eMedicine Specialties > Emergency Medicine > Obstetrics & Gynecology

Vulvovaginitis

Mark J Leber, MD, MPH, Clinical Assistant Professor of Emergency Medicine, Weill Medical College of Cornell University; Consulting Staff, Department of Emergency Medicine, Brooklyn Hospital Medical Center
Anuritha Tirumani, MD, Research Coordinator, Department of Emergency Medicine, Brooklyn Hospital Center

Updated: Aug 12, 2009

Introduction

Background

Vulvovaginitis is common, affecting women of all ages. Vulvovaginitis is an inflammation of the vagina and vulva, most often caused by a bacterial, fungal, or parasitic infection. Vulvovaginitis, one of the most common reasons why women visit their gynecologist, causes vaginal discharge, irritation, and itching. Normally, a woman may have a vaginal discharge, the amount and consistency of which varies during the course of the menstrual cycle; however, vulvovaginitis causes a symptomatic increased vaginal discharge. Other symptoms associated with this condition are dyspareunia, dysuria, and odor.

Women with vulvovaginitis tend to be embarrassed or are worried about sexually transmitted diseases (STD). Self-treatment is usually the norm and close to 50% ineffective.¹  In this country alone, millions of dollars are wasted on over-the-counter antifungals because of self-treatment for candidiasis.² Providers may also be uncomfortable or do not have adequate time to diagnose the true etiology and may treat the wrong condition. Thus, vulvovaginitis is probably underdiagnosed.

Etiologies and the approach of management for a patient with vulvovaginitis are age dependent. Vulvovaginitis can be divided into 3 age categories: premenarchal, childbearing, and postmenopausal.

Pathophysiology

The normal vaginal epithelium cornifies (develops into a thickened layer of epithelial cells) under the influence of estrogen, protecting women against infection. A normal vaginal discharge consists of 1-4 mL of fluid that is white or transparent, thick, and odorless. This physiologic discharge is formed by sloughing epithelial cells, normal bacteria, and vaginal transudate. The discharge may be noticeable during pregnancy, oral contraceptive pill use, or at mid menstrual cycle, close to the time of ovulation.

The normal pH of vaginal secretions is 4.0-4.5.³ The pH is maintained by lactobacillus, which produces hydrogen peroxide and lactic acid; diphtheroids; and Staphylococcus epidermidis.² Lactobacillus is found in 62-88% of women.³ Vaginal pH may increase with age, phase of menstrual cycle, sexual activity, contraception choice, pregnancy, presence of necrotic tissue or foreign bodies, and use of hygienic products or antibiotics.³

Bacterial vaginosis is secondary to bacterial overgrowth and not due to tissue inflammation. The organisms associated with bacterial vaginosis are Gardnerella vaginalis, Mycoplasma hominis, and Mobiluncus, a facultative anaerobe.^4,5 Summarizing, practically any condition changing the vaginal milieu may result in vulvovaginitis.

Frequency

United States

Premenarchal

Vulvovaginitis is the most common gynecologic problem affecting prepubertal girls and is responsible for the largest number of visits to the gynecologist.

Childbearing age

Bacterial vaginosis is the most important cause of vulvovaginitis. Estimating the number of patients presenting with bacterial vaginosis is difficult because G vaginalis can be recovered from the vagina in 30-50% of asymptomatic women.⁶

Trichomonas vaginalis affects 2-3 million women annually in the United States. The organism also is detected in 30-40% of men who are exposed to women with T vaginalis.³ The prevalence of T vaginalis infection at clinics treating sexually transmitted diseases (STDs) varies from 8-31%. In men, T vaginalis may account for as many as 17% of cases of nongonococcal, nonchlamydial urethritis. T vaginalis infection appears to be more common in the southern United States.

Candidal vulvovaginitis is considered slightly less common than bacterial vaginosis, yet, 3 out of every 4 women in the United States will have at least 1 bout of vulvovaginal candidiasis (VVC) during their lifetime.^4,6 Patients with recurrent or severe vulvovaginal candidiasis warrant a screening test for diabetes mellitus.

Postmenopausal

After menopause, most women experience some vaginal atrophy as estrogen levels fall. Incidence of atrophic vaginitis depends on how it is defined. Vulvovaginitis related to infection is much less common after menopause. Desquamative inflammatory vaginitis, an exception, has an unknown etiology, but a Gram stain of culture often reveals streptococci. This is treated with intravaginal clindamycin cream or a topical or intravaginal steroid.⁷ Postirritation vulvovaginitis may occur in women undergoing pelvic irradiation for cancer.

International

Bacterial vaginosis is the most common cause of vaginitis in women of childbearing age, with prevalence of 50-60% across the globe.

Trichomoniasis affects 180 million women worldwide.

Mortality/Morbidity

No mortality has been documented primarily from vulvovaginitis.

