What is the diagnosis and treatment for Bacterial Vaginosis (BV)?

From the Guidelines

Bacterial vaginosis (BV) should be treated with oral metronidazole 500 mg twice daily for 7 days or metronidazole gel 0.75% applied intravaginally once daily for 5 days, as these regimens have been shown to be effective in relieving symptoms and improving clinical outcomes 1.

Diagnosis of BV

The diagnosis of BV is typically made based on the presence of symptoms such as thin, grayish-white discharge with a fishy odor, particularly noticeable after intercourse, and the results of a physical examination and laboratory tests, including a wet mount preparation and pH test 1.

Treatment of BV

The treatment of BV typically involves antibiotics, with metronidazole being the first-line option. Alternative treatments include oral clindamycin 300 mg twice daily for 7 days or clindamycin cream 2% applied intravaginally at bedtime for 7 days 1.

Special Considerations

In pregnant women, BV is associated with adverse pregnancy outcomes, including premature rupture of the membranes, preterm labor, preterm birth, and postpartum endometritis. Therefore, all symptomatic pregnant women should be tested and treated for BV, and high-risk pregnant women who have asymptomatic BV may be evaluated for treatment 1.

Key Points

• BV is a common vaginal infection caused by an overgrowth of bacteria, disrupting the normal vaginal flora.
• Treatment typically involves antibiotics, with metronidazole being the first-line option.
• Alternative treatments include oral clindamycin or clindamycin cream.
• Pregnant women with BV should be treated to relieve symptoms and reduce the risk of adverse pregnancy outcomes.
• Patients should avoid alcohol consumption with metronidazole and abstain from sexual intercourse or use condoms during treatment.

From the FDA Drug Label

A randomized, double-blind, placebo-controlled clinical trial in 235 non-pregnant women was conducted to evaluate the efficacy of tinidazole for the treatment of bacterial vaginosis. A clinical diagnosis of bacterial vaginosis was based on Amsel's criteria and defined by the presence of an abnormal homogeneous vaginal discharge that (a) has a pH of greater than 4. 5, (b) emits a "fishy" amine odor when mixed with a 10% KOH solution, and (c) contains ≥20% clue cells on microscopic examination. Tinidazole oral tablets given as either 2 g once daily for 2 days or 1 g once daily for 5 days demonstrated superior efficacy over placebo tablets as measured by therapeutic cure, clinical cure, and a microbiologic cure.

The diagnosis of Bacterial Vaginosis (BV) is based on:

• Amsel's criteria, which include:
  • Abnormal homogeneous vaginal discharge with a pH of greater than 4.5
  • "Fishy" amine odor when mixed with a 10% KOH solution
  • Presence of ≥20% clue cells on microscopic examination
• Microbiologic diagnosis based on Gram stain of the vaginal smear, demonstrating:
  • Markedly reduced or absent Lactobacillus morphology
  • Predominance of Gardnerella morphotype
  • Absent or few white blood cells, with a Nugent score ≥4

The treatment for BV is:

• Tinidazole oral tablets, given as either 2 g once daily for 2 days or 1 g once daily for 5 days 2

From the Research

Diagnosis and Treatment of Bacterial Vaginosis (BV)

• The diagnosis and treatment of BV involve the use of antibiotics, such as metronidazole and clindamycin, which are the current and only FDA-approved treatment regimens for BV 3.
• For nonpregnant women, the preferred treatment for BV includes metronidazole (500 mg orally twice daily for 7 days), clindamycin vaginal cream (2%, once daily for 7 days), or metronidazole vaginal gel (0.75%, twice daily for 5 days) 4, 5.
• For pregnant women, the treatment of BV focuses on the elimination of symptoms, and data on adverse pregnancy outcomes for women with BV remain insufficient to recommend treatment of asymptomatic patients 5.
• The treatment for recurrent BV consists of an extended course of metronidazole treatment (500 mg twice daily for 10-14 days); if ineffective, metronidazole vaginal gel 0.75% for 10 days, followed by two times per week for 3-6 months, is an alternate treatment regimen 6.
• Alternative strategies for the treatment and prevention of BV include probiotics, vaginal microbiome transplantation, pH modulation, and biofilm disruption, as well as behavioral modifications such as smoking cessation, condom use, and hormonal contraception 3, 7.

Treatment Options

• Metronidazole (500 mg orally twice daily for 7 days) is the preferred treatment for BV 4, 5.
• Clindamycin vaginal cream (2%, once daily for 7 days) is an effective alternative treatment regimen 4, 5.
• Metronidazole vaginal gel (0.75%, twice daily for 5 days) is another effective treatment option 4, 5.
• Tinidazole is also an effective treatment option for BV 6, 7.
• Secnidazole may be an attractive new option due to one-time dosing 6.

Recurrence and Prevention

• Recurrence of BV is a common problem, with 50-80% of women experiencing a recurrence within a year of completing antibiotic treatment 6, 3.
• The use of probiotics, prebiotics, and acidifying agents may help to reestablish the physiologic vaginal environment and prevent recurrence 3, 7.
• Behavioral modifications such as smoking cessation, condom use, and hormonal contraception may also help to prevent recurrence 3.