eMedicine Specialties > Obstetrics and Gynecology > General Gynecology

Bacterial Vaginosis: Follow-up

Author: Diana Curran, MD, FACOG, Clinical Assistant Professor, Associate Program Director, Department of Obstetrics and Gynecology, University of Michigan Health Systems
Contributor Information and Disclosures

Updated: Oct 8, 2008

Follow-up

Further Inpatient Care

  • Inpatient care is not necessary for patients with bacterial vaginosis.
  • Obtain cultures of blood and infected tissue (if feasible) from inpatients who develop obstetric/gynecologic postoperative fever or signs of infection to try to elucidate the infectious etiologic organism. Blood cultures may not demonstrate growth of Gardnerella vaginalis unless gelatin is added to the media to prevent inhibition from the anticoagulant, sodium polyethanol sulfonate (SPS).

Further Outpatient Care

  • Uncomplicated cases of bacterial vaginosis (BV) typically resolve after the standard antibiotic treatment.
  • BV that does not resolve after one course of treatment may be cured by a second course with the same agent. Another option is to switch to another agent (ie, metronidazole to clindamycin, or clindamycin to metronidazole) as other concomitant organisms may respond better to an alternate medication. Metronidazole is favored because it allows faster return of colonization of H2 O2 -producing lactobacilli.6
  • Some women with recurrent episodes of BV may benefit from treatment of Gardnerella vaginalis in their sexual partner if colonization is demonstrated. Repeating wet preps is useful because patients can develop new, non-BV infections such as Candida.
  • Testing for other infections, such as N gonorrhoeae, C trachomatis, and herpes simplex virus type 1 (HSV-1) may be appropriate in individuals with BV because the incidence of sexually transmitted diseases (STDs) may be increased in this population depending upon the risk factors and demographics.
  • Therapy with metronidazole or clindamycin may alter the vaginal flora and predispose the patient to development of vaginal candidiasis.

Inpatient & Outpatient Medications

Metronidazole and clindamycin are the preferred medications used to treat Gardnerella infections. See Medication for specific information on these medications.

Deterrence/Prevention

Predisposing factors that may contribute to development of bacterial vaginosis (BV) are listed below. Correction or modification of these factors may help reduce the incidence or recurrence of BV.

  • Recent antibiotic use
  • Decreased estrogen production of the host
  • Wearing an IUD
  • Douching
  • Sexual activity leading to transmission, as evidenced by the patient having a new sexual partner, an increased number of sexual partners in the month preceding the onset of BV symptoms, and an increased number of lifetime sexual partners

Complications

  • Bacterial vaginosis (BV) may lead to an increased risk of salpingitis and/or endometritis, postsurgical infections (eg, postcesarean endometritis, posthysterectomy vaginal cuff cellulitis), and adverse outcomes in pregnancy, including premature rupture of membranes, premature labor, chorioamnionitis, and postpartum endometritis.
  • Mixed infections with Trichomonas and yeast can occur among patients with BV.
  • Bacteremia
    • Gardnerella vaginalis bacteremia occurs much more commonly in women than in men and occurs most commonly in postpartum and postgynecologic procedure infections (eg, postpartum endometritis, chorioamnionitis, septic abortion) but is rare.
    • SPS, the anticoagulant used in blood culture media, is toxic to G vaginalis and inhibits its growth unless a neutralizing gelatin is added to counteract this effect. Routine blood cultures, therefore, may not grow G vaginalis, leading to underdiagnosis and underrecognition of this organism as the etiologic agent in these types of infections.
  • Genitourinary infections
    • Although G vaginalis urinary tract infections (UTI) occur much more frequently in women than in men, the overall occurrence of G vaginalis as a causative etiology in this infection is low (<0.6%). However, the overall frequency may be underestimated because of a lack of optimal laboratory growth conditions (eg, aerobic incubation, short anaerobic growth period, urine not properly refrigerated prior to being cultured) and absence of associated pyuria occurring in women with concomitantly positive urine cultures.
    • In men, infections caused by G vaginalis are uncommon. Infection of the prostate and urinary bladder have been documented, although this occurs rarely and probably arises as a result of ascending spread of the organism from the colonized urethra. Balanoposthitis from G vaginalis has also been described.
  • Other infections caused by G vaginalis include chorioamnionitis, endometritis, cervicitis, pelvic inflammatory disease, vaginal cuff cellulitis following hysterectomy, and bacteremia.
  • Case reports include disc space infection (lumbar spine), vaginitis emphysematosa, liver abscess (postcesarean), neonatal meningitis, and neonatal cellulitis/skin abscess.

