Guideline sources The following summarized guidelines for the evaluation and management of bacterial vaginosis (BV) 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). 1 2 3 4 5 6 7 8 8 8 9 9 Definition BV, previously referred to as Gardnerella vaginitis, is a disease resulting from overgrowth of normal vaginal bacterial flora. 8 Epidemiology 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. 8 Pathophysiology https://web.pathway.md/diseases/recjDNg52vuWBkD06 1/5 6/29/23, 3:16 AM Bacterial vaginosis Pathway In the United States, 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. 9 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. 9 Prognosis and risk of recurrence BV has a high recurrence rate of up to 50% within a year of treatment. 8 Calculator Pathway Calculator Amsel's diagnostic criteria for b Bacterial vaginosis Nugent sc Diagnosis and management Guidelines 1. Screening and diagnosis Indications for screening: Do not obtain screening for BV in pregnant individuals not at increased risk for preterm delivery. D Insufficient evidence to recommend screening for or treating BV in the general pregnant population in order to prevent adverse outcomes, such as preterm birth. Show 2 more Obtain screening for BV at the first obstetric visit of patients with a history of cervical insufficiency. Treat patients with identified BV. A Diagnostic criteria: As per IUSTI 2018 guidelines, use the Hay-Ison criteria during microscopic evaluation for the diagnosis of BV. A As per SOGC 2015 guidelines, diagnose BV using either clinical (Amsel) or laboratory (Gram stain with objective scoring system) criteria. B 2. Medical management Antibiotic therapy: https://web.pathway.md/diseases/recjDNg52vuWBkD06 2/5 6/29/23, 3:16 AM Bacterial vaginosis Pathway 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. E 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. E As per IUSTI 2018 guidelines, offer topical or oral metronidazole for 5-7 days or intravaginal clindamycin for 7 days in patients with uncomplicated BV, depending on personal choice and circumstances. A As per SOGC 2015 guidelines, offer oral metronidazole 500 mg BID for 7 days in patients with symptomatic BV. Offer vaginal metronidazole gel and oral or vaginal clindamycin cream as alternatives. A Alternative therapies: as per SOGC 2015 guidelines, insufficient evidence to support the use of alternative therapies for the treatment of BV, such as probiotics and vitamin C. I Management of sexual partners: do not offer treatment for male sexual partners of patients diagnosed with BV. Offer treatment for female partners if they have BV. D 3. Specific circumstances Pregnant patients: As per IUSTI 2018 guidelines, offer clindamycin for the treatment of BV in pregnant patients. B As per SOGC 2017 guidelines, test for and treat BV for symptom resolution in symptomatic pregnant patients. A Show 4 more 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. B As per SOGC 2015 guidelines, offer longer courses of antibiotic therapy in patients with documented multiple recurrences of BV. A https://web.pathway.md/diseases/recjDNg52vuWBkD06 3/5 6/29/23, 3:16 AM Bacterial vaginosis Pathway Clinical findings Symptoms Past medical history Fishy vaginal odor Human immunodeficiency virus infection Foul-smelling vaginal discharge Sexually transmitted diseases Foul-smelling vaginal odor Vaginitis Natural lack of lactobacilli bacteria Social history No history of vaginal odor Vaginal discharge Multiple sexual partners Past events Lab findings Douching vaginal fluid pH gardnerella vaginalis deoxyRNA probe test Genitourinary exam vaginal sialidase test White or gray vaginal discharge on vaginal walls Histological findings Clue cells on wet mount Likelihood Ratios Pertinent positives The following findings increase the probability of bacterial vaginosis in adults. 