• Premenarchal: Persistent vulvovaginitis in children is sometimes mistaken for an infection rather than for a foreign body. Labial adhesion, possibly to the point of occlusion of the vaginal orifice, may occur as an isolated finding, be secondary to urinary tract infections (UTIs), or be secondary to vulvovaginitis. These adhesions usually do not cause long-term problems. The presence of chlamydia or gonorrhea from vaginal secretions indicates child abuse.
• Childbearing age
  • A variety of complications has been associated with bacterial vaginosis, including the following:
    • Pelvic inflammatory disease
    • Increased incidence of abdominal pain, uterine bleeding, and uterine and adnexal tenderness
    • Increased complications of pregnancy, especially premature delivery, chorioamnionitis, postpartum endometritis, and ectopic pregnancy
  • Candidal vulvovaginitis may develop into chronic or recurrent candidal infection related to the following:^8,3,9
    • Diabetes mellitus⁷
    • Oral contraceptive (OCP) use
    • Antibiotic use
    • Immunodeficiency
    • Tight-fitting undergarments
  • Some authors have suggested that T vaginalis, considered a sexually transmitted organism, may act as a vector for other types of infections. The organism can be identified in 30-40% of male sexual partners of infected women, although carriage in men is self-limited and transient.
• Postmenarchal: Vaginal bleeding may occur from the thin mucosa. Dyspareunia may also occur as a complication.

Race

• Premenarchal: Significance of race is not clearly defined.
• Childbearing age: In the National Health and Nutrition Examination Survey (NHANES) IV, the overall incidence in women of Trichomonas vaginalis was 3.9%. Incidence varied across different ethnic groups: white non-Hispanic 1.1%, Mexican American 1.8%, and African American 13.3%.^8,10 These differences remained after controlling for sociodemographic, sexual, and behavioral variables. Overall, 1 in 7 women attending an STD clinic over a year period became infected with Trichomonas. Bacterial vaginosis does not seem to have any significant racial variation.¹¹

Sex

Vulvovaginitis does not occur in males. Males may be carriers of G vaginalis and T vaginalis.

Age

• Premenarchal: Vulvovaginitis predominately affects school-aged children.
• Childbearing age
  • Trichomonas species can occur in any age group, yet it is most common in older women peaking at the age of 30-34 years.¹²
  • Bacterial vaginosis has a fairly equal distribution across all age groups up until menopause. Prevalence does not vary significantly with age.
  • Candida species infections are most common during childbearing years.
• Postmenarchal: Atrophic vaginitis may develop several years after menopause. Most women with vaginal atrophy do not develop symptomatic atrophic vaginitis.

Clinical

History

Different historical aspects should be ascertained depending on what vulvovaginitis category the patient may have.

• Premenarchal⁸
  • Wiping the anus from posterior to anterior, wearing tight-fitting synthetic undergarments, and using vaginal irritants such as bubble baths
  • Recent upper respiratory infection or pharyngitis can lead to group A beta-hemolytic streptococci (GABHS) vaginitis.⁸
  • Vaginal pruritus, especially at night, suggests pinworm infection.^8,13
  • Itching, soreness, bleeding, and vaginal discharge; bloody and foul-smelling discharge may suggest a vaginal foreign body.
  • Vulvovaginitis may be secondary to sexual abuse of the child. Parents often equate vulvovaginitis with abuse, although this is not justified in most cases.
  • Asymptomatic vaginal discharge often occurs in the months prior to menarche and represents a physiologic response to increasing estrogen levels.
  • Skin conditions (ie, eczema, psoriasis, seborrhea) occasionally involve the vagina, and a history of these conditions should be sought.
• In obtaining a history of women in childbearing age, record a complete sexual history, last menstrual period, number of sexual partners, and methods of birth control. A new sexual partner increases the risk of STD and pregnancy. Inquire about antibiotics, high estrogen oral contraceptive pills, and any abdominal pain; ask about the patient's hygienic practices (daily use of panty liners and feminine products).³
  • Irritants such as soaps, baths, spermicides, perfumes, douches, and creams can cause vulvovaginitis. Tight-fitting, synthetic undergarments can increase moisture, exacerbating this condition.⁸
  • Vulvovaginitis is usually related to infections secondary to Gardnerella, Trichomonas, or Candida species. Vaginal discharge, pruritus, burning sensation, foul-smelling odor, superficial dyspareunia, and dysuria may be the presenting complaint.⁴ With candidiasis, the patient may describe a thick, white, cottage cheese–like discharge associated with pruritus.^8,10,3
• Inquire about social stressors including homelessness, threats to personal safety, and insufficient resources, which appear to increase the risk.³
• In postmenopausal women, inquire about vaginal bleeding or spotting, dysuria, pruritus, watery discharge, or dyspareunia and decreased sexual activity.

