I Guideline Information
Guidelines program of the DGGG, OEGGG and SGGG
For information on the guidelines program, please refer to the end of the guideline.
Citation format
Bacterial Vaginosis: Guideline of the DGGG, OEGGG and SGGG (S2k-Level, AWMF Registry
No. 015/028, June 2023). Geburtsh Frauenheilk 2023; 83: 1331–1349
Guideline documents
The complete German-language long version and a slide version of these guidelines
as well as a list of the conflicts of interest of all the authors are available on
the homepage of the
AWMF: http://www.awmf.org/leitlinien/detail/ll/015-028.html
Guideline authors
See [Tables 1] and [2].
Table 1 Lead and/or coordinating guideline author.
|
Author
|
AWMF professional society
|
|
Ap.Prof. Priv.-Doz. Dr. Dr. Alex Farr, MPH
|
Austrian Society for Gynecology and Obstetrics (Österreichische Gesellschaft für Gynäkologie und Geburtshilfe, OEGGG)
European Society for Infectious Diseases in Obstetrics and Gynecology (ESIDOG)
Austrian Society for Pre- and Perinatal Medicine (Österreichische Gesellschaft für Prä- und Perinatale Medizin, ÖGfPPM)
|
Table 2 Contributing guideline authors.
|
Author
Mandate holder
|
DGGG working group (AG)/
AWMF/non-AWMF professional society/
organization/association
|
|
* This person attended as an expert (not eligible to vote in the consensus process).
|
|
Alex Farr
|
OEGGG, ÖGfPPM, ESIDOG
|
|
Brigitte Frey Tirri
|
SGGG
|
|
Udo Hoyme*
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AGII
|
|
Werner Mendling
|
DGGG, AGII
|
|
Inge Reckel-Botzem
|
BVF
|
|
Daniel Surbek
|
SGGG
|
|
Sonja Swidsinski
|
DGHM
|
|
Gisela Walter
|
DSTIG, AEGGF
|
|
Birgit Willinger
|
OEGHMP
|
The following professional societies/working groups/organizations/associations stated
that they wished to contribute to the guideline text and participate in the consensus
conference and
nominated representatives to attend the conference ([Table 2]).
Abbreviations
BV:
bacterial vaginosis
BVAB:
BV-associated bacteria
CDC:
Center for Disease Control and Prevention
CFU:
colony-forming units
CST:
community state types
FISH:
fluorescence in situ hybridization
HIV:
human immunodeficiency virus
HPV:
human papillomaviruses
HSV:
herpes simplex virus
IVF:
in vitro fertilization
KOH:
potassium hydroxide
NAAT:
nucleic acid amplification test
NGS:
next generation sequencing
PID:
pelvic inflammatory disease
spp.:
abbreviation of species (plural)
STI:
sexually transmitted infection
VVC:
vulvovaginal candidiasis
WSW:
women having sex with women
II Guideline Application
Purpose and objectives
The aim of this guideline is to provide optimal care to patients with bacterial vaginosis,
whether they are outpatients, day patients or inpatients. The intention must be to
provide
targeted therapy depending on the symptoms. The aim is also to prevent unnecessary
or inadequate therapies. The prevention and early detection of bacterial vaginosis
is also one of the aims
of this guideline.
Targeted areas of care
Outpatient care, day-patient care, inpatient care and specialized cared.
Target user groups/target audience
This guideline is addressed to the following groups of people: hospital-based gynecologists
and gynecologists in private practice, hospital-based microbiologists, and microbiologists
in
private practice. Other target groups (providing them with information) include: general
practitioners, hospital-based midwives and midwives in private practice, nursing staff,
biomedical
analysts, professional medical societies and associations, public health institutions
und decision-makers at national and federal state levels, and funding agencies.
Adoption and period of validity
The validity of this guideline was confirmed by the executive boards/representatives
of the participating medical professional societies, working groups, organizations,
and associations and
the boards of the DGGG, SGGG, and OEGGG and the DGGG/OEGGG/SGGG Guidelines Commission
in June 2023 and was thereby approved in its entirety. This guideline is valid from
1 June 2023 through
to 30 May 2027. The guideline can be updated earlier if urgently necessary. Similarly,
the guidelineʼs period of validity can be extended if the guideline still reflects
the current state of
knowledge.
