BIOSOFT HELP FILES

Box 3 Management of vaginal infections

Bacterial vaginosis

Metronidazole 2 g as a single oral dose, metronidazole 400-500 mg twice daily for five to seven days, intravaginal clindamycin cream (2%) once daily for seven days, or intravaginal metronidazole gel (0.75%) once daily for five days4
The infection often recurs and acidic vaginal jelly (such as Relact from Kora Healthcare) may reduce relapse rates27
Partner notification not needed
Vulvovaginal candidiasis

Vaginal imidazole preparations (such as clotrimazole, econazole, miconazole—various preparations are available including single dose ones), or fluconazole 150 mg orally8
The role of alternative treatments like tea tree oil and yoghurt containing Lactobacillus acidophilus have not been evaluated9
Oral versus vaginal treatment depends on preference
Treatment for candidiasis is available over the counter in the UK
Partner notification not needed
Chlamydia trachomatis

Doxycycline 100 mg twice daily for seven days (contraindicated in pregnancy), azithromycin 1 g orally in a single dose (WHO recommends azithromycin in pregnancy but the British National Formulary advises against its use unless no alternatives are available)13
A test of cure is not indicated13
Partner notification required
Gonorrhoea

Cefixime 400 mg as a single oral dose or ceftriaxone 250 mg intramuscularly as a single dose16
Referral to a genitourinary medical unit is encouraged because of the existence of resistant strains of the organism16
A test of cure is not routinely indicated if an appropriately sensitive antibiotic has been given, symptoms have resolved, and there is no risk of reinfection16
Partner notification required
Trichomonas vaginalis

Metronidazole 2 g orally in a single dose or metronidazole 400-500 mg twice daily for five to seven days17
Partner notification required
Readers should refer to BASHH guidelines, the British National Formulary, and local policies for full treatment options, including treatment in pregnancy

Spence D and Melville C. Vaginal discharge. Clinical Review. BMJ. 2007 Dec 1; 335(7630): 1147–1151. doi: 10.1136/bmj.39378.633287.80, PMCID: PMC2099568

1)      Physiological – scanty, clear, thin discharge turning thicker with ovulation, breastfeeding, sex, colorless, odorless, no itching or burning or pain at genitals,

2)      Cervical ectopy

3)      Foreign body – foul smelling, purulent discharge

4)      Bacterial Vaginosis – Most asymptomatic, others scanty, thin, white or grey discharge, fishy odor, strongest after sex, vulval itching and burning, redness, and swelling of the vulvovaginal area, Ix – wet vaginal smear clue cells seen, Whiff’s test positive ie, add KOH to the discharge gives a strong amine odor.  Tx – oral metronidazole 400-500 mg bid for 5-7 days OR a single 2 G dose, in recurrent BV advise avoidance of douches, shower gels, antiseptic agents, shampoos in bath,

5)      VulvoVaginal Candidiasis – white, cottage-cheese like, vulval pain and swelling and itching, dyspareunia, recurrent attacks, predisposing factors like pregnancy, diabetes, hot and sweaty genitals,   Tx – Topical azole therapy – Clotrimazole 1% cream 5 G per day intravaginally for 1-2/52 OR Clotrimazole 100 mg vaginal tablet intravaginally bid for 3 days OR Clotriazole 500 mg vaginal tablet intravaginally once OR Miconazole 2% cream 4 G daily intravaginally for 1/52, OR Miconazole 200 mg vaginal supp daily for 3 days OR Miconazole 100 mg vaginal supp daily for 1/52 OR Nystatin 100,000 unit vaginal tablet intravaginally for 2/52 OR Tioconazole 6.5% cream 5 G intravaginally once OR Terconazole cream 0.4% 5 G vaginally daily for 1/52 OR Terconazole 0.8% cream 5 G daily intravaginally for 3 days OR Terconazole 80 mg vaginal tablet 1 supp daily for 3 days, Oral antifungals - Fluconazole 150 mg once PO OR any topical antifungal therapy, in pregnancy topical therapy only for 1 week, in recurrences for more than 4 per annum, exclude antibacterial therapy, pregnancy, DM, OC use, infection reservoirs at digits, nails, umbilicus, GIT, bladder, partner, treat with Fluconazole 100 mg one dose PO weekly for 6/12 OR Itraconazole 200 mg 2 doses in a day every month for 6/12 OR Clotrimazole vaginal pessary one dose every week for 6/12,

6)      Trichomonas vaginalis – watery, yellowish or greenish bubbly discharge, unpleasant  odor, vulval itching, dysuria, worse after periods, Tx – oral metronidazole 400 mg bid for 5-7 days OR a single 2 g oral dose, partner notification and treatment essential

