BASHH question

Options for Questions 13-14

Instructions: For each scenario below, choose the single most appropriate management from the above list of options. Each option may be used once, more than once, or not at all.

Explanation

Could you please advice on answers to these questions? 

Why in question 13 are we not taking HVS for microscopy/culture to confirm diagnosis? 

Question 14 - the guideline on BASHH candida suggests that HVS should be taken

Below is the explanation provided for this question. With respect to your comment about question 14, there is no option with HVS. The instructions are that you SELECT SQL_CALC_FOUND_ROWS the most appropriate from the list provided - not something that is not on the list.

Vaginal discharge – MRCOG II 2019

Low risk of STI and no symptoms indicative of upper reproductive tract infection:

Empirical treatment based on clinical and sexual history

1) Non-offensive white discharge with an itch : Candida – antifungal
2) Offensive discharge without itch: Bacterial vaginosis – metronidazole

Indications for investigations

• Recurrent infection
• High risk of STI
• Upper reproductive tract symptoms
• Woman requesting investigation
• Pregnant, postpartum, post-abortion
• Recurrent infection
• Failed treatment
• Medical conditions

Bacterial vaginosis (MRCOG II 2019)

• Thin discharge. Offensive or fishy odour
• No itch
• Discharge coating vagina and vestibule
• No vulval inflammation,
• Vaginal pH ≥4.5
• High vaginal swab (from lateral vaginal walls – diagnosis made using Amsel’s criteria (3/4 present): White discharge, pH>4.5, Fishy odour (with addition of 10% KOH to discharge), Clue cells (vaginal epithelial cells surrounded by bacteria)

Candida (MRCOG II 2019)

• Thick white discharge
• Non-offensive
• Vulval itch or soreness
• Superficial dyspareunia
• External dysuria
• Normal findings or Vulval erythema, oedema, fissuring, satellite lesions
• Vaginal pH <4.5

Trichomonas vaginalis (MRCOG II 2019)

• Anaerobic, flagellated protozoan parasite, causes trichomoniasis
• Commonest pathogenic protozoan infection of humans in industrialized countries
• Infection rates similar in men and women but women more symptomatic
• Transmission typically through vaginal intercourse
• Causes frothy, greenish vaginal discharge with a musty malodorous smell
• Only 2% of infected women have a "strawberry" cervix (an erythematous cervix with pinpoint areas of exudation) or vagina on examination
• May cause urethritis and prostatitis in males
• Diagnosis made on cervical smear, infected women have a transparent "halo" around their superficial cell nucleus however this has low sensitivity
• T. vaginalis was traditionally diagnosed via a wet mount, in which "corkscrew" motility was observed
• Currently, the most common method of diagnosis is via overnight culture
• Treated with metronidazole or tinidazole with contact tracing

Treatment Options

Bacterial vaginosis

Oral regimens (70–80% cure): Recommended: Metronidazole: 400–500 mg twice daily for 5–7 days or single 2 g dose

Alternatives
Vaginal regimens (70–80% cure)

Metronidazole gel (0.75%): 5 g applicator nightly for 5 days

Clindamycin cream (2%): 5 g applicator nightly for 7 days

Oral clindamycin: 300 mg twice daily for 7 days

Tinidazole 2 g oral single dose

Recurrent infection

Suppressive therapy

• Oral metronidazole: 400 mg twice daily for 3 days at the beginning and end of menstruation
• Intravaginal metronidazole (0.75%): 5 g applicator twice weekly for 4–6 months after an initial 10-day course (outside product licence)
• Avoid douching, and shampoo, gels and antiseptics in the bath
• Routine screening and treatment of male sexual partners not recommended

Candida

• Vaginal regimens (80–95% cure): Recommended: Clotrimazole pessary: single 500 mg dose, 200 mg nightly for 3 days or 100 mg nightly for 6 days
• Econazole pessary: one 150 mg pessary or 150 mg nightly for 3 days
• Feticonazole pessary: single 600 mg pessary at night or 200 mg pessary nightly for 3 days
• Miconazole intravaginal cream (2%): 5 g applicator nightly for 10–14 days or twice daily for 7 days. Can apply to anogenital area

Oral regimens

• Fluconazole capsule: 150 mg single dose; Itraconazole capsule: 200 mg twice daily for 1 day

Vaginal regimens (70–90% cure)

• Nystatin vaginal cream (100 000 units): 4 g for 14 nights or nystatin pessary (100 000 units): 1–2 for 14 nights

Recurrent infection (four or more episodes in 12 months)

• Induction regimen (as above for initial treatment)

Maintenance regimen

• Oral fluconazole: 100 mg as a single dose weekly for 6 months
• Clotrimazole pessary: a single 500 mg pessary weekly for 6 months
• Oral itraconazole: 400 mg (two divided doses in 1 day) monthly for 6 months
• Avoid local irritants, perfumed products, tight-fitting synthetic clothing
• Routine screening and treatment of male sexual partners not recommended

Treatment in pregnancy

Treatment with topical azoles as above but longer duration of treatment (7 days) may be required. Avoid oral regimens due to potential teratogenicity

Trichomoniasis

Oral regimens (95% cure): Metronidazole: 400–500 mg twice daily for 5–7 days or single 2 g dose

Recurrent infection / treatment failure

• Exclude vomiting with metronidazole and repeat standard regimen as above
• Check risk of re-infection, partner notification and treatment, and compliance
• If drug resistance is suspected seek specialist advice
• Spontaneous cure rate of 20–25%
• Partner notification and treatment is recommended. Screen for other STIs
•