III Methodology
Basic principles
The method used to prepare this guideline was determined by the class to which this
guideline was assigned. The AWMF Guidance Manual (version 1.0) has set out the respective
rules and
requirements for different classes of guidelines. Guidelines are differentiated into
lowest (S1), intermediate (S2), and highest (S3) class. The lowest class is defined
as consisting of a
set of recommendations for action compiled by a non-representative group of experts.
In 2004, the S2 class was divided into two subclasses: a systematic evidence-based
subclass (S2e) and a
structural consensus-based subclass (S2k). The highest S3 class combines both approaches.
This guideline was classified as: S2k.
Grading of recommendations
The grading of evidence based on the systematic search, selection, evaluation, and
synthesis of an evidence base which is then used to grade the recommendations is not
envisaged for S2k
guidelines. The individual statements and recommendations are only differentiated
by syntax, not by symbols ([Table 3]).
Table 3 Grading of recommendations (based on Lomotan et al., Qual Saf Health Care 2010).
|
Description of binding character
|
Expression
|
|
Strong recommendation with highly binding character
|
must/must not
|
|
Regular recommendation with moderately binding character
|
should/should not
|
|
Open recommendation with limited binding character
|
may/may not
|
Statements
Expositions or explanations of specific facts, circumstances, or problems without
any direct recommendations for action included in this guideline are referred to as
“statements.” It is
not possible to provide any information about the level of evidence for these statements.
Achieving consensus and level of consensus
At structured NIH-type consensus-based conferences (S2k/S3 level), authorized participants
attending the session vote on draft statements and recommendations. The process is
basically as
follows. A recommendation is presented, its contents are discussed, proposed changes
are put forward, and all proposed changes are voted on. If a consensus (> 75% of votes)
is not
achieved, there is another round of discussions, followed by a repeat vote. Finally,
the extent of consensus is determined, based on the number of participants ([Table 4]).
Table 4 Level of consensus based on extent of agreement.
|
Symbol
|
Level of consensus
|
Extent of agreement in percent
|
|
+++
|
Strong consensus
|
> 95% of participants agree
|
|
++
|
Consensus
|
> 75 – 95% of participants agree
|
|
+
|
Majority agreement
|
> 50 – 75% of participants agree
|
|
–
|
No consensus
|
< 51% of participants agree
|
Expert consensus
As the term indicates, this refers to consensus decisions taken relating specifically
to recommendations/statements issued without a prior systematic search of the literature
(S2k) or where
evidence is lacking (S2e/S3). The term “expert consensus” (EC) used here is synonymous
with terms used in other guidelines such as “good clinical practice” (GCP) or “clinical
consensus
point” (CCP). The strength of the recommendation is graded as previously described
in the chapter Grading of recommendations but without the use of symbols; it is only expressed
semantically (“must”/“must not” or “should”/“should not” or “may”/“may not”).
IV Guideline
1 Summary of recommendations
Bacterial vaginosis (BV) is characterized by a strong increase in the number of bacteria
(bacterial overgrowth), especially of Gardnerella (G.) species (spp.), a high microbial
diversity as
well as the displacement of potentially protective lactobacilli in the vaginal fluid.
Gardnerella spp. is the predominant bacterial species in BV and is also the species
with the highest virulence potential. They are integrated in a biofilm matrix with
other BV-associated
types of bacteria (BVAB), and this is what appears to be responsible for treatment
failures and chronic recurrences. Chronically recurrent BV is when the patient has
at least 3 episodes per
year; this may be an indication that the pathogenesis of BV could be biofilm-related.
BV is associated with specific risk factors, and particular attention should be paid
to them when making
the diagnosis. The aim should be to eliminate predisposing host factors where possible.
In clinical practice, women with vulvovaginal symptoms must be investigated for BV,
particularly if they present with a thin homogeneously gray discharge (with or without
a fishy odor) and
an alkaline vaginal pH. Diagnostic investigations must be guided by the patientʼs
prior medical history, clinical findings, and the microscopic evidence of clue cells
in the unfixed vaginal
smear as well as an evaluation based on the Amsel criteria if necessary. Lab diagnostics
should include Gram staining with quantitative comparison of different morphotypes
using the Nugent
scoring system. Lab diagnostics based on molecular genetic procedures only play a
minor role and should currently only be used in special cases.
