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CONTINUING EDUCATION The ABCDs of bacterial vaginosis: Abnormal fl ora, Bothersome symptoms, Chronicity, and By Alisa Pascale, DNP, WHNP-BC

Faculty: Accreditation statement: This activity has been evalu- Alisa Pascale, DNP, WHNP-BC, is a women’s health nurse ated and approved by the Continuing Education Approval practitioner at the Vulvovaginal Disorders Program & Gynecology Program of the National Association of Nurse Practitioners at Massachusetts General Hospital and Clinical Instructor at MGH in Women’s Health (NPWH), and has been approved for 1.0 Institute of Health Professions, both in Boston, Massachusetts. contact hours, including 0.5 contact hours of pharmacology Intended audience: This continuing education (CE) activity credit. has been designed to meet the educational needs of nurse prac- Faculty disclosures: NPWH policy requires all faculty to titioners who provide care for women of any age. disclose any affi liation or relationship with a commercial inter- CE approval period: Now through December 31, 2019 est that may cause a potential, real, or apparent confl ict of in- terest with the content of a CE program. NPWH does not imply Estimated time to complete this activity: 1 hour that the affi liation or relationship will aff ect the content of the CE approval hours: 1.0 contact hours, including 0.5 contact CE program. Disclosure provides participants with information hours of pharmacology credit (NCC code 2A) that may be important to their evaluation of an activity. Fac- ulty are also asked to identify any unlabeled/unapproved uses Goal statement: To understand the abnormal vaginal eco- of drugs or devices made in their presentation. system in women prone to bacterial vaginosis (BV) and to use . Alisa Pascale, DNP, WHNP-BC, disclosed that she served as A current evidence and guidelines in treating single episodes of BV and in reducing chronic/recurrent episodes of BV. a consultant and speaker for Symbiomix Therapeutics in 2016. here Needs assessment: This activity for Women’s Healthcare is Disclosure of unlabeled use: NPWH policy requires based on a CE presentation developed by the author and pre- authors to disclose to participants when they are presenting sented at the NPWH annual conference held in Seattle, Wash- information about unlabeled use of a commercial product or ington, in October 2017. In this article, the author provides back- device or an investigational use of a drug or device not yet ground information on BV (e.g., prevalence, risk factors, adverse approved for any use. sequelae, characteristics of a healthy ) and then focuses on Disclaimer: Participating faculty members determine the the ABCDs of BV: abnormal fl ora, bothersome symptoms, chro- editorial content of the CE activity; this content does not nicity, and the diff erential diagnosis. necessarily represent the views of NPWH. This content has Educational objectives: At the conclusion of this educa- undergone a blinded peer review process for validation of tional activity, participants should be able to: clinical content. Although every eff ort has been made to ensure that the information is accurate, clinicians are respon- 1. Describe normal vaginal fl ora and the alterations that result in sible for evaluating this information in relation to generally episodic/chronic/recurrent BV. accepted standards in their own communities and integrat- 2. Discuss adverse sequelae of BV in nonpregnant and pregnant ing the information in this activity with that of established women. recommendations of other authorities, national guidelines, 3. Diff erentiate between BV and other conditions that cause FDA-approved package inserts, and individual patient char- alterations of vaginal fl ora. acteristics. 4. List treatment options for episodic/chronic/recurrent BV. To participate in this CE program, click To

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4thQ 2018_WH-6_Print.indd 10 11/19/18 4:55 PM Successful completion of the activity: Successful com- 4. Complete the post-test and evaluation. You must earn a pletion of this activity, J-18-04, requires participants to: score of 70% or better on the post-test to receive CE credit. 1. Log on to npwh.org/courses/home/details/1156 and 5. Print out the CE certificate if successfully completed. “Sign In” at the top right-hand corner of the page if you have an NPWH account. You must be signed in to receive *If you are an NPWH member, were once a member, or have taken credit for this course. If you do not remember your user- CE activities with NPWH in the past, you have a username and pass- name or password, please follow the “Forgot Password” word in our system. Please do not create a new account. Creation of multiple accounts could result in loss of CE credits as well as other link and instructions on the sign-in page. If you do not NPWH services. If you do not remember your username or password, have an account, please click on “Create an Account.”* please either click on the “Forgot Username” or “Forgot Password” 2. Read the learning objectives, disclosures, and disclaimers link or call the NPWH office at (202) 543-9693, ext. 1. on the previous page. Commercial support: The content for this article was 3. Study the material in the learning activity during the ap- supported by an educational grant from Symbiomix Thera- proval period (now through December 31, 2019). peutics.

