What is ‘Mixed’ Vaginitis? How and When to Treat

Learning Objectives and CME/Disclosure Information

This activity is intended for healthcare providers delivering care to women and their families.

After completing this activity, the participant should be better able to:

1. Choose the pathogens that, if identified, require independent treatment
2. Contrast coinfection and mixed infection

Estimated time to complete activity: 0.25 hours

Faculty:

Susan J. Gross, MD, FRCSC, FACOG, FACMG
President and CEO, The ObG Project

Disclosure of Conflicts of Interest

Postgraduate Institute for Medicine (PIM) requires faculty, planners, and others in control of educational content to disclose all their financial relationships with ineligible companies. All identified conflicts of interest (COI) are thoroughly vetted and mitigated according to PIM policy. PIM is committed to providing its learners with high quality accredited continuing education activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of an ineligible company.

The PIM planners and others have nothing to disclose. The OBG Project planners and others have nothing to disclose.

Faculty: Susan J. Gross, MD, receives consulting fees from Cradle Genomics, and has financial interest in The ObG Project, Inc.

Planners and Managers: The PIM planners and managers, Trace Hutchison, PharmD, Samantha Mattiucci, PharmD, CHCP, Judi Smelker-Mitchek, MBA, MSN, RN, and Jan Schultz, MSN, RN, CHCP have nothing to disclose.

Method of Participation and Request for Credit

Fees for participating and receiving CME credit for this activity are as posted on The ObG Project website. During the period from Dec 31 2017 through Jan 25 2023, participants must read the learning objectives and faculty disclosures and study the educational activity.

If you wish to receive acknowledgment for completing this activity, please complete the post-test and evaluation. Upon registering and successfully completing the post-test with a score of 100% and the activity evaluation, your certificate will be made available immediately.

For Pharmacists: Upon successfully completing the post-test with a score of 100% and the activity evaluation form, transcript information will be sent to the NABP CPE Monitor Service within 4 weeks.

Joint Accreditation Statement

In support of improving patient care, this activity has been planned and implemented by the Postgraduate Institute for Medicine and The ObG Project. Postgraduate Institute for Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

Physician Continuing Medical Education

Postgraduate Institute for Medicine designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Continuing Nursing Education

The maximum number of hours awarded for this Continuing Nursing Education activity is 0.2 contact hours.

Read Disclaimer & Fine Print

CLINICAL ACTIONS:

When treating vaginitis, the following pathogens, if identified on culture or PCR, must be treated independently as well:
- Trichomonas vaginalis
- Chlamydia trachomatis
- Neisseria gonorrhea
- Herpes simplex
- Bacterial vaginosis (BV) associated microorganism (Gardnerella vaginalis, Atopobium vaginae)
The following pathogens do not require independent treatment, although their presence cannot be ignored in the setting of persistent symptoms of vaginitis following treatment of the primary pathogen:
- Candida species
- Streptococcus pyogenes (Group A streptococcus)

SYNOPSIS:

Mixed vaginitis is rare, and is due to the presence of at least two different infectious agents, both contributing to signs and symptoms, and both requiring therapy. An example of mixed vaginitis is a positive PCR result for Chlamydia in a patient with a malodorous discharge of BV. Both pathogens would require treatment. ‘Mixed’ vaginitis should not be confused with the more commonly occurring coinfection, where two infectious agents are present, but only one is responsible for signs and symptoms.

KEY POINTS:

Pruritis, vulvovaginal inflammation, or a clumpy discharge in a patient with BV should signal a high likelihood of mixed infection with Candida
- This is a mixed vaginitis: Treat both
Trichomoniasis and bacterial vaginosis are relatively common mixed infections, both benefiting from elevated vaginal pH and anaerobic environment
- Treating with metronidazole will treat both
A positive culture for Candida in a woman with a malodorous discharge of BV does not mandate antifungal treatment as this represents coinfection
Limit polytherapy to clinical situations where cultures indicate serious co-pathogens (e.g. chlamydia or gonorrhea) or where Candida coinfection is likely to cause a secondary vulvovaginal candidiasis (VVC) after the primary infection is treated, for example when treating a diabetic patient

Learn More – Primary Sources:

Mixed Vaginitis—More Than Co-infection and With Therapeutic Implications

Take a post-test and get CME credits

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What is ‘Mixed’ Vaginitis? How and When to Treat