Vulvovaginitis in Emergency Medicine Medication

Treatment should be aimed at bacterial, parasitic, or fungal infection.

Class Summary

Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the clinical setting.^[25]

A 7-day oral course yields a 90% cure, and single oral dose therapy yields an 80% cure. Relapses are common requiring a longer duration of treatment.^[26] Combinations of antibiotics have no benefit.^{[25, 26]} If single oral dose therapy is ineffective, either administer a second oral dose in 48 hours or initiate weeklong therapy. Some patients prefer intravaginal medication.^[10] Treatment of bacterial vaginosis before 20 weeks' gestation may decrease preterm delivery.^[27] Only those women who are symptomatic from bacterial vaginosis should be screened.^{[10, 28, 5]} Topical metronidazole gel poorly achieves therapeutic concentration in the urethra and Skene's gland and therefore is not indicated in Trichomonas infections.^[19] Tinidazole may have less side effects than metronidazole and can be used in the rare case of metronidazole resistance.^[29]

Metronidazole (Metro-Gel, Noritate)

Imidazole ring-based antibiotic active against various anaerobic bacteria and protozoa. Indicated for treatment of bacterial vaginosis (formerly referred to as Haemophilus vaginitis, Gardnerella vaginitis, nonspecific vaginitis, Corynebacterium vaginitis, anaerobic vaginosis).

Penicillin VK (Veetids, Beepen-VK)

Indicated when the offending organism is group A streptococci. Inhibits biosynthesis of cell wall mucopeptide and is effective during active replication. Inadequate concentrations may produce only bacteriostatic effects.

Tinidazole (Tindamax)

5-Nitroimidazole derivative used for susceptible protozoal infections. The mechanism by which tinidazole exhibits activity against Giardia and Entamoeba species is not known.

Erythromycin (EES, E-Mycin, Ery-Tab)

DOC for penicillin-allergic patients with infections caused by susceptible strains of microorganisms, including group A streptococci. Inhibits RNA-dependent protein synthesis, possibly by stimulating dissociation of peptidyl tRNA from ribosomes, which inhibits bacterial growth.

In children, age, weight, and severity of infection determine proper dosage. When bid dosing is desired, half-total daily dose may be taken q12h. For more severe infections, double the dose.

Clindamycin (C/T/S, Clinda-Derm, Cleocin HCl)

Useful as treatment against serious skin and soft tissue infections caused by most staphylococcal strains. Inhibits bacterial protein synthesis by inhibiting peptide chain initiation at the bacterial ribosome, where it preferentially binds to the 50S ribosomal subunit, causing bacterial growth inhibition. Has a 90% cure rate and is used as an alternative to metronidazole.

Class Summary

These agents are used to treat extreme vaginal pruritus. Cream is for symptomatic relief, especially in pediatric vulvovaginitis.

These agents are adrenocorticosteroid derivatives incorporated into a vehicle suitable for application to skin or external mucous membranes.

Hydrocortisone topical (Cortef Feminine Itch, Delcort)

DOC because of its mineralocorticoid activity and glucocorticoid effects.

Primary therapeutic effects of topical corticosteroids are from their anti-inflammatory activity, which is nonspecific (ie, they act against most causes of inflammation including mechanical, chemical, microbiological, immunological).

Do not use very high or high-potency agents on the face, groin, or axilla.

Class Summary

These agents are used to treat candidal vulvovaginitis. Topical azole antifungals achieve cure rates of 85-95%. Nystatin demonstrates a 75-80% cure rate. Oral fluconazole has a cure rate comparable to topical azole antifungals.^[30] It may be preferred by patients because of the ease of one-time dosing.

Intravaginal and topical therapies with a variety of antifungals, such as clotrimazole, miconazole, terconazole, and tioconazole, are highly effective. Many of the preparations are now available OTC. 1-, 3-, and 7-day regimens can be used. Cure rates of 90% are reported with longer courses.

Butoconazole (Femstat)

Broad-spectrum antifungal agent that inhibit yeast growth by altering cell membrane permeability, which causes fungal cell death.

Tioconazole (Vagistat)

Broad-spectrum antifungal agent that inhibit yeast growth by altering cell membrane permeability, which causes fungal cell death.

Clotrimazole (Mycelex-7)

Broad-spectrum antifungal agents that inhibit yeast growth by altering cell membrane permeability, which causes fungal cell death.

Fluconazole (Diflucan)

Synthetic oral antifungal (broad-spectrum bistriazole) that selectively inhibits fungal cytochrome P-450 and sterol C-14 alpha-demethylation. Consider ease of use, although direct cost may be a limiting factor. Do not recommend PO antifungals in pregnancy.

Miconazole vaginal (Monistat Vaginal)

Broad-spectrum antifungal agent that inhibit yeast growth by altering cell membrane permeability, which causes fungal cell death.

Terconazole (Terazol 3, Terazol 7)

Broad-spectrum antifungal agent that inhibit yeast growth by altering cell membrane permeability, which causes fungal cell death.

Ketoconazole topical (Kuric 2%, Xolegel 2%)

Broad-spectrum antifungal agents that inhibit yeast growth by altering cell membrane permeability, which causes fungal cell death.

Nystatin

Broad-spectrum antifungal agent that inhibit yeast growth by altering cell membrane permeability, which causes fungal cell death.

Class Summary

These agents are used in treatment of atrophic vaginitis in postmenopausal women. Oral estrogen replacement also is effective and has other health benefits. Oral estrogen therapy generally should be initiated by a primary care provider rather than an ED clinician.

Conjugated estrogens (Premarin)

Several topical steroid preparations are available, including equine estrogen, estradiol, and dienestrol. Estrogens are indicated for atrophic vaginitis and atrophic urethritis associated with menopause.

Class Summary

These agents are used to treat parasitic infections. Parasite biochemical pathways are sufficiently different from the human host to allow selective interference by chemotherapeutic agents in relatively small doses.

Mebendazole (Vermox)

Indicated drug to treat pinworm. Kills worms by selectively and irreversibly blocking glucose uptake and other nutrients in the susceptible adult intestine where helminths dwell.

Pyrantel pamoate (Pin-Rid, Pin-X, Reese Pinworm)

Used as an alternative to mebendazole; a depolarizing neuromuscular blocking agent that inhibits cholinesterases, resulting in spastic paralysis of the worm. Active against E vermicularis (ie, pinworm) and Ascaris lumbricoides (ie, roundworm). Also effective against Ancylostoma duodenale (ie, hookworm). Purging is not necessary; may be taken with milk or fruit juices.

Class Summary

These agents competitively bind to estrogen receptor, producing a nuclear complex that decreases DNA synthesis and inhibits estrogen effects.

Tamoxifen (Nolvadex)

May be used for women who are very concerned about estrogen exposure. Known to have both estrogen antagonist and agonist effects, depending on target tissue.