10 12 13 Finding LR+ Value Presence of clue cells on wet mount* 3.4 No history of vaginal odor 2.2 (1.4-3.6) Increased vaginal fluid pH (> 4.5) 1.8 > 20% clue cells Pertinent negatives The following findings decrease the probability of bacterial vaginosis in adults. 10 12 13 Finding LR- Value History of vaginal odor 0.30 (0.24-0.38) vaginal fluid pH not increased ( 4.5) 0.47 Absence of clue cells on wet mount* 0.6 > 20% clue cells https://web.pathway.md/diseases/recjDNg52vuWBkD06 4/5 6/29/23, 3:16 AM Bacterial vaginosis Pathway References 1. van Schalkwyk J, Yudin MH, INFECTIOUS DISEASE COMMITTEE. Vulvovaginitis: screening for and management of trichomoniasis, vulvovaginal candidiasis, and bacterial vaginosis. J Obstet Gynaecol Can. 2015 Mar;37 3 266 274. Open 2. No authors listed. Vaginitis in Nonpregnant Patients: ACOG Practice Bulletin, Number 215. Obstet Gynecol. 2020 Jan;135 1):e1-e17. Open 3. US Preventive Services Task Force, Douglas K Owens, Karina W Davidson et al. Screening for Bacterial Vaginosis in Pregnant Persons to Prevent Preterm Delivery US Preventive Services Task Force Recommendation Statement. JAMA. 2020 Apr 7;323 13 1286 1292. Open 4. Sherrard J, Wilson J, Donders G et al. 2018 European IUSTI/WHO International Union against sexually transmitted infections IUSTI World Health Organisation WHO guideline on the management of vaginal discharge. Int J STD AIDS. 2018 Nov;29 13 1258 1272. Open 5. Mark H Yudin, Deborah M Money. No. 211 Screening and Management of Bacterial Vaginosis in Pregnancy. J Obstet Gynaecol Can. 2017 Aug;39 8):e184-e191. Open 6. Kimberly A Workowski, Laura H Bachmann, Philip A Chan et al. Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR Recomm Rep. 2021 Jul 23;70 4 1 187. Open 7. Brown R, Gagnon R, Delisle MF. Cervical insufficiency and cervical cerclage. J Obstet Gynaecol Can. 2013 Dec;35 12 1115 1127. Open 8. Bagnall P, Rizzolo D. Bacterial vaginosis: A practical review. JAAPA. 2017 Dec;30 12 15 21. Open 9. Paavonen J, Brunham RC. Bacterial Vaginosis and Desquamative Inflammatory Vaginitis. N Engl J Med. 2018 Dec 6;379 23 2246 2254. Open 10. Lowe NK, Neal JL, Ryan-Wenger NA. Accuracy of the clinical diagnosis of vaginitis compared with a DNA probe laboratory standard. Obstet Gynecol. 2009 Jan;113 1 89 95. Open 11. R Hemalatha, Baru Anantha Ramalaxmi, Eluru Swetha et al. Evaluation of vaginal pH for detection of bacterial vaginosis. Indian J Med Res. 2013 Sep;138 3 354 9. Open 12. Bradshaw CS, Morton AN, Garland SM et al. Evaluation of a point-of-care test, BVBlue, and clinical and laboratory criteria for diagnosis of bacterial vaginosis. J Clin Microbiol. 2005 Mar;43 3 1304 8. Open 13. Bornstein J, Lakovsky Y, Lavi I et al. The classic approach to diagnosis of vulvovaginitis: a critical analysis. Infect Dis Obstet Gynecol. 2001;9 2 105 11. Open 14. Simel D, Rennie D. The Rational Clinical Examination: Evidence-Based Clinical Diagnosis. Mayo Clin Proc. 2009 Nov; 84 11 1045. Open 15. US Preventive Services Task Force, Bibbins-Domingo K, Grossman DC et al. Screening USPSTF for Gynecologic Conditions With Pelvic Examination US Preventive Services Task Force Recommendation Statement. JAMA. 2017;317 9 947 953. Open 16. Suzanne Reiter, Susan Kellogg Spadt. Bacterial vaginosis: a primer for clinicians. Postgrad Med. 2019 Jan;131 1 8 18. Open 17. R P Nugent, M A Krohn, S L Hillier. Reliability of diagnosing bacterial vaginosis is improved by a standardized method of gram stain interpretation. 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