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Vaginitis | Questions & Answers | 2010 Treatment Guidelines

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Question 1: What is the treatment for a positive Gardnerella vaginalis test?

Answer: For Gardnerella vaginalis CDC recommends treatment with metronidazole 500 mg. orally twice daily for seven days, or metronidazole gel 0.75%, one full applicator (5 g.) intravaginally, once a day for five days, or clindamycin cream 2%, one full applicator (5 g.) intravaginally at bedtime for seven days. It is important to advise patients receiving metronidazole as a treatment that they should avoid consuming alcohol during treatment and for 24 hours thereafter. Patients that receive clindamycin cream should be advised that the treatment is oil-based and might weaken latex condoms and diaphragms for five days after use.

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Bacterial Vaginosis (BV)

Question 2: Is bacterial vaginosis (BV) now considered a sexually-transmitted disease?

Answer: It is unclear. Certainly for some women, and possibly when two female sex partners are involved, unprotected sex does seem to "promote" BV.

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Question 3: What is the best way to test for bacterial vaginosis (BV)? We use Affirm VPIII vag panel testing.

Answer: Affirm VPIII is a reasonable point-of-care test that has compared favorably to Amsel clinical criteria when Gram stain (Nugent score) is used as a gold standard.

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Question 4: Why the shift in not routinely screening pregnant women for bacterial vaginosis (BV)? Where is the evidence that BV doesn't affect rates of preterm labor and delivery?

Answer: The 2010 STD Treatment Guidelines explicitly state that there is no evidence to support routine screening of BV or trichomoniasis in asymptomatic pregnant women since there is really no evidence that treatment of women with either of these infections, at least at the population level, reduces the adverse outcomes, and those include preterm delivery and/or low birthweight. Those recommendations reflect the opinion of the U.S. Preventive Services Task Force Guidelines, but it is a shift for a lot of people, particularly in the infected world among infectious disease specialists.

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Question 5: Can you clarify the treatment for bacterial vaginosis (BV)?

Answer: The 2010 STD Treatment Guidelines recommended regimens for BV include metronidazole 500 mg. orally twice a day for seven days, OR metronidazole gel 0.75%, one full applicator (5 g.) intravaginally, once a day for five days OR clindamycin cream 2%, one full applicator (5 g.) intravaginally at bedtime for seven days. Please also see the 2010 STD Treatment Guidelines (page 57) for a detailed discussion of treatment for BV.

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Question 6: Are there recommendations to treat partners with chronic bacterial vaginosis (BV)?

Answer: Data do not support provision of any type of antibiotic therapy to male partners of women with persistent or recurrent BV. For women with BV who have female sex partners, there is a high likelihood of that partner also having BV; however, no data exist to support presumptive treatment of BV in those women.

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Bacterial Vaginosis and Trichomoniasis

Question 7: Are there alternative treatments for bacterial vaginosis (BV) and trichomoniasis if a patient is allergic to metronidazole/tindazole?

Answer: For BV any of the clindamycin-recommended or alternate regimens should be tolerated. See the 2010 STD Treatment Guidelines (page 57). Unfortunately, the only class of drugs useful for oral or parenteral therapy of trichomoniasis is the nitroimidazoles. Metronidazole and tindazole are both nitroimidazoles. Patients with an immediate-type allergy to a nitroimidazole can be managed by metronidazole desensitization in consultation with a specialist. Topical therapy with drugs other than nitroimidazoles can be attempted, but cure rates are low (<50%). See the 2010 STD Treatment Guidelines (pages 59–60)

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Trichomoniasis

Question 8: Can you explain the nucleic acid amplification test (NAAT) for men for trichomoniasis? How is the specimen obtained?

Answer: A NAAT for T. vaginalis was recently approved to test endocervical and vaginal swabs and urine in women. Data on its performance in men (on urine and urethral swab) are expected soon.

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Question 9: What is the recommended treatment for females diagnosed with trichomoniasis?

Answer: The recommended treatments for trichomoniasis are metronidazole 2 g. orally in a single dose, or tinidazole 2 g. orally in a single dose.  Please see the 2010 STD Treatment Guidelines (page 58, column 2) for a detailed discussion of treatment for trichomoniasis.

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Question 10: Are there effective alternatives to imidazoles in the treatment of trichomoniasis?

Answer: Nitroimidazoles (metronidazole or tinidazole) are the preferred treatment. For women who can't tolerate these treatments due to true allergy, topical paromomycin cream is an option. Patients with an immediate-type allergy to a nitroimidazole can be managed by metronidazole desensitization in consultation with a specialist [see Am J Obstet Gynecol 2008;198:370–7]. CDC’s Division of STD Prevention can also be consulted for advice.

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Question 11: What are the sequelae of untreated trichomoniasis?

Answer: Sequelae of untreated trichomoniasis include transmission to sex partners, as well as preterm delivery during pregnancy.

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