Learning Objectives
By the end of this section, you will be able to:
- Describe the common vaginal infections of bacterial vaginitis and candidiasis
- Educate patients regarding the diagnosis, treatment, and prevention of bacterial vaginitis and candidiasis
Bacterial vaginitis and vulvovaginal candidiasis are common infectious causes of vaginitis. Anaerobic bacteria cause bacterial vaginitis, while vulvovaginal candidiasis is caused by a fungal infection (Paladine & Desai, 2018). Group B strep infection is a bacterial infection that can colonize the vagina and infect a newborn during delivery (CDC, 2022b).
Bacterial Vaginitis
The condition bacterial vaginitis (BV) occurs when there is an imbalance between the good bacteria and the harmful bacteria in the vagina, resulting in a larger amount of anaerobic bacteria. Symptoms may be minimal but include a homogeneous, thin vaginal discharge with a fishy odor (CDC, 2021b).
Incidence
Bacterial vaginitis is the most common cause of vaginal symptoms in persons assigned female at birth and affects over 21 million of them in the United States each year (CDC, 2021b). It affects 23 percent to 29 percent of persons AFAB across the world.
Screening and Diagnosis
Routine screening for BV is not indicated, but persons experiencing symptoms should report them to their provider. A person assigned female at birth whose partner is BV positive should get tested (CDC, 2021b).
Diagnosis can be made using clinical criteria or a gram stain. The most common diagnostic test is the Amsel diagnostic criteria, which requires that three out of four of the following be present:
- thin, homogeneous discharge
- positive whiff test
- clue cells present on microscopy (Figure 7.8)
- vaginal pH > 4.5
A whiff test is done by mixing a few drops of potassium hydroxide (KOH) with a vaginal sample. The KOH kills bacteria and leaves only yeast behind, revealing if there is a yeast infection. In addition, there is a fishy odor before or after the addition of 10 percent KOH to the sample (Paladine & Desai, 2018). Newer lab tests use DNA probes to detect BV (CDC, 2021b).
Clinical Safety and Procedures (QSEN)
Vaginal Culture and Pap Smear
Disclaimer: Always follow the agency’s policy for vaginal culture and Pap smear.
Definition: Reduce the risk of harm to patients through effective, efficient, and competent performance.
Knowledge: The nurse will analyze basic safety principles, understand evidence-based practice standards, and reflect on unsafe nursing practices to ensure that patients are screened properly.
Skill: Demonstrate effective strategies to reduce the risk of harm. The nurse will do the following:
- Perform hand hygiene before patient contact. Don appropriate personal protective equipment (PPE) based on the patient’s need for isolation precautions or the risk of exposure to bodily fluids.
- Introduce yourself to the patient.
- Verify the correct patient using two identifiers.
- Determine whether the patient has had any previous pelvic examinations, procedures, or surgeries. Also determine if there are any questions the patient needs answered, as well as the patient’s ability to cooperate for the examination.
- Have the patient empty the bladder.
- Ensure that the light source works.
- Set up supplies for the examination and specimen collection.
- Assist the patient into the lithotomy position with the buttocks at the edge of the table and place a pillow under the head. Drape the patient’s abdomen and lower extremities so that only the perineal area is exposed. Do not place the patient into this position until just before the physical examination begins. Be prepared to provide assistance if a weak or dizzy patient is not able to maintain this position.
- Ensure that a chaperone is present for all breast, genital, and rectal examinations performed by the practitioner.
- Papanicolaou (Pap) smear: Provider to obtain this specimen first.
- Obtain a specimen to diagnose Candida (yeast) organisms and submit it on a slide or on a swab per the organization’s practice. This may be done by a nurse or provider, depending on the organization.
- KOH dissolves other types of cells and protein, which makes it easier to see the Candida cells. On exam, will see clue cells—vaginal epithelial cells studded with adherent bacteria.
- Assist the patient with removing the feet from the footrests.
- Offer the patient a damp washcloth and towel to use to cleanse self after the examination.
- In the presence of the patient, label the specimen per the organization’s practice.
- Place the labeled specimen in a biohazard bag and transport it to the laboratory immediately per the organization’s practice.
- Assess, treat, and reassess pain.
- Discard supplies, remove PPE, and perform hand hygiene.
Attitude: The nurse will respect their role in assisting with vaginal cultures and Pap smears by adhering to safe, evidence-based practice standards.
Management and Treatment
Bacterial vaginitis can be treated with metronidazole (Flagyl) 500 mg orally 2 times a day for 7 days or metronidazole gel 0.75 percent one full applicator (5 g) intravaginally once a day for 5 days or clindamycin cream (Cleocin Vaginal) 2 percent one full applicator (5 g) intravaginally at bedtime for 7 days (CDC, 2021b). Douching can increase the risk of BV and should be avoided. Regular condom use can help prevent BV. The exact cause of the infection is not well understood (CDC, 2021b).
Complications
Bacterial vaginitis can cause discomfort, such as vaginal itching, copious discharge from the vagina that may be foul smelling, and burning during urination (WHO, 2023). It can also increase the risk of HIV, gonorrhea, chlamydia, and herpes infections (Paladine & Desai, 2018). Bacterial vaginitis during pregnancy can cause preterm delivery (CDC, 2021b).
