Treatment of bacterial vaginosis

Maintaining Updated Patient's Medication Records: Introduction of an Order-on-Behalf Service by Pharmacists

INTRODUCTION

Accurate medication records are integral to healthcare, especially for obstetrics and gynecology and pediatric patients. When pharmacists perform verbal interventions with prescribers, these were often not updated in the patients' medication records. To address this issue, the order-on-behalf (OOB) service by pharmacists was implemented in late November 2015, with the aim of providing timely updates of patients' medication records. The impact of service will be evaluated in this article.

METHODS

The OOB records from December 2015 to April 2017 were collected and reviewed. Details collected include patient type, date performed, date of prescription, and details of interventions. Respective pharmacists who entered the orders were approached for further clarifications, where required. This was a process improvement project exempted from review.

RESULTS

A total of 1501 entries (824 for women, 677 for children) were reviewed. Top three medication-related problems identified were inappropriate dosage regimen (845), improper drug selection (185), and therapeutic substitution (226). The most commonly implicated drugs were hormones (28%) and antibiotics (18%) for obstetrics and gynecology-related entries and antibiotics (27%) and antiepileptic drugs (6%) for pediatric-related entries.

CONCLUSIONS

The OOB service has updated many patients' medication records. Having updated records enhances patient safety because it provides the most accurate information for the prescribers at the next patient visit. Review of OOB data identified the most common types of medication-related problems, as well as the patient subtypes involved. This provides a platform for future work to be performed on system optimizations to improve patient safety.

Current indications for the use of clindamycin: A critical review

OBJECTIVES

To review the literature and develop evidence-based guidelines for the use of the antibiotic clindamycin.

DATA SOURCES

A search of the MEDLINE database for randomized clinical trials, cohort studies and review articles that examine the therapeutic use or potential adverse effects of clindamycin was undertaken for the years 1966 to 1996. In addition, relevant citations obtained from the references cited in the identified reviews, book chapters and antibiotic guidelines were included.

DATA EXTRACTION

Selected articles examining the indications for or adverse effects from the prophylactic or therapeutic use of clindamycin were selected. A level of evidence was assigned to the indication according to published criteria.

DATA SYNTHESIS AND CONCLUSIONS

Randomized clinical trials (level 1 evidence) support the use of clindamycin in a number of common conditions, including preoperative prophylaxis, intra-abdominal infections, recurrent group A streptococcal pharyngitis, Chlamydia trachomatis cervicitis and anaerobic lung infections. Cohort studies (level 2 evidence) support the use of clindamycin for bone and soft tissue infections. Expert opinion (level 3 evidence) supports the use of clindamycin for invasive group A streptococcal infection and the treatment of diabetic foot infections. Clindamycin's disadvantages are its high cost, the common occurrence of rash and the predisposition of patients taking clindamycin to Clostridium difficile-associated colitis. Based on cohort studies, the risk of severe diarrhea in out-patients is as low as one per 1000, but the risk of in-patients acquiring C difficile colonization may be as high as 30%.

Postcoital bleeding: a study of the current practice amongst consultants in the United Kingdom

OBJECTIVES

To measure the variations amongst consultant gynaecologists all over the UK in managing women with postcoital bleeding (PCB).

STUDY DESIGN

A questionnaire was sent to 1020 consultant gynaecologists in the UK, using the database of The Royal College of Obstetricians and Gynaecologists, enquiring about their opinions and the details of practice.

RESULTS

Six hundred and fourteen (60%) replies were received. Three hundred and thirty-seven (59.8%) of the respondents agree that PCB is a significant clinical issue that requires developing national guidelines for management, 452 (80.1%) do not have local guidelines in their departments, 336 (59.6%) agree with The Department of Health guidelines for referral. Two hundred and eighty-one (49.8%) respondents see women in gynaecology clinic, 94 (16.7%) in colposcopy clinic, while 163 (28.9%) see them in either clinics depending on the workload. Only 275 (48.8%) respondents repeat the cervical smear for those with negative smear history who are still within the national screening interval. Chlamydia testing is performed by 450 (79.8%) respondents, whereas 68 (12.1%) consider investigating the endometrium in selected cases.

CONCLUSION

The results highlight the wide variations in managing women with PCB. Given the well-reported association with serious pathology, it may be prudent to standardise the management in the UK based on the best available evidence.