Physical

• Premenarchal
  • Genital examination of a prepubertal girl may produce a great deal of anxiety. Explaining the examination to the child and parent, keeping the parent at the patient's side, and explaining the difference between allowing a clinician or anyone else to examine her genitals may make the examination less traumatic. Sedation rarely is necessary.¹⁴
  • Cultures are not necessary most of the time. History and physical examination should indicate when to obtain a culture from the patient.  If there is a history of trauma, sexual abuse, or vaginal discharge, then endocervical and urethral specimens should be obtained. Urine specimens are not as accurate.⁸   Only cultures are accepted and not nucleic acid amplification techniques (NAAT) as legal evidence of child sexual abuse.⁸
• Childbearing age
  • A complete pelvic examination is needed to evaluate possible upper genital tract infection.
  • Specific clinical descriptions and physical examination findings have been described for each of the 3 etiologies (Gardnerella, Trichomonas, and Candida species), yet these often overlap.
  • More than one infection may be present simultaneously. This usually necessitates additional diagnostic testing to confirm the diagnosis.
  • Pathologic vaginal discharge may be odor producing and may adhere to the vaginal walls, unlike odorless physiologic discharge found in the dependent areas of the vagina.
  • Bacterial vaginosis typically presents with an unpleasant fishy-smelling discharge that is more noticeable after unprotected intercourse.⁹ A thin, gray-white vaginal discharge that is homogeneous may adhere to the vaginal walls and be present at the introitus. The discharge is usually moderate to profuse.¹⁵ Pruritus and inflammation are unusual in bacterial vaginosis. The absence of inflammation is the basis for the term vaginosis rather than vaginitis.^10,6
  • Trichomonal infection may be asymptomatic or may produce a profuse, frothy, yellow-gray, homogenous discharge.¹⁵ This discharge may adhere to the vaginal walls and may not be present at the vaginal introitus. In contrast to bacterial vaginosis, vulvar and vaginal erythema and edema with Trichomonas species often are present. Punctate hemorrhages may be visible on the vagina and cervix (2% of cases).^8,3,9
  • Candida species infection typically is found as an isolated infection, heralded by pruritus. A thick, odorless, white, cottage cheese–like discharge often is found adhering to the vagina.^10,2,15 Erythema, edema, and excoriation may be present. Dysuria and urinary frequency occasionally may be present. Candida can occur in women who are not sexually active.⁸
• Postmenarchal⁷
  • Vaginal mucosa is thin with diffuse erythema, occasional petechiae or ecchymoses, and few or no vaginal folds.
  • Hair loss may occur over the mons and labia majora.
  • Loss of rugae may occur.
  • Thinned mucosa may become friable.

Causes

• Premenarchal^8,4
  • Nonspecific - No defined etiologic agent or poor perineal hygiene
  • Chemical irritants (eg, bubble baths, lotions)
  • Vaginal foreign bodies
  • Pinworm infection
  • GABHS infection
  • Skin conditions - Eczema, psoriasis, seborrhea
  • Etiologies usually associated with women of childbearing age - Bacterial vaginosis, Trichomonas species, Candida species, and gonorrhea (Many of these are associated with sexual abuse.)
• Childbearing age
  • Sexual contact especially with multiple sexual contacts
  • No method of birth control
  • History of STD
  • Bacterial or fungal infections such as G vaginalis (bacterial vaginosis), Candida species, and Trichomonas species
  • Chemical irritants⁸
  • Recent broad-spectrum antibiotics such as tetracycline, ampicillin, and cephalosporins
  • Pregnancy
• Postmenarchal - Atrophic vaginitis (most common cause of vulvovaginitis in postmenarchal women)

Differential Diagnoses

Workup

Laboratory Studies

• Laboratory evaluation, if indicated, for a patient with vulvovaginitis consists of checking vaginal pH, performing microscopy, and obtaining a culture.¹⁰
• Measurement of vaginal pH using nitrazine paper is the single most important finding that drives the diagnostic process and should always be determined. Vaginal pH can be tested using a narrow-range pH paper. A pH above 4.5 suggests infections such as bacterial vaginosis or trichomoniasis (pH 5-6) and helps to exclude candidal vulvovaginitis (pH 4-4.5).^10,3,5 Remember, the specimen should be obtained in the mid vagina, usually the side walls and not the posterior fornix, since that area is contaminated by cervical mucous that is alkaline. pH testing performed by the patient is available on the market. Studies have shown good agreement between patient and doctor performed testing.^16,17
• A wet preparation and/or mount can be prepared by placing a drop of vaginal secretion on a slide with a drop of saline and viewing the slide under a microscope. This can be used to look for candidal buds or hyphae, motile Trichomonas, epithelial cells studded with adherent coccobacilli (clue cells), and polymorphonuclear cells.^10,4

The photomicrograph reveals bacteria adhering to vaginal epithelial cells known as clue cells. The presence of clue cells is a sign that the patient has bacterial vaginosis. Source CDC Phil/ M.Rein.

