Treatment for BV, Mycoplasma, and Ureaplasma parvum
Treat the bacterial vaginosis with metronidazole 500 mg orally twice daily for 7 days, but do not treat the Mycoplasma or Ureaplasma parvum unless the patient has symptoms of pelvic inflammatory disease or urethritis. 1, 2
Rationale for BV Treatment
- Metronidazole 500 mg orally twice daily for 7 days achieves 95% efficacy, which is superior to the single-dose 2g regimen (84% efficacy) 1, 2
- Alternative regimens include metronidazole gel 0.75% intravaginally once daily for 5 days, or clindamycin cream 2% intravaginally at bedtime for 7 days 1, 2
- Tinidazole 2g once daily for 2 days or 1g once daily for 5 days is also FDA-approved and effective 3
Critical Patient Instructions for BV Treatment
- Patients must avoid all alcohol consumption during metronidazole therapy and for 24 hours after the last dose to prevent disulfiram-like reactions 1, 2
- Refrain from sexual intercourse until treatment is completed (minimum 7 days) 2
- Oil-based vaginal creams weaken latex condoms and diaphragms if topical therapy is chosen 1, 2
Why Mycoplasma and Ureaplasma Should NOT Be Routinely Treated
- Mycoplasma hominis and Ureaplasma parvum are part of the normal vaginal flora in many healthy women and their presence alone does not indicate disease 1
- These organisms are frequently found in women with BV as part of the altered anaerobic flora, but they are not primary pathogens requiring specific treatment in asymptomatic patients 1
- Treatment should only be considered if the patient has clinical evidence of upper genital tract infection (pelvic inflammatory disease) or urethritis with symptoms 1
When to Treat Mycoplasma/Ureaplasma
Treat only if the patient has:
- Lower abdominal pain with cervical motion tenderness, uterine tenderness, or adnexal tenderness suggesting PID 1
- Mucopurulent cervical discharge 1
- Dysuria with pyuria but negative standard urine culture (suggesting urethritis) 2
If PID is present, use:
- Ceftriaxone 250 mg IM single dose PLUS doxycycline 100 mg orally twice daily for 14 days WITH metronidazole 500 mg orally twice daily for 14 days 1
- OR Levofloxacin 500 mg orally once daily for 14 days WITH metronidazole 500 mg orally twice daily for 14 days 1
Common Pitfalls to Avoid
- Do not use single-dose metronidazole 2g for BV when multiple organisms are present—the 7-day regimen has significantly higher efficacy 1, 2
- Do not treat Mycoplasma/Ureaplasma based solely on positive testing without clinical symptoms 1
- Do not assume all vaginal discharge represents only BV—rule out trichomoniasis, gonorrhea, and chlamydia, especially in sexually active patients 2
- Antibacterial therapy for BV may trigger vaginal candidiasis in 10-20% of patients; if this occurs, add fluconazole 150 mg as a single oral dose 2
Partner Management
- Male partners of women with BV do not require treatment, as partner therapy does not prevent BV recurrence or alter clinical outcomes 1, 2, 4
- Partners should only be evaluated and treated if sexually transmitted infections (gonorrhea, chlamydia) are identified 2