Advancing vaginal drug delivery

Bacterial vaginosis and vulvovaginal candidiasis are the two most common forms of vaginitis in female patients. Although a variety of effective treatments have been available to eradicate these infections, limitations have lessened the utility of previously available products. Oral therapies are often fraught with systemic adverse reactions, as well as the potential to interact with concomitant medications. Vaginal preparations, although generally perceived as safer, have historically been undesirable for women to use due to their multiple days of dosing; messy, dripping creams; and requisite night-time dosing. Recognising that the therapeutic delivery of the active agent plays a critical role in the overall success of therapy, and attempting to circumvent the weaknesses of traditional vaginal drug delivery while maintaining and even improving safety profiles, a new form of vaginal drug delivery was developed. This unique and proprietary delivery system, with both bioadhesive and sustained release properties, introduces the convenience of a single dose of medication that can be applied at any time, with efficacy rates equivalent to lengthier durations of treatment. This advance in science and technology has now been successfully applied to two products, Gynazole-1(butoconazole nitrate 2%) and Clindesse(clindamycin phosphate 2%) indicated for the treatment of vulvovaginal candidiasis and bacterial vaginosis, respectively, in order to enhance convenience and compliance for the treatment of two very common clinical conditions.

Bacterial vaginosis - a disturbed bacterial flora and treatment enigma. Review article IV

The syndrome bacterial vaginosis (BV) is characterized by a disturbed vaginal microflora in which the normally occurring lactobacilli yield quantitatively to an overgrowth of mainly anaerobic bacteria. As BV is a possible cause of obstetrics complications and gynaecological disease--as well as a nuisance to the affected women--there is a strong impetus to find a cure. In BV treatment studies, the diagnosis criteria for diagnosis of BV vary considerably and different methods are used for cure evaluation. The design of study protocols varies and there is no consensus respecting a suitable time for follow-up visits. For the purpose of this review, available data were recalculated for 4-week post treatment cure rates. For oral metronidazole the 4-week cure rate was found not to exceed 60-70%. Treatment regimens with topical clindamycin or topical metronidazole have the same cure rates. It can thus be said that no sound scientific basis exists for recommending any particular treatment. There is no evidence of beneficial effects on BV engendered by partner treatment, or by addition of probiotics or buffered gel. Long-term follow-up (longer than 4 weeks) shows a relapse rate of 70%. With a primary cure rate of 60-70%, and a similar relapse rate documented in the reviewed literature, clinicians simply do not have adequate data for determining treatment or designing clinical studies. This is unfortunate since--apart from the obvious patient benefits--clinical studies can often serve as a guide for more basic studies in the quest for underlying disease mechanisms. In the case of BV there is still a need for continued basic studies on the vaginal flora, local immunity to the flora and host-parasite interactions as an aid when designing informative clinical studies.

A Randomized, Double-Blind Clinical Trial of Vaginal Acidification versus Placebo for the Treatment of Symptomatic Bacterial Vaginosis

BACKGROUND AND OBJECTIVES

Vaginal acidification has been suggested as a means of normalizing the vaginal flora.

GOAL

The purpose of this study was to determine the effectiveness of an acetic acid-based vaginal gel in the treatment of bacterial vaginosis (BV).

STUDY DESIGN

Forty-four patients with BV were enrolled in a randomized, double-blind clinic trial. Of these, 29 were evaluable. Patients were randomized to receive either 5 mL acetic acid gel (n = 14) or placebo gel (n = 15) intravaginally twice daily for 7 days. Clinical criteria and vaginal Gram stain scores were compared between the initial visit and at 2 weeks after initiating therapy.

RESULTS

No significant differences were noted when comparing drug and placebo in terms of subjective or clinical improvement or improvement in Gram stain smears for bacterial vaginosis.

CONCLUSION

Vaginal acidification with an acetic acid gel formulated to pH 3.9 to 4.1 was ineffective therapy for bacterial vaginosis.

The inhibitory effect of clindamycin on Lactobacillus in vitro

OBJECTIVE

To evaluate the in vitro effect of varying concentrations of clindamycin on Lactobocillus spp.

METHODS

Concentrations of clindamycin ranging from 1.95-20,000 microg/ml were studied for their effect on the growth of six strains of Lactobacillus.

RESULTS

Clindamycin concentrations between 1.95-31.25 microg/ml had no statistically significant effect on growth of lactobacilli (p > 0.05). Concentrations 125 and 250 microg/ml had a bacteriostatic effect. The mean minimum inhibitory concentration (MIC) for studied Lactobacillus strains was determined as 1,000 microg/ml.

CONCLUSION

High concentrations of clindamycin achieved in the vagina by intravaginal application might be inhibitory for Lactobacillus.

Antibiotic use in the emergency department. IV: Single-dose therapy and parenteral-loading dose therapy

There are a number of infectious diseases that can be treated efficaciously with a single dose of an antimicrobial agent. Other infections that can be treated with oral antibiotics on an outpatient basis may resolve more quickly if a parenteral loading dose is given in the emergency department (ED) prior to discharge. This article reviews the supporting literature and indications for single-dose and parenteral first-dose-loading antimicrobial therapy in the ED. This approach may be appropriate for such diverse infections as streptococcal pharyngotonsillitis, otitis media, urinary tract infections, chlamydial genital infections, vaginitis due to yeast, bacteria, or trichomoniasis, pneumonia, gonorrhea and pelvic inflammatory disease, and pediatric fever without a source.