United States, depending on race, Before reading the article, click hereA to take the pretest. ethnicity, and geographic area. Based on a representative sample of lterations in vaginal microflora cause a vaginal dysbiosis that U.S. women who participated in the can lead to asymptomatic or symptomatic bacterial vaginosis National Health and Nutrition Exam- ination Survey (NHANES) 2001-2004, (BV). Because the underlying mechanism of BV is not well A overall BV prevalence in this country understood and long-term restoration of the normal can was 29% among women aged 14-49 be challenging, BV often recurs or becomes chronic despite initially years,4,5 making it the most com- successful treatment. Healthcare providers (HCPs) caring for women mon vaginal infection in this age 6 should be familiar with the diagnosis and treatment of BV, as well as group. According to this NHANES survey, non-Hispanic white women the management of recurrent BV. Because BV is sometimes mistaken had lower rates of BV (23%) than did for other vaginal conditions, HCPs should be alert for these other African American women (51%) or diagnoses, particularly in women with chronic or recurrent symptoms. Mexican American women (32%).4

Key words: bacterial vaginosis, recurrent , vaginal microflora, Risk factors Amsel criteria A systematic review and meta-analy- sis showed that BV was significantly Bacterial vaginosis (BV) is a common nal environment are described. associated with sexual contact with condition that results from a shift new and multiple male and/or fe- in the balance of a woman’s vaginal Background information male partners.7 The precise relation- microflora. BV is manifested by a de- Prevalence of BV varies widely from ship between sexual activity and BV crease in predominantly hydrogen country to country, from region to development is not known.8 General peroxide-producing lactobacilli and region within the same country, consensus among vaginitis experts an increase in anaerobic . and even within similar population is that BV can be sexually associated, The depletion of lactobacilli leads groups.1 Five decades of intense but that it is not considered to be to a rise in vaginal pH, and enzymes research have established many sexually transmitted at this time. produced by the anaerobes lead to risk factors for BV acquisition, but Two studies showed that women some of the classic symptoms asso- because of the condition’s complex- with genital herpes or HIV infection ciated with BV. Before the article’s ity and the lack of a reliable animal had an increased risk of developing main focus on the ABCDs of BV— model for studying it, its exact etiol- BV.9,10 Also, BV acquisition has been abnormal flora, bothersome symp- ogy remains elusive.2 associated with douching.5 toms, chronicity, and differential diagnosis—background information Prevalence Adverse sequelae on BV prevalence, risk factors, and A systematic review by Kenyon et Many studies have shown BV to be adverse sequelae is provided and al.3 suggested that BV prevalence a risk factor for acquiring HIV infec- the characteristics of a healthy vagi- ranged from 6% to 51% in the tion, herpes, gonorrhea, chlamydia,

