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.