Treatment
Compared to
single
vaginal infection, mixed vaginitis has atypical clinical manifestations,
is hard to eradicate and often recurs.
Therefore,
mixed vaginitis poses a therapeutic challenge. Since the treatment of
vaginitis is largely dependent on the pathogen, such infections may
require treatment with multiple drugs.
However,
many countries have banned the availability of combination antimicrobial
products for use in vaginitis, and
little consideration has been given to the possibility or frequency of
mixed vaginitis. Previously, a
study confirmed that approximately 30% of women with vaginal symptoms
failed to receive any kind of vaginitis diagnosis(36).
With the development
of
laboratory-based diagnostics, including antigen detection, DNA probes,
and PCR, recognition of the coexistence of multiple pathogens will
increase. This phenomenon will increase
the demand for
polytherapy
comprising multiple antimicrobials.
Standard treatment for mixed vaginitis has not yet been established.
The choice of multiple
antimicrobials depends on the type of
infection.
Various
guidelines for the treatment of different forms of mixed vaginitis state
the following:(3, 32, 37-39): ①Mixed VVC infections (such as VVC plus
BV; VVC plus TV; VVC plus AV)
should be treated with topical or oral antifungal drugs along with
treatment for other vaginitis. For example, oral or topical
nitroimidazole is used for BV. Oral high-dose nitroimidazole is the
first choice for TV treatment.
Since treatment of AV with
broad-spectrum antibiotics may increase the risk of recurrence and
persistent infection in patients with VVC, combined topical bactericide
and antifungal drugs should be considered. ②Mixed AV infection (such as
AV plus BV; AV plus TV)
treatment
is based on antibiotic targeting of aerobic pathogens associated with
this condition. There are several
regimens to treat AV plus BV, such
as oral anti-aerobic drugs plus nitroimidazoles,
oral anti-aerobic drugs plus
topical nitroimidazole formulations and topical bactericides.
For AV plus TV,
oral
anti-aerobic drugs plus nitroimidazoles are available. ③Mixed BV
infections (such as BV plus TV) should be treated with
oral
nitroimidazole for BV plus TV; treatment should be provided as either
two doses a day for 7 days or a
single dose plus an intravaginal suppository. It should be noted that
combination therapy is indicated for confirmed mixed vaginitis.
In pathogen coinfection, although
two pathogens may be identified, a
potential pathogen may be present but may not be the cause of existing
vaginal symptoms. One challenge is that individual signs and symptoms
have shown only modest value in diagnosing mixed vaginitis. Therefore,
how to identify at-risk subpopulations requires further consideration.
Although anti-infective treatments
are available and are usually highly efficient in eradicating pathogenic
microorganisms, the long-term
efficiency is hampered by
relapse(40).
Mixed vaginitis usually has an intricate microecology. Therefore, in
addition to the administration of antibiotics, the management of mixed
vaginitis should target the recovery of the vaginal
microecosystem
and
the immune system. Probiotics are recommended to maintain vaginal
homeostasis and immune modulation(41). Combining lactobacilli probiotics
with antibiotics may play an important role in strengthening the
efficacy of the antibiotics and preventing the recurrence of mixed
vaginitis. The main treatment objectives are the alleviation of
symptoms, the elimination of pathogens, and eventually the recovery from
disturbed to healthy lactobacilli-dominated vaginal flora.
In summary,
mixed
infections are largely ignored and poorly studied. Currently, mixed
vaginitis has the characteristics of atypical signs and symptoms, a lack
of conclusive diagnostic criteria, and little valid prevalence data.
This review is of great
significance for improving clinical awareness of mixed vaginitis,
accurate diagnosis and appropriate treatment, and promoting recovery of
the dynamic balance of the vaginal
microecology to improve female
reproductive health.