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4thQ 2018_WH-6_Print.indd 11 11/19/18 4:55 PM This biofi lm makes abnormal fl ora as over time.25 and lactic produced by these more resistant both to the vagina’s lactobacilli and other vaginal fl ora enhance the antimicrobial immune own natural defenses and to response. Some healthy women have low , likely accounting for the numbers of vaginal lactobacilli and high numbers of other lactic with which women have acid-producing bacteria and/or frequency variable concentrations of anaerobic bacteria that have been associated persistent and recurrent infections. with BV.30 The percentage of appar- ently healthy asymptomatic women with a vaginal microbiota not dominated by lactobacilli is higher A B N O R M A L among women with African and/or Hispanic heritage, who also have a and .11-14 BV also routine screening for BV in asymp- higher vaginal pH than do white or may play a role in the development tomatic pregnant women.26-28 Asian women.30 of pelvic infl ammatory and This recommendation is based on 15,16 , as well as in the per- evidence indicating that although A bnormal sistence of human papillomavirus treatment of BV in pregnant women vaginal fl ora infection17 and in the development can eradicate the infection, it has not Although is the of cervical precancerous lesions.18 been shown to decrease preterm best known pathogen linked to BV, In pregnant women, BV may in- birth rates.29 Early screening and the condition is associated with at crease the risk for , cho- treatment for BV may be considered least a dozen other species (spp) as rioamnionitis, , and in women at high risk for preterm well, including Atopobium vaginae, postpartum .19-23 BV birth, although no clear criteria/ , Myco- was reported to be 3 times more characteristics have been defi ned. plasma spp, and others.31 Absence prevalent among infertile women Pregnant women with any vulvovag- of localized infl ammation associated than fertile women, and it doubled inal complaints or symptoms should with infection by any of these bacte- the risk for loss following be evaluated for BV and treated if BV ria is the basis for the term vaginosis in vitro fertilization-embryo trans- is present. rather than vaginitis. fer.24 Of note, Nasioudis et al.25 pos- Vaginal biofi lms are well-de- ited that most links between BV and Characteristics of a scribed microbial communities em- adverse pregnancy outcomes have healthy vagina bedded in a self-produced extracel- been derived from inadequately A healthy vagina’s microbiota is lular matrix to which other species designed studies that did not fully characterized by a dominance of lac- also can adhere.32,33 In one study, G. evaluate other causes of pregnan- tobacilli, which maintain the acidic vaginalis comprised 90% of bacteria cy-related pathology. vaginal pH at 4.0-4.5. The makeup in the biofi lm and A. vaginae ac- Because BV is asymptomatic in of a healthy vagina in one woman counted for most of the remainder.34 many cases and because its pres- may diff er from that in another. The This biofi lm makes abnormal fl ora ence increases the risk for a variety vagina may be colonized by one or more resistant both to the vagina’s of adverse sequelae in pregnant more species of lactobacilli, includ- own natural defenses and to an- women, healthcare providers (HCPs) ing crispatus, L. gasseri, tibiotics, likely accounting for the may wonder about screening rou- L. iners, and L. jensenii.30 Further- frequency with which women have tinely for BV in this population. At more, the composition of the vag- persistent and recurrent infections.35 present, the U.S. Preventive Services inal microbiota is not static; many Task Force, the American College women experience large variations B othersome symptoms of Obstetricians and Gynecologists, within a single or Many women with BV are asymp- and the CDC do not recommend between successive cycles, as well tomatic8 and do not learn of this

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4thQ 2018_WH-6_Print.indd 12 11/19/18 4:55 PM diagnosis until they undergo a rou- should see their HCP for an evalua- At least three of these four tine gynecologic examination by tion and clinical diagnosis. criteria must be met to make the an HCP who notes the typical signs. diagnosis. Vaginal pH paper, saline, But many women with BV do have Physical examination KOH, slides, and a microscope are , typically a thin On physical exam of women who all that are needed to make a quick white or gray ; may have BV, the external genitalia offi ce diagnosis of BV. This testing itching or burning in the vagina; a usually appear normal, although a is inexpensive and can often yield strong fi sh-like odor, especially after thin milky discharge may be present a diagnosis at the time of the visit, sex; burning when urinating; and/ at the introitus. The characteristic facilitating treatment. or itching around the outside of the vaginal discharge is thin, homo- vagina.8 Many women associate BV geneous, and white, gray, or even Other laboratory tests onset with recent sexual activity,36 yellow. A fi shy/amine-positive odor Several commercial products such which can cause embarrassment may be perceptible. In many women as the BD Affi rm™ VPIII Microbial and self-consciousness and prompt with BV, physical exam fi ndings can Identifi cation System and the some to change or limit their sexual appear normal. OSOM® BVBlue® point-of-care relationships or activities. Self-help testing can identify the microbes remedies such as douching may Offi ce-based testing present in a patient’s vaginal fl uid. only exacerbate the problem.37 In the clinical setting, BV diagnosis is Use of such a product adds cost to made based on Amsel criteria39: the visit and can delay diagnosis. Making the diagnosis • Vaginal pH >4.5; Of note, BV diagnosis should not The telephone is not an eff ective • Homogeneous white, gray, or be made solely on the basis of a tool for diagnosis of BV. Because even yellow (milky) discharge; positive G. vaginalis culture because patient self-diagnosis and telephone • Release of an amine (fi shy) this bacterium is present in ~50%- triage diagnosis are notoriously odor after addition of 10% po- 80% of healthy, asymptomatic inaccurate,38 women experiencing tassium hydroxide (KOH) solu- women.40,41 Positive test results any of the aforementioned vaginal tion to the vaginal fl uid; and should be interpreted in the con- signs/symptoms, particu- • Presence of clue cells on saline text of the entire clinical picture to B larly recurrent symptoms, wet prep . make the diagnosis. Treating symptoms and O infection According to the CDC, the bene- T Women experiencing fi ts of BV therapy in nonpregnant women are symptom relief and any of the aforementioned infection cure.42 Another potential H benefi t is a reduction of the risk of acquiring a sexually transmitted E vaginal signs/ infection.

