Guidelines for Nurse Practitioners in Gynecologic Settings 2016
Care Plan – Bacterial Vaginosis
N76.0: Acute vaginitis
I. DEFINITION
BV is a polymicrobial clinical syndrome characterized by replacement of the normal hydrogen peroxide–producing Lactobacillus species with an overgrowth of anaerobic bacteria (e.g., Prevotella and Mobiluncus species),
G. vaginalis, Ureaplasma, and numerous fastidious or uncultivated anaerobes (per the Centers for Disease Control and Prevention (CDC) guidelines, 2014)
II. ETIOLOGY
A. BV is a vaginosis rather than vaginitis. As such, there is usually little or no inflammation of the epithelium associated with the syndrome (relative absence of polymorphonuclear leukocytes). It is not caused by a single pathogen but is probably a disturbance of the vaginal microbial ecology, with a displacement of normal lactobacillary flora by anaerobic microorganisms.
B. It is a sexually associated rather than a sexually transmitted syndrome (BV is found more often in sexually active women). A male version of BV has not been identified.
III. HISTORY
A. What the patient may present with
1. History of having multiple sex partners: male and female, a new sex partner, douching, no use of condoms; but also negative history of sexual activity
2. Vaginal odor (fishy)
3. Increased vaginal discharge: milky white, thin adherent discharge or dark or dull gray discharge
4. Vaginal burning after intercourse; vulvar pruritis (15% of women)
5. No symptoms in many patients
B. Additional information to be considered
1. Previous vaginal infections; diagnosis, treatment; compliance with treatment
2. Chronic illness; careful history of seizure disorders
3. Sexual activity; partner preference; multiple partners, new sex partner
4. History of STI or PID
5. Last intercourse
6. LMP, pregnancy
7. Method of birth control, other medications
8. Description of discharge
a. Onset
b. Color
c. Odor stronger during intercourse
d. Consistency
e. Constant versus intermittent
f. Relationship of symptoms to sexual contact
g. Relationship of symptoms to menses
h. Amount
9. Use of vaginal deodorant sprays; deodorant tampons, panty lin- ers, or pads; douches; perfumed toilet tissue
10. Change in laundry soaps, fabric softener, body soap
11. Clothing: consistent wearing of tight-crotched pants, nylon underwear, or underwear to bed
12. Personal hygiene
13. Recent change in lifestyle (stress, personal crisis)
14. Partner symptoms
IV. PHYSICAL EXAMINATION
A. External examination
Perineum usually has a normal appearance; occasional irritation
B. Vaginal examination (speculum)
1. Inspection of vaginal walls: check if smoothly covered with white discharge
2. Inspection of cervix
3. Discharge: characteristically adherent, homogeneous, whitish in color, and of a fishy, musty odor with a pH greater than 4.5; take smear from lateral walls of vagina, not cervix, for accurate pH (use nitrazine paper for test)
C. Bimanual examination if indicated
V. LABORATORY EXAMINATION
A. Diagnosis (three of four Amsel criteria)
1. White, thin, adherent discharge
2. pH greater than 4.5
3. Positive whiff test (fishy amine odor from vaginal fluid mixed with 10% KOH)
4. Clue cells on wet mount: epithelial cells dotted with large numbers of bacteria that obscure cell borders; should see more than 20% clue cells
5. Gram stain
B. Office lab tests: FemExam, PIP Activity TestCard; Affirm VPIII DNA probe-based test; OSOM BVBlue Test—vaginal swab in test tube with reagent—positive for BV if it turns blue or green (performance of these tests comparable to Gram stain)
C. Few WBCs seen on wet mount; decreased Lactobacilli
D. Further laboratory work as indicated by history or wet prep/card, BVBlue test results
VI. DIFFERENTIAL DIAGNOSIS
A. Trichomoniasis
B. Presence of foreign body
VII. TREATMENT: RECOMMENDED REGIMENS FOR ACUTE BV
A. Medications
1. Metronidazole 500 mg orally twice a day for 7 days or
2. Metronidazole gel 0.75% one applicatorful (5 g) once a day for 5 days or
3. Clindamycin phosphate cream (Cleocin vaginal cream 2% one applicator full, 5 g) intravaginally at bedtime for 7 nights. Clindamycin is contraindicated with colitis and other chronic bowel disease. Use cautiously in patients with asthma or impaired renal or hepatic function. (Note: The mineral oil in Cleocin vaginal cream may weaken latex or rubber products such as condoms or vaginal diaphragms for 5 days after use.)