Prognosis

  • The prognosis for uncomplicated cases of bacterial vaginosis is generally excellent.
  • The prognosis for complicated cases of bacterial vaginosis leading to other infections varies depending on the particular infectious process.

Patient Education

Miscellaneous

Medicolegal Pitfalls

  • For patients presenting with atypical clinical features of bacterial vaginosis, the clinician must be aware of the possibility of a coinfection, such as vaginal candidiasis, trichomoniasis, infection with C trachomatis or N gonorrhoeae, HSV infection, or an alternative diagnosis.
  • Provide patients at risk of HIV with HIV counseling and testing.

Special Concerns

  • No adequate and well-controlled human trials evaluating teratogenicity of clindamycin or metronidazole in pregnant women have been performed.
  • The use of the cream formulation of clindamycin may result in preterm birth.
  • Several clinical trials using both preparations in pregnancy have been conducted. The use of metronidazole after the first trimester is considered within the standard of care.
 
Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous authors Eric A Hansen, DO and Burke A Cunha, MD to the development and writing of this article.



More on Bacterial Vaginosis

Overview: Bacterial Vaginosis
Differential Diagnoses & Workup: Bacterial Vaginosis
Treatment & Medication: Bacterial Vaginosis
Follow-up: Bacterial Vaginosis
References
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Further Reading

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Keywords

bacterial vaginosis, Gardnerella vaginalis, , bacterial vaginosis, BV, anaerobic vaginosis, nonspecific vaginitis, lactobacilli, sexually transmitted disease, STD, vaginal odor, vaginal discharge, chorioamnionitis, endometritis, cervicitis, pelvic inflammatory disease, vaginal cuff cellulitis following hysterectomy, bacteremia, balanoposthitis, premature rupture of membranes, prematurelabor, postabortion infection, vulvar irritation, dysuria, dyspareunia

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Contributor Information and Disclosures

Author

Diana Curran, MD, FACOG, Clinical Assistant Professor, Associate Program Director, Department of Obstetrics and Gynecology, University of Michigan Health Systems
Diana Curran, MD, FACOG is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Medical Association, Central Association of Obstetricians and Gynecologists, and Nebraska Medical Association
Disclosure: Nothing to disclose.

Medical Editor

Thomas Michael Price, MD, Associate Professor of Reproductive Endocrinology, Director of Reproductive Fellowship Training Program, Duke University Medical Center
Thomas Michael Price, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Obstetricians and Gynecologists, American Society for Reproductive Medicine, Endocrine Society, Phi Beta Kappa, Society for Gynecologic Investigation, and South Carolina Medical Association
Disclosure: Clinical Advisors Group Consulting fee Consulting; MEDA Corp Consulting Consulting fee Consulting; Gerson Lehrman Group Advisor  Consulting fee Consulting; Roche/GSK Spokesperson  Consulting fee Consulting

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

A David Barnes, MD, PhD, MPH, FACOG, Consulting Staff, Department of Obstetrics and Gynecology, Mammoth Hospital (Mammoth Lakes, California), Pioneer Valley Hospital (Salt Lake City, Utah), Warren General Hospital (Warren, Pennsylvania), and Mountain West Hospital (Tooele, Utah)
A David Barnes, MD, PhD, MPH, FACOG is a member of the following medical societies: American College of Forensic Examiners, American College of Obstetricians and Gynecologists, American Medical Association, Association of Military Surgeons of the US, and Utah Medical Association
Disclosure: Nothing to disclose.

CME Editor

Frederick B Gaupp, MD, Consulting Staff, Department of Family Practice, Hancock Medical Center
Frederick B Gaupp, MD is a member of the following medical societies: American Academy of Family Physicians
Disclosure: Nothing to disclose.

Chief Editor

Michel E Rivlin, MD, Professor, Coordinator of Quality Assurance/Quality Improvement, Department of Obstetrics and Gynecology, University of Mississippi School of Medicine
Michel E Rivlin, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Medical Association, Mississippi State Medical Association, and Royal College of Surgeons of Edinburgh
Disclosure: Nothing to disclose.

 
 
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