Treatment for BV must only be initiated after a proper diagnostic investigation has
been carried out and medically confirmed. Women with vulvovaginal symptoms and confirmed
BV must be
treated in accordance with medical guidelines, and therapy must consist of oral or
topical clindamycin or metronidazole. Alternatively, local antiseptics may be used.
The treatment of
bacterial vaginosis in pregnancy must consist primarily of vaginal clindamycin or
antiseptics. In cases with chronically recurrent BV, treatment should consist of local
antiseptics or
suppressive maintenance therapy with topical metronidazole followed by vaginal probiotics
to reduce the probability of recurrence.
Lactic acid and probiotics appear to have a positive impact in therapy and as recurrence
prophylaxis and may be used as a complementary approach after the completion of therapy
to
regenerate the lactobacilli flora. Treating the patientʼs partner may be considered
in cases with chronic recurrence, although the evidence for this is limited. Women
with BV must always be
informed about which measures could prevent the recurrence of bacterial vaginosis
in their case. Women with BV who wish to become pregnant very soon should be treated
even if they are
asymptomatic. The same applies to women with aerobic or desquamative inflammatory
vaginitis.
Future research into BV should focus on reducing the high rate of recurrence and chronic
recurrence of disease.
2 Definition
|
Consensus-based statement 2.S1
|
|
Expert consensus
|
Level of consensus +++
|
|
Bacterial vaginosis is characterized by excessive numbers of bacteria, especially
Gardnerella species, a high microbial diversity of anaerobic and facultatively anaerobic
bacterial species, as well as the displacement of potentially protective lactobacilli
in vaginal fluid.
|
|
Consensus-based recommendation 2.E1
|
|
Expert consensus
|
Level of consensus +++
|
|
Chronic recurrent bacterial vaginosis is defined as the occurrence of at least 3 episodes
per year and may indicate that the pathogenesis is biofilm-related.
|
BV is the most common vaginal disease worldwide with a prevalence of between 23% and
29% in sexually active women [1]. It is considered a form of vaginal
dysbiosis where the vaginal microbiota is significantly different to that of healthy
women without BV. The difference includes a strong increase in the numbers of bacteria,
especially of
Gardnerella spp., a high microbial diversity of facultatively and strictly anaerobic
bacteria, and the displacement of protective lactobacilli. There are some indications
for the presence of
a biofilm on vaginal epithelium consisting predominantly of Gardnerella spp. but also
including numerous other BVAB. The existence of such a biofilm would explain some
of the changes to the
vaginal microbiota and could be considered a pathogenetic factor [2].
3 Microbiology
|
Consensus-based statement 3.S2
|
|
Expert consensus
|
Level of consensus +++
|
|
Gardnerella species is the predominant bacterial species found in bacterial vaginosis
and the species with the highest virulence potential. It forms part of a biofilm matrix
which
includes other BV-associated bacterial species and appears to be responsible for the
ultimate failure of therapy and for chronically recurrent disease.
|
Gardnerella spp. is the predominant bacterial species in 95 – 100% of women with BV
[3], and includes four different named species (G. vaginalis, G. piotii,
G. leopoldii, and G. Swidsinskii) and a further 9 as yet unnamed species [4]. Gardnerella spp. are gram-positive bacteria and is part of the Bifidobacteriaceae
family [5]. Because of their unusually thin cell walls, in gram-stained specimens they appear
as gram-negative or gram-variable coccobacilli [6]. The specific virulence properties of Gardnerella spp. include its pronounced ability
to adhere to vaginal epithelial cells and its biofilm-producing capacity
[7]. The BV biofilm consists mainly of tightly packed adjacent Gardnerella spp. Many
other different BVAB are integrated in its matrix. Their concentrations
are significantly higher than in normal vaginal microbiota but still lower than the
concentrations of Gardnerella spp. With the exception of Fannyhessia vaginae (previously
Atopobium
vaginae), none of the non-Gardnerella species are present in > 60% of BV biofilms.
The range of different BVAB is enormous; in addition to the most common species Fannyhessia
vaginae,
Fusobacterium nucleatum, Mobiluncus mulieris, Mycoplasma hominis, Prevotella bivia,
and Ureaplasma urealyticum, it also includes lactobacilli such as L. iners [8], [9]. The Gardnerella spp. dominate the polymicrobial biofilm; they are responsible for
the increased resistance to hydrogen peroxide, lactic acid,
bactericides, and host immune defense [10] and are the main cause of the high failure rate of standard antibiotic therapy and
for BV recurrence [11]. STI pathogens also benefit from ecological interactions with the BV biofilm. The
risk of contracting sexually transmissible infections is significantly higher
for women with BV compared to women with a normal vaginal microbiota [12], [13]. Women with BV are also more susceptible to
other genital infections [14].
