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Bacterial vaginosis - Management
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Who should I treat?

  • Offer treatment to all pregnant women with symptomatic bacterial vaginosis (BV).
  • Women who are pregnant should not be offered routine screening for BV. However, if a pregnant woman is incidentally found to have BV and has no symptoms, discuss with the woman's obstetrician whether treatment is appropriate.
Basis for recommendation

Treating all symptomatic pregnant women

Screening for BV in asymptomatic pregnant women

  • The National Institute for Health and Clinical Excellence (NICE) does not recommend routine screening for BV because the evidence suggests that identification and treatment of asymptomatic BV does not lower the risk for pre-term birth and other adverse reproductive outcomes [NICE, 2008].
  • The British HIV Association recommends screening for BV in pregnant women who are infected with HIV because there is an increased risk of mother-to-child transmission of HIV-1 in the presence of BV [de Ruiter et al, 2008].

Seeking advice regarding whether to treat an asymptomatic pregnant woman

  • Because the evidence regarding the treatment of BV to prevent adverse outcomes in pregnancy is conflicting, CKS recommends that the management of asymptomatic pregnant women be considered on an individual basis, after discussion with the woman's obstetrician.

How should I treat a pregnant woman with bacterial vaginosis?

  • Oral metronidazole is the treatment of choice.
    • A dose of 400 mg twice a day for 7 days is recommended.
    • High-dose regimens (single oral dose of 2 g) are not recommended during pregnancy.
  • Intravaginal metronidazole gel or intravaginal clindamycin cream are alternative choices for achieving cure if the woman prefers a topical treatment or is unable to tolerate oral metronidazole:
    • Intravaginal metronidazole gel 0.75% once a day for 5 days, or
    • Intravaginal clindamycin cream 2% once a day for 7 days.
  • Oral clindamycin may also be considered, but is less preferred.
    • Oral clindamycin (300 mg twice a day for 7 days) is not widely recommended in primary care because of an increased risk of pseudomembranous colitis.
  • Testing should be repeated after 1 month to ensure that cure was achieved.
Basis for recommendation

Antibiotic choice for eradication of bacterial vaginosis

  • Evidence from a Cochrane systematic review (10 randomized controlled trials) indicated that both oral and intravaginal antibiotics are effective at eradicating bacterial vaginosis in pregnant women. Although there was no direct comparison, oral antibiotics appeared to have similar efficacy to intravaginal antibiotics, and clindamycin (oral or intravaginal) appeared to have similar efficacy to other antibiotic treatments.
  • High-dose regimens of metronidazole (2 g single dose) are not recommended in pregnancy [ABPI Medicines Compendium, 2008; BNF 56, 2008].
  • Metronidazole is preferred over tinidazole in women who are pregnant because there is more experience with metronidazole.

Test of cure

  • The recommendation to test all pregnant women 1 month after completion of treatment is based on expert opinion and is consistent with UK guidelines [RCGP and BASHH, 2006].

How should I manage a woman with persistent or recurrent symptoms during pregnancy?

  • If symptoms persist or recur after initial treatment:
    • Reconsider the diagnosis of bacterial vaginosis.
    • Check adherence with treatment.
    • Ensure that the current episode is adequately managed.
      • Oral metronidazole 400–500 mg twice a day for 7 days is generally considered to be the most effective treatment.
    • Consider discussing further treatment options with the woman's obstetrician or a genito-urinary physician.
Basis for recommendation

CKS found no evidence regarding treatment options if initial treatment is unsuccessful in a woman who is pregnant. Discussion with the woman's obstetrician or a genito-urinary physician is recommended, to avoid exposing the woman to repeated courses of antibiotics.

Prescriptions

For information on contraindications, cautions, drug interactions, and adverse effects, see the electronic Medicines Compendium (eMC) (http://emc.medicines.org.uk), or the British National Formulary (BNF) (www.bnf.org).

Oral metronidazole

Age from 12 years onwards
Metronidazole tablets: 400mg twice a day for 7 days
Metronidazole 400mg tablets
Take one tablet twice a day for 7 days.
Supply 14 tablets.
Age: from 12 years onwards
NHS cost: £0.83
Licensed use: yes

Intravaginal antibiotics

Age from 12 years onwards
Metronidazole 0.75% vaginal gel: use at night for 5 nights
Zidoval 0.75% gel
Insert one 5g applicatorful into the vagina each night for 5 nights.
Supply 40 grams.
Age: from 12 years onwards
NHS cost: £4.31
Licensed use: yes
Clindamycin 2% vaginal cream: use at night for 7 nights
Clindamycin 2% vaginal cream
Insert one 5g applicatorful into the vagina each night for 7 nights.
Supply 40 grams.
Age: from 12 years onwards
NHS cost: £10.86
Licensed use: yes

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