- 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 April 2024.
Tactuum has been working hard to address the issues experienced during the last week. They have identified a series of three mitigation measures and put the first of these in place on Friday 3rd May. If this does not resolve the problems, the second mitigation will be actioned, and then the third if necessary.
Please keep a lookout for any slowing down of the system or getting locked out. Please email myself, mbuchner@tactuum.com and onivarova@tactuum.com if you experience any problems, and also please raise an urgent support ticket via the Support Portal.
Thank you for your patience and understanding while we achieve a full resolution.
A rotating carousel presenting some of the key RDS tools and capabilities, and an editable slideset, are now available in the Resources for RDS providers section of the Learning and Support toolkit.
The redesign of RDS Search and Browse is still on-track for delivery by mid-June 2024. We then plan to have a 3-week user acceptance testing phase before release to live. All editors and toolkit owners on this mailing list will be invited to participate in the UAT.
The archiving and version control functionality is also progressing well and we will advise on timescales for user acceptance testing shortly.
Tactuum is also progressing with the deep linking to individual toolkits within the mobile RDS app. There are several unknowns around the time and effort required for this work, which will only become clear as the work progresses. So we need to be careful to protect budget for this purpose.
These have all been compiled and effort estimated. Once the redesign work is complete, these will be prioritised in line with the remaining budget. We expect this to take place around late June.
Many thanks to those of you completed the value and impact survey we distributed in February. Here are some key findings from the 65 responses we received.
Figure 1: Impact of RDS on direct delivery of care
Key figures
Figure 2 shows RDS impact to date on delivery of health and care services
Key figures
These data show how RDS is already contributing to NHS reform priorities and supporting delivery of more sustainable care.
Saving time and money
Quality assurance and governance
Service innovation and workforce development
A few examples of toolkits published to live in the last month:
Some of the toolkits the RDS team is currently working on:
Please contact his.decisionsupport@nhs.scot if you would like to learn more about a toolkit. The RDS team will put you in touch with the relevant toolkit lead.
Thanks to all of you who have responded to the retrospective quality audit survey and to the follow up questions. We still have some following up to do, and to work with owners of a further 23 toolkits to complete responses. An interim report is being presented to the HIS Quality and Performance Committee.
Eight clinical services and two public library services are undertaking tests of change to implement the Being a partner in my care app. This app aims to support patients and the public to become active participants in Realistic Medicine. It has a strong focus on personalised, person-centred care and a library of shared decision aids, as well as simple explanations and videoclips to help the public to understand the aims of Realistic Medicine. The tests of change will inform guidance and an implementation model around wider adoption and spread of the app.
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)