4 Host, virulence and risk factors
|
Consensus-based recommendation 4.E2
|
|
Expert consensus
|
Level of consensus +++
|
|
BV is associated with certain risk factors, and particular attention should be paid
to them when making the diagnosis. The aim should be to eliminate predisposing host
factors
where possible.
|
No definite gene locus which could be partly responsible for developing BV has been
identified yet [15]. However, an association with womenʼs ethnic
affiliations has been reported [16], [17]. The incidence of BV is higher in women from South and East Africa than in women
from West Africa, Europe, Australia, or New Zealand. In the USA, the reported prevalence
of BV was 51% in Afro-American women, 32% in Hispanic women, 23% in white American
women and 33% in
native American women [11], [18], [19]. Exogenous host factors for BV include smoking,
excessive vaginal hygiene, chronic stress, frequent changes of sexual partner, and
imminent menstruation [18], [20], [21], [22]. Brookheart et al. [23] reported that BV occurred more often in women with a high body
weight or body mass index. There are some indications that BV biofilms may be sexually
transmitted. Women who have been previously treated for BV have a higher risk of recurrence
if they
have sexual intercourse with the same partner again without using a condom [24], [25], [26].
Women with same-sex partners (WSW, women having sex with women) have a higher risk
per se of BV [27]. Taking combined oral contraceptives is associated with a
lower prevalence of BV [28] – [30], although this appears to be associated with the estradiol in the contraceptive
[31]. The use of copper intrauterine devices appears to be associated with an increased
risk of BV [32].
5 Symptoms
|
Consensus-based recommendation 5.E3
|
|
Expert consensus
|
Level of consensus +++
|
|
Women with vulvovaginal symptoms, especially with a thin homogeneous grayish discharge
(with or without a fishy odor) and an alkaline vaginal pH, must be investigated for
bacterial vaginosis.
|
The characteristic symptom of BV is increased homogeneous vaginal discharge [33], [34]. The discharge is thin with a grayish,
slightly milky color [35], [36], [37], and is accompanied by a fishy smell and a vaginal pH of
> 4.5 [34]. Additional irritations in the genital area include burning sensation, redness,
itching, dyspareunia, or dysuria. Many women present to their GP
because of menstrual disorders or bladder infection symptoms [33], [38]. In pregnancy, BV may present with symptoms such as
preterm labor, cervical shortening, or premature rupture of membranes [39], [40]. In women with sexually transmissible
infections including HIV, the other infections may mask the symptoms of BV making
it more difficult to arrive at the correct diagnosis [41], [42], [43]. Vulvovaginal candidiasis (VVC) is the most important differential diagnosis, although
the main symptom of VVC is
vestibular itching [44], [45]. The majority of women (85%) with trichomoniasis are asymptomatic [46], [47], although one third of these women go on to develop symptoms within 6 months [48]. Classic symptoms also
include vaginal discharge, which is often foul-smelling and has a yellow-green color,
accompanied by dysuria, itchiness, and abdominal pain. In contrast to BV, infection
with Chlamydia
trachomatis is usually characterized by a limited cervical discharge, cervical contact
bleeding, urethritis, menstrual disorders, and in some cases endometritis, salpingitis
and lower
abdominal pain [44].
6 Diagnosis
|
Consensus-based recommendation 6.E4
|
|
Expert consensus
|
Level of consensus +++
|
|
Diagnostic investigations for bacterial vaginosis must be guided by the patientʼs
prior medical history, clinical findings, and the microscopic evidence of clue cells
in the
unfixed vaginal smear, as well as an evaluation based on the Amsel criteria if necessary.
|
|
Consensus-based recommendation 6.E5
|
|
Expert consensus
|
Level of consensus +++
|
|
After the initial diagnostic workup, lab diagnostics for bacterial vaginosis should
include Gram staining with quantitative comparison of different morphotypes using
the Nugent
scoring system.
|
|
Consensus-based recommendation 6.E6
|
|
Expert consensus
|
Level of consensus +++
|
|
Lab diagnostics for bacterial vaginosis based on molecular genetic procedures only
play a minor role in clinical practice and should currently only be used in special
cases.
