SOGC CLINICAL PRACTICE GUIDELINE
Vulvovaginitis: Screening for and Management of Trichomoniasis, Vulvovaginal Candidiasis, and Bacterial Vaginosis

https://doi.org/10.1016/S1701-2163(15)30316-9Get rights and content

Abstract

Objective

To review the evidence and provide recommendations on screening for and management of vulvovaginal candidiasis, trichomoniasis, and bacterial vaginosis.

Outcomes

Outcomes evaluated include the efficacy of antibiotic treatment, cure rates for simple and complicated infections, and the implications of these conditions in pregnancy.

Evidence

Published literature was retrieved through searches of MEDLINE, EMBASE, CINAHL, and The Cochrane Library in June 2013 using appropriate controlled vocabulary (e.g., vaginitis, trichomoniasis, vaginal candidiasis) and key words (bacterial vaginosis, yeast, candidiasis, trichomonas vaginalis, trichomoniasis, vaginitis, treatment). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. There were no date limits, but results were limited to English or French language materials. Searches were updated on a regular basis and incorporated in the guideline to May 2014. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, and national and international medical specialty societies.

Values

The quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1).

Section snippets

Summary Statements

  • 1.

    Vulvovaginal candidiasis affects 75% of women at least once. Topical and oral antifungal azole medications are equally effective. (I)

  • 2.

    Recurrent vulvovaginal candidiasis is defined as 4 or more episodes per year. (II-2)

  • 3.

    Trichomonas vaginalis is a common non-viral sexually transmitted infection that is best detected by antigen testing using vaginal swabs collected and evaluated by immunoassay or nucleic acid amplification test. (II-2)

  • 4.

    Cure rates are equal at up to 88% for trichomoniasis treated with

Recommendations

  • 1.

    Following initial therapy, treatment success of recurrent vulvovaginal candidiasis is enhanced by maintenance of weekly oral fluconazole for up to 6 months. (II-2A)

  • 2.

    Symptomatic vulvovaginal candidiasis treated with topical azoles may require longer courses of therapy to be resolved. (1-A)

  • 3.

    Test of cure following treatment of trichomoniasis with oral metronidazole is not recommended. (I-D)

  • 4.

    Higher-dose therapy may be needed for treatment-resistant cases of trichomoniasis. (I-A)

  • 5.

    In pregnancy, treatment

VULVOVAGINAL CANDIDIASIS

Vulvovaginal candidiasis is a very common condition that affects up to 75% of women at least once in their lifetime.1 Risk factors for VVC include sexual activity, recent antibiotic use, pregnancy, and immunosuppression from such conditions as poorly controlled HIV infection or diabetes.2., 3.

The Organism

T. vaginalis is an anaerobic parasitic protozoan flagellated organism that adheres to epithelial cells of the urogenital tract. For the most part, infection is limited to the genitourinary tract. With infection, the condition is referred to as Trichomoniasis.

The Disease

The prevalence of T. vaginalis in the United States is reported as 3.1% among women of reproductive age (14–49).20 Globally, it is considered the most common non-viral STI, with an estimated 170 million cases reported annually.21 It is not

The Organism

Normal vaginal flora consists of both aerobic and anaerobic bacteria, with Lactobacillus species being the predominant microorganisms and accounting for greater than 95% of all bacteria present.41., 42. Lactobacilli are believed to provide defense against infection in part by maintaining an acidic pH in the vagina and ensuring hydrogen peroxide is present in the environment. In contrast, bacterial vaginosis is a polymicrobial syndrome resulting in a decreased concentration of lactobacilli and

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      These are in accordance with existing research, stating that antibiotics without probiotics have a high recurrence rate (Hillier et al., 2017; Nyirjesy & Schwebke, 2018; Schwebke et al., 2017). Metronidazole is the recommended treatment option for BV (van Schalkwyk et al., 2015; Workowski et al., 2015). However, its recurrence rate is reported to be 21.2%–25.5% compared to probiotics which are 10.6%–11% (Faught & Reyes, 2019).

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    This clinical practice guideline has been prepared by the Infectious Diseases Committee, reviewed by the CANPAGO and Family Physician Advisory Committees, and approved by the Executive and Board of the Society of Obstetricians and Gynaecologists of Canada.

    Disclosure statements have been received from all contributors.

    This document reflects emerging clinical and scientific advances on the date issued and is subject to change. The information should not be construed as dictating an exclusive course of treatment or procedure to be followed. Local institutions can dictate amendments to these opinions. They should be well documented if modified at the local level. None of these contents may be reproduced in any form without prior written permission of the SOGC.

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