Pediatric emergency medicine trisk 2128 2128
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diagnosis is being considered. Microscopic examination of a sample of vaginal
discharge suspended in 10% potassium hydroxide solution to clear the field of
cellular debris can provide a rapid diagnosis of candidiasis if hyphae are seen.
However, in as many as 50% of cases, wet mounts are falsely negative.
Therefore, although the presence of C. albicans can be confirmed by laboratory
tests, the diagnosis and subsequent treatment of this infection should be guided by
the presence or absence of clinical disease. It is important to remember that
candidal vaginitis does not exclude sexually transmitted infections.
Management
Topical imidazoles will promptly cure 80% to 90% of patients with candidal
infections. Most are available without prescription. The creams are packaged with
intravaginal applicators, but many premenarcheal and virginal girls can be treated
adequately and more comfortably by applying cream to the vulva alone.
Effective, nonprescription, short-course treatments of patients with mild to
moderate candidal vulvovaginitis include clotrimazole 2% cream (5 g
intravaginally at bedtime for three nights), miconazole 200-mg suppositories (one
suppository at bedtime for three nights), and tioconazole 6.5% ointment (one full
applicator as a single dose). For patients with severe discomfort, one of the 5- or
7-day formulations of a topical agent is likely to be more effective. Creams and
suppositories in this regimen are oil-based and might weaken latex condoms and
diaphragms. Fluconazole, 150-mg oral tablet in a single dose, cures candidal
vulvovaginitis as effectively as the topical preparations, and many patients prefer
oral to topical treatment. However, the risks, albeit low, of systemic toxicity and
allergy are important disadvantages of oral antifungal agents.
BACTERIAL VAGINOSIS
Clinical Considerations
Clinical Recognition
Bacterial vaginosis is a syndrome characterized clinically by the presence of three
of the following four signs: (i) a homogeneous, white adherent vaginal discharge;
(ii) vaginal pH above 4.5; (iii) a fishy, amine-like odor released when 10%
potassium hydroxide solution is added to a sample of the discharge; and (iv) the
presence of clue cells (Amsel criteria). The syndrome occurs when lactobacilli
that normally predominate in the genital tract are displaced by an overgrowth of
mixed flora, including Gardnerella vaginalis, Mobiluncus species, other
anaerobes, and Mycoplasma hominis. What accounts for this change in the
