TREATMENT OF BACTERIAL VAGINOSIS - Vulvovaginal Disorders

TREATMENT OF BACTERIAL VAGINOSIS

For the most up to date info on treatment of BV, go to https://www.cdc.gov/std/tg2015/bv/.htm

Treatment action	Topical/behavioral	Oral meds	Vaginal meds	Testing/Notes
Comfort measures, general care, and prevention	Sitz bath, gentle cleansing, topical petrolatum, avoidance of irritants or tight clothing. Stop smoking. Use condoms. Partners do not need to be treated.			BV is not a cause of pain. Rule out atrophy in breastfeeding or postmenopausal women. Then, adhere to Amsel’s criteria for diagnosis: Homogeneous, thin, gray-white discharge coating vaginal walls Vaginal pH greater than 4.5 Positive whiff test: presence of fishy odor when 10% KOH is added to drop of discharge Presence of clue cells on wet mount (LINK to Anno P, Bacterial Vaginosis)
CDC- recommended treatment regimens¹for bacterial vaginosis in non-pregnant women		Metronidazole 500 mg orally twice a day for 7 days OR vaginal rx	Metronidazole gel, 0.75%, one full applicator (5 g) intravaginally, once a day for 5 days OR Clindamycin cream, 2%, one full applicator (5 g) intravaginally at bedtime for 7 days	Avoid alcohol during treatment and for 24 hrs after treatment is completed with Metronidazole. Clindamycin cream may weaken latex condoms and diaphragms for 5 days after use. Never give women with connective tissue disease (e.g. lupus, scleroderma, polymyositis, rheumatoid arthritis, Sjögren) any form of metronidazole.
CDC -recommended alternative regimens² for bacterial vaginosis in non-pregnant women		Clindamycin 300 mg orally twice a day for 7 days OR Tinidazole 2 g orally once daily for 2 days OR Tinidazole 1 g orally once daily for 5 days OR vaginal rx	Clindamycin ovules 100 mg intravaginally once at bedtime for 3 days	Same warnings. Avoid alcohol for 72 hrs after Tinidazole. Clindamycin ovules may weaken latex condoms or diaphragms, as well.
CDC-recommended treatment regimens for bacterial vaginosis in pregnancy³		Metronidazole 500 mg orally twice daily for seven days OR Metronidazole 250 mg orally three times daily for seven days	Clindamycin cream, 2%, one full applicator (5 g) intravaginally at bedtime for 7 days	There is no evidence for routine screening for BV in asymptomatic pregnant women at high or low risk for preterm birth. Treatment is recommended for symptomatic women. See CDC guidelines for current research on asymptomatic women and those at high risk of preterm birth. Tinidazole should be avoided during pregnancy.
Treatment of bacterial vaginosis in breastfeeding women	If treating, monitor infant for diarrhea, candidiasis (thrush or diaper rash) or, rarely, blood in the stool indicating possible antibiotic-associated colitis. Infant side- effects are less likely with vaginal than oral treatment. The AAP considers use of oral metronidazole and tinidazole of concern in nursing women because of an association of these drugs with carcinogenesis in rodents, although outcome data of maternal metronidazole use has not shown a significant increase in adverse events compared to use of other antimicrobials. Use of vaginal metronidazole has not been studied during breastfeeding. After vaginal administration, plasma levels are less than 2 percent of those after a 500 mg oral dose, so vaginal use of metronidazole during breastfeeding is unlikely to be of concern.	Clindamycin use is acceptable in breastfeeding women according to The American Academy of Pediatrics (AAP).⁴Clindamycin 300 mg orally twice a day for 7 days or vaginal rx	Clindamycin cream, 2%, one full applicator (5 g) intravaginally at bedtime for 7 days OR Clindamycin ovules 100 mg intravaginally once at bedtime for 3 days	Lower oral Metronidazole doses are now considered compatible with breastfeeding. Do not use the single 2 g dose.
Treatment of recurrence and relapse in bacterial vaginosis		Metronidazole 500 mg orally twice a day x seven days followed by boric acid capsules 600 mg inserted vaginally for 21 nights, possibly followed by the Metronidazole gel regimen twice weekly	Metronidazole gel 0.75%, one full applicator (5 g) intravaginally, once a day for 5 days then used twice weekly for four months.ORCompounded metronidazole 500 mg with 100,000 units of Nystatin ovules Insert vaginally once nightly for three months*	The compounded metronidazole and nystatin suppositories have been used in one study only and for five days only. This treatment is experimental. The couple must use condoms and cessation of smoking is recommended.
Treatment for candidiasis which is common with metronidazole use.		Fluconazole 150 mg orally every other day x 3 OR Vaginal rx	Any of the azole vaginal treatments. See treatment of candidiasis.

Updated 7/11/14 LINK to Bacterial Vaginosis, Annotation P.

References

https://www.cdc.gov/std/tg2015/bv.htm
https://www.cdc.gov/std/tg2015/bv.htm
https://www.cdc.gov/std/tg2015/bv.htm
American Academy of Pediatrics Committee on Drugs. Transfer of drugs and other chemicals into human milk. Pediatrics. 2001; 108:776.