• For Trichomonas, the saline should be at room temperature and not cold to enhance Trichomonas movement, and microscopy should be performed within 10-20 minutes to reduce the possibility of loss of any trichomonas. It is best to use high power with the condenser dampened to produce the greatest contrast.³
• A potassium hydroxide (KOH) preparation is prepared by placing a drop of vaginal secretion on a slide with a drop of 10-20% KOH and using a coverslip to protect the microscope lens. This is particularly useful in diagnosis of candidal vaginitis. Smelling ("whiffing") the slide immediately after applying KOH is useful for detecting the fishy (amine) odor of bacterial vaginosis. Sensitivity to detect candidiasis is 40-60%.⁷
• These diagnostic point-of-care testing are available commercially, providing a rapid test in confirming the diagnosis of bacterial vaginosis.
  • Quickvue Advance ph+amines³
  • QuickVue Advance tests for proline iminopeptidase activity a marker for G vaginalis³
  • OSOM BV Blue tests for sialidase activity: These are especially useful for practitioners who are unable to perform microscopy. The test detects the presence of elevated vaginal pH level and increased amine, with a sensitivity of 87-92% and a specificity of 92%.³  
  • The tests are expensive with poor reimbursement, so they are not performed in routine or emergency settings.
• Vaginal fungal culture is the criterion standard for fungal infection. However, it takes 7 days to run and is expensive. Rapid immunoassay testing is being developed that is as accurate as cultures.¹⁸
• Cultures are not useful for bacterial vaginosis. Gardnerella species can be cultured as typical flora in many women who are asymptomatic; therefore, a culture that is reported as positive for Gardnerella species should not be assumed to indicate a vaginal infection that requires treatment unless the woman also has complaints of vaginitis.
• Culture may be useful in trichomonad infection in case of diagnostic uncertainty after a negative wet mount.⁵
• Two other point-of-care tests for Trichomonas are being used:⁶
  • The OSOM Trichomonad Rapid Test - Overall sensitivity of 83%^3,5
  • The Affirm VP 111^19,5
  • PCR techniques are also under development but are not cleared by the FDA.^8,20,5
• Routine workup in prepubertal girls is as follows:
  • For most patients, laboratory evaluation does not lead to an etiologic diagnosis; thus, lengthy evaluations are not indicated. A complete history and physical examination are all that are required.
  • Culture for GABHS and a urine culture may be appropriate in children.
  • For patients in whom abuse is suspected, perform cultures for gonorrhea and chlamydia.
  • If a vaginal foreign body is suspected, irrigating the vagina with saline may dislodge certain types of foreign bodies (eg, toilet paper). An examination sometimes requires conscious sedation or general anesthesia.
  • If pinworms are suspected, the infection may be diagnosed by direct visualization of the worm (typically at night). Another method is to use transparent tape applied to the perineum in the morning in hopes of collecting the eggs of Enterobius vermicularis (ie, pinworm), which then can be observed under low-power microscopy.
• Routine workup in females of childbearing age is as follows: 
  • Remember, the physician diagnosis of vulvovaginitis is not very accurate, because of unfamiliarity with microscopy. Errors are made particularly with mixed infections and candidiasis.²¹ Trichomonas seen on pap smear makes a woman more prone to a mixed infection as bacterial vaginosis.²²  Also, the patient's self-diagnosis of vaginitis is not reliable.²³
  • The correct diagnosis is typically obtained by checking pH and performing microscopy. Vaginal pH of a physiologic discharge caused by Candida species is 4-4.5. Bacterial vaginosis is associated with a pH of 5-6. Trichomonas species infection has the highest pH, generally 6-7. Chlamydial infection does not change the vaginal pH.²⁴
  • In bacterial vaginosis, the presence of clue cells is the single most reliable predictor of bacterial vaginosis. Clue cells are vaginal epithelial cells studded with adherent coccobacilli that are best appreciated at the edge of the cell. At least 20% of the epithelial cells on wet mount should be clue cells.^4,3
  • In 80-90% of women with symptomatic trichomonal infections, a wet preparation or mount viewed under high power reveals many leucocytes and mobile trichomonas. The accuracy drops to 50% if the patient is asymptomatic or has few Trichomonas.
  • Consider screening for other STDs such as syphilis, gonorrhea, and chlamydiae. Urine or endocervical smears can be performed for gonorrhea and chlamydia.¹⁹
  • KOH preparation in candidal vaginitis may reveal budding filaments, mycelia, or pseudohyphae. A fungal culture may be used if the diagnosis is uncertain. For recurrent or severe vulvovaginitis, consider a screening test for diabetes, either serum glucose or urine dip for glucose.

Candida albicans photomicrograph. Source CDC.

• Perform a pregnancy test on all women of reproductive age.
• Workup in postmenopausal women is as follows:
  • History and physical examination generally provide sufficient information to diagnose atrophic vaginitis.
  • Vaginal pH, if performed, generally is 6-7.
  • A wet mount or preparation may demonstrate inflammatory cells and an increased number of parabasal epithelial cells.
  • Culture and a KOH preparation usually are unrewarding.

Treatment

Prehospital Care

• Prehospital care rarely is needed.
• Some women with recurrent candidal infections opt for treatment with over-the-counter (OTC) medications that generally are highly effective for candidiasis. Preparations for intravaginal administration of butoconazole, clotrimazole, miconazole, and tioconazole are available OTC. Self-medication with OTC preparations should be advised only for women who have been diagnosed previously with vulvovaginal candidiasis and who have a recurrence of the same symptoms. Any woman whose symptoms persist after using an OTC preparation or who has a recurrence of symptoms within 2 months should seek medical care.²³ Unnecessary or inappropriate use of OTC preparations is common and can lead to delay of treatment of other etiologies of vulvovaginitis that could result in adverse clinical outcomes. Studies on women treating themselves for candidiasis revealed a 28% accuracy rate.³

Emergency Department Care

• No specific ED care is needed.
• If sexual abuse of a child is suspected, call upon further resources, such as a social work and child welfare agency.
• Medical treatment should be tailored to the suspected pathogen.

Consultations

• Consultations are not necessary for most patients.
• Suspected child sexual abuse must be reported to the child welfare agency and police. Strongly consider consultation with a clinician experienced in the area of child abuse, if available.
• A patient with a vaginal foreign body that is difficult to observe or remove may require sedation or referral to a gynecologist for examination under general anesthesia.
• Patients with infections that are difficult to treat or that are recurrent occasionally require gynecologic consultation.

Medication

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

Antibiotics

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).

