Treatment of Indeterminate Bacterial Vaginosis Results
Treatment is not recommended for women with indeterminate bacterial vaginosis (BV) results unless they are symptomatic or fall into specific high-risk categories. 1, 2
Diagnostic Criteria for BV
- BV diagnosis requires meeting at least 3 of 4 Amsel criteria: homogeneous white discharge, clue cells on microscopy, vaginal pH >4.5, and positive whiff test 3
- Alternatively, Gram stain can be used to determine the relative concentration of bacterial morphotypes characteristic of BV 3
- Laboratory testing fails to identify a cause of vaginitis in a substantial minority of women 3
Treatment Recommendations for Indeterminate Results
When to Treat
- Only women with symptomatic disease require treatment, as the principal goal of therapy is to relieve vaginal symptoms and signs 3
- Treatment is not recommended for asymptomatic women with indeterminate results unless they fall into specific high-risk categories 1, 2
Exceptions - When to Consider Treatment Despite Indeterminate Results
- Before surgical abortion procedures (treatment of BV with metronidazole has been shown to substantially reduce post-abortion PID) 3
- Before hysterectomy or other invasive gynecological procedures due to increased risk for postoperative infectious complications 2
- High-risk pregnant women with history of preterm delivery (may reduce risk of prematurity) 3, 2
Treatment Options When Indicated
First-Line Treatment
- Metronidazole 500 mg orally twice daily for 7 days (95% cure rate) 2
- Metronidazole gel 0.75%, one full applicator (5g) intravaginally once daily for 5 days 2
- Clindamycin cream 2%, one full applicator (5g) intravaginally at bedtime for 7 days 2
Alternative Regimens
- Metronidazole 2g orally in a single dose (84% cure rate) - useful when compliance is a concern 2, 4
- Clindamycin 300 mg orally twice daily for 7 days 3, 2
Important Clinical Considerations
- Patients using metronidazole should avoid alcohol during treatment and for 24 hours afterward due to potential disulfiram-like reaction 3, 2
- Clindamycin cream is oil-based and might weaken latex condoms and diaphragms 3, 2
- Intravaginal metronidazole has significantly fewer side effects than oral administration while maintaining equal efficacy 5
- Treatment of male sex partners has not been shown to alter the clinical course or reduce recurrence rates of BV 3, 2
- BV has a high recurrence rate (50-80% within a year after treatment) 4, 6
Clinical Pitfalls to Avoid
- Treating asymptomatic women with indeterminate results unnecessarily exposes them to medication side effects without clear benefit 3
- Failing to treat before invasive gynecological procedures may increase risk of post-procedure infections 2
- Not considering alternative diagnoses when symptoms persist despite treatment 7
- Inadequate treatment duration can lead to recurrence - extended treatment courses are recommended for recurrent cases 4, 7