eMedicine Specialties > Obstetrics and Gynecology > General Gynecology

Bacterial Vaginosis: Treatment & Medication

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

Treatment

Medical Care

  • Antibiotics are the mainstay of therapy for bacterial vaginosis (BV).
  • Asymptomatic women with Gardnerella vaginalis colonization do not need treatment.
  • Studies of topically applied and orally administered yogurt/lactobacilli preparations, which are used to help reestablish the lactobacilli population in the vagina, have demonstrated inconsistent results.
  • Some women with recurrent cases of BV may benefit from evaluation and/or treatment of G vaginalis colonization in their sexual partner. This approach is controversial.
  • Treat BV occurring in pregnant women to reduce the risk of pregnancy-associated complications related to infection.
  • Although not tested by clinical trials, treatment prior to cesarean delivery, total abdominal hysterectomy, and insertion of an IUD is also recommended.

Surgical Care

Surgery is not indicated for bacterial vaginosis.

Consultations

Consultation with an infectious disease specialist or obstetrician/gynecologist may be warranted for patients with nonresolving and/or recurring BV or more serious infections, such as endometritis, pelvic inflammatory disease, and chorioamnionitis.

Diet

Studies are conflicting regarding the efficacy of a diet supplemented with Lactobacillus (acidophilus).

Activity

Restriction of activities is not necessary for patients with bacterial vaginosis. Other, more serious Gardnerella infections may require restriction of activity based on the severity and nature of the illness.

Medication

Antibiotics are the mainstay of therapy for bacterial vaginosis. Medications include metronidazole (Flagyl), clindamycin (Cleocin) oral or vaginal suppositories, and metronidazole vaginal gel (MetroGel-Vaginal).

Antibiotics

Therapy must be comprehensive and cover all likely pathogens in the context of this clinical setting.


Clindamycin (Cleocin)

Bacteriostatic antibiotic used against gram-positive aerobes and gram-positive and gram-negative anaerobes. Inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest. Available as capsule and 2% vaginal cream formulation.

Adult

300 mg PO bid for 7 d
5 g intravaginally qhs for 7 d
Alternatively, vaginal ovules, 100 mg, qhs for 3 d

Pediatric

Not established

Increases duration of neuromuscular blockade induced by tubocurarine and pancuronium; erythromycin may antagonize effects of clindamycin; antidiarrheals may delay absorption of clindamycin

Documented hypersensitivity; regional enteritis; ulcerative colitis; hepatic impairment; antibiotic-associated colitis

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dose in severe hepatic dysfunction; no adjustment necessary in renal insufficiency; associated with severe and possibly fatal colitis; maculopapular skin rash (hypersensitivity reaction); rare cases of erythema multiforme and Stevens-Johnson syndrome; no adequate and well-controlled studies of the use of clindamycin in pregnancy exist (use of the cream formulation of clindamycin may result in preterm birth)


Metronidazole (Flagyl)

Bactericidal antibiotic enters bacterial cell and is reduced by electron transport proteins. Free radicals are formed, which react with intracellular components and/or DNA and result in subsequent cell death. Antimicrobial spectrum includes many gram-positive and gram-negative anaerobes and protozoal parasites.

Adult

Alternative dosing regimens: 250 mg PO tid for 7 d; 500 mg PO bid for 7 d; 750 mg ER PO qd for 7 d

Pediatric

<12 years: Not established
>12 years: Administer as in adults

Cimetidine may increase toxicity of metronidazole; may increase effects of anticoagulants; may increase toxicity of lithium and phenytoin; disulfiramlike reaction may occur with orally ingested ethanol

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dose in hepatic disease; monitor for seizures and development of peripheral neuropathy


Metronidazole vaginal gel (MetroGel-Vaginal)

Bactericidal antibiotic enters the bacterial cell and is reduced by electron transport proteins. Free radicals are formed, which react with intracellular components and/or DNA and result in subsequent cell death. Antimicrobial spectrum includes many gram-positive and gram-negative anaerobes and protozoal parasites.

Adult

5 g intravaginally bid for 7 d

Pediatric

<12 years: Not established
>12 years: Administer as in adults

Cimetidine may increase toxicity of metronidazole; may increase effects of anticoagulants; may increase toxicity of lithium and phenytoin; disulfiramlike reaction may occur with orally ingested ethanol

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dose in hepatic disease; monitor for seizures and development of peripheral neuropathy; do not engage in sexual intercourse while using; symptoms of vaginal candidiasis may become prominent during therapy; crosses the placental barrier and enters the fetal circulation rapidly (restrict use in pregnancy to those patients in whom alternative treatment has been inadequate); effects on organogenesis are not known

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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