Bacterial Vaginosis Plan of Care
Discussion Two: Bacterial Vaginosis (BV)
A 40-year-old patient is presented to the primary care office complaining of vaginal discharge with a fishy odor. First, a thorough patient history should be reviewed to evaluate the timing of the onset of the symptoms together with a full explanation of the vaginal discharge. Many external and internal influences easily alter the delicate vagina environment. Thus, there is a need to conduct a differential diagnosis to ascertain the relationship of the patient’s symptoms to stress, menstrual cycle (ovulatory mucus production/ menstruation), coitus, changes in atrophic mucosal after menopause, medications (particularly antibiotics), and glycosuria. Besides, a comprehensive sexual history will be used to detect whether the female patient is at high risks for developing STIs. It is vital to determine if the patient’s spouse has infection symptoms (lesion or penile discharge) and if the patient has done self-treatments, spermicidal preparations, bubble baths, feminine hygiene deodorants, and douches.
The possible infection could be physiological leucorrhea, Candidiasis, Bacterial vaginosis, trichomoniasis, or Atrophic vaginitis. The common causes of characteristic complaints with symptoms of abnormal vagina discharge, burning, and itching are yeast, bacteria, and parasite infections. The bacterial vaginosis is mainly instigated by Gardnerella, accounting for about 50 percent of total vagina infections (Dunphy et al. 2019). The USPSTF endorses against BV screening among pregnant women who are not at amplified risks for preterm birth. Candidiasis and trichomoniasis account for about 25% and 20% of vaginal infections. These vaginal infections can be diagnosed as per the clinical presentation, including type, volume, odor, colour, and discharge pH. Furthermore, a physical examination can be conducted through the visualization of the vagina and vulva for atrophy, lesions, erythema, or discharge. Also, the cervix is then examined for erythema, lesions, friability, or erosion. In the bimanual examination, particular focus should be on reviewing masses, cervical motion, uterine, or adnexal tenderness. 
The laboratory tests are usually directed by findings derived from patient history and the physical examination. The test consists of saline wet vaginal discharge mount to govern Gardnerella, atrophic vaginitis, or Trichomonas (Dunphy et al. 2019). Also, a potassium hydroxide wet mount can be used to establish the Candida presence. The Gram stain of discharge could also reveal whether there is the presence of gonorrhea. Lastly, a urinalysis test is done to rule out UTI. BV is diagnosed based on clinical action criteria, either the Amsel Diagnostic Criteria, or the Gram stain. The 2015 CDC Guidelines consider the Gram stain as the gold standard lab technique used in the diagnosis as it determines the lactobacilli concentration (the long Gram positive rods, Gram negative plus Gram-variable cocci and rods, and curve Gram-negative rods characteristic of BV (Schwebke et al. 1996). The clinical presentation necessitate three of these four symptoms: homogenous white vaginal discharge, the “fishy” odor, pH greater than 4.5, clue cells microscopic examination plus positive amine tests (10% KOH is applicable to vaginal discharge releasing fishy odor as per the whiff lab test). An Additional test is the Affirm VP III. This is a DNA hybridization probe lab test for higher G. vaginalis concentrations. The final test is the OSOM BV Blue lab test that identifies fluid sialidase action. Pap tests and G. vaginalis culture should not be used in clinical consideration.
The 2015 STD treatment Guidelines offer guidance on drugs commonly used in the BV treatment (CDC 2015). Treatment is usually recommended for patients with the above symptoms, and the proven benefits of treatment therapy include relieving vaginal infection signs among non-pregnant patients. The other possible theraoy benefits include a decrease in the risks for acquiring gonorrhoeae, trachomatis vaginalis, herpes simplex type 2, and HIV (Rebecca et al. 2010). The treatment is either metronidazole 500 milligram PO 2 times per day for up to seven days or metronidazole gel 0.75 percent one whole applicator (5 gram) intravaginally once a day ( five days) or clindamycin cream percent one whole applicator (5 gram) intravaginally in bed time ( seven days). The prescribing considerations are avoiding alcohol ingestion with metronidazole and up to 24 hours after completion of treatment. Also, the patient should not use condom and contraceptive diaphragm for 72 hours after completion of therapy. The adverse reactions comprise GI upset, incontinence, metallic taste, Candida overgrowth, dysuria, seizures, peripheral neuropathy, cystitis, and neutropenia. The preferred medication is oral in pregnancy category B in the second and third trimesters. The patient should not have a history of colitis or enteritis and is not commended for the nursing mothers.
Follow-up visits are not necessary if the symptoms resolve. But since recurrent and persistent BV is common, the patient should return for assessment if the symptoms persist. The use of different CDC recommended treatment plan is considered though retreatment using the same regimen is a suitable approach for the treatment of recurrent or persistent BV following the initial occurrence (Bunge et al., 2009). If the patient has multiple BV recurrences after completing their recommended treatment regimen, the 0.75 percent metronidazole gel two times per week for a period between 4 and 6 months has proven to decrease recurrences. However, the benefit cannot persist if suppressive therapy has been discontinued.
References
Bunge, K. E., Beigi, R. H., Meyn, L. A., & Hillier, S. L. (January 01, 2009). The Efficacy of Retreatment With the Same Medication for Early Treatment Failure of Bacterial Vaginosis. Sexually Transmitted Diseases Philadelphia-, 36, 11, 711-713.
Centers for Disease Control and Prevention (2015, June 4). 2015 STD Treatment Guidelines – Bacterial Vaginosis – Updated diagnostic, treatment, and screening recommendations for STDs. Retrieved from https://www.cdc.gov/std/tg2015/bv.htm
Dunphy, L. M. H., In Winland-Brown, J. E., In Porter, B. O., & In Thomas, D. J. (2019). Primary care: The art and science of advanced practice nursing. Philadelphia, PA: F.A. Davis Company.
Rebecca, M. B., Mark, A. K., Tonja, R. N., Kai, F. Y., William, W. A., Jun, Z., & Jane, R. S. (December 15, 2010). Bacterial Vaginosis Assessed by Gram Stain and Diminished Colonization Resistance to Incident Gonococcal, Chlamydial, and Trichomonal Genital Infection. Journal of Infectious Diseases, 202, 12, 1907-1915.
Schwebