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bacterial vaginitis; bacterial vaginosis; vaginal dysbiosis
Etiology:
- Gardnerella vaginalis
- Mycoplasma hominis
- Mobiluncus
- Atopobium vaginae
- other gram-negative bacteria
- not a sexually transmitted disease
Epidemiology:
1) primarily sexually active women
2) most common lower genital tract infection in reproductive age women
Pathology:
- bacterial vaginosis is non-inflammatory
Clinical manifestations:
- fishy odor of volatile amines, especially when mixed with KOH (whiff test)*
- thin, homogeneous, gray-white, adherent discharge*
- 50% of women are asymptomatic [1]
- symptomatic women may not have bacterial vaginosis [1]
* 3 of 4 criteria makes diagnosis (other 2 criteria in Laboratory)
Laboratory:
- also see vaginitis
- vaginal fluid pH >= 4.5*
- microscopy: saline wet mount: > 20% epipthelial clue cells* (first step) [7]
* 3 of 4 criteria makes diagnosis (other 2 criteria in Clinical manifestations) [2]
* image of clue cells [8]
- Atopobium vaginae DNA
- bacterial vaginosis associated bacterium 2 DNA
- bacterial vaginosis whiff test
- bacterial vaginosis interpretation in vaginal fluid
Complications:
- see vaginitis
Management:
1) metronidazole
a) 500 mg PO BID for 7 days (95% cure rate)
b) 2 g single dose (84% cure rate)
c) metronidazole gel, 5 grams vaginally BID for 5 days
2) clindamycin
a) preferred agent if pregnant
b) 2% cream, 5 grams vaginally BID for 5 days
c) 300 mg PO BID for 7 days
3) dequalinium chloride 10 mg vaginal tablet once a day for 6 days [10]
4) only symptomatic women need be treated
5) vaginal administration of Lactobacillus crispatus reduces risk for recurrent bacterial vaginosis by 34% [6]
6) treatment of male partners has NO effect on outcome
7) screening for bacterial vaginosis not recommended for pregnant women [5]
General
vaginitis
urogenital infection
bacterial infection
References
- Journal Watch 24(18):146, 2004
Klebanoff MA, Schwebke JR, Zhang J, Nansel TR, Yu KF, Andrews WW.
Vulvovaginal symptoms in women with bacterial vaginosis.
Obstet Gynecol. 2004 Aug;104(2):267-72.
PMID: 15291998
- Medical Knowledge Self Assessment Program (MKSAP) 17, 18.
American College of Physicians, Philadelphia 2015, 2018.
- Subtil D, Brabant G, Tilloy E et al
Early clindamycin for bacterial vaginosis in pregnancy (PREMEVA):
a multicentre, double-blind, randomised controlled trial
The Lancet. October 12, 2018
PMID: 30322724
https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)31617-9/fulltext
- Klebanoff MA, Brotman RM
Treatment of bacterial vaginosis to prevent preterm birth
The Lancet. October 12, 2018
PMID: 30322725
https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)32115-9/fulltext
- Paavonen J, Brunham RC.
Bacterial Vaginosis and Desquamative Inflammatory Vaginitis.
N Engl J Med 2018; 379:2246-2254
PMID: 30575452
https://www.nejm.org/doi/full/10.1056/NEJMra1808418
- US Preventive Services Task Force Recommendation Statement
Screening for Bacterial Vaginosis in Pregnant Persons to Prevent Preterm Delivery
JAMA. 2020;323(13):1286-1292
PMID: 32259236
https://jamanetwork.com/journals/jama/fullarticle/2764189
- Cohen CR, Wierzbicki MR, French AL et al.
Randomized trial of Lactin-V to prevent recurrence of bacterial vaginosis.
N Engl J Med 2020 May 14; 382:1906
PMID: 32402161
https://www.nejm.org/doi/10.1056/NEJMoa1915254
- Eckert LO
Clinical practice. Acute vulvovaginitis.
N Engl J Med 2006;355:1244-52
PMID: 16990387
https://www.nejm.org/doi/pdf/10.1056/NEJMcp053720
- Image of Clue cell
https://kpi.nejmgroup.org/605_feedback_figure.jpg
- Paavonen J, Brunham RC.
Bacterial Vaginosis and Desquamative Inflammatory Vaginitis.
N Engl J Med. 2018 Dec 6;379(23):2246-2254
PMID: 30575452 Review.
https://www.nejm.org/doi/pdf/10.1056/NEJMra1808418
- Raba G, Durkech A, Malik T et al
Efficacy of Dequalinium Chloride vs Metronidazole for the Treatment of Bacterial
Vaginosis. A Randomized Clinical Trial.
JAMA Netw Open. 2024;7(5):e248661.
PMID: 38696172 PMCID: PMC11066704 Free PMC article. Clinical Trial
https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2818221