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Section 7  Syndromic Approach to the Management of STDs
Section 7 Objectives
Section 7.1  Mucopurulent Cervicitis
Section 7.2 Urethritis
Section 7.3 Genital Ulcerative Disease
Section 7.4 Pelvic Inflammatory Disease
Section 7.5 Vaginitis
5.0  Etiology and Epidemiology
5.1  Pathogenesis
5.2  Clinical Manifestations
5.3.0  Diagnosis
5.4  Laboratory Diagnosis
5.5  Treatment
5.5.1  Bacterial Vaginosis
5.5.2  Vulvovaginal Candidiasis (VVC)
5.5.3  Trichomonas Vaginalis
5.6  Partner Management
5.7  Follow-Up
7.5.8 Interactive Web-Based Case
6.0  Review Questions
7.6.1 CME Credit Questions
7.6.2  References
1.0  Pathophysiology and Definition
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Keypoints
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Anatomical Figures
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Clinical Images
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Vaginitis

5.5.1 Treatment

Bacterial Vaginosis

Centers for Disease Control Homepage Recommended Treatment for Non-pregnant Women:

Treatment is generally reserved for symptomatic women. Treatment is not recommended for sexual partners or asymptomatic women unless these women are to undergo a surgical abortion. BV has been associated with endometritis, PID or vaginal cuff cellulitis in women undergoing ambulatory invasive procedures (endometrial biopsies, hysteroscopy, IUD insertions) and vaginal/abdominal surgery. Although data are insufficient to recommend treatment of asymptomatic patients prior to procedures other than surgical abortions, many providers elect to treat asymptomatic BV before any procedure involving the upper genital tract.

Metronidazole

500 mg orally twice a day for 7 days (cure rate of over 90-95%)

Intravaginal clindamycin cream

2% daily for 7 days

Intravaginal metronidazole

0.75% once or twice a day for 5 days (78-87% cure rate)

Clindamycin ovules 100 g intravaginally once at bedtime for 3 days.

Alternative regimens

Oral Clindamycin

300 mg twice a day for 7 days is also effective

Metronidazole

Single dose oral 2 gm stat (cure rates of 80-85%)

Intravaginal lactobacilli formulations are ineffective in preventing relapses because these organisms are not adapted to the vaginal environment, do not adhere to the epithelium, and do not contain hydrogen peroxide producing organisms.
Treatment not recommended for sexual partners.

Centers for Disease Control Homepage Recommended Treatment of Pregnant Women:

All symptomatic women should be treated for BV.

Metronidazole

250 mg orally three times a day for 7 days

OR
Clindamycin

300 mg orally twice a day for 7 days

Alternative regimens:

Metronidazole

2 g orally single dose

The use of topical agents is not recommended. Some specialists believe that systemic delivery allows for treatment for possible subclinical infection of the upper genital tract. In addition, clindamycin cream has been shown to increase preterm birth and is therefore not recommended.

There is no evidence of teratogenicity from metronidazole even when used in the first trimester. Some experts suggest that treating early in pregnancy may be important in preventing adverse outcomes.

Centers for Disease Control Homepage Recommended regimen for pregnant women who are asymptomatic but at high risk for preterm labor.

BV has been associated with adverse pregnancy outcomes including preterm labor. Three out of four studies done to evaluate the effect on treating BV in women at high risk for preterm labor (history of previous premature delivery) demonstrated a decreased rate of subsequent preterm labor in those women treated. While the optimal treatment regimen has not been established, the one trial that did not show a benefit treated women at 19 weeks and later. Therefore, it is recommended that women at high risk for preterm labor be screened and treated for BV at the first prenatal visit occurring ideally in the first trimester or early second trimester. Recommended regimens are identical to those listed for symptomatic pregnant women. A follow-up appointment one month after treatment should be considered for those women treated under these circumstances.

 

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