Patient Education
Partners AMAB do not require treatment, but partners AFAB can spread the infection to each other. Bacterial vaginitis may go away without treatment, but it can increase the risk of complications (CDC, 2021b). The patient should be educated that douching can change the pH of the vagina and lead to BV and should always be avoided (CDC, 2021b).
Life-Stage Context
Vaginitis in Those over 65
Vaginitis in patients over the age of 65 requires normal evaluation in addition to evaluation for vulvovaginal atrophy and genital neoplasia. Vulvovaginal atrophy is common in menopausal patients who may experience watery, white, or yellow discharge; vaginal burning or irritation; itching; and other urinary symptoms. Microscopy findings are nonspecific, and treatment includes topical estrogen therapy (Sobel, 2023).
Vulvovaginal Candidiasis
The yeast Candida causes the fungal infection vulvovaginal candidiasis (VVC). This yeast normally lives on the skin and within the body without causing problems. It can cause a problem when there is overgrowth caused by hormones, medications, or changes in the immune system. Obesity and pregnancy can increase endogenous estrogen, which increases the risk. Diabetes mellitus, immunosuppressant medications, and broad-spectrum antibiotics can also raise the risk of acquiring VVC (Jeanmonod et al., 2023). VVC can cause vaginal itching and soreness, dyspareunia, external dysuria, and abnormal vaginal discharge (CDC, 2022b).
Incidence
About 75 percent of all persons assigned female at birth will have at least one occurrence of VVC in their lifetime, and 40 percent to 45 percent will have two or more episodes (CDC, 2022b). VVC is classified as noncomplicated or complicated. VVC is considered noncomplicated when it is infrequent and mild to moderate in a person who is not immunocompromised, and it is likely caused by Candida albicans. VVC is complicated when it is recurrent or severe, a non-albicans candidiasis, or in a person with diabetes or other immunocompromising conditions, such as HIV, or who is on immunosuppressive therapy (CDC, 2022b).
Screening and Diagnosis
There is no routine screening for VVC. Patients may complain of dysuria, pruritis, pain, swelling, redness, dyspareunia, and postcoital bleeding. They may also have a thick discharge with curds. The diagnosis can be made by the health-care provider noting the thick discharge on the vaginal walls or with a wet preparation: A slide of vaginal discharge under a microscope will show yeast (Figure 7.9). A 10 percent KOH preparation added to the slide will improve visualization of yeast. A vaginal culture can also be used to make the diagnosis (CDC, 2022b).
Management and Treatment
Fluconazole (Diflucan) is the only prescription oral treatment, which consists of one 150 mg dose. There are numerous over-the-counter vaginal creams, ointments, or suppositories used to treat VVC. These include clotrimazole, miconazole, and tioconazole. Prescription vaginal creams, ointments, or suppositories that are available include butoconazole (Gynazole-1) and terconazole (Terazol 3) (CDC, 2022b). During pregnancy, any of the topical azole medications is appropriate for treatment, but oral fluconazole should not be used, as it has been shown to increase the risk of spontaneous abortion and congenital anomalies (CDC, 2022b).
Pharmacology Connections
Fluconazole
- Generic Name: fluconazole
- Trade Name: Diflucan
- Class/Action: antifungal agent
- Route/Dosage: oral, 150 mg one time; severe infection, 150 mg every 72 hours for 2 to 3 doses
- High Alert/Black Box Warning: may occasionally cause dizziness or seizures, caution with driving
- Indications: used to treat vulvovaginal candidiasis
- Mechanism of Action: interferes with fungal activity, decreasing synthesis and cell formation
- Contraindications: hypersensitivity to fluconazole; coadministration with CYP3A4 substrates
- Adverse Reactions/Side Effects: headache, rash, abdominal pain, diarrhea, nausea, vomiting, dizziness, prolonged cardiac QT interval
- Parent/Family Education: Tell your doctor if you are pregnant or may be pregnant. Fluconazole can cause fetal harm.
Complications
Patients with complicated VVC should have a vaginal culture or PCR test to confirm the diagnosis and determine if the cause is non-albicans Candida. Patients with complicated VVC usually need a longer course of treatment. A longer course of a non-fluconazole treatment is recommended for non-albicans VVC (CDC, 2022b).
Patient Education
Poorly controlled diabetes can increase the risk of VVC. HIV-positive patients and patients taking immunosuppressant medications are at an increased risk of getting VVC, as are patients taking antibiotics. These patients may need longer treatment of VVC (CDC, 2022b). Creams and suppositories used to treat VVC are oil based and can weaken latex condoms and diaphragms. Sex partners do not usually require treatment (CDC, 2022b). The nurse should instruct the AFAB patient to follow these guidelines to prevent VVC:
- Do not douche because it alters normal bacteria.
- Do not use scented feminine products.
- Change tampons, pads, and panty liners often.
- Do not wear tight underwear, pantyhose, or clothes, which can increase the temperature.
- Wear underwear with a cotton crotch to stay dry.
- Change out of wet swimsuits and workout clothes as soon as possible.
