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Respiratory Pathogens
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Vulvovaginitis may be caused by bacterial pathogens, with respiratory pathogens being the most common. Streptococcus pyogenes (group A β-hemolytic streptococci) is the most common respiratory pathogen isolated in girls with vulvovaginitis.7 Another common pathogen is H. influenzae.7 The mode of transmission is likely self-inoculation by hand from the nose and mouth to the vulvar region. Recurrent vulvovaginitis with S. pyogenes may be associated with persistent asymptomatic bacterial carriage in the nasopharynx.1
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In addition to vaginal discharge, an erythematous dermatitis involving the vulva and perianal tissues is often noted.1 Treatment is directed toward the specific bacteria isolated. Empiric therapy with oral penicillin or amoxicillin for 10 days may be started if symptoms and discharge are profuse once cultures are taken.1,5 If treatment with amoxicilin fails for H. Influenzae cases, treatment with amoxicillin/clavulanate is recommended.1
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Enteric pathogens including Shigella and Yersinia may be a cause of vaginitis in the prepubertal child.5 Shigella flexneri can cause a mucopurulent, bloody discharge sometimes seen after an episode of diarrhea.5 Diagnosis is made by culture of the vaginal discharge.8 Treatment should be directed toward antibiotic sensitivities, and options include trimethoprim/sulfamethoxazole, ampicillin, ceftriaxone, and azithromycin.1,8
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Vulvovaginal Candidiasis
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Candidal vaginitis occurs more frequently in adolescents than younger girls because Candida albicans colonizes the vagina after the onset of puberty, when estrogen is present to promote fungal growth.1 Candidal infections are, therefore, uncommon in the prepubertal girl, except in the presence of diabetes mellitus, immunodeficiency, antibiotic use or diaper use.2
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The symptoms of candidal vaginitis include inflammation of the vulva and perianal region, and a thick, whitish discharge.5 Satellite lesions and white plaques may sometimes be identified.9 A wet mount with a potassium hydroxide preparation is used to make the diagnosis.5 If the diagnosis is still in question, specific cultures for yeast may be sent.9
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Treatment includes topical antifungals (nystatin, miconazole, clotrimazole, or terconazole) for external genitalia.5 If topical antifungals are unsuccessful, oral fluconazole should be considered.1