Medication Summary
The goals of pharmacotherapy in vaginitis are to reduce morbidity, prevent complications, and eradicate the infection. Drugs used for infectious causes of vaginitis may be applied topically or may require oral or parenteral administration.
Nitroimidazoles
Class Summary
Nitroimidazoles (eg, metronidazole, secnidazole) are highly effective for treating Trichomonas vaginalis infections and bacterial vaginosis. 5-nitroimidazoles enters the bacterial cell as an inactive prodrug where the nitro group is reduced by bacterial enzymes to radical anions. It is believed that these radical anions interfere with bacterial DNA synthesis of susceptible isolates.
Metronidazole (Flagyl)
Metronidazole causes a chemical reduction reaction within anaerobic bacteria and sensitive protozoa. It is readily absorbed and permeates all tissues, including cerebrospinal fluid (CSF), breast milk, and alveolar bone. It is metabolized and excreted in the liver and kidneys. Treatment of partners increases cure rates.
Secnidazole (Solosec)
Indicated for bacterial vaginosis in adult women. Also indicated for trichomoniasis caused by Trichomonas vaginalis in adults. Administered as a one-time, single oral dose.
Antifungals
Class Summary
The antifungal agents used to treat vaginitis are imidazole derivatives that exert a fungicidal effect by altering permeability of the fungal cell membrane. The mechanism of action also may involve alteration of RNA and DNA metabolism or an intracellular accumulation of peroxides toxic to fungal cell.
Intravaginal and topical therapy with a variety of antifungals (eg, clotrimazole, miconazole, terconazole, tioconazole) is highly effective. Many of these preparations are now available over the counter. Various 1-, 3-, and 7-day regimens may be used. Cure rates of 90% are reported with longer courses.
The oral triterpenoid agent, ibrexafungerp, is the first non-azole antifungal approved for vulvovaginal candidiasis (VVC) and the first drug approved in a new antifungal class for VVC in more than 20 years.
Fluconazole (Diflucan)
Fluconazole is a synthetic PO antifungal agent (a broad-spectrum bistriazole) that selectively inhibits fungal cytochrome P-450 and sterol C-14 alpha-demethylation. Whereas ease of use should be considered, direct cost may be a limiting factor. PO antifungals should not be recommended in pregnancy. Current recommendations are for a 7-day course of antifungal topical therapy.
Ibrexafungerp (Brexafemme)
Inhibits glucan synthase, an enzyme involved in the formation of 1,3-beta-D-glucan, an essential component of the fungal cell wall. It is indicated for vulvovaginal candidiasis (VVC) in adult and postmenarchal females.
Miconazole vaginal (Monistat-7, Monistat-1)
Miconazole damages the fungal cell wall membrane by inhibiting biosynthesis of ergosterol. Membrane permeability is increased, causing nutrients to leak out, which results in fungal cell death. Metabolism occurs in the liver. Recurrent infections usually are treated with intravaginal regimens for 10-14 days, followed by maintenance oral treatment for 6 months. Dual Pak is not for use in children.
Clotrimazole (Gyne-Lotrimin-3, Gyne-Lotrimin-7)
Clotrimazole is a broad-spectrum antifungal agent that inhibits yeast growth by altering cell membrane permeability, causing the death of fungal cells. The recommended duration of intravaginal therapy is generally 3-7 days.
Terconazole (Terazol 7, Terazol 3)
Terconazole damages the fungal cell wall membrane by inhibiting biosynthesis of ergosterol. Membrane permeability is increased, causing nutrients to leak out, which results in fungal cell death.
Tioconazole (Vagistat 1, 1-Day)
Tioconazole is a broad-spectrum antifungal agent that inhibits yeast growth by altering cell membrane permeability, causing the death of fungal cells.
Butoconazole (Gynazole-1)
Butoconazole is a broad-spectrum antifungal agent that inhibits yeast growth by altering cell membrane permeability, causing the death of fungal cells. It is effective only for vaginitis caused by candidal organisms.
Nystatin vaginal
Nystatin is a fungicidal and fungistatic antibiotic obtained from Streptomyces noursei. It is effective against various yeasts and yeastlike fungi. It changes the permeability of the fungal cell membrane after binding to cell membrane sterols, causing cellular contents to leak.