Dosing

Adult

2 g PO once or 500 mg PO bid for 7 d for Trichomonas
For bacterial vaginosis: 500 mg PO bid for 7 d
Alternatively: Metronidazole gel 0.75%, 1 applicatorful (5 g) intravaginally qd for 5 d effective as oral metronidazole
Less efficacious (<50% cure for Trichomonas)

Pregnancy: 500 mg PO bid for 7 d or 250 mg PO tid for 7 days or 2 g PO once for T vaginalis

Pediatric

15-30 mg/kg/d PO divided bid for 7 d; not to exceed 500 mg or 40 mg/kg PO once
Alternatively: Insert 1 applicatorful as in adults

Interactions

Cimetidine may increase toxicity of metronidazole; may increase effects of anticoagulants; may increase toxicity of lithium and phenytoin; avoid alcohol during treatment and 24 h after that

Contraindications

Documented hypersensitivity; use of alcohol

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dose in hepatic disease; monitor for seizures and development of peripheral neuropathy; known or previously unrecognized vaginal candidiasis may present more prominent symptoms during metronidazole vaginal gel therapy; more than 6% of patients have developed symptomatic candidal vaginitis during or immediately after therapy
Avoid alcohol 24 h before therapy and 72 h after therapy

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.

Dosing

Adult

500 mg PO q6h for 10 d

Pediatric

<12 years: 40-50 mg/kg/d PO divided tid/qid; not to exceed 3 g/d
>12 years: Administer as in adults

Interactions

Probenecid can increase penicillin effectiveness by decreasing its clearance; conversely, coadministration of tetracyclines can decrease penicillin effectiveness

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Caution in impaired renal function

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.

Dosing

Adult

500 mg PO bid for 5 d
Alternatively, 2 g PO one dose for Trichomonas

Pediatric

<3 years: Not established
>3 years: 50 mg/kg PO qd for 3 d with food; not to exceed 2 g/dose

Interactions

Limited data exist; interaction information based on experience with other nitroimidazole derivatives (ie, metronidazole); may prolong PT when coadministered with warfarin; avoid alcoholic beverages and preparations containing ethanol or propylene glycol during and 3 d following administration (may cause disulfiramlike reaction); may increase serum levels of lithium, phenytoin, cyclosporine, tacrolimus, and fluorouracil; CYP450 inducers (eg, phenobarbital, rifampin, phenytoin) may increase elimination; CYP450 inhibitors (eg, cimetidine, ketoconazole) may decrease elimination; concurrent administration with cholestyramine may decrease oral bioavailability; oxytetracycline may antagonize effect

Contraindications

Documented hypersensitivity; first trimester of pregnancy; breastfeeding women (recommend interruption during therapy and for 3 d following last dose)

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

X - Contraindicated; benefit does not outweigh risk

Precautions

Caution in blood dyscrasias, organic neurological dysfunction, late trimesters of pregnancy, seizure disorders, and hepatic and renal impairment
Carcinogenicity has been observed in mice and rats treated chronically with metronidazole (another nitroimidazole), although not observed with tinidazole, use cautiously; may cause metallic/bitter taste, nausea, anorexia, vomiting, weakness, fatigue, dizziness, or headache; if administered on day of hemodialysis, administer additional dose equivalent to one-half of recommended dose following dialysis

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.

Dosing

Adult

250 mg erythromycin stearate/base, or 400 mg ethylsuccinate PO q6h 1 h ac or 500 mg q12h for 10 d

Pediatric

30-50 mg/kg/d PO divided q6-8h for 10 d, not to exceed 2 g/d; double dose for severe infections

Interactions

Coadministration may increase toxicity of theophylline, digoxin, carbamazepine, and cyclosporine; may potentiate anticoagulant effects of warfarin; coadministration with lovastatin and simvastatin increases risk of rhabdomyolysis

Contraindications

Documented hypersensitivity; hepatic impairment

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Caution in liver disease; estolate formulation may cause cholestatic jaundice; GI adverse effects are common (administer doses pc); discontinue use if nausea, vomiting, malaise, abdominal colic, or fever occurs

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.

Dosing

Adult

Cream 2%: 1 applicatorful (5 g)intravaginally hs for 7 d
Alternatively: Administer 300 mg PO bid for 7 d or clindamycin ovules 100 g intravaginally qhs for 3 d

Pediatric

20-30 mg/kg/d PO divided tid/qid for 7 d

Interactions

None reported

Contraindications

Documented hypersensitivity; regional enteritis; ulcerative colitis; hepatic impairment

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Avoid contact with eyes; vaginal cream contains ingredients that cause burning and irritation of the eye; in event of accidental contact, rinse eye with copious amounts of cool tap water; use of clindamycin vaginal cream may result in overgrowth of nonsusceptible organisms, particularly yeasts, in vagina; clindamycin cream and ovules are oil-based and might weaken latex condoms and diaphragms; antibiotic-associated colitis has been reported with both oral and topical clindamycin

Corticosteroids

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 (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.

Dosing

Adult

Apply sparingly bid to vagina in affected areas

Pediatric

Apply as in adults

Interactions

None reported

Contraindications

Documented hypersensitivity; viral, fungal, and bacterial skin infections

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Prolonged use, applying over large surface areas, applying potent steroids, and using occlusive dressings may increase systemic absorption of corticosteroids and may cause Cushing syndrome, reversible HPA-axis suppression, hyperglycemia, and glycosuria

Antifungal agents

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.