|
The correct diagnosis of BV is of special clinical importance for women with recurrent
disease and women with failure of first-line therapy [49] as well as
for women wanting to have children or women being investigated for a history of preterm
birth [50], [51]. Classic microscopic
examinations such as unfixed vaginal smear and gram-staining of specimens are still
recommended as the reference methods [49], [50]. But these methods can only identify the morphotypes and therefore only permit general
statements to be made about the existing changes to the vaginal microbiota. In recent
years,
molecular genetic methods (FISH, NAAT/PCR, NGS) have been developed to diagnose BV,
which provide much more detailed information about changes to the vaginal microbiota,
permitting a more
precise diagnosis and therefore a more targeted therapy [52].
In patients with the typical symptoms of BV, the diagnosis can be made based on the
patientʼs medical history, local findings, examination of an unfixed vaginal smear,
and determination of
the vaginal pH [44]. With BV, an unfixed smear obtained from the vaginal discharge (phase-contrast microscopy
× 400) will show numerous short coccobacilli on
the epithelial cells of the vagina, which Gardner has called clue cells [53]. Lactobacilli and other morphotypes or leukocytes cannot be detected or are
almost undetectable [44]. The Amsel criteria are met if 3 of the 4 following characteristics are present:
homogeneous grayish-white vaginal discharge; vaginal
pH > 4.5; vaginal discharge has a fishy smell, especially after the addition of a
drop of 10% potassium hydroxide (KOH); and/or confirmation of at least 20% clue cells
in relation to the
total number of epithelial cells in the unfixed vaginal smear visible in the field
of vision [54].
The Nugent scoring system is a standardized assessment method for Gram-stained vaginal
smears where points (0 to 10) are used for a semiquantitative assessment; large gram-positive
bacilli
are scored as 0 to 4, small gram-variable and gram-negative bacilli as 0 to 4, and
curved Mobiluncus-like bacilli as 0 to 2 [55]. With this scoring system,
women with clinical symptoms of BV usually have scores between 7 and 10, whereas healthy
women have scores between 0 and 3. Scores from 4 to 6 are considered “intermediate”
and do not permit
clinically relevant statements to be made [56]. The Hay-Ison score may be used as an alternative scoring system. It differentiates
between 5 categories
(grades 0 to 4), whereby grade 0 indicates that only epithelial cells without lactobacilli
or indications of BV are present. Grade 1 constitutes a normal state with a predominance
of vaginal
lactobacilli, grade 2 represents intermediate mixed vaginal flora with some Gardnerella
and Mobiluncus morphotypes, grade 3 stands for typical BV with clue cells dominated
by anaerobes
(without lactobacilli or with only a few lactobacilli). Grade 4 indicates gram-positive
cocci, with indications of BV or lactobacilli morphotypes [57].
Fluorescence in situ hybridization (FISH) is used to obtain a clear taxonomic identification
of the microorganisms and to assess the spatial organization and morphological features
of the
investigated specimen [58]. Next generation sequencing (NGS) is used to identify the genotype of microorganisms
in microbial communities even if only small
amounts are present in the clinical sample [59]. Quantitative multiplex polymerase chain reaction (qPCR) has a sensitivity of 80%
and a specificity of up to
92% [60]. But this method should be reserved for women who wish to become pregnant, women
who are already pregnant, and women undergoing IVF, or to screen
patients with an increased risk of STI. Additional laboratory tests include the BD
Affirm VPIII assay, a synthetic oligonucleotide probe test [61], [62], [63], [64], and diverse point-of-care tests such as the OSOM BVBLUE test which is based on
the
detection of sialidase activity [65], [66], and the FemExam test which detects the metabolite trimethylamine and proline
aminopeptidase activity [64], [67].
