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Bacterial vaginosis
From WikEM
Contents
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
- Bacterial vaginosis
- Candida vaginitis
- Trichomonas vaginalis
- Contact vulvovaginitis
- Atrophic vaginitis
- Lichen sclerosus
- Tinea cruris
- Chlamydia/Gonorrhea infection
Evaluation
Work-up
- Wet mount shows clue cells: bacteria that line the borders of the vaginal epithelial cells
- 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
- Metronidazole 250mg PO q8h x 7 days[1]
- Metronidazole 2g PO x 1 dose is also acceptable[1]
- Multiple studies have not demonstrated teratogenicity from metronidazole use[1]
Prophylaxis (Sexual Assault)
- Metronidazole 2 g PO x 1 OR
- Tinidazole 2 g PO x 1
Disposition
- Discharge