Dosing

Adult

3-d therapy:
2% cream: Insert 5 g, 1 applicatorful, intravaginally qhs for 3 d

Pediatric

Administer as in adults

Interactions

None reported

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

If sensitivity or chemical irritation occurs, discontinue use; use only externally; avoid contact with eyes

Tioconazole (Vagistat)

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

Dosing

Adult

1-d therapy:
6.5% ointment: Insert 5 g, 1 applicatorful, intravaginally once

Pediatric

Administer as in adults

Interactions

None reported

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

If sensitivity or chemical irritation occurs, discontinue use; use only externally; avoid contact with eyes

Clotrimazole (Mycelex-7)

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

Dosing

Adult

1-d therapy:
500-mg tab: Insert 1 applicatorful intravaginally once
3-d therapy:
100-mg tab: Insert 2 tab intravaginally qhs for 3 d
7-d therapy:
Applicator: Insert 5 g, 1 applicatorful, of 1% vaginal cream intravaginally qhs for 7-14 d
Vaginal tab: Insert 1 tab (100 mg) intravaginally qhs for 7 d

Pediatric

Administer as in adults

Interactions

None reported

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

If irritation (5%-10% will have local burning)or sensitization occurs, discontinue use; chronic or recurrent candidiasis may be a symptom of unrecognized diabetes mellitus or a damaged immune system (including HIV infection); persistently resistant infections may be re-infections, thus evaluate sources of re-infection; if lack of response, repeat microbiologic studies to confirm diagnosis and exclude other pathogens before re-instituting antifungal therapy; do not use creams in mouth or eyes; no well-controlled studies have been performed during first trimester of pregnancy; these products may compromise condoms and diaphragms

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.

Dosing

Adult

1-d therapy:
150 mg PO once may repeat on the third day if infection not improved

Pediatric

3-6 mg/kg PO qd for 14-28 d, depending on severity of infection

Interactions

Levels may increase with hydrochlorothiazides; levels may decrease with chronic coadministration of rifampin; coadministration of fluconazole may decrease phenytoin concentrations; may increase concentrations of theophylline, tolbutamide, glyburide, and glipizide; effects of anticoagulants may increase with fluconazole coadministration; increases in cyclosporine concentrations may occur when administered concurrently

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Monitor closely if rashes develop and discontinue drug if lesions progress; may cause clinical hepatitis, cholestasis, and fulminant hepatic failure (including death) with underlying medical conditions such as AIDS or a malignancy and while taking multiple concomitant medications; not recommended for women who are breastfeeding

Miconazole (Monistat Vaginal)

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

Dosing

Adult

3-d therapy:
200-mg vaginal suppository: Insert 1 supp intravaginally qhs for 3 d

7-d therapy:
2% cream: Instill 5 g, 1 applicatorful, intravaginally qhs for 7 d
100-mg vaginal supp: Insert 1 supp intravaginally qhs for 7 d

Pediatric

Administer as in adults

Interactions

May impair barrier contraceptives

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

If sensitivity or chemical irritation occurs, discontinue use; use only externally; avoid contact with eyes; adverse effects include vaginal burning, irritation, and dyspareunia

Terconazole (Terazol 3, Terazol 7)

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

Dosing

Adult

3-d therapy:
0.8% cream: Insert 5 g, 1 applicatorful, intravaginally qhs for 3 d
80-mg vaginal supp: Insert 1 supp intravaginally qhs for 3 d

7-d therapy:
0.4% cream: Insert 5 g, 1 applicatorful, intravaginally for 7 d
Tab: Insert 2 tab (100 mg each) intravaginally qhs for 3 d or a 500-mg tab intravaginally once
1% vaginal cream: Apply to external genitalia bid

Pediatric

Not established

Interactions

May impair barrier contraceptives

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

If sensitivity or chemical irritation occurs, discontinue use; use only externally; avoid contact with eyes; high doses may cause fever or flulike symptoms

Ketoconazole (Kuric 2%, Xolegel 2%)

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

Dosing

Adult

2% cream: Rub gently into affected area qd/bid

Pediatric

Not established

Interactions

None reported

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

If sensitivity or irritation develops, discontinue use; for external use only; avoid contact with eyes

Nystatin

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

Dosing

Adult

Insert 1 vaginal tab (100,000 U) qhs for 2 wk

Pediatric

Administer as in adults

Interactions

None reported

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Do not use to treat systemic mycoses

Estrogens

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.

Dosing

Adult

0.3-1.25 mg PO qd, depending on tissue response of patient
Topical: Insert 2-4 g, 0.5-1 applicatorful intravaginally qhs
Recommendation: Cyclical administration consisting of 3 wk of daily estrogen and 1 wk off

Pediatric

Not established

Interactions

May reduce hypoprothrombinemic effects of anticoagulants; coadministration of barbiturates, rifampin, and other agents that induce hepatic microsomal enzymes may reduce estrogen levels; pharmacologic and toxicologic effects of corticosteroids may occur as a result of estrogen-induced inactivation of hepatic P450 enzyme; loss of seizure control has been noted when administered concurrently with hydantoins

Contraindications

Documented hypersensitivity; known or suspected pregnancy; breast cancer; undiagnosed abnormal genital bleeding; active thrombophlebitis or thromboembolic disorders; history of thrombophlebitis, thrombosis, or thromboembolic disorders associated with previous estrogen use (except when used in treatment of breast or prostatic malignancy)

Precautions

Pregnancy

X - Contraindicated; benefit does not outweigh risk

Precautions

Certain patients may develop undesirable manifestations of excessive estrogenic stimulation, such as abnormal or excessive uterine bleeding or mastodynia; estrogens may cause some degree of fluid retention (exercise caution); prolonged unopposed estrogen therapy may increase risk of endometrial hyperplasia

Anthelmintics

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.

