- Thin, offensive smelling vaginal discharge
- Vaginal odour
Frequently recurs
NB: Not typically associated with itch, soreness or irritation
Welcome to the Right Decision Service (RDS) newsletter for August 2024.
Following the recent RDS outages, Tactuum and the RDS team have been reviewing the learning from these incidents. We are committed to doing all we can to ensure a positive outcome by strengthening the RDS to make it fully robust and clinically resilient for the future.
We would like to invite you to a webinar on 26th September 3-4 pm on national and local contingency planning for future RDS outages. Tactuum and the RDS team will speak about our business continuity plans and the national contingency arrangements we are putting in place. This will also be a space to share local contingency plans, ideas and existing good practice. We would also like to gather your views on who we should send communications to in the event of future outages.
I have sent a meeting request for this date to all editors – please accept or decline to indicate attendance, and please forward on to relevant contacts. You can also contact Olivia.graham@nhs.scot directly to register your interest in participating.
2.National IV fluid prescribing calculator
This UK CA marked calculator is now live at https://righdecisions.scot.nhs.uk/ivfluids . It has been developed by a multiprofessional steering group of leads in IV fluids management, as part of the wider Modernising Patient Pathways Programme within the Centre for Sustainable Delivery. It aims to address a known cause of clinical error in hospital settings, and we hope it will be especially useful to the new junior doctors who started in August.
Please do spread the word about this new calculator and get in touch with any questions.
The following toolkits are now live;
We have updated and simplified this guidance within our standard operating procedures. We have clarified the guidance on how to determine whether an RDS tool is a medical device, and have provided an interactive powerpoint slideset to steer you through the process.
We have developed a guide to support editors and toolkit leads through the process of scoping, designing, delivering, quality assuring and implementing a new RDS toolkit. We hope this will help in project planning and in building shared understanding of responsibilities throughout the full development process. The guide emphasises that the project does not end with launch of the new toolkit. Implementation, communication and evaluation are ongoing activities throughout the lifetime of the toolkit.
To book a place, please contact Olivia.graham@nhs.scot, providing your name, organisation, job role, and level of experience with RDS editing (none, a little, moderate, extensive.)
7 Evaluation projects
Dr Stephen Biggart from NHS Lothian has kindly shared with us the results of a recent survey of use of the Edinburgh Royal Infirmary of Edinburgh Anaesthesia toolkit. This shows that the majority of consultants are using it weekly or monthly, mainly to access clinical protocols, with a secondary purpose being education and training purposes. They tend to find information by navigating by specialty rather than keyword searching, and had some useful recommendations for future development, such as access to quick reference guidance.
We’d really appreciate you sharing any other local evaluations of RDS in this way – it all helps to build the evidence base for impact.
If you have any questions about the content of this newsletter, please contact his.decisionsupport@nhs.scot If you would prefer not to receive future newsletters, please email Olivia.graham@nhs.scot and ask to be removed from the circulation list.
With kind regards
Right Decision Service team
Healthcare Improvement Scotland
What’s New
Tinidazole no longer available
Delaquinium chloride is a licensed 2nd line option
Note IUSTI guideline advice that BV commoner in women with an IUCD
Bacterial Vaginosis is the most common microbiological cause of abnormal vaginal discharge.
It is caused by an overgrowth of anaerobic organisms.
Frequently recurs
NB: Not typically associated with itch, soreness or irritation
Thin, white homogenous discharge coating introitus and vaginal walls, it may look slightly frothy. A characteristic odour is often noted
NB: vulval inflammation is not typical in BV
In genitourinary settings two approaches to the diagnosis of BV are widely used:
Amsel’s criteria and the Hay/Ison criteria 1. Both require microscopy to be available, which is not always the case in sexual health clinics. Where available, microscopy can be used, but syndromic management is supported by national guidelines1,2
The Hay/Ison Criteria (used in the NaSH microscopy page) are:
Grade 0 no bacteria seen
Grade 1 (Normal): Lactobacillus morphotypes predominate
Grade 2 (Intermediate): Mixed flora with some Lactobacilli present, but Gardnerella or Mobiluncus morphotypes also present
Grade 3 (BV): Predominantly Gardnerella and/or Mobiluncus morphotypes. Few or absent Lactobacilli.
Grade 4 Gram positive cocci predominate (consider aerobic vaginitis)
Amsel’s criteria are at least three out of:
(1) Thin, white, homogeneous discharge
(2) Clue cells on microscopy of wet mount
(3) pH of vaginal fluid >4.5
(4) Release of a fishy odour on adding alkali (10% KOH).
