Bacterial vaginosis (BV) is the most common cause of abnormal vaginal discharge in reproductive-age females. Treatment is aimed at relieving symptoms, although many individuals are asymptomatic. Of those with symptoms, abnormal vaginal discharge and fishy odor are typical.
Commonly associated bacteria – The major bacteria detected in females with BV are
Gardnerella vaginalis,
Prevotella species,
Porphyromonas species,
Bacteroides species,
Peptostreptococcus species,
Mycoplasma hominis, and
Ureaplasma urealyticum, as well as
Mobiluncus,
Megasphaera,
Sneathia, and
Clostridiales species
CLINICAL FEATURES
Individuals can present with classic symptoms, symptoms that suggest multiple etiologies of vaginal discharge, or be asymptomatic.
Classic symptoms – Symptomatic individuals typically present with vaginal discharge and/or vaginal odor. The discharge is off-white, thin, and homogeneous; the odor is an unpleasant "
fishy smell" that may be more noticeable after sexual intercourse and during menses
Although supporting data are limited, in our experience, in the absence of microscopy, a lack of fishy odor (negative whiff test) makes the diagnosis of BV less likely
Symptomatic patients
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Treatment: For nonpregnant persons with confirmed symptomatic BV, we suggest multiday treatment with
metronidazole or
clindamycin rather than treatment with other antibiotics. As efficacy is similar for oral or vaginal regimens of both metronidazole or clindamycin, choice of treatment route is driven by patient preference around treatment route, drug availability, and cost. Treatment of patients with a neovagina and/or HIV infection is the same.
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Preferred treatment regimens include:
Metronidazole 500 mg twice daily orally for seven days.
or
Metronidazole gel 0.75% (5 grams containing 37.5 mg metronidazole) once daily vaginally for five days.
or
Clindamycin 2% vaginal cream once daily at bedtime for seven days. During therapy with clindamycin cream, latex condoms should not be used.
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Alternate regimens – Oral
tinidazole and
secnidazole have demonstrated efficacy similar to oral
metronidazole and convenient dosing.