Dosing

Adult

100 mg PO once
Alternatively: Administer 100 mg PO bid on 3 consecutive days; second course may be administered if patient is not cured within 3-4 wk

Pediatric

<2 years: Not established
>2 years: Administer as in adults

Interactions

Carbamazepine and phenytoin may increase mebendazole metabolism, decreasing its efficacy; conversely, cimetidine may increase mebendazole levels

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Avoid in pregnancy, especially during first trimester; may need to adjust dose in hepatic impairment

Pyrantel (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.

Dosing

Adult

11 mg/kg (5 mg/lb) PO not to exceed 1 g once without regard to ingestion of food or time of day

Pediatric

<2 years: Not established
>2 years: Administer as in adults

Interactions

In ascariasis, pyrantel and piperazine are mutually antagonistic and should not be used concomitantly; theophylline serum levels may increase in pediatric patients following pyrantel pamoate administration

Contraindications

Documented hypersensitivity; hepatic disease

Precautions

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Caution in liver impairment, anemia, and malnutrition

Estrogen receptor antagonists

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.

Dosing

Adult

10-20 mg PO bid

Pediatric

Not established

Interactions

May exacerbate hepatotoxic effects of allopurinol; may increase cyclosporine serum levels; increases anticoagulant effects of warfarin; aminoglutethimide reduces serum concentration of tamoxifen; cyclophosphamide, methotrexate, and 5-FU increase thrombotic risk of tamoxifen

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Caution in leukopenia, thrombocytopenia, and hyperlipidemia; decreased visual acuity, corneal changes, and retinopathy may occur with >1 y of use; may induce ovulation

Follow-up

Further Outpatient Care

• Premenarchal:⁸ Most patients do not have an identifiable etiologic agent for infection. Therefore, treatment aims at improving perineal hygiene and decreasing moisture.
  • A period of supervised defecation may be helpful, stressing the need to wipe thoroughly and anteriorly to posteriorly. Stress the importance of wearing loose-fitting, cotton undergarments. Stress the need to avoid vaginal irritants such as bubble baths and creams. A sitz bath with baking soda may be helpful. Thoroughly drying the perineum and avoiding unnecessary moisture, such as prolonged exposure to a wet bathing suit, may be helpful. If these methods are unsuccessful, perform a vaginal culture.⁸
  • If a bacterial etiology seems likely, consider a course of broad-spectrum antibiotics.
  • Topical estrogen cream for up to 2 weeks may help if local measures do not work. If pruritus is severe, a short trial of a topical steroid such as 0.5% hydrocortisone may be used.⁴
  • Remove vaginal foreign bodies, possibly with the use of sedation.
  • Streptococcal infections respond to penicillin or erythromycin.
  • Treat pinworms with mebendazole or pyrantel pamoate. The entire family may need to be treated to eradicate the infection.⁸
  • Treat STDs appropriately using pediatric doses. All STDs should prompt an evaluation for sexual abuse.
• Childbearing age: In women of childbearing age, treat irritant causes of vulvovaginitis by removing the offending agent.
  • Perform a pregnancy test, since the treatments may be contraindicated in pregnancy.
  • Bacterial vaginosis is treated in women with metronidazole, orally or intravaginal. Several dosing regimens are available. The recommended treatment is metronidazole 500 mg PO twice a day for 7 days. Clindamycin may be used as an alternative except in late pregnancy. Treatment of sexual partners generally is not beneficial. Follow-up visits are unnecessary if symptoms resolve.⁵
  • Because recurrence of bacterial vaginosis is not unusual, women should be advised to return for additional therapy if symptoms recur. Another recommended treatment regimen may be used to treat recurrent disease. No long-term maintenance regimen with any therapeutic agent is recommended.
  • Condom use is recommended to reduce incidence of bacterial vaginosis.¹⁰
  • Douching is not recommended.²³
  • Trichomonas species infection is treated very effectively with metronidazole in nonpregnant women. Several dosing regimens are available. Sexual partners should be treated, even if asymptomatic, although re-infection rate appears to be low even if the partner is not treated.⁴ Patients should be instructed to avoid sex until she and her sex partner are cured (ie, when therapy has been completed and patient and partner are asymptomatic [in the absence of a microbiologic test of cure]). The primary treatment is metronidazole 2 g PO for 1 dose. Follow-up is unnecessary for men and women who become asymptomatic after treatment or who are initially asymptomatic. If treatment failure occurs with either regimen, the patient should be retreated with metronidazole 500 mg twice a day for 7 days. If treatment failure occurs again, the patient should be treated with a single, 2-g dose of metronidazole once a day for 3-5 days.⁴
  • Trichomonas infection in pregnant women is treated in the same manner as in nonpregnant women. There is no evidence that metronidazole is related to preterm birth.³¹
  • Candida species infection can be treated successfully with a variety of topical antifungals. Many are now available over-the-counter with 1-, 3-, 5-, and 7-day dosing regimens. Oral therapy with single-dose fluconazole is effective but may repeat on the third day. Recurrent and chronic infections are best treated more aggressively with low-dose prophylactic fluconazole.^4,3,23
• Postmenarchal: In postmenopausal women with atrophic vaginitis, therapy focuses on topical estrogen replacement. Some women on oral estrogen replacement still develop atrophic vaginitis.
  • A variety of topical estrogen preparations is available for intravaginal, once-a-day use, generally for 1-2 weeks. When symptoms improve, frequency may be decreased to once or twice per week.
  • Though rarely place in the emergency department, the estradiol vaginal ring is preferred rather than topical estrogen.³²
  • Systemic estrogen absorption from the vagina seems to diminish as the vaginal epithelium matures. Tamoxifen may be used for women who are very concerned about estrogen exposure.