- Always wipe from front to back when using the bathroom.
- Avoid hot tubs and taking hot baths (U.S. Department of Health and Human Services, 2021).
Group B Streptococcus
The bacterium group B streptococcus (GBS) can live in a person’s gastrointestinal and genital tracts without causing problems; it is not an STI pathogen. Sometimes, the bacteria can invade the body and cause infection. They also can be passed to a fetus during a vaginal delivery. Newborns infected with GBS can have severe complications, including death (CDC, 2022a).
Incidence
More than 28,000 cases of invasive group B streptococcus (GBS) are diagnosed in the United States each year (CDC, 2022a). About 1 in 4 pregnant persons have GBS in their body (CDC, 2022a). While the incidence in the United States has decreased due to maternal treatment, there are still 320,000 cases of newborns affected with GBS each year in the world (Berardi et al., 2021).
Screening and Diagnosis
Cultures should be taken to determine if an infection is present. These cultures can consist of blood, urine, or spinal fluid (CDC, 2022a). All pregnant persons should have a lower vaginal and rectal swab to test for GBS at 36 to 37 weeks’ gestation. Universal screening has yielded an 80 percent reduction in early-onset GBS in newborns. The swab should test for sensitivity if the patient has a severe penicillin allergy (Baker, 2023).
Management and Treatment
Treatment depends on the type of infection that the patient has. In pregnant persons with a positive GBS culture, intrapartum antibiotics should be given. Patients who have a history of giving birth to an infant with early-onset disease or who had GBS bacteriuria during the current pregnancy should also receive intrapartum antibiotics. Pregnant persons who have an unknown culture status (culture not performed or result not available) should receive antibiotics if they have
- intrapartum fever (≥100.4° F [≥38° C]) or
- preterm labor (<37+0 weeks of gestation) or
- preterm prelabor rupture of membranes or
- prolonged rupture of membranes (≥18 hours) or
- intrapartum nucleic acid amplification test (NAAT) positive for GBS.
Patients who have a scheduled cesarean section do not need intrapartum antibiotics (Baker, 2023).
Penicillin is the treatment of choice for pregnant persons with group B strep. The usual dose is 5 million units administered intravenously (IV) for the initial dose, followed by 2.5 to 3 million units IV every 4 hours until delivery. Ampicillin 2 g IV initial dose, followed by 1 g every 4 hours until delivery, can also be used. If there is a high risk for anaphylaxis to penicillin, susceptibility should be performed to see if the bacteria are susceptible to erythromycin or clindamycin (Baker, 2023).
Complications
Adults with a group B strep infection can develop sepsis. Infants born to persons with untreated GBS can experience serious consequences. Newborns can exhibit fever, difficulty in feeding, irritability or lethargy, difficulty in breathing, or blue color of the skin. These infants can also develop meningitis, which can cause death. Other long-term complications include deafness and developmental disabilities (CDC, 2022a).
Patient Education
Patients should be educated on the importance of testing for GBS during pregnancy. Patients should also be aware of their GBS results during pregnancy. Results should be at the place of birth where the patient delivers the baby, but in case they are not, the patient should be able to tell the nurse and provider their GBS status. Table 7.6 summarizes information about vaginal infections and other conditions.
| Disease | Organism | Signs and Symptoms | Lab Diagnosis | Treatment per CDC Guidelines |
|---|---|---|---|---|
| Bacterial vaginitis | Gardnerella. vaginalis, Prevotella species, Mobiluncus species, Atopobium vaginae, and other BV-associated anaerobic bacteria | Thin white or gray vaginal discharge; pain, itching, or burning in vagina; strong fish-like odor, especially after sex; burning with urination; itching around outside of vagina | Microscopy, vaginal pH, and Whiff test | Metronidazole 500 mg orally 2 times/day for 7 days OR Metronidazole gel 0.75% one full applicator (5 g) intravaginally, once a day for 5 days OR Clindamycin cream 2% one full applicator (5 g) intravaginally at bedtime for 7 days |
| Vulvovaginal candidiasis | Candida albicans | Vaginal itching or soreness, pain during sexual intercourse, pain or discomfort when urinating, or abnormal vaginal discharge | Wet preparation (saline, 10% KOH) of vaginal discharge demonstrates budding yeasts, hyphae, or pseudohyphae; and vaginal culture | Clotrimazole 2% cream 5 g intravaginally daily for 3 days OR Miconazole cream intravaginally daily for 7 days OR Miconazole vaginal suppository OR Tioconazole 6.5% ointment intravaginally in a single application OR other prescription antifungals |
| Group B streptococcus | Group B Streptococcus | Usually no symptoms; with cystitis: may have urinary frequency, urgency, or dysuria; with pyelonephritis: may have fever, urinary symptoms, nausea and vomiting, flank pain; infected newborn can have fever, difficulty in feeding, difficulty in breathing, lethargy, irritability, or bluish skin | Urine culture or vaginal culture | Penicillin G (during labor) 5 million units IV initial dose, then 2.5 to 3 million units every 4 hours until delivery OR Ampicillin 2 g IV initial dose, then 1 g IV every 4 hours until delivery |