R symptoms, particularly Multiple-dose regimens recurrent symptoms, For a single episode of BV, the CDC S recommends these regimens42: • 500 mg orally O should see their HCP twice daily for 7 days OR • metronidazole gel 0.75%, 1 full for an evaluation and applicator (5 g) intravaginally, M once daily for 5 days OR clinical diagnosis. • cream 2%, 1 full E applicator (5 g) intravaginally at bedtime for 7 days.

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4thQ 2018_WH-6_Print.indd 13 11/19/18 4:55 PM C H requiring fewer doses may im- zole from 7 to 10 days in patients Women express 49 R prove adherence, four diff erent with recurrent BV. The addition considerable single-dose regimens are available. of (compounded 600 O Single-dose intravaginal regimens mg vaginally x21 days) to the initial include clindamycin 2% cream course of oral nitroimidazole may N frustration, (Clindesse®) and metronidazole gel improve results.49,50 Another option 1.3% (Nuvessa®); these intravaginal is high-dose metronidazole (com- I embarrassment, products are not recommended pounded 750 mg vaginally x 7 days), for pregnant women and are less which has a higher cure rate than C and distress eff ective than multiple-dose reg- does the 500-mg dose.51 Once the imens.43,44 New in 2018 is secnid- current infection is treated, a regi- with recurrences azole 2 g (Solosec™), a novel, sin- men of metronidazole vaginal gel gle-dose oral product. Secnidazole 2%, 1 applicator intravaginally twice and the need is formulated as a packet of granules weekly for 4-6 months, has shown that are sprinkled onto applesauce, effi cacy in suppressing or prevent- for repeated yogurt, or pudding and then con- ing recurrences.31 All of the regi- sumed.45,46 Unlike metronidazole, mens discussed in this paragraph or ongoing this product has no warning to avoid are prescribed off label. alcohol consumption. An FDA preg- Because BV is a sexually associ- . nancy category has not yet been ated infection, condom use may treatment assigned for secnidazole. Although prevent BV recurrences and should single-dose treatments are well liked be suggested to patients with re- by patients, they tend to increase current BV. are popular out-of-pocket cost. with patients; two particular lacto- Alternative regimens include the bacilli strains—L. rhamnosus and 42 following : C hronic/recurrent BV L. reuteri—taken orally for 30 days, • tinidazole 2 g orally once daily Chronic or recurrent BV is defi ned as may help reduce BV recurrences.52 for 2 days OR three or more episodes per year.47 However, strong evidence of lacto- • tinidazole 1 g orally once daily The recurrence rate may be as high bacilli benefi t for the treatment or for 5 days OR as 80% in some populations.48 As prevention of recurrent BV is lacking. • clindamycin 300 mg orally discussed previously, the underlying Novel agents that disrupt the vag- twice daily for 7 days OR mechanism of the shift to abnormal inal biofi lm, including , • clindamycin ovules 100 mg fl ora in BV is not well understood. probiotics/prebiotics, plant-derived intravaginally once at bedtime In addition, to date, no treatments compounds, natural antimicrobials, for 3 days. target the biofi lm, leading to chal- acidifying/buff ering agents, and lenges in resolving chronic cases. DNases, are being investigated as With regard to treatment with Women express considerable frus- treatments for recurrent BV.53 Mar- nitroimidazoles such as metronida- tration, embarrassment, and distress razzo et al.54 have described a novel zole and tinidazole, users should ab- with recurrences and the need for boric acid-based vaginal anti-in- stain from alcohol use for 24 hours repeated or ongoing treatment.37 fective with enhanced anti-biofi lm after completion of the Until novel treatment options come activity (TOL-463) that may show regimen to avoid the chance of a along, treatment regimens for promise for treating recurrent BV in disulfi ram-like reaction. Clindamycin recurrent BV aim to fi rst treat the the future. cream and ovules are oil based and current infection and then suppress might weaken latex condoms and recurrence(s). HCPs should treat the D ifferential diagnosis diaphragms for 3-5 days after the current infection as per CDC guide- Bacterial vaginosis is distinctive in regimen is completed. lines—that is, with one of the rec- terms of the characteristics of the ommended or alternative regimens. vaginal discharge, the fi shy odor, Single-dose regimens Some experts suggest extending the elevated vaginal pH, and the Because a regimen the initial course of oral metronida- presence of clue cells on wet prep.

