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Bacterial vaginosis

Definition
BV, previously referred to as Gardnerella vaginitis, is a disease resulting from overgrowth of normal vaginal bacterial flora.
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Pathophysiology
BV is idiopathic; however, sexual transmission has been implicated. It is associated with fluctuations in vaginal microbiota, with a relative increase in Gardnerella vaginalis, Atopobium vaginae, Prevotella species, and Mobiluncus species, in addition, to a decrease in lactobacilli.
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Epidemiology
In the US, about 7.4 million cases of BV occur yearly. In nonpregnant women with symptomatic vaginal discharge, the overall prevalence of BV is 24.4% based on Nugent's scoring system.
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Disease course
BV is characterized by milky and malodorous vaginal discharge, resulting in vulvovaginal discomfort and irritation. It has a strong association with preterm birth, first-trimester miscarriage in women undergoing IVF, chorioamnionitis, amniotic-fluid infection, endometritis after childbirth or abortion, and infections after hysterectomy.
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Prognosis and risk of recurrence
BV has a high recurrence rate of up to 50% within a year of treatment.
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Key sources
The following summarized guidelines for the evaluation and management of bacterial vaginosis are prepared by our editorial team based on guidelines from the Center for Disease Control (CDC 2021), the American College of Obstetricians and Gynecologists (ACOG 2020), the U.S. Preventive Services Task Force (USPSTF 2020), the International Union Against Sexually Transmitted Infections (IUSTI/WHO 2018), and the Society of Obstetricians and Gynaecologists of Canada (SOGC 2017; 2015; 2013).
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Guidelines

1.Screening and diagnosis

Indications for screening: do not obtain screening for BV in pregnant individuals not at increased risk for preterm delivery.
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  • Diagnostic criteria

2.Medical management

Antibiotic therapy
As per CDC 2021 guidelines:
Offer any of the following regimens as first-line therapy in patients with BV:
metronidazole 500 mg PO BID for 7 days
metronidazole gel 0.75% one full applicator (5 g) intravaginally, once daily for 5 days
clindamycin cream 2% one full applicator (5 g) intravaginally at bedtime for 7 days
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Offer any of the following regimens as second-line therapy in patients with BV:
clindamycin 300 mg PO BID for 7 days
clindamycin ovules 100 mg intravaginally once at bedtime for 3 days
secnidazole 2 g PO granules in a single dose
tinidazole 2 g PO once daily for 2 days
tinidazole 1 g PO once daily for 5 days
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  • Alternative therapies

  • Management of sexual partners

3.Specific circumstances

Pregnant patients: as per IUSTI 2018 guidelines, offer clindamycin for the treatment of BV in pregnant patients.
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4.Follow-up and surveillance

Management of recurrent bacterial vaginosis: as per IUSTI 2018 guidelines, offer intravaginal metronidazole in patients with persistent or recurrent BV.
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