NU 641 Discussion: Bacterial Vaginosis

Sample Answer for NU 641 Discussion: Bacterial Vaginosis Included After Question

Initial Post

In your initial post, answer all the questions and provide rationales for your answers with supporting evidence using APA formatting. Integrate two evidence-based resources to include clinical practice guidelines as well as the course textbook.

Read the scenario and answer the following questions:

R.S. is a 32-year-old Caucasian woman who seeks treatment for a vaginal discharge that she has had for the past month. She is sexually active and has had the same partner for the past 6 months. She reports noticing an odor, especially after sexual intercourse. Her history reveals that she has been using a commercial douche on a bi-weekly basis during the past year for hygienic purposes in an attempt to prevent vaginal infections. She denies any other associated symptoms.

The physical examination reveals a white vaginal discharge. Microscopic examination of the vaginal discharge shows clue cells, and the pH is 5.5.

Diagnosis: Bacterial Vaginosis

  1. List specific goals of treatment for this patient.
  2. What drug therapy would you prescribe? Why?
  3. What are the parameters for monitoring the success of the therapy?
  4. Discuss specific patient education based on the prescribed therapy.
  5. List one or two adverse reactions for the selected agent that would cause you to change therapy.
  6. What would be the choice for second-line therapy? Provide rationale
  7. What OTC or alternative medications would be appropriate for this patient?
  8. What dietary or lifestyle changes should be recommended?
  9. Describe one or two drug–drug or drug–food interaction for the selected agent.

Reply Posts

Your response should be in a well-developed paragraph (300–350 words) integrating an evidence-based resource that is different than the one you used for the initial post.

Respectfully agree and disagree with your peers’ responses and explain your reasoning by including your rationales in your explanation.

Please refer to the Grading Rubric for details on how this activity will be graded.

The described expectations meet the passing level of 80%. Students are directed to review the Discussion Grading Rubric for criteria which exceed expectations.

A Sample Answer For the Assignment: NU 641 Discussion: Bacterial Vaginosis

Title: NU 641 Discussion: Bacterial Vaginosis

Diagnosis: Bacterial Vaginosis

List specific goals of treatment for this patient.

R.S. has been diagnosed with bacterial vaginosis, which is characterized by the normal hydrogen peroxide-producing lactobacilli that are present in the vaginal flora being replaced by an overgrowth of anaerobic organisms, such as Mycoplasma hominis, Gardnerella vaginalis, Prevotella spp., or Mobilucus spp (Woo & Robinson, 2020, p. 1289). This condition is associated with a biofilm that strongly adheres to vaginal epithelial cells, which promotes the growth and adherence of other offending organisms (Tomás et al., 2020). The first goal of treatment is to eliminate the symptoms that R.S. is experiencing, such as the foul-odored and high pH discharge (Woo & Robinson, 2020, p. 810). In order to do this, some of the other specific main goals of treatment for bacterial vaginosis include the destruction of biofilms, a reestablishment of the healthy vaginal flora, and the eradication of the associated pathogens (Tomás et al., 2020). In addition, bacterial vaginosis that goes untreated has been associated with adverse effects such as pelvic inflammatory disease, abnormal Pap smear results, and pregnancy complications for women who are pregnant (Woo & Robinson, 2020, p. 810). Therefore, another goal would be to avoid these complications through the treatment of this condition. 

What drug therapy would you prescribe? Why?

According to the International Union against sexually transmitted infections (IUSTI) World Health Organisation (WHO) guidelines for treating bacterial vaginosis, 5-7 days of topical or oral metronidazole or 7 days of intravaginal clindamycin are both considered to be first-line treatments for uncomplicated bacterial vaginosis (Sherrard et al., 2018). Cost-effectiveness, the individual circumstances, and the personal choice of the patient should be the main factors in considering the treatment regime (Sherrard et al., 2018). Both of these treatments have equal efficacy, but clindamycin tends to have fewer side effects than metronidazole (Sherrard et al., 2018). However, oral metronidazole is cheaper than the other options (Sherrard et al., 2018). Therefore, I would let R.S. know the cost and common side effects that may be expected with both of these treatments and use her personal input in my decision. However, for the purposes of this post, I will assume that that cost is the most important factor for R.S., and therefore I would prescribe seven days of oral metronidazole 500mg twice daily (Sherrard et al., 2018). This drug is available in 500mg tablets (Vallerand & Sanoski, 2020, p. 865). 

