Bacterial vaginosis: Difference between revisions

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== Management ==
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==Background==
   
  +
===Microbiology===
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* First-line:
  
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** [[Metronidazole]] 500 mg PO bid for 7 days
  
  +
*Shift in vaginal flora from [[Lactobacillus]] to high bacterial diversity that includes facultative anaerobes
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** [[Metronidazole]] gel 0.75% 5 g (one full applicator) intravaginally once daily for 5 days
  
  +
*The new flora includes: [[Gardnerella vaginalis]], [[Prevotella]], [[Porphyromonas]], [[Bacteroides]], [[Peptostreptococcus]], [[Mycoplasma hominis]], [[Ureaplasma urealyticum]], [[Mobiluncus]], [[Megasphaera]], [[Clotridiales]], [[Fusobacterium]], and [[Atopobium]]
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** [[Clindamycin]] 2% cream 5 g (one full applicator) intravaginally at bedtime for 7 days
  
  +
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* Alternatives:
  
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===Pathophysiology===
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** [[Clindamycin]] 300 mg PO bid for 7 days
  
  +
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** [[Clindamycin]] ovule (vaingal suppository) 100 mg intravaginally daily for 3 days
  
  +
*The new bacterial flora produce volatile amines, which increases the vaginal pH >4.5 (from the normal range of 4 to 4.5)
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** [[Tinidazole]] 2 g PO daily for 2 days
  
  +
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** [[Tinidazole]] 1 g PO daily for 5 days
  
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==Clinical Manifestations==
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*Common cause of [[Causes::vaginal discharge]], classically copious thin, grey discharge
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=== Prognosis and Complications ===
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* About 30% will relapse within 3 months, and 50% within 12 months
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  +
==Diagnosis==
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  +
===Amsel Criteria===
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  +
*Requires microscopy but not Gram staining
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*At least three of the following criteria:
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**Characteristic vaginal discharge: homogeneous, thin, grayish-white discharge that smoothly coats the vaginal walls
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**Elevated pH >4.5
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**Clue cells on saline wet mount, which are vaginal epithelial cells studded with adherent coccobacilli
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**Positive whiff-amine test, where a fishy odor is detected after a drop of 10% KOH is added to a sample of vaginal discharge
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  +
===Nugent Criteria===
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  +
*Based on the Gram stain
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*Considered the gold standard, but is more resource-intensive than wet mount microscopy used for Amsel criteria
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  +
{| class="wikitable"
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!Score
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!Lactobacillus
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!Gardnerella and Bacteroides
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!Curved gram-variable bacilli
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|-
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|0
  +
|4+
  +
|0
  +
|0
  +
|-
  +
|1
  +
|3+
  +
|1+
  +
|1+ or 2+
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|-
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|2
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|2+
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|2+
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|3+ or 4+
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|-
  +
|3
  +
|1+
  +
|3+
  +
|
  +
|-
  +
|4
  +
|0
  +
|4+
  +
|
  +
|}
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  +
*Interpretation is based on total score:
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**0 to 3: normal
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**4 to 6: indeterminate
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**7 to 10: bacterial vaginosis
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  +
===Others===
  +
  +
*Culture is not relevant to diagnosis of bacterial vaginosis
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  +
==Management==
  +
  +
===Non-Pregnant Woman===
  +
  +
*First-line:
  +
**[[Metronidazole]] 500 mg PO bid for 7 days
  +
**[[Metronidazole]] gel 0.75% 5 g (one full applicator) intravaginally once daily for 5 days
  +
**[[Clindamycin]] 2% cream 5 g (one full applicator) intravaginally at bedtime for 7 days
  +
*Alternatives:
  +
**[[Clindamycin]] 300 mg PO bid for 7 days
  +
**[[Clindamycin]] ovule (vaingal suppository) 100 mg intravaginally daily for 3 days
  +
**[[Tinidazole]] 2 g PO daily for 2 days
  +
**[[Tinidazole]] 1 g PO daily for 5 days
  +
  +
===Pregnant Women===
  +
  +
*[[Metronidazole]] 500 mg PO bid for 7 days
  +
*[[Metronidazole]] 250 mg PO tid for 7 days
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*[[Clindamycin]] 300 mg PO bid for 7 days
  +
  +
=== Relapse and Recurrence ===
  +
  +
* Symptomatic relapses can be treated with recurrent 7-day courses of oral [[metronidazole]] or [[clindamycin]]
  +
* Can also consider [[boric acid]] vaginal suppositories for 30 days, either before or after oral treatment
  +
** Avoid if pregnant
  +
** Keep out or reach of children (can cause death if ingested)
  +
** May cause skin irritation in sexual partners
  +
* Chronic suppressive therapy can be offere to patients with more than 3 documented episodes of BV within 12 months
  +
** [[Metronidazole]] 0.75% vaginal gel is preferred, twice weekly for 4 to 6 months
  +
** Can be preceded by [[metronidazole]] oral induction for 7 to 10 days
  +
** Decreases 12-month recurrence from 60% to 26%, though can cause vaginal candidiasis
  +
* Adjunctive therapy:
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** Abstinence or condom use
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** [[Lactobacillus crispatus]] vaginal suppositories has some promise
  +
* Avoid: vaginal acidifying agents and general probiotics
   
