Sections

Treatment

Approach Considerations

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).

Surgery is not indicated for bacterial vaginosis.

Medical Care

Note the following:

Antibiotics are the mainstay of therapy for bacterial vaginosis (BV), but 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.
Advise patients to stop douching or using bubble bath or any other over-the-counter vaginal hygiene products.
Wash only with hypoallergenic bar soaps or no soap at all. Avoid liquid soaps and body washes.

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 and Activity

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

Ya et al conducted a placebo-controlled trial to assess the effectiveness of a vaginal probiotic product (8 billion units of Lactobacillus rhamnosus, L acidophilus, and Streptococcus thermophilus per capsule) for recurrent bacterial vaginosis prevention. The dosage regimen consisted of short-term use of 7 days on, 7 days off, then 7 days on. Probiotic prophylaxis resulted in lower recurrence rates for bacterial vaginosis and Gardnerella vaginalis for 2 months. A lower incidence was also reported during follow-up (2-11 months) in women in the probiotic group.^[20]

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.

Guidelines

Brocklehurst P, Gordon A, Heatley E, Milan SJ. Antibiotics for treating bacterial vaginosis in pregnancy. Cochrane Database Syst Rev. 2013 Jan 31. 1:CD000262. [QxMD MEDLINE Link].
Amsel R, Totten PA, Spiegel CA, Chen KC, Eschenbach D, Holmes KK. Nonspecific vaginitis. Diagnostic criteria and microbial and epidemiologic associations. Am J Med. 1983 Jan. 74(1):14-22. [QxMD MEDLINE Link].
Schuyler JA, Mordechai E, Adelson ME, Sobel JD, Gygax SE, Hilbert DW. Identification of intrinsically metronidazole-resistant clades of Gardnerella vaginalis. Diagn Microbiol Infect Dis. 2015 Oct 8. [QxMD MEDLINE Link].
Tabrizi SN, Fairley CK, Bradshaw CS, Garland SM. Prevalence of Gardnerella vaginalis and Atopobium vaginae in virginal women. Sex Transm Dis. 2006 Nov. 33(11):663-5. [QxMD MEDLINE Link].
Patterson JL, Girerd PH, Karjane NW, Jefferson KK. Effect of biofilm phenotype on resistance of Gardnerella vaginalis to hydrogen peroxide and lactic acid. Am J Obstet Gynecol. 2007 Aug. 197(2):170.e1-7. [QxMD MEDLINE Link]. [Full Text].
Fredricks DN, Fiedler TL, Thomas KK, Oakley BB, Marrazzo JM. Targeted PCR for detection of vaginal bacteria associated with bacterial vaginosis. J Clin Microbiol. 2007 Oct. 45(10):3270-6. [QxMD MEDLINE Link]. [Full Text].
Meriwether KV, Rogers RG, Craig E, Peterson SD, Gutman RE, Iglesia CB. The effect of hydroxyquinoline-based gel on pessary-associated bacterial vaginosis: a multicenter randomized controlled trial. Am J Obstet Gynecol. 2015 Nov. 213 (5):729.e1-9. [QxMD MEDLINE Link].
Harrison P. Bacterial Vaginosis Raises HIV Risk, Lowers Tenofovir Level. Medscape Medical News. Available at http://www.medscape.com/viewarticle/866342. July 19, 2016; Accessed: December 7, 2016.
Payne SC, Cromer PR, Stanek MK, Palmer AA. Evidence of African-American women's frustrations with chronic recurrent bacterial vaginosis. J Am Acad Nurse Pract. 2010 Feb. 22(2):101-8. [QxMD MEDLINE Link].
Marrazzo JM, Fiedler TL, Srinivasan S, et al. Extravaginal reservoirs of vaginal bacteria as risk factors for incident bacterial vaginosis. J Infect Dis. 2012 May 15. 205(10):1580-8. [QxMD MEDLINE Link]. [Full Text].
Coughlin G, Secor M. Bacterial vaginosis: update on evidence-based care. Adv Nurse Pract. 2010 Jan. 18(1):41-4, 53. [QxMD MEDLINE Link].
