An 18-year-old woman comes to the office for evaluation of vaginal discharge that is thin, gray, and malodorous. The patient has had no vulvovaginal pruritus or pelvic pain. She is sexually active with multiple partners and uses oral contraceptives but does not consistently use condoms. Her general health is good. She recently completed a course of antibiotics for uncomplicated cystitis. Review of systems is negative.
Vital signs are normal. Speculum examination reveals a gray, adherent, malodorous discharge on the walls of the vaginal vault. The cervix appears normal and there is no cervical motion tenderness.
Vaginal pH is 5. Microscopic examination is shown below:

Which of the following is the best therapy for this patient?

Question

An 18-year-old woman comes to the office for evaluation of vaginal discharge that is thin, gray, and malodorous.  The patient has had no vulvovaginal pruritus or pelvic pain.  She is sexually active with multiple partners and uses oral contraceptives but does not consistently use condoms.  Her general health is good.  She recently completed a course of antibiotics for uncomplicated cystitis.  Review of systems is negative.
Vital signs are normal.  Speculum examination reveals a gray, adherent, malodorous discharge on the walls of the vaginal vault.  The cervix appears normal and there is no cervical motion tenderness.
Vaginal pH is 5.  Microscopic examination is shown below:

Which of the following is the best therapy for this patient?

Quizplus · Accepted Answer

11ec193a_97d9_22e9_853d_9f9bb52db577_MD0002_00 Vaginitis is common, and bacterial vaginosis, trichomoniasis, and candidal vulvovaginitis compose the majority of cases. Bacterial vaginosis is diagnosed when 3 of the 4 following Amsel criteria are present: Thin, gray vaginal dischargeVaginal pH >4.5Amine odor after application of potassium hydroxide (eg, "whiff" test)Clue cells (epithelial cells covered in bacteria) on wet mount microscopy Thin, gray vaginal discharge Vaginal pH >4.5 Amine odor after application of potassium hydroxide (eg, "whiff" test) Clue cells (epithelial cells covered in bacteria) on wet mount microscopy This patient's thin, gray, malodorous discharge and vaginal pH of 5 suggest bacterial vaginosis. Vulvovaginal pruritus and pelvic pain are usually not present. The vaginal epithelium and cervix typically are not inflamed (eg, vaginosis). Identifying clue cells, characteristic epithelial cells diffusely coated with bacteria, on wet mount microscopy of the discharge confirms the diagnosis. Bacterial vaginosis is treated with oral or vaginal metronidazole. Clindamycin is an effective alternate agent. clue cells Trichomonas vaginitis is often associated with inflammation (erythema) of the vulvovaginal area. The lack of trichomonads on microscopy suggests another diagnosis. Metronidazole is first-line treatment for trichomoniasis. trichomonads (Choices A and B) Ceftriaxone (covers Neisseria gonorrhoeae) and doxycycline (covers Chlamydia trachomatis) are indicated for acute cervicitis, which presents with mucopurulent cervical discharge and cervical friability. acute cervicitis (Choice C) Fluconazole is indicated for the treatment of vulvovaginal candidiasis, which can occur after antibiotic use. However, patients typically have vulvovaginal pruritus; a thick, white, clumpy discharge; and pseudohyphae on wet mount microscopy. pseudohyphae (Choice E) Trimethoprim-sulfamethoxazole is not indicated for the treatment of vaginitis. Educational objective: Diagnostic criteria for bacterial vaginosis include a thin, gray, malodorous vaginal discharge; a vaginal pH >4.5; an amine odor after the application of potassium hydroxide (eg, "whiff" test); and clue cells on wet mount microscopy. Treatment is with metronidazole or clindamycin. __________ References: Bacterial vaginosis: a synthesis of the literature on etiology, prevalence, risk factors, and relationship with chlamydia and gonorrhea infections. (http://www.ncbi.nlm.nih.gov/pubmed/26877884) Bacterial vaginosis: a critical analysis of current knowledge. (http://www.ncbi.nlm.nih.gov/pubmed/27396541)

An 18-Year-Old Woman Comes to the Office for Evaluation of Vaginal