Clinical Manual for Management of the HIV-Infected ... - myCME.com

5–46 | Clinical Manual for Management of the HIV-Infected Adult/2006
P: Plan
Diagnostic Evaluation
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Obtain a cervical sample for STI testing, if
indicated.
Obtain smears from the vaginal wall for wet mounts
and pH.
Wet mounts: Perform microscopic examination of
saline and potassium hydroxide (KOH) preparations
for the following:
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WBCs, clue cells, motile trichomonads (saline
slide)
Yeast forms (KOH)
Perform a whiff test of KOH preparation; if positive,
check pH (if >4.5, presume BV).
Treatment depends on the specific diagnosis, and in
general is the same as for HIV-negative women.
Trichomoniasis
Trichomoniasis is caused by the protozoan Trichomonas
vaginalis. Many infected women have a diffuse,
malodorous, yellow-green discharge. Most men who
are infected with T vaginalis have no symptoms;
others have symptoms of nongonococcal urethritis.
The diagnosis is usually made by visualization of
motile trichomonads on microscopic examination
of wet mounts. Newer diagnostic tests using
immunochromatographic or nucleic acid assays (eg,
OSOM Trichomonas Rapid Test or Affirm VP III,
respectively) have greater specificity and sensitivity than
wet mount preparations. Culture of vaginal secretions
is the most sensitive and specific diagnostic test for T
vaginalis.
The sex partners of patients with trichomoniasis should
be treated. Patients should avoid sexual intercourse until
they and their partners have completed treatment and
symptoms have resolved.
Treatment: Recommended regimen
♦ Metronidazole 2 g orally in a single dose
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Tinidazole 2 g orally in a single dose
Treatment: Alternative regimen
♦ Metronidazole 500 mg orally twice a day for 7 days
Treatment during pregnancy
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Pregnant women may be treated with a single dose
of metronidazole 2 g orally.
Note: Patients must avoid alcohol while taking
metronidazole. This combination may cause a
disulfiram-like reaction. Patients taking ritonavir or
tipranavir may also experience symptoms because of the
small amount of alcohol in the capsules.
Treatment failure
Certain strains of T vaginalis have diminished
susceptibility to metronidazole and must be treated with
higher doses. If treatment failure occurs with either
regimen, repeat treatment using metronidazole 500 mg
orally twice daily for 7 days. If treatment failure occurs
again, the patient should be treated with metronidazole
2 g once daily for 3-5 days. If this regimen is not
effective, consult with a specialist.
Bacterial Vaginosis
BV is a clinical syndrome resulting from loss of the
normal vaginal flora, particularly Lactobacillus, and
replacement with anaerobic bacteria such as Gardnerella
vaginalis and Mycoplasma hominis. BV appears as a
homogeneous, white, noninflammatory discharge on the
vaginal walls. The diagnosis is made by the detection of
clue cells on the wet-mount slide, a vaginal fluid pH of
>4.5, and a fishy odor to the vaginal discharge before or
after the addition of KOH (whiff test).
Many studies have documented an association between
BV and infections such as endometritis, PID, and
vaginal cuff cellulitis after gynecologic procedures.
Therefore, the U.S. Centers for Disease Control and
Prevention (CDC) recommends screening for and
treating BV before invasive gynecologic procedures.
The sex partners of women with BV do not need to be
treated.
Treatment: Recommended regimen
♦ Metronidazole 500 mg orally twice daily for 7 days
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Metronidazole gel 0.75%, 1 full applicator (5 g)
intravaginally at bedtime for 5 days
Clindamycin cream 2%, 1 full applicator (5 g)
intravaginally at bedtime for 7 days