Below is my prescription for R.S.: 

Downey Family Practice

1234 Health Road

Richmond, VA 23223

(555) 555-5555

Nicole Downey, BSN, DNP, FNP-C Date: March 21, 2022 

Patient: R.S.  DOB: 02/19/90 Weight: 50 kg Phone: (628) 456-4567

Metronidazole 500mg tablets

Disp: 14 tablets

Sig: Take one tablet by mouth twice a day for 7 days to treat bacterial vaginosis. Please finish the entire course of this medication even if symptoms resolve. 

No refills.

What are the parameters for monitoring the success of the therapy?

The parameters for monitoring the success of therapy involve the resolution of R.S.’ symptoms. For example, treatment would be successful if she is no longer experiencing white, foul-smelling discharge. 

Discuss specific patient education based on the prescribed therapy.

A major point of education that I would provide to R.S. would be to ensure that she finishes the entire course of therapy and takes the medication as directed (Vallerand & Sanoski, 2020, p. 865). In addition, it is important that she understands the need to avoid alcohol intake for at least 72 hours after treatment with metronidazole, as the concurrent use of both may cause a disulfiram-like reaction consisting of nausea, vomiting, abdominal cramping, headache, and flushing (Vallerand & Sanoski, 2020, p. 866). I would tell R.S. that she may take this drug on an empty stomach, or if she is experiencing gastrointestinal discomfort, she may take it with food or milk (Vallerand & Sanoski, 2020, p. 865).

In addition, I would let her know that this medication has the potential to cause a metallic taste that may be unpleasant and can also cause dry mouth (Vallerand & Sanoski, 2020, p. 866). To combat this, I would advise her to use sugar-free gum, candy, mouth rinses, and overall good oral hygiene (Vallerand & Sanoski, 2020, p. 866). Further, I would ask R.S. to inform her provider of any new rash, fever, blisters, or muscle or joint aches that develop, since a rare but potential adverse reaction of this drug is Stevens-Johnson syndrome, which would require the drug to be discontinued (Vallerand & Sanoski, 2020, p. 865). 

List one or two adverse reactions for the selected agent that would cause you to change therapy.

I would change R.S.’s therapy if she were to experience a hypersensitivity reaction or if she developed hepatitis due to this drug (Vallerand & Sanoski, 2020, p. 864). The development of Stevens-Johnson syndrome is very rare, but would be a potential adverse effect of metronidazole that would cause me to change therapy if severe (Vallerand & Sanoski, 2020, p. 865). Further, this drug is contraindicated during the first trimester of pregnancy, so I would discontinue this drug if R.S. reported that she believed she may be pregnant or is attempting to become pregnant (Vallerand & Sanoski, 2020, p. 864). I would ask her about pregnancy and her plans to become pregnant before I prescribed this medication as well. 

What would be the choice for second-line therapy? Provide rationale

Another appropriate choice for treatment of R.S.’ bacterial vaginosis would be intravaginal 2% clindamycin cream daily for seven days, which is still considered first-line treatment (Sherrard et al., 2018). Below would be my prescription for R.S.:

Downey Family Practice

1234 Health Road

Richmond, VA 23223

(555) 555-5555

Nicole Downey, BSN, DNP, FNP-C Date: March 21, 2022 

Patient: R.S.  DOB: 02/19/90 Weight: 50 kg Phone: (628) 456-4567

2% clindamycin vaginal cream 

Disp: 1 tube

Sig: Administer cream vaginally daily for 7 days to treat bacterial vaginosis. Please finish the entire 7-day course of this treatment even if symptoms resolve. 

No refills.

 Other alternative treatment regimes that may also be used as second-line therapies include metronidazole 2g by mouth in a single dose or tinidazole 2g by mouth in a single dose (Sherrard et al., 2018). However, it should be mentioned that cure rates are lower for single-dose therapies (Sherrard et al., 2018). Other alternative treatments may include tinidazole 1g by mouth for five days, clindamycin 300mg by mouth twice a day for seven days, or dequalinium chloride 10mg vaginal tablet daily for six days (Sherrard et al., 2018). While vaginal dequalinium has similar cure rates when compared to vaginal clindamycin, it is more expensive than other treatments (Sherrard et al., 2018). 

What OTC or alternative medications would be appropriate for this patient?