7)      Chlamydia trachomatis – see under genital discharge

8)      Neisseria Gonorrhea – see under genital discharge

9)      Genital herpes – see under genital ulcers

10)    Pregnancy – minor symptoms of pregnancy

11)    Pelvic inflammatory disease – see under abdominal pain

1)      Elderly (pelvic exam and speculum exam of cervix indicated, unhealthy cervix requires referral)

2)      High risk of STI - < 25 hrs, change in the sexual partner last year, more than 1 sexual partner

3)      Upper reproductive tract infections – as suggested by pain, dyspareunia, bleeding,

4)      Treatment failure

5)      Postnatal discharge

6)      Post-miscarriage or post-abortion discharge

7)      Within 3 weeks of IUCD insertion

8)      Change in color, odor, consistency, or quantity – signifies a pathological discharge

9)      Prepubertal child with vaginal discharge – sexual abuse

10)    Unexplained persistent vaginal discharge – gyn referral for further  evaluation indicated

(NCC-PC Referral Guidelines for Suspected Cancer  in Adults and Children)

(BNF-50 Online)

(CDC - 2006)

1)      Benign Paroxysmal Positional Vertigo – BPPV – vertigo precipitated by head movements, turning over in bed, sitting or lying down, extending the neck, vertigo accompanied by nausea and vomiting and rarely diarrhea, brief episodes of vertigo, rotatory nystagmus, brief nystagmus usually lasting 40 secs, nystagmus co-occur with vertigo, Dix-Hallpike testing positive, repeated testing causes attenuation of vertigo and nystagmus, the latency of several seconds for vertigo and nystagmus with provocative positioning, 

1)      Unilateral sensorineural deafness (to be confirmed by an audiogram, asymmetrical sensorineural hearing loss), unilateral tinnitus, facial numbness, facial twitching, headache (acoustic neuroma) 

1)      Migraine – blurred vision lasting a few hrs as a typical aura of migraine

2)      TIA’s – recurrent brief episodes

3)      Refractive errors – bilateral, gradual onset, painless, distance-dependent, pinhole-corrected blurred vision, myopia (nearsightedness), hyperopia (farsightedness),  astigmatism and presbyopia  

4)      Visual fatigue – intensive use of eyes, visual display terminal  workers, Tx – visual ergonomics, proper vision care

5)      Foreign body in the eye – eye pain, tearing, red eye, scratchy sensation on eye movements, blurred vision, vision loss, conjunctival or subconjunctival hemorrhage, hyphema, corneal abrasions treated with antibiotic creams and analgesics, any injury other than simple corneal abrasion requires ophthalmologist referral

6)      Chemical Splashes -  Irrigate the eye with normal saline 1 liter, topical anesthetic eye drops, tetanus prophylaxis, ophthalmologist  referral within 24 hrs in all except minor chemical burns without vision effects

7)      Arc eye or Welder’s Flashburn – UV radiation due to unprotected welding or severe sun exposure, usually present within few hrs of exposure, red, painful, tearing eyes, light sensitivity, blurred vision, Tx – atropine eye drops to relax the eye muscles and relieve pain, padded dressing to cover the eyes, antibiotic eye drops, review within 24-48 hrs to check on healing, ophthalmologist referral if severe (determined by the degree of pain and loss of vision)

8)      Amaurosis Fugax – transient, monocular, partial blindness lasting few seconds to 2 hrs., carotid doppler ultrasound to see carotid stenosis, ECHO of heart to see any valvular dysfunction, Tx – management of TIA

1)      Migraine

2)      Refractory errors -

3)      Hyperventilation

4)      Amblyopia – a unilateral or bilateral decrease of vision, 2-line difference of visual acuity between the 2 eyes, higher visual acuity with single letters than with a line of letters, difficulty in assessing the depth, amblyopia may be caused by squint, myopia, hypermetropia or astigmatism.

5)      Myopia – onset in childhood, progressive, 

1)      Unexplained temporary (< few hrs) blurred vision

2)      Recurrent brief episodes of blurring - Papilloedema (RICP)

3)      Unexplained painless loss lasting days to weeks (exclude retinal detachment, vitreous hemorrhage, cataracts)

4)      Painful loss (acute angle closure glaucoma, optic neuritis (painful eye movements), uveitis, corneal hydrops that is keratoconus)

5)      Sudden unilateral painless complete loss of vision (central retinal vessel occlusion, ischemic optic neuropathy, vitreous hemorrhage, retinal detachment)

6)      Age-related macular degeneration – yellow deposits in and around the macula, seen in dry macular degeneration, 

1)      Recent change in visual acuity

2)      The parent has had retinoblastoma

3)      Sibling has had retinoblastoma

4)      Preterm babies (prematurity can cause retinopathy, myopia, squint)

5)      Roving nystagmus (a marker of the visual defect)

6)      TORCH syndrome

7)      Fixed squint

8)      Mental retardation

9)      Drug use in pregnancy