Alcaide ML, Chisembele M, Malupande E, Arheart K, Fischl M, Jones DL. A cross-sectional study of bacterial vaginosis, intravaginal practices and HIV genital shedding; implications for HIV transmission and women's health. BMJ Open. 2015 Nov 9. 5 (11):e009036. [QxMD MEDLINE Link].
Thurman AR, Kimble T, Herold B, et al. Bacterial Vaginosis and Subclinical Markers of Genital Tract Inflammation and Mucosal Immunity. AIDS Res Hum Retroviruses. 2015 Nov. 31 (11):1139-52. [QxMD MEDLINE Link].
Schwiertz A, Taras D, Rusch K, Rusch V. Throwing the dice for the diagnosis of vaginal complaints?. Ann Clin Microbiol Antimicrob. 2006 Feb 17. 5:4. [QxMD MEDLINE Link]. [Full Text].
Mohanty S, Sood S, Kapil A, Mittal S. Interobserver variation in the interpretation of Nugent scoring method for diagnosis of bacterial vaginosis. Indian J Med Res. 2010 Jan. 131:88-91. [QxMD MEDLINE Link].
West B, Morison L, Schim van der Loeff M, et al. Evaluation of a new rapid diagnostic kit (FemExam) for bacterial vaginosis in patients with vaginal discharge syndrome in The Gambia. Sex Transm Dis. 2003 Jun. 30(6):483-9. [QxMD MEDLINE Link].
Reid G, Burton J, Hammond JA, Bruce AW. Nucleic acid-based diagnosis of bacterial vaginosis and improved management using probiotic lactobacilli. J Med Food. 2004 Summer. 7(2):223-8. [QxMD MEDLINE Link].
Masson L, Arnold KB, Little F, et ak. Inflammatory cytokine biomarkers to identify women with asymptomatic sexually transmitted infections and bacterial vaginosis who are at high risk of HIV infection. Sex Transm Infect. 2015 Oct 28. [QxMD MEDLINE Link].
Abramovici A, Lobashevsky E, Cliver SP, Edwards RK, Hauth JC, Biggio JR. Quantitative polymerase chain reaction to assess response to treatment of bacterial vaginosis and risk of preterm birth. Am J Perinatol. 2015 Oct. 32 (12):1119-25. [QxMD MEDLINE Link].
Ya W, Reifer C, Miller LE. Efficacy of vaginal probiotic capsules for recurrent bacterial vaginosis: a double-blind, randomized, placebo-controlled study. Am J Obstet Gynecol. 2010 Aug. 203(2):120.e1-6. [QxMD MEDLINE Link].
[Guideline] Workowski KA, Bachmann LH, Chan PA, et al. Sexually transmitted infections treatment guidelines, 2021. MMWR Recomm Rep. 2021 Jul 23. 70 (4):1-187. [QxMD MEDLINE Link]. [Full Text].
SOLOSEC: Prescribing Information. Symbiomix Therapeutics LLC. Available at https://www.accessdata.fda.gov/drugsatfda_docs/label/2017/209363s000lbl.pdf. 2017; Accessed: September 20, 2017.
Schwebke JR, Morgan FG Jr, Koltun W, Nyirjesy P. A phase-3, double-blind, placebo-controlled study of the effectiveness and safety of single oral doses of secnidazole 2 g for the treatment of women with bacterial vaginosis. Am J Obstet Gynecol. 2017 Sep 1. [QxMD MEDLINE Link]. [Full Text].
Bohbot JM, Vicaut E, Fagnen D, Brauman M. Treatment of bacterial vaginosis: a multicenter, double-blind, double-dummy, randomised phase III study comparing secnidazole and metronidazole. Infect Dis Obstet Gynecol. 2010. [QxMD MEDLINE Link]. [Full Text].
Subtil D, Brabant G, Tilloy E, et al. Early clindamycin for bacterial vaginosis in pregnancy (PREMEVA): a multicentre, double-blind, randomised controlled trial. Lancet. 2018 Oct 12. [QxMD MEDLINE Link].
De Backer E, Verhelst R, Verstraelen H, et al. Antibiotic susceptibility of Atopobium vaginae. BMC Infect Dis. 2006 Mar 16. 6:51. [QxMD MEDLINE Link]. [Full Text].
Amaya-Guio J, Viveros-Carreño DA, Sierra-Barrios EM, Martinez-Velasquez MY, Grillo-Ardila CF. Antibiotic treatment for the sexual partners of women with bacterial vaginosis. Cochrane Database Syst Rev. 2016 Oct 1. 10:CD011701. [QxMD MEDLINE Link].

