R.S is a 32-year-old Caucasian woman with a history of odorous vaginal discharge, especially after sex. She is sexually active and uses commercial douche bi-weekly. She has been with her partner for 6 months. She was found to have white vaginal discharge with a pH of 5.5 and diagnosed with bacteria vaginosis.
The goal of treatment for R.S. includes relieving the signs and symptoms of infection and to prevent secondary infection (e.g. pelvic inflammatory disease) related to lack of treatment or inadequate treatment (Sobel et al., 2022; Woo & Robinson, 2020). Additionally, to prevent the risk of postoperative infection should she have any type of pelvic surgery, for example, therapeutic abortion (Sobel et al., 2022).
The recommended treatment for bacteria vaginosis is Metronidazole orally or vaginally (Johnson et al., 2022; Sobel et al., 2022; Woo & Robinson, 2020). Additionally, Metronidazole is cost effective. The vaginal preparation is the preferred method of administration; however, many women find it messy. Therefore some women prefer the oral preparation which has the risk of more side effects compared to the vaginal preparation. In the oral form, Metronidazole 500mgs PO BID x 7days is prescribed; in the vaginal form, Metrogel 0.75% 1 applicator vaginally every night x 7 night is prescribed (Johnson et al., 2022; Sobel et al., 2022; Woo & Robinson, 2020). Both preparations should treat bacteria vaginosis effectively.
Parameters for monitoring the success of treatment for R.S will involve monitoring her signs and symptoms. Resolution of her signs and symptoms indicates the success of treatment (Woo & Robinson, 2020). R. S. will be educated to refrain from ingesting alcohol while taking the medication. She may chew gum or suck on hard candy or ice to resolve dry mouth or metallic taste related to taking Metronidazole (Woo & Robinson, 2020). If she is using the vaginal preparation, she should place an applicator-full at night before going to sleep and refrain from sex. Dark urine is not unusual when taking metronidazole. R. S should report CNS symptoms like ataxia, confusion, seizures promptly. CNS symptoms: ataxia, confusion, peripheral neuropathy (Johnson et al., 2022; Sobel et al., 2022; Woo & Robinson, 2020). The medication will be changed if R. S. has CNS symptoms like ataxia, confusion, peripheral neuropathy or if she has an allergic reaction like urticaria, flushing or bronchospasm (Johnson et al., 2022; Sobel et al., 2022; Woo & Robinson, 2020)
Clindamycin is the recommended alternative treatment for bacteria vaginosis. As with Metronidazole, the vaginal preparation is preferred especially because of the potential risk of Clostridioides (formerly Clostridium) difficile-associated diarrhea associated with oral Clindamycin (Sobel et al., 2022). For the oral preparation, Clindamycin 300mg PO BID x 7days will be prescribed. For the vaginal preparation, Cleocin 2% vaginal cream 1 applicator vaginally every night x 7 nights will be prescribed (Sobel et al., 2022; Woo & Robinson, 2020). Alternative medications for R. S. medication include probiotics (Sobel et al., 2022). Though systemic reviews of trials of probiotics for treatment of bacteria vaginosis have not found sufficient evidence for or against the efficacy many clinicians advised women to use probiotics (Sobel et al., 2022).
R. S. will be educated not to douche. Many women douche though there is no proven benefit of douching. The vagina is normally able to maintain a healthy balance of bacteria; douching can upset this balance and potentially flush harmful bacteria into the upper genital tracts causing frequent infections (Sobel et al., 2022). R. S. will also be advised to limit the number of sexual partners. Women with multiple sexual partners are at higher risk of developing bacterial vaginosis and sexually transmitted infections (Sobel et al., 2022). R. S. will also be educated to use of condoms with male partners if she has recurrent BV (Sobel et al., 2022).
Patients prescribed metronidazole should let their clinician know all the medications they are taking to reduce the risk of drug interactions. For example, Metronidazole decreases the clearance of phenytoin by approximately 15 percent thereby prolonging its elimination half-life (Johnson et al., 2022). This reduced elimination may result in increased serum concentrations of phenytoin. Metronidazole can also increase the anticoagulant effect of warfarin (Johnson et al., 2022).
Johnson, E., Hooper, D. C. & Bogorodskaya, M. (2022). Metronidazole: An Overview. UpToDate
Sobel, J. D., Marrazzo, J., & Eckler, K. (2022) Bacteria vaginosis: Treatment. UpToDate
Woo, T. M