 
[[Category:Gynecologic infections]]
  
[[Category:Gynecologic infections]]

Latest revision as of 19:59, 12 February 2022

Background

Microbiology

Pathophysiology

  • The new bacterial flora produce volatile amines, which increases the vaginal pH >4.5 (from the normal range of 4 to 4.5)

Clinical Manifestations

Prognosis and Complications

  • About 30% will relapse within 3 months, and 50% within 12 months

Diagnosis

Amsel Criteria

  • Requires microscopy but not Gram staining
  • At least three of the following criteria:
    • Characteristic vaginal discharge: homogeneous, thin, grayish-white discharge that smoothly coats the vaginal walls
    • Elevated pH >4.5
    • Clue cells on saline wet mount, which are vaginal epithelial cells studded with adherent coccobacilli
    • Positive whiff-amine test, where a fishy odor is detected after a drop of 10% KOH is added to a sample of vaginal discharge

Nugent Criteria

  • Based on the Gram stain
  • Considered the gold standard, but is more resource-intensive than wet mount microscopy used for Amsel criteria
Score Lactobacillus Gardnerella and Bacteroides Curved gram-variable bacilli
0 4+ 0 0
1 3+ 1+ 1+ or 2+
2 2+ 2+ 3+ or 4+
3 1+ 3+
4 0 4+
  • Interpretation is based on total score:
    • 0 to 3: normal
    • 4 to 6: indeterminate
    • 7 to 10: bacterial vaginosis

Others

  • Culture is not relevant to diagnosis of bacterial vaginosis

Management

Non-Pregnant Woman

  • First-line:
    • Metronidazole 500 mg PO bid for 7 days
    • Metronidazole gel 0.75% 5 g (one full applicator) intravaginally once daily for 5 days
    • Clindamycin 2% cream 5 g (one full applicator) intravaginally at bedtime for 7 days
  • Alternatives:

Pregnant Women

Relapse and Recurrence

  • Symptomatic relapses can be treated with recurrent 7-day courses of oral metronidazole or clindamycin
  • Can also consider boric acid vaginal suppositories for 30 days, either before or after oral treatment
    • Avoid if pregnant
    • Keep out or reach of children (can cause death if ingested)
    • May cause skin irritation in sexual partners
  • Chronic suppressive therapy can be offere to patients with more than 3 documented episodes of BV within 12 months
    • Metronidazole 0.75% vaginal gel is preferred, twice weekly for 4 to 6 months
    • Can be preceded by metronidazole oral induction for 7 to 10 days
    • Decreases 12-month recurrence from 60% to 26%, though can cause vaginal candidiasis
  • Adjunctive therapy:
  • Avoid: vaginal acidifying agents and general probiotics
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