GYN
CMECNE

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

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Learning Objectives and CME/Disclosure Information

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

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Related ObG Topics:

Screening for Sexually Transmitted Diseases – Who, When and How Often?
Bacterial Vaginosis – CDC Diagnosis and Treatment Recommendations
Trichomoniasis: CDC Diagnosis and Treatment Guidelines
Chlamydia: CDC Recommendations for Diagnosis and Treatment

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