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4thQ 2018_WH-6_Print.indd 14 11/19/18 4:55 PM Table. Bacterial vaginosis: Differential diagnosis

Disease or How it resembles BV How it diff ers from BV Recommended treatment55-58 condition

Trichomoniasis* Frequently asymptomatic; With BV, fi shy odor is often One 2-g dose of oral if S/S are present, they may worse during menses or after metronidazole or one 2-g dose include vaginal discharge, sex. Trichomoniasis is an STI. of oral tinidazole; alternative strong fi shy odor, itching Discharge is usually yellow/ regimen, metronidazole 500 mg (less common in BV); high pH green/gray and frothy, many BID x 7d WBCs are seen on wet prep, and itchiness occurs in vaginal or vulvar area.

Genitourinary May be asymptomatic; S/S The underlying mechanism Local vaginal estrogen products syndrome of include vaginal discharge, is a loss of estrogenʼs eff ect (tablet, insert, ring, cream) change in odor, elevated pH on vaginal tissues, which can or OTC acidifying vaginal result in vaginal dryness and moisturizers irritation, , and .

Gonorrhea* Frequently asymptomatic; Gonorrhea is an STI. Common One 250-mg dose of IM if S/S are present, they may S/S are pain and burning while ceftriaxone and one 1-g dose include vaginal discharge urinating and intermenstrual of oral azithromycin bleeding.

Chlamydia* Abnormal vaginal discharge Chlamydia is an STI. A One 1-g dose of oral common symptom is a burning azithromycin or doxycycline sensation when urinating. 100 mg orally BID x 7d

Desquamative Vaginal discharge, odor S/S include dysuria, Clindamycin vaginal gel infl ammatory dyspareunia. The discharge qhs x 14d or compounded vaginitis is usually profuse and hydrocortisone vaginal mucopurulent and sometimes suppositories, 100 mg qhs x 14- bloody, with many WBCs 30d, then qod x 2-4 weeks, and present. then 2/weekly (either treatment used off label)

*Can be distinguished from BV by culture or PCR/NAA testing. BV, bacterial vaginosis; IM, intramuscular; NAA, nucleic acid amplifi cation; OTC, over-the-counter; PCR, polymerase chain reaction; S/S, signs/symptoms; STI, sexually transmitted infection; WBC, white blood cell.

Nevertheless, other conditions and D I F F E R E N T I A L bear similarities to BV and may need to be ruled out. For ex- ample, the genitourinary syndrome Desquamative infl ammatory vaginitis is of menopause may present with an elevated vaginal pH and a shift a condition that in vaginal fl ora. Correction of the less well known underlying low estrogen state with local estrogen or acidic vaginal can be confused with BV because moisturizers may sometimes cor- rect the vaginal dysbiosis without it causes pH elevation, vaginal a need for antibiotics. Coexistence of along with BV, or as a discharge, and loss of lactobacilli. result of antibiotic treatment for BV, should be considered. Desquama- tive infl ammatory vaginitis is a less