7 Therapy
|
Consensus-based recommendation 7.E7
|
|
Expert consensus
|
Level of consensus +++
|
|
Women with vulvovaginal symptoms and confirmed bacterial vaginosis must be treated
in accordance with medical guidelines.
|
|
Consensus-based recommendation 7.E8
|
|
Expert consensus
|
Level of consensus +++
|
|
The treatment of bacterial vaginosis must consist of oral or topical clindamycin or
metronidazole. Alternatively, local antiseptics may be used.
|
|
Consensus-based recommendation 7.E9
|
|
Expert consensus
|
Level of consensus +++
|
|
The treatment of chronically recurrent bacterial vaginosis should consist of local
antiseptics or suppressive maintenance therapy using topical metronidazole, followed
by vaginal
probiotics to reduce the probability of recurrence after completing therapy.
|
|
Consensus-based recommendation 7.E10
|
|
Expert consensus
|
Level of consensus +++
|
|
Pregnant women with symptomatic bacterial vaginosis must be treated to reduce symptoms
and reduce complications in pregnancy and puerperium.
|
|
Consensus-based recommendation 7.E11
|
|
Expert consensus
|
Level of consensus +++
|
|
Therapy for symptomatic bacterial vaginosis in pregnancy must consist primarily of
treatment with clindamycin. Alternatively vaginal antiseptics may be used.
|
|
Consensus-based recommendation 7.E12
|
|
Expert consensus
|
Level of consensus +++
|
|
Treatment for bacterial vaginosis must only be initiated after a proper diagnostic
workup and a medically confirmed diagnosis.
|
|
Consensus-based recommendation 7.E13
|
|
Expert consensus
|
Level of consensus +++
|
|
Lactic acid and probiotics appear to have a positive impact during therapy and as
recurrence prophylaxis and may be used as a complementary approach.
|
|
Consensus-based statement 7.E14
|
|
Expert consensus
|
Level of consensus +++
|
|
If a woman suffers from chronic recurrent BV, treating her partner may be considered
although the evidence for this is limited.
|
|
Consensus-based recommendation 7.E15
|
|
Expert consensus
|
Level of consensus +++
|
|
Women with bacterial vaginosis must be informed about measures which can prevent the
recurrence of bacterial vaginosis in their case.
|
|
Consensus-based recommendation 7.E16
|
|
Expert consensus
|
Level of consensus +++
|
|
Women with bacterial vaginosis who wish to become pregnant soon should be treated
even if they are asymptomatic. The same applies to women with aerobic or desquamative
inflammatory vaginitis.
|
Treatment of BV is indicated for all patients with vulvovaginal symptoms [49]. But asymptomatic women with BV also benefit indirectly from therapy as
treatment reduces the risk of endometritis, PID and STIs, which are associated with
possible subsequent infertility [68]. BV can have a significant negative
impact on the quality of life of women with recurrent disease or failure of first-line
therapy, and treatment is often difficult and protracted.
If metronidazole is used as first-line therapy for BV, the resistance mechanisms of
Gardnerella spp. often lead to treatment failure [69]. If oral therapy
consists of 500 mg metronidazole, the recommended treatment is to take it twice a
day for 7 days or once or twice within 48 hours for 2 g metronidazole. Therapy with
300 mg clindamycin taken
two to three times a day for 7 days is less often limited by treatment resistance.
Recommended alternative topical therapies include vaginal metronidazole or 2% clindamycin
cream once a day
for 7 days, as well as vaginal clindamycin ovules for 3 days. In some randomized controlled
studies, antiseptics such as 10 mg dequalinium chloride administered once a day for
6 days,
octenidine vaginal spray or iodine-containing preparations were found to have good
results when treating BV [70] – [74]. Using
antiseptics as a treatment alternative appears to be useful, especially given the
fact that metronidazole is often ineffective against the BV biofilm and the increasing
resistance to
antibiotics, even though antiseptics reduce the already low percentage of lactobacilli
in women with BV even further [75], [76], [77]. More rarely used treatment alternatives include 2 g secnidazole taken orally as
a one-off therapy or 2 g oral tinidazole for 2 days or 1 g
tinidazole taken orally for 5 days. The administration of probiotics after completing
antibiotic or antiseptic therapy aims to restore vaginal microbiota [78]. The risk of repeatedly suffering the same symptoms after completing first-line
BV therapy is high. Review articles report a recurrence rate of 80% within 3 – 12 months
after
completion of therapy [34], [79]. The biofilms which are usually responsible for recurrence cannot be removed with
standard
first-line antibiotics [80], [81], although a disruptive effect has been reported in vitro for dequalinium chloride
[82]. Local antiseptics could therefore represent a useful alternative to treat recurrent
disease [72]. There have been attempts to
use some regimens to suppress recurrence but none of them have been consistently effective,
meaning that suppressive maintenance therapy may be proposed, as is used to treat
chronically
recurrent VVC. Topical metronidazole administered twice a week for a total of 16 weeks
may be an appropriate therapeutic approach [83].