Deterrence/Prevention

• A randomized study of metronidazole gel for 5 days followed by metronidazole gel twice weekly for up to 6 months prevented the acquisition of sexually transmitted diseases.^25,2
• Patients with recurrent vulvovaginal candidiasis may require individually tailored maintenance fluconazole to prevent relapse.³³

Complications

• Pelvic inflammatory disease
• Intrauterine infections
• Chorioamnionitis
• Postpartum endometritis
• Vaginitis emphysematous
• Preterm labor
• Premature rupture of membranes
  • Screening and treatment of high-risk women who have symptoms of bacterial vaginosis or have a history of preterm delivery is indicated.
• Newborn infections
• Posthysterectomy vaginal cuff cellulitis
• Trichomonas is associated with an increased rate of HIV infection.^10,34

Prognosis

• Premenarchal
  • Improved hygiene and methods to decrease moisture may help 50% of these patients.
  • If symptoms persist, consider the possibility of a foreign body.
  • A course of antibiotics or topical estrogen occasionally helps.
  • Streptococcal and pinworm infections respond promptly to antimicrobials.
• Childbearing age
  • Bacterial vaginosis is cured with single-dose treatment in 80% of patients and with weeklong treatment in 90%.
  • Cure rates for Trichomonas species infection are higher than for bacterial vaginosis.
  • Candidal treatment with topical or oral therapy yields a cure rate of 90%. Approximately 5% of women have difficult-to-treat infections. Recurrence is common.

Patient Education

• Premenarchal: Focus patient education on improved perineal hygiene and on avoiding irritants.
• Childbearing age: Patient education should review the sexually transmitted nature of Trichomonas species and, possibly, bacterial vaginosis.
• Postmenopausal: Patient education should stress the treatable nature of atrophic vaginitis; it does not have to be a natural consequence of aging.
• For excellent patient education resources, visit eMedicine's Pregnancy and Reproduction Center, Yeast and Fungal Infections Center, Women's Health Center, and Parasites and Worms Center. Also, see eMedicine's patient education articles Vaginal Infections, Candidiasis (Yeast Infection), Understanding Vaginal Yeast Infection Medications, FemaleSexualProblems, and Trichomoniasis.

Miscellaneous

Medicolegal Pitfalls

• Failure to consider child sexual abuse in the correct clinical context
• Failure to appreciate that endometrial and/or endocervical lesions also may be etiologies of vaginal spotting after menopause

Multimedia

Media file 1: The photomicrograph reveals bacteria adhering to vaginal epithelial cells known as clue cells. The presence of clue cells is a sign that the patient has bacterial vaginosis. Source CDC Phil/ M.Rein.

Media file 2: Candida albicans photomicrograph. Source CDC.

Media file 3: Video on Trichomonas vaginalis features. Image courtesy of AJ Cann.

Video available at http://img.medscape.com/pi/emed/ckb/emergency_medicine/756148-794917-797497-1698515.flv.

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16. Ferris DG, Francis SL, Dickman ED, Miler-Miles K, Waller JL, McClendon N. Variability of vaginal pH determination by patients and clinicians. J Am Board Fam Med. Jul-Aug 2006;19(4):368-73. [Medline].

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Keywords

vulvovaginitis, vaginitis, vaginal yeast infection, vaginosis, bacterial vaginosis, lactobacillus, inflammation of vagina, inflammation of vulva, vaginal discharge, vaginal itching, vaginal irritation, vaginal fluid, vaginal pH, Gardnerella vaginalis, G vaginalis, Staphylococcus epidermis, S epidermis, Trichomonas vaginalis, T vaginalis, vulvovaginal candidiasis, VVC, candidal vulvovaginitis, desquamative inflammatory vaginitis, atrophic vaginitis, trichomoniasis

Contributor Information and Disclosures

Author

Mark J Leber, MD, MPH, Clinical Assistant Professor of Emergency Medicine, Weill Medical College of Cornell University; Consulting Staff, Department of Emergency Medicine, Brooklyn Hospital Medical Center
Mark J Leber, MD, MPH is a member of the following medical societies: American College of Emergency Physicians and American College of Physicians
Disclosure: Nothing to disclose.

Coauthor(s)

Anuritha Tirumani, MD, Research Coordinator, Department of Emergency Medicine, Brooklyn Hospital Center
Disclosure: Nothing to disclose.

Medical Editor

David S Howes, MD, Residency Program Director, Professor of Medicine, Section of Emergency Medicine, University of Chicago/Pritzker School of Medicine
David S Howes, MD is a member of the following medical societies: American College of Emergency Physicians, American College of Physicians-American Society of Internal Medicine, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Mark Zwanger, MD, MBA, Assistant Professor, Department of Emergency Medicine, Thomas Jefferson University
Mark Zwanger, MD, MBA is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and American Medical Association
Disclosure: Medicines Company Consulting fee Consulting; Pfizer Salary Employment

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Pamela L Dyne, MD, Professor of Clinical Medicine/Emergency Medicine, David Geffen School of Medicine at UCLA; Attending Physician, Department of Emergency Medicine, Olive View-UCLA Medical Center
Pamela L Dyne, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author, Reza Keshavarz, MD, to the development and writing of this article.

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