B. Alternative regimens
1. Tinidazole 2 g orally once daily for 3 days or
2. Tinidazole 1 g orally once daily for 5 days or
3. Clindamycin 300 mg orally twice daily for 7 days or
4. Clindamycin (Cleocin) vaginal ovules 100 mg intravaginally once at bedtime for 3 days
5. In pregnancy: symptomatic women require treatment with
a. Metronidazole 500 mg orally twice a day for 7 days or
b. Metronidazole 250 mg orally three times a day for 7 days or
c. Clindamycin 300 mg orally twice a day for 7 days
6. In pregnancy: asymptomatic women at low risk for preterm delivery
a. Controversial whether to treat or not to treat: Use of clindamy- cin cream in the second half of pregnancy might be associated with adverse outcomes.
b. Increase in adverse events: Use clindamycin only in the first half of pregnancy per CDC 2015 recommendations.
7. Treatment for partner not recommended by the CDC (no decrease in recurrences with partner treatment and no effect on cure rates)
8. Note: If BV coexists with candidiasis:
a. Treat a predominant organism first. If symptoms persist, recheck and treat as indicated.
b. Consider local treatment for candidiasis concurrently with oral treatment for BV as previously mentioned.
c. Clindamycin also kills Lactobacilli, so candidiasis is common after treatment. Consider sequential treatment.
d. If BV coexists with group B Streptococcus, treat concurrently.
C. General measures
1. Stress avoidance of intercourse until symptoms subside, then use condoms until end of treatment; condom therapy for 4 to 6 weeks (without antibiotic treatment) often results in resolution of BV.
2. Stress no douching during treatment or after.
3. Stress necessity of completing course of medication.
4. Nausea, vomiting, and cramps can occur if patient is on metronidazole. Stress no alcohol intake during treatment and for 48 hours after completing medications.
5. Stress appropriate choice of medications if pregnant, if possibly pregnant, or if nursing.
6. Stress hygiene: cotton underwear, loose clothing, no underpants while sleeping, wipe front first and then back, no feminine deodorants or hygiene sprays.
7. Carefully review history for seizure disorders.
8. Metronidazole can cause GI upset even with no alcohol.
9. No data to suggest decreased likelihood of relapse or recurrence by treating a woman’s sex partner(s). Routine treatment of sex partners is not recommended.
VIII. TREATMENT: CHRONIC, RECURRING
A. For recurring BV, consider treatment with a different regimen.
B. If no relief, consider consultation with a specialist.
C. Try metronidazole gel 0.75% twice a week for 4 to 6 months after completion of recommended regimen as mentioned previously; oral nitroimidazole followed by intravaginal boric acid and suppressive metronidazole gel for women in remission; or monthly oral metro- nidazole with fluconazole as suppressive therapy per the CDC (2015).
IX. COMPLICATIONS
Bacterial vaginosis has been associated with PID, endometritis, cervicitis, inflammation, or atypical squamous cells (ASCs) on Pap smears, possible link to low-grade squamous intraepithelial lesion (LGSIL) on Pap smears, preterm rupture of membranes, preterm labor, preterm birth, low birth weight, chorioamnitis, postpartum endometritis, and increased risk of HIV acquisition.
X. CONSULTATION/REFERRAL
If no response to treatment as discussed previously
XI. FOLLOW-UP
A. None necessary unless
1. Symptoms persist after treatment
2. Symptoms recur
3. Pregnancy: asymptomatic women at high risk, consider evaluation 1 month after completion of treatment
See Appendix I and Bibliographies.
Website: www.cdc.gov/std/tg2015/tg-2015-Print.pdf