History
Diagnosis can be made on the basis of
It is important to take a sexual history to consider the risk of STI and offer STI testing as appropriate as Chlamydia and Gonorrhoea can co-exist. A cervical screening history should be taken as cervical cancer is a differential diagnosis of a smelly discharge. Also consider if a tampon could have been retained.
If possible undertake vulval and speculum examination to visualise any discharge. Inspect the cervix to
exclude any abnormality as a cause of offensive discharge.
Tests options
Not recommended:
High vaginal swabs are of limited value in diagnosing BV as organisms such as gardnerella can be present in 30-40% asymptomatic women. A culture reported as normal does not exclude clinical BV. Microscopy and vaginal pH are far more useful and women reporting recurrent symptoms are better to have a microscopy slide taken.
Asymptomatic women do not need treatment (asymptomatic women should not be being diagnosed as
without symptoms there is no indication to take a test).
General advice
The best ways of preventing BV are not know but avoiding anything that upsets the natural balance of
bacteria in the vagina may help. This includes avoiding:
Use of emollients as a soap substitute for the genital area (available from any pharmacy) is recommended.
BV is more common in women with an IUCD5
If a woman is experiencing recurrent episodes of BV alternative methods can be discussed.
1st line
Metronidazole 400mg oral twice daily 5-7 days (slightly lower relapse rate)
1st line in pregnancy
OR
Metronidazole 2g single oral dose (not recommended in pregnancy)
2nd Line
Clindamycin 300mg oral twice daily 7 days (risk of pseudomembranous colitis)
Or
Dequalinium chloride 10mg vaginal tablets One 10mg vaginal tablet daily for six days6
Insufficient evidence to assess effectiveness but anecdotally useful
Licensed indications
Treatment of BV in adults
Relactagel® : 5 mL( 1 tube) to vagina nightly for 7 nights
Relactagel® is unsuitable for people with an allergy to shellfish as the glycogen is derived from oysters.
There may be a potential risk to a partner who is allergic to shellfish if these have been used.
Balance Activ® is not licenced for treatment
Refer to WOS Pregnancy and STI’s Guideline instead
Non–pregnant women: Not necessary unless symptomatic
Pregnant women: test of cure after a month1
No evidence of benefit in studies of screening and treating male partners
No studies of treatment in female partners although high incidence in female partners of women with BV. If a
female partner is asymptomatic treatment need not be offered routinely.
Consider alternative diagnosis
Check compliance with treatment
Try alternative therapy option - longer course of metronidazole may be more effective than single dose
Sporadic Recurrences
Up to 30% of women have a recurrence within 3 months
Examination and investigation should be considered but may not be necessary if a previous episode of the
signs and symptoms of BV responded to antibiotic treatment, and there are no grounds to suspect an STI or
cervical abnormality.
Frequent Recurrences of Bacterial Vaginosis
This is widely defined as more than four recurrences per year.
Speculum examination should be carried out. The diagnosis should be confirmed with microscopy or HVS.
Negative swabs (or negative dry slide) and persistent symptoms should prompt referral to a sexual health
clinic with microscopy available.
Persistent, symptomatic BV may be associated with the presence of an IUD and an alternative method of
contraception may need to be considered if there is no response to therapy.
Suppressive/preventive treatment
400mg metronidazole oral twice daily for 3 days at start and/or end of menstruation
or
5g 0.75% metronidazole gel intravaginally twice weekly for 16 weeks1
or
Relactagel®: 5 mL (1 tube) nightly to vagina for 2–3 nights after menstruation5
or
Balance Activ RX gel® 5 mL (1 tube) to vagina 1–2 times a week
British National Formulary prices accessed February 2021 NB local contracts may result in
different prices.
Metronidazole 2g | £1.07* |
Metronidazole 400mg b.d. 7 days | £3.50-4.50 |
Metronidazole gel | £4.31 |
Clindamycin 2% Cream | £10.86 |
Clindamycin 300mg b.d. 7 days | £17.84 |
Relactagel 7 x 5ml tubes | £5.25 |
Balance Activ 7 x 5ml tubes | £5.25 |
Delquinium Chloride( Fluomizin) | £6.95 |
Not in BNF : local over labelled pack price 2020
Patient information leaflets
BV information leaflet
https://www.bashhguidelines.org/media/1124/bv_pil_print_2014.pdf (accessed 14/05/2021)
What do you know about...Vaginal health?
http://www.healthscotland.com/documents/3419.aspx
online versions in English, Polish, Chinese, Urdu, Romanian (accessed 14/05/2021)