Media Gallery

of 0

Author

Philippe H Girerd, MD Associate Professor, Department of Obstetrics and Gynecology, Virginia Commonwealth University, Medical College of Virginia

Philippe H Girerd, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, Association of Professors of Gynecology and Obstetrics, Medical Society of Virginia, AAGL

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

A David Barnes, MD, MPH, PhD, FACOG Consulting Staff, Department of Obstetrics and Gynecology, Mammoth Hospital (Mammoth Lakes, CA), Pioneer Valley Hospital (Salt Lake City, UT), Warren General Hospital (Warren, PA), and Mountain West Hospital (Tooele, UT)

A David Barnes, MD, MPH, PhD, FACOG is a member of the following medical societies: American College of Forensic Examiners Institute, American College of Obstetricians and Gynecologists, The Society of Federal Health Professionals (AMSUS), American Medical Association, Utah Medical Association

Disclosure: Nothing to disclose.

Chief Editor

Michel E Rivlin, MD Former Professor, 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, Royal College of Surgeons of Edinburgh, Royal College of Obstetricians and Gynaecologists

Disclosure: Nothing to disclose.

Additional Contributors

Thomas Michael Price, MD Professor Emeritus, Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, Former Director of Reproductive Endocrinology and Infertility Fellowship 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, Phi Beta Kappa, Society for Reproductive Endocrinology and Infertility, Society for Reproductive Investigation

Disclosure: Received research grant from: Insigtec Inc<br/>Received consulting fee from Clinical Advisors Group for consulting; Received consulting fee from MEDA Corp Consulting for consulting; Received consulting fee from Gerson Lehrman Group Advisor for consulting; Received honoraria from ABOG for board membership.

Acknowledgements

Burke A Cunha, MD Professor of Medicine, State University of New York School of Medicine at Stony Brook; Chief, Infectious Disease Division, Winthrop-University Hospital

Burke A Cunha, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Diana Curran, MD, FACOG Assistant Professor, Residency 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, and Central Association of Obstetricians and Gynecologists

Disclosure: Nothing to disclose.

Eric A Hansen, DO, Fellow, Clinical Instructor, Department of Internal Medicine, Division of Infectious Diseases, Winthrop-University Hospital, State University of New York at Stony Brook

Disclosure: Nothing to disclose.

Clinical Elements		Bacterial Vaginosis	Trichomoniasis	Vaginal Candidiasis
Symptoms	Vaginal odor	+	+/-	-
	Vaginal discharge	Thin, gray, homogenous	Green-yellow	White, curdlike
	Vulvar irritation	+/-	+	+
	Dyspareunia	-	+	-
Signs	Vulvar erythema	-	+/-	+/-
	Bubbles in vaginal fluid	+	+/-	-
	Strawberry cervix	-	+/-	-
Microscopy	Saline wet mount
	Clue cells	+	-	-
	Motile protozoa	-	+	-
	KOH test
	Pseudohyphae	-	-	+
	Whiff test	+	+/-	-
	pH	>4.5	>4.5	< 4.5

Bacterial Vaginosis Treatment & Management

Approach Considerations

Medical Care

Consultations

Diet and Activity

References

Tables

Contributor Information and Disclosures

What would you like to print?