Since treatment with the recommended antibiotics is still associated with high failure and recurrence rates, it is important to provide R.S. with alternative strategies that may be combined with conventional treatments in order to treat her infection more effectively (Tomás et al., 2020). For example, using probiotics, prebiotics, and acidifying agents may assist to reestablish a more normal physiologic vaginal (Tomás et al., 2020). In addition, R.S. may benefit from other antimicrobials, antiseptics, and natural compound products (Tomás et al., 2020). For example, the antiseptics chlorhexidine and hydrogen peroxide provide large spectrum antibacterial activity through the non-specific disruption of the cell membrane (Tomás et al., 2018). The use of chlorhexidine 0.5% vaginal gel has been shown to be effective and well-tolerated for curing bacterial vaginosis, so this may be appropriate and beneficial for R.S. to use. 

What dietary or lifestyle changes should be recommended?

R.S. reported that she uses a vaginal douche bi-weekly in an effort to reduce her risk of vaginal infections. While the evidence in the literature remains mixed regarding the association between the use of a vaginal douche and bacterial vaginosis, multiple studies have shown that douching may promote the development or recurrence of bacterial vaginosis (Coudray & Madhivanan, 2020). Therefore, I would educate R.S. about this potential contributing factor and discuss with her that avoiding the use of a vaginal douche may be beneficial.  

In addition, using cotton or cloth products for menstrual hygiene was associated with a higher risk of bacterial vaginosis as compared to using sanitary pads (Coudray & Madhivanan, 2020). Therefore, I would recommend that R.S. avoid cotton or cloth menstrual hygiene products.

Describe one or two drug–drug or drug–food interaction for the selected agent.

As previously mentioned, ingesting alcohol while taking metronidazole therapy has the potential to produce a disulfiram-like reaction consisting of nausea, vomiting, headache, flushing, and abdominal cramping (Vallerand & Sanoski, 2020, p. 866). In addition, taking metronidazole with cimetidine may decrease the metabolism of cimetidine (Vallerand & Sanoski, 2020, p. 864). The effects of phenytoin, lithium, and warfarin may be increased while taking metronidazole as well (Vallerand & Sanoski, 2020, p. 864). 

References

Coudray, M. S., & Madhivanan, P. (2020). Bacterial vaginosis—A brief synopsis of the literature. European Journal of Obstetrics & Gynecology and Reproductive Biology, 245, 143-148.

Sherrard, J., Wilson, J., Donders, G., Mendling, W., & Jensen, J. S. (2018). 2018 European (IUSTI/WHO) International Union against sexually transmitted infections (IUSTI) World Health Organisation (WHO) guideline on the management of vaginal discharge. International Journal of STD & AIDS, 29(13), 1258-1272.

Tomás, M., Palmeira-de-Oliveira, A., Simões, S., Martinez-de-Oliveira, J., & Palmeira-de-Oliveira, R. (2020). Bacterial vaginosis: Standard treatments and alternative strategies. International Journal of Pharmaceutics, 587, 119659.

Vallerand, A., & Sanoski, C. (2020). Davis’s drug guide for nurses (Seventeenth ed.). F.A. Davis Company.

Woo, T. M., & Robinson, M. V. (2020). Pharmacotherapeutics for advanced practice nurse prescribers (5th edition). FA Davis.

A Sample Answer For the Assignment: NU 641 Discussion: Bacterial Vaginosis

Title: NU 641 Discussion: Bacterial Vaginosis

1. List specific goals of treatment for this patient.


Specific goals of treatment for bacterial vaginosis (BV) include relief of symptoms, which in this case includes odor and discharge (Sobel, 2022). Another goal of treatment for BV includes reducing the risk of developing a sexually transmitted infection (STI) (Sobel, 2022). Treatment of BV can lower the risk of acquiring an STI (Sobel, 2022).

 
2. What drug therapy would you prescribe? Why?


Bacterial vaginosis occurs when there is a reduction in lactobacilli, or normal vaginal bacteria, and an increase in other organisms (Sobel & Mitchell, 2022). These organisms are typically anaerobic gram negative rods, such as gardenerella vaginalis, prevotella, bacteriocides, and peptostreptococcos species (Sobel & Mitchell, 2022). Metronidazole is effective against BV as it disrupts protein synthesis and DNA in certain organisms (Vallerand & Sanoski, 2020). Additionally, metronidazole works very well against anaerobic bacteria, such as those that cause BV (Vallerand & Sanoski, 2020). According to Sobel (2022), both metronidazole and clindamycin are approved for the treatment of BV and have similar efficacy. Sobel (2022) notes that metronidazole is less likely to cause a secondary infection of clostridium difficile than clindamycin. The following prescription would be written for J.S, based on dosing from Sobel (2022):

Metronidazole 500 mg tablets

 
Take one tablet by mouth two times per day for seven days.