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4thQ 2018_WH-6_Print.indd 15 11/19/18 4:55 PM well known condition that can be 2004 National Health and Nutrition Transm Dis. 2013;40(2):117-122. Examination Survey Data. Obstet confused with BV because it causes 16. Marrazzo M, Wiesenfeld HC, Gynecol. 2007;109(1):114-120. pH elevation, vaginal discharge, and Murray PJ, et al. Risk factors for 6. CDC. Bacterial Vaginosis (BV) cervicitis among women with loss of lactobacilli. Disease entities Statistics. Prevalence. Page last bacterial vaginosis. J Infect Dis. and conditions that may need to be reviewed December 17. 2015. cdc. 2006;193(5):617-624. considered because of their over- gov/std/bv/stats.htm 17. Guo YL, You K, Qiao J, et al. Bac- lapping symptomatology or their 7. Fethers KA, Fairley CK, Hocking terial vaginosis is conducive to the coexistence with BV are listed in the JS, et al. Sexual risk factors and persistence of HPV infection. Int J Table, along with recommended bacterial vaginosis: a systematic STD AIDS. 2012;23(8):581-584. treatments.55-58 review and meta-analysis. Clin In- 18. Gillet E, Meys JF, Verstraelen H, et fect Dis. 2008;47(11):1426-1435. al. Association between bacterial Conclusion 8. CDC. Bacterial Vaginosis: CDC vaginosis and cervical intraepithe- Fact Sheet. Page last updated Feb- lial neoplasia: systematic review Many woman are unfamiliar with ruary 16, 2017. cdc.gov/std/bv/ and meta-analysis. PLoS One. the condition of BV, which is far stdfact-bacterial-vaginosis.htm 2012;7(10):e45201. more common than women or their 9. Esber A, Vicetti Miguel RD, Cher- 19. Nelson DB, Hanlon AL, Wu G, et HCPs may realize. BV involves a dis- pes TL, et al. Risk of bacterial vag- al. First trimester levels of BV-as- ruption in healthy vaginal microflora inosis among women with herpes sociated bacteria and risk of mis- and is not always symptomatic, but simplex virus type 2 infection: a carriage among women early in it can have major adverse sequelae. systematic review and meta-analy- pregnancy. Matern Child Health J. In addition, recurrence rates are sis. J Infect Dis. 2015;212(1):8-17. 2015;19(12):2682-2687. high and are quite bothersome for 10. Jamieson DJ, Duerr A, Klein RS, 20. Gibbs RS. and et al. Longitudinal analysis of bac- bacterial vaginosis. Am J Obstet many women. Standard treatment terial vaginosis: findings from the Gynecol. 1993;169(2 pt 2):460-462. includes metronidazole or clinda- HIV epidemiology research study. 21. Hillier SL, Nugent RP, Eschen- mycin, although new treatments are Obstet Gynecol. 2001;98(4):656- bach DA, et al. Association be- emerging. More research is needed 663. tween bacterial vaginosis and for both better understanding of BV 11. Atashili J, Poole C, Ndumbe PM, preterm delivery of a low-birth- pathogenesis and new and novel et al. Bacterial vaginosis and weight infant. N Engl J Med. treatment options. = HIV acquisition: a meta-analy- 1995;333(26):1737-1742. sis of published studies. AIDS. 22. Manns-James L. Bacterial vagino- 2008;22(12):1493-1501. sis and preterm birth. J Midwifery References 12. Gallo MF, Macaluso M, Warner Womens Health. 2011;56(6):575-583. 1. Bitew A, Asebaw Y, Bekele D, L, et al. Bacterial vaginosis, gon- Mihret A. Prevalence of bacterial 23. Jacobsson B, Pernevi P, Chide- orrhea, and chlamydial infection vaginosis and associated risk fac- kel L, Jörgen Platz-Christensen J. among women attending a sex- tors among women complaining Bacterial vaginosis in early preg- ually transmitted disease clinic: a of genital tract infection. Int J Mi- nancy may predispose for preterm longitudinal analysis of possible crobiol. 2017;2017:4919404. birth and postpartum endometri- causal links. Ann Epidemiol. tis. Acta Obstet Gynecol Scand. 2. Turovskiy Y, Noll KS, Chikindas 2012;22(3):213-220. 2002;81(11):1006-1010. ML. The aetiology of bacterial 13. Aghaizu A, Reid F, Kerry S, et al. vaginosis. J Applied Microbiol. 24. van Oostrum N, De Sutter P, Meys Frequency and risk factors for 2011;110(5):1105-1128. J, Verstraelen H. Risks associated incident and redetected Chla- with bacterial vaginosis in infer- 3. Kenyon C, Colebunders R, Cru- mydia trachomatis infection in tility patients: a systematic review citti T. The global epidemiology sexually active, young, multi-eth- and meta-analysis. Hum Reprod. of bacterial vaginosis: a system- nic women: a community based 2013;28:1809-1815. atic review. Am J Obstet Gynecol. cohort study. Sex Transm Infect. 2013;209(6):505-523. 2014;90(7):524-528. 25. Nasioudis D, Linhares IM, Ledger WJ, Witkin SS. Bacterial vaginosis: 4. Koumans EH, Sternberg M, Bruce 14. Balkus JE, Richardson BA, Rabe a critical analysis of current knowl- C, et al. The prevalence of bacte- LK, et al. Bacterial vaginosis and edge. BJOG. 2017;124(1):61-69. rial vaginosis in the United States, the risk of 2001-2004: associations with acquisition among HIV-1-neg- 26. U.S. Preventive Services Task symptoms, sexual behaviors, and ative women. Sex Transm Dis. Force. Final Recommendation reproductive health. Sex Transm 2014;41(2):123-128. Statement: Bacterial Vaginosis in Dis. 2007;34(11):864-869. Pregnancy to Prevent Preterm De- 15. Taylor BD, Darville T, Haggerty livery: Screening. October 2014. 5. Allsworth JE, Peipert JF. Preva- CL. Does bacterial vaginosis cause uspreventiveservicestaskforce. lence of bacterial vaginosis: 2001- pelvic inflammatory disease? Sex

