What is the recommended treatment plan for Aerobic Vaginosis (AV) caused by E. coli and Enterococcus faecalis, considering interactions with current medications, such as fluoxetine (Selective Serotonin Reuptake Inhibitor - SSRI)?

Treatment Plan for Aerobic Vaginosis with E. coli and Enterococcus faecalis

Drug Interaction Assessment

There are no clinically significant interactions between Augmentin (amoxicillin-clavulanate) and fluoxetine (SSRI). The proposed treatment regimen is safe to proceed without medication adjustments.

Recommended Treatment Regimen

Primary Antibiotic Therapy

Augmentin Duo Forte 875/125 mg orally twice daily for 7 days is the appropriate choice for this patient's aerobic vaginitis caused by E. coli and Enterococcus faecalis. 1, 2

• Amoxicillin-clavulanate provides broad-spectrum coverage against enteric gram-positive and gram-negative aerobes, which are the hallmark pathogens in aerobic vaginitis 1
• This agent is bactericidal and has minimal interference with vaginal microbiota restoration 2
• The 7-day duration is essential for maximal effectiveness in vaginal dysbiosis conditions 3

Critical Adjunctive Therapy: Vaginal Probiotics

Vaginal probiotic therapy is mandatory in this case due to complete lactobacilli depletion (0.00). 4, 1

• Biome for Her vaginal probiotics nightly × 7 nights, then twice weekly × 8 weeks is appropriate for recolonization 4
• The absence of lactobacilli eliminates the vaginal defense mechanism and allows pH elevation above 5, perpetuating the dysbiosis 4
• Without lactobacilli restoration, recurrence rates are extremely high 1

Oral Probiotics

• Oral probiotics (Biome for Her) 1 capsule daily × 12 weeks supports systemic and vaginal microbiome restoration 4, 1
• This addresses the enteric source of vaginal colonization with E. coli and Enterococcus 1

Optional Boric Acid Therapy

Boric acid 600 mg intravaginally can be considered as adjunctive therapy but must be discontinued before attempting conception. 5

• Boric acid provides antibiofilm activity and helps break down clumpy discharge 5
• Dosing: 600 mg nightly × 7 nights, then twice weekly × 2-4 weeks 5
• Critical caveat: Must be completely discontinued before ovulation/conception attempts due to potential reproductive toxicity 5

Behavioral and Sexual Health Modifications

Abstain from intercourse during the initial 7-day treatment period. 1

• Aerobic vaginitis is NOT sexually transmitted; partner treatment is not indicated 4, 1
• Avoid all vaginal irritants: soaps, douches, scented products, glycerin-based lubricants 1
• Cotton underwear and loose clothing reduce moisture and bacterial overgrowth 1

Fertility Considerations

Delay conception attempts until 2-3 weeks after completing antibiotics AND until repeat microbiome testing confirms lactobacilli restoration. 4

• E. faecalis in aerobic vaginitis has been associated with increased risk of HPV 16 infection and cervical intraepithelial lesions (CIN) 4
• The inflammatory milieu (elevated IL-6, IL-8, TNF) created by E. faecalis reduces fertility and increases adverse pregnancy outcomes 4
• Lactobacilli restoration is essential before conception to provide protective vaginal environment 4

Red Flag Symptoms Requiring Urgent Evaluation

Seek immediate medical attention if any of the following develop:

• Pelvic pain or lower abdominal pain 1
• Fever or systemic symptoms 1
• Worsening discharge despite treatment 1
• Signs of pelvic inflammatory disease (PID) 4

Follow-Up Protocol

Telehealth review in 2 weeks to assess treatment response. 1

• Repeat vaginal microbiome testing at 8-12 weeks to confirm lactobacilli restoration and pathogen eradication 4, 1
• Clinical improvement should be evident within the first week of appropriate therapy 1
• If symptoms persist beyond 2 weeks, consider resistant organisms or alternative diagnosis 1

Common Pitfalls to Avoid

Do not treat this as bacterial vaginosis (BV)—aerobic vaginitis requires different management. 1, 2

• BV is anaerobic and non-inflammatory; AV is aerobic and inflammatory 1
• Metronidazole alone (standard BV treatment) is inadequate for aerobic pathogens 1, 2
• Vaginal cultures alone should not guide treatment; microscopy findings are essential 1

Do not omit probiotic therapy—antibiotics alone will fail without lactobacilli restoration. 4, 1

• The complete absence of lactobacilli (0.00) means the vaginal ecosystem cannot self-correct 4
• Recurrence is nearly inevitable without active recolonization efforts 1

Do not allow conception during active treatment or before microbiome restoration. 4

• Active AV with E. faecalis increases risk of adverse pregnancy outcomes 4
• Boric acid has reproductive toxicity concerns 5