Bacterial vaginosis

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Background

  • Accounts for up to 50% of cases of vaginitis
  • Associated with preterm labor and premature rupture of membranes

Clinical Features

  • whitish-gray discharge and odor
    • Lack of discharge makes diagnosis less likely
  • May have history of "physiologic whiff test" after contact with male ejaculate which is alkaline (like KOH)

Differential Diagnosis

Vulvovaginitis

Evaluation

Work-up

A "clue cell": note effacement of borders by bacteria, as compared to normal epithelial cells below.
Normal vaginal epithelial cells on wet mount: note clean borders. Presence of lactobacilli (tiny rods) is normal.
  • Wet mount shows clue cells: vaginal epithelial cells with "stippled appearance" due to coverage by bacteria
  • Whiff Test: fishy odor with 10% KOH prep
  • CDC recommends testing all women with BV for HIV and other STDs [1]

Amsel criteria for diagnosis (3/4 must be present)

  • Homogeneous, thin, gray-white discharge
  • Positive whiff test
  • Vaginal pH>4.5
  • Clue cells on wet mount (at least 20% of epithelial cells)

Management

  • No need to treat if asymptomatic (even if pregnant)
  • Do NOT need to treat sexual partner

Antibiotics

First Line Therapy[2]

  • Metronidazole 500 mg PO BID for 7 days OR
  • Metronidazole gel 0.75%, one full applicator (5 g) intravaginally, qd for 5 days OR
  • Clindamycin cream 2%, one full applicator (5 g) intravaginally qHS for 7 days

Alternative Regimin

  • Tinidazole 2 g PO qd for 2 days OR
  • Tinidazole 1 g PO qd for 5 days OR
  • Clindamycin 300 mg PO BID for 7 days OR
  • Clindamycin ovules 100 mg intravaginally qHS for 3 days (do not use if patient has used latex condom in last 72 hrs)

Pregnant

Prophylaxis (Sexual Assault)

Disposition

  • Discharge

See Also

References

  1. 1.0 1.1 1.2 1.3 CDC Pregnancy BV Treatment Guidelines.cdc.gov
  2. Workoski KA and Bolan GA. Sexually transmitted diseases treatment guidelines, 2015. MMWR Recommen and Reports. 2015; 64(3):1-140.