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4thQ 2018_WH-6_Print.indd 16 11/19/18 4:55 PM org/Page/Document/Recommen- 37. Bilardi J, Walker S, McNair R, scape Pharmacists. January 14, 2010. dationStatementFinal/bacteri- et al. Women’s management medscape.com/viewarticle/714690 al-vaginosis-in-pregnancy-to-pre- of recurrent bacterial vaginosis 48. Marrazzo J. Vaginitis. National vent-preterm-delivery-screening and experiences of clinical care: Network of STD/HIV Prevention 27. American College of Obstetricians a qualitative study. PLoS One. Training Centers. 2010. nnptc.org/ and Gynecologists. ACOG Prac- 2016;11(3):e0151794. resources/vaginitis/ tice Bulletin. Assessment of risk 38. Allen-Davis JT, Beck A, Parker R, 49. Sobel JD. Bacterial Vaginosis: factors for preterm birth. Clinical et al. Assessment of vulvovaginal Treatment. UpToDate. Last up- management guidelines for obste- complaints: accuracy of telephone dated May 21, 2018. uptodate. trician-gynecologists. Number 31, triage an in-office diagnosis. Obstet com/contents/bacterial-vagino- October 2001. Gynecol. 2002;99(1):18-22. sis-treatment 28. CDC. Sexually transmitted disease 39. Amsel R, Totten PA, Spiegel CA, 50. Reichman O, Akins R, Sobel JD. treatment guidelines 2006—Dis- et al. Nonspecific vaginitis. Diag- Boric acid addition to suppressive eases characterized by vaginal nostic criteria and microbial and antimicrobial therapy for recurrent discharge. MMWR Recomm Rep. epidemiologic associations. Am J bacterial vaginosis. Sex Transm 2006;55(RR-11):50-52. Med. 1983;74(1):14-22. Dis. 2009;36(11):732-734. 29. Brocklehurst P, Gordon A, Heatley 40. Stockdale CK. A positive culture 51. Aguin T, Akins RA, Sobel JD. E, Milan SJ. Antibiotics for treating result for Gardnerella is not diag- High-dose vaginal maintenance bacterial vaginosis in pregnancy. nostic of bacterial vaginosis. J Low metronidazole for recurrent bac- Cochrane Database Syst Rev. Genit Tract Dis. 2016;20(4):281-282. terial vaginosis: a pilot study. Sex 2013;1:CD000262. 41. Beamer MA, Austin MN, Avolia Transm Dis. 2014;41(5):290-291. 30. Ravel J, Gajer P, Abdo Z, et al. Vagi- HA, et al. Bacterial species col- 52. Homayouni A, Bastani P, Ziyadi S, nal microbiome of reproductive-age onizing the vagina of healthy et al. Effects of probiotics on the women. Proc Natl Acad Sci U S A. women are not associated with recurrence of bacterial vaginosis: 2011;108(suppl 1):4680-4687. race. Anaerobe. 2017;45:40-43. a review. J Low Genit Tract Dis. 31. Sobel JD, Ferris D, Schwebke J, 42. CDC. 2015 Sexually Transmitted 2014;18(1):79-86. et al. Suppressive antibacterial Diseases Treatment Guidelines. 53. Machado D, Castro J, Palmei- therapy with 0.75% metronidazole Bacterial Vaginosis. Page last up- ra-de-Oliveira A, et al. Bacterial vaginal gel to prevent recurrent dated June 4, 2015. cdc.gov/std/ vaginosis : challenges bacterial vaginosis. Am J Obstet tg2015/bv.htm to current therapies and emerg- Gynecol. 