iv infusion plus IV doxycycline 100mg BD daily, followed by oral doxycyline 100mg BD and oral metronidazole 400mg BD for a total of 14 days