Infection Drug Dose, route Bacterial vaginosis Metronidazole 500 mg orally bid for days Metronidazole gel 0.75% One full applicator vaginally daily for days One orally twice daily for days Clindamycin 300 mg Vulvovaginal candidiasis Intravaginal agents Butoconazole 2% cream a Butoconazole 2% cream (butoconazole 1-sustained release) Clotrimazole 1% cream a Clotrimazole 100-mg vaginal tablet Miconazole 2% cream a Miconazole 100 mg vaginal suppository a Miconazole 200 mg vaginal suppository a Miconazole 1,200 mg vaginally suppository a Tioconazole 6.5% ointment a Terconazole 0.4% cream Terconazole 0.8% cream g intravaginally for days Single intravaginal application g intravaginally for 7–14 days One vaginally daily for days tablets vaginally for days g intravaginally for days One vaginally daily for days One vaginally daily for days Once vaginally One vaginally daily for 14 days g intravaginally daily for days g intravaginally daily for days g intravaginally daily for days Terconazole 80 mg vaginal suppository Oral agent: fluconazole 150 mg Trichomoniasis Metronidazole Tinidazole One vaginally daily for days Once orally g orally as single dose g orally as single dose a Over-the-counter preparations Adapted from Workowski KA, Bolan GA; Centers for Disease Control and Prevention Sexually transmitted diseases treatment guidelines, 2015 MMWR Recomm Rep 2015;64(RR-3):1–137 Vaginitis should be suspected if there is discomfort or a change in the character of their typical discharge The etiology, clinical manifestations, diagnosis, and treatment of common vaginal infections are presented in this chapter For a review of the differential diagnosis of vaginal bleeding and discharge, see Chapters 79 Vaginal Bleeding and 80 Vaginal Discharge Table 92.1 summarizes the treatment of common vaginal infections Nonspecific vulvovaginitis is responsible for up to 75% of vaginitis in prepubertal girls Factors such as poor hygiene, bubble baths, and tight clothing can increase the risk of vulvovaginitis but all prepubertal girls are at risk given lack of labial development, unestrongenized thin mucosa, and alkaline vaginal pH That said, in symptomatic premenarcheal girls with vaginal discharge visible on physical examination (as opposed to only irritation and erythema) up to 50% will have specific vaginal infections that warrant antimicrobial treatment Among prepubertal girls in the United States, infections may be caused by respiratory flora, Shigella species, Streptococcus pyogenes, and in infants (from maternal passage) and after puberty has begun, Trichomonas vaginalis Although staphylococci and Haemophilus influenzae usually colonize the lower genital tract without producing symptoms, they are associated with vaginal discharge in only a small proportion of patients Candida albicans is the most common vaginal pathogen among both pubertal (but premenarcheal) and postmenarcheal girls The relative prevalence of vaginal infections in a population of postmenarcheal adolescents depends primarily on how many of them are sexually active Bacterial vaginosis is found commonly and nearly exclusively among sexually active adolescents Diabetes mellitus, pregnancy, immunodeficiency, and the use of broad-spectrum antibiotics and corticosteroids predispose patients to developing Candida vulvovaginitis, but the infection is most often seen in patients who lack any of these risk factors Trichomoniasis is transmitted vertically or by sexual contact Up to one-third of patients with trichomoniasis have an additional concurrent gonorrhea, so should have further testing performed TRICHOMONAL VAGINITIS Clinical Considerations Clinical Recognition A small proportion of vaginally delivered female neonates acquire trichomonal vaginitis from their infected mothers Infants harboring only a few trichomonads may never develop clinical disease, but the remainder will have a thin whitish or yellowish vaginal discharge that appears within 10 days after birth and may persist for several months if untreated Infected babies may be fussy but are otherwise well FIGURE 92.1 A: Trichomonad in the vaginal discharge of a 17-year-old patient with gonococcal pelvic inflammatory disease The flagellated protozoan is elliptical and somewhat larger than the adjacent polymorphonuclear leukocytes (×225 magnification) B: After suspension in saline solution for microscopy, trichomonads gradually become swollen and immobile This balloon-shaped trichomonad is barely recognizable (×225 magnification) The classic vaginal discharge of trichomonal vaginitis after puberty is pruritic, frothy, and yellowish However, many infected women not complain of excessive discharge and the discharge may be scant or nondescript A “strawberry cervix” with multiple punctate areas of hemorrhage is pathognomonic for