Dispense 14 tablets. 

3. What are the parameters for monitoring the success of the therapy?


Success of BV treatment would be resolution of BV symptoms and absence of infection (Vallerand & Sanoski, 2020; Sobel, 2022). 



4. Discuss specific patient education based on the prescribed therapy.


Patient education regarding metronidazole includes ensuring the patient knows to complete the entire course of antibiotics, even if symptoms resolve before the course is complete (Vallerand & Sanoski, 2020). R.S. should also be instructed to take the doses evenly spaced in the day as much as possible (Vallerand & Sanoski, 2020)  R.S. should also be educated on avoiding alcohol while taking metronidazole, as it may cause disulfiram- like symptoms (Sobel, 2022).




5. List one or two adverse reactions for the selected agent that would cause you to change therapy.

Adverse reactions that may occur with metronidazole include the development of Stevens Johnson syndrome, vomiting, diarrhea and abdominal pain (Vallerand & Sanoski, 2020)
Less significant adverse effects that can be seen with oral metronidazole include nausea and metallic taste in the mouth (Sobel, 2022).




6. What would be the choice for second-line therapy? Provide rationale


If the patient could not tolerate or adhere to oral metronidazole, metronidazole can also be administered via vaginal gel (Sobel, 2022). The vaginal gel is a 0.75% gel in a 5 gram per applicator preparation, to be administered once daily (Sobel, 2022). Efficacy is like that of oral metronidazole (Sobel, 2022). Education should include proper administration as well as avoiding intercourse for a period after administration (Vallerand & Sanoski, 2020). 




7. What OTC or alternative medications would be appropriate for this patient?



There is mixed literature on the use of probiotics like lactobacillus in conjunction with metronidazole and for the prevention of recurrence of BV (Sobel, 2022). Probiotics should be considered as a supplement for J.S.



8. What dietary or lifestyle changes should be recommended?


R.S. should be instructed on avoiding vaginal douching. Vaginal douching is associated with decreased amounts of good bacteria including lactobacilli (Hesham et al., 2021). Vaginal douching is associated with higher rates of BV, as seen with R.S., and can also increase the likelihood of urinary tract infections, due to lower levels of lactobacilli (Hesham et al., 2021). Another consideration for R.S. should be using condoms during intercourse, which have been shown to decrease likelihood of recurrence of BV (Sobel, 2022). Additionally, oral contraceptives have been shown to decrease rates of BV, and this may be a consideration for R.S. (Sobel, 2022).




9. Describe one or two drug–drug or drug–food interaction for the selected agent.


A drug-drug interaction noted with metronidazole is that it can increase the effects of phenytoin, lithium and warfarin (Vallerand & Sanoski, 2020). Additionally, as previously discussed, metronidazole may interact with alcohol and cause disulfiram-like reaction (Vallerand & Sanoski, 2020).


References


Hesham, H., Mitchell, A. J., Bergerat, A., Hung, K., & Mitchell, C. M. (2021). Impact of vaginal douching products on vaginal Lactobacillus, Escherichia coli and epithelial immune responses. Scientific reports, 11(1), 1-8.

Sobel, J. (2022). Bacterial vaginosis: Treatment. Up to Date. https://www-uptodate-com.regiscollege.idm.oclc.org/contents/bacterial-vaginosis-treatment?search=bacterial%20vaginosis%20treatment&source=search_result&selectedTitle=1~111&usage_type=default&display_rank=1

Sobel, J. & Mitchell, C. Bacterial vaginosis: clinical manifestations and diagnosis. Up to Date. https://www-uptodate-com.regiscollege.idm.oclc.org/contents/bacterial-vaginosis-clinical-manifestations-and-diagnosis?search=bacterial%20vaginosis&topicRef=113103&source=see_link

Vallerand, A., & Sanoski, C. (2020). Davis’s drug guide for nurses (Seventeenth ed.). F.A. Davis Company.