Antibiotic treatment of BV is effective in pregnancy, although it does not significantly
reduce the overall risk of preterm birth [84]. But treatment is
recommended for all symptomatic pregnant women to reduce their symptoms and because
symptomatic BV during pregnancy has been found to be associated with premature rupture
of membranes,
preterm birth, amniotic infection syndrome and postpartum endometritis [85], [86], [87]. In
addition to symptomatic women, there are indications that the diagnosis and therapy
of asymptomatic BV before the 23rd week of gestation can reduce the rate of preterm
births [88]. Because of its anti-inflammatory and cytokine-inhibiting effect as well as its
broad antibiotic spectrum, clindamycin appears to be more suitable for use
during pregnancy than metronidazole [49]. The administration of tinidazole should be avoided during pregnancy. Because of
their clinically comparable
efficacy, other antiseptics such as dequalinium chloride or octenidine may be considered
suitable alternatives [71], [73].
Povidone-iodine should not be administered during pregnancy.
According to the research to date, full-blown BV and chronically recurrent BV cannot
be cured with lactic acid or lactobacilli preparations alone [89]. In
their systematic review, Plummer et al. [90] reported that because of the divergent methods and results it is not possible to
make a clear recommendation for
or against the use of lactic acid as prophylaxis or treatment against BV. Similarly,
the administration of vaginal or oral lactobacilli and probiotics as prophylaxis or
therapy to treat BV
is still controversial [91], [92], [93], even though individual studies have shown significant
benefits associated with the use of probiotics during or after BV [78]. Oral probiotics are only detectable about 1 – 2 weeks later in the vagina and remain
there as long as they continue to be taken orally [94], [95]. Other alternative and complementary therapeutics include a
vaginal preparation with ascorbic acid [96] and a polymer made of a combination of Aloe barbadensis and lactic acid [97].
The rate of BV recurrence depends on a number of factors; re-infection with BVAB and
re-infection through endogenous sources but also re-infection via the patientʼs sexual
partner all play
a role [31], [98]. However, the Center for Disease Control and Prevention (CDC) does not recommend
routine co-treatment of the
partner in cases with recurrent BV. The rate of recurrence may be reduced by avoiding
other predisposing host or risk factors, for example avoiding stress, having a healthy
life style and a
normal body weight [99]. There is an association between BV and infertility although the precise pathomechanism
of this is not clear. On the one hand, women
with BV have a higher risk of developing ascending infections such as cervicitis,
endometritis and pelvic inflammatory disease (PID) [68]. Chronic
endometritis may often be clinically inapparent for years, leading to inflammatory
processes which can interfere with implantation of the fertilized oocyte and may lead
to tubal sterility
[100] – [104]. On the other hand, BV biofilms also appear to play a role in fertility [58].
Overall, poor IVF outcomes have been reported for women with low microbial diversity
and women with a higher percentage of abnormal vaginal microbiota [105].
Antibiotic therapy with doxycycline after hysteroscopy and endometrial scratching
improves the pregnancy rate [106].
8 Outlook
|
Consensus-based recommendation 8.E17
|
|
Expert consensus
|
Level of consensus +++
|
|
Future research into bacterial vaginosis should focus on preventing the high rates
of recurrence and chronic recurrence of disease.
|
Avoiding resistance and chronic recurrence as well as the prevention of BV are therefore
at the top of the agenda for future research. The efficacy of alternative therapies
and the current
treatment plan should be expanded and amended based on the results of new clinical
studies into modern approaches and precision medicine [28], [31], [107], [108]. Treatment with Lactobacillus crispatus CTV-05 (LACTIN-V) could also be an
interesting approach as it has been shown that the application of LACTIN-V after initial
treatment with vaginal metronidazole resulted in a significantly lower rate of BV
recurrence after 12
weeks [109]. The current evidence on the efficacy of astodrimer is relatively limited [110], [111] as is the evidence for a vaginal polycarbophil cream consisting of 0.04% lauryl
glucoside and glycerides, although the data obtained for polycarbophil regarding a
reduction in
the rate of BV recurrence has been promising [112], [113]. The data from clinical studies into TOL-463, an antiseptic based
on boric acid which is especially effective against vaginal biofilms of bacteria and
fungi, are still not in [114], [115].
Finally, research is also increasingly focusing on co-treatment of the patientʼs partner
[116].