2006;194(5):1283-1289. 43. Schwebke JR, Marrazzo J, Beelen ing solutions. Front Microbiol. 32. Swidsinski A, Mendling W, Loen- AP, Sobel JD. A phase 3, multi- 2016;6:1528. ing-Baucke V, et al. Adherent bio- center, randomized, double-blind, 54. Marrazzo JM, Dombrowski JC, films in bacterial vaginosis. Obstet vehicle-controlled study evaluating Wierzbicki MR, et al. Safety and Gynecol. 2005;106(5 pt 1):1013. the safety and efficacy of metro- efficacy of a novel vaginal anti-in- 33. Muzny CA, Schwebke JR. Biofilms: nidazole vaginal gel 1.3% in the fective, TOL-463, in the treatment an underappreciated mechanism treatment of bacterial vaginosis. Sex of bacterial vaginosis and vulvo- of treatment failure and recurrence Transm Dis. 2015;42(7):376-381. vaginal candidiasis: a randomized, in vaginal infections. Clin Infect 44. Bradshaw CS, Sobel JD. Current single-blind, phase 2, controlled Dis. 2015;61(4):601-606. treatment of bacterial vaginosis-lim- trial. Clin Infect Dis. 2018 Aug 31. 34. Verstraelen H, Swidsinski A. The itations and need for innovation. J [Epub ahead of print] in bacterial vaginosis: Infect Dis. 2016;214(suppl 1):S14-S20. 55. CDC. Trichomonas. Page last up- implications for epidemiology, di- 45. Hillier SL, Nyirjesy P, Waldbaum dated March 24, 2017. cdc.gov/ agnosis and treatment. Curr Opin AS, et al. Secnidazole treatment of std/trichomonas/default.htm Infect Dis. 2013;26(1):86-89. bacterial vaginosis: a randomized 56. CDC. Gonorrhea. Page last up- 35. Sobel JD. Vaginal biofilm: much controlled trial. Obstet Gynecol. dated October 6, 2017. cdc.gov/ ado about nothing, or a new ther- 2017;130(2):379-386. std/gonorrhea/default.htm apeutic challenge? Clin Infect Dis. 46. Schwebke JR, Morgan FG Jr, 57. CDC. Chlamydia. Page last updated 2015;61(4):607-608. Editorial Com- Koltun W, Nyirjesy P. A phase-3, October 4, 2017. cdc.gov/std/ mentary. double-blind, placebo-controlled chlamydia/stdfact-chlamydia.htm study of the effectiveness and 36. Bilardi J, Walker S, Mooney- 58. Sobel JD, Reichman O, Misra Somers J, et al. Women’s views safety of single oral doses of secnidazole 2 g for the treat- D, Yoo W. Prognosis and treat- and experiences of the triggers ment of desquamative inflam- for onset of bacterial vaginosis ment of women with bacterial vaginosis. Am J Obstet Gynecol. matory vaginitis. Obstet Gynecol. and exacerbating factors associ- 2011;117(4):850-855. ated with recurrence. PLoS One. 2017;217(6):678.e1-678.e9. 2016;11(3):e0150272. 47. Teitelman AM. Can anything prevent Web resource recurrent bacterial vaginosis? Med- A. npwh.org/courses/home/details/1156

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