Ketoconazole (Nizoral)
Ketoconazole is an imidazole broad-spectrum antifungal agent. It inhibits synthesis of ergosterol, causing cellular components to leak, which results in fungal cell death. Ketoconazole is generally used as maintenance therapy for recurrent vulvovaginal candidiasis
Antibiotics
Class Summary
Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.
The use of antibiotic combinations usually is recommended for the treatment of serious gram-negative bacillary infections. This approach ensures coverage for a broad range of organisms and polymicrobial infections, prevents emergence of bacterial subpopulations that may be resistant to one of the antibiotic components, and provides additive or synergistic effects. Once organisms and sensitivities are known, however, antibiotic monotherapy is recommended.
Clindamycin (Cleocin)
Clindamycin is a lincosamide used to treat serious skin and soft tissue staphylococcal infections. It is also effective against aerobic and anaerobic streptococci (except enterococci). Clindamycin inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest. It is widely distributed in the body without penetrating the central nervous system (CNS). It is protein-bound and is excreted by the liver and kidneys.
Clindamycin has been used as an alternative to metronidazole in pregnancy; however, intravaginal use is not recommended for pregnant women, because it has been associated with an increased risk of preterm delivery. Treatment of bacterial vaginosis with oral clindamycin during the second and third trimesters of pregnancy has been shown to reduce the occurrence of preterm birth.
For recurrent infections, administer a trial of alternative regimens.
Ceftriaxone (Rocephin)
Ceftriaxone is a third-generation cephalosporin that has a broad gram-negative spectrum, lower efficacy against gram-positive organisms, and higher efficacy against resistant organisms. It arrests bacterial cell wall synthesis and inhibits bacterial growth by binding to 1 or more of the penicillin-binding proteins.
Erythromycin (E.E.S., Erythrocin, Ery-Tab)
Erythromycin is indicated for the treatment of infections caused by susceptible strains, including Staphylococcus aureus. It is an alternative for the treatment of chlamydial infection in pregnancy.
Metronidazole (Flagyl, MetroGel-Vaginal, Vandazole)
Metronidazole is active against various anaerobic bacteria and protozoa. It appears to be absorbed into the cells; the intermediate metabolized compounds that are formed bind DNA and inhibit protein synthesis, causing cell death.
Metronidazole is indicated for the treatment of bacterial vaginosis (formerly referred to as Haemophilus vaginitis, Gardnerella vaginitis, nonspecific vaginitis, Corynebacterium vaginitis, or anaerobic vaginosis). Treatment of bacterial vaginosis with oral metronidazole during the second and third trimester of pregnancy does not reduce the occurrence of preterm delivery.
Metronidazole is highly effective in treating trichomoniasis with 1 dose. Topical metronidazole is not effective therapy for trichomoniasis. The numbers of T vaginalis cases with metronidazole resistance are increasing.
Cefixime (Suprax)
Cefixime is an oral third-generation cephalosporin indicated for management of infections caused by susceptible gram-positive cocci and gram-negative rods. It is used to treat gonorrhea, tonsillitis, and pharyngitis.
Doxycycline (Doryx, Monodox, Vibramycin)
Doxycycline inhibits protein synthesis and thus bacterial growth by binding with the 30S and, possibly, 50S ribosomal subunits of susceptible bacteria.
Azithromycin (Zithromax, Zmax)
Azithromycin is used to treat mild-to-moderate infections caused by susceptible strains of microorganisms. It is indicated for chlamydial infections of the genital tract.
Hormones
Class Summary
Hormones are indicated for management of atrophic vaginitis resulting from diminished levels of circulating estrogens. A relative lack of estrogen also predisposes the vagina and vulva to infection.
Estrogen (Premarin)
Estrogen is indicated for the treatment of atrophic vaginitis and atrophic urethritis associated with menopause. It should be reserved for women experiencing vaginal changes secondary to a deficiency of estrogen.
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(A) Two trophozoites of Trichomonas vaginalis obtained from in vitro culture, stained with Giemsa. (B) Trophozoite of T vaginalis in vaginal smear, stained with Giemsa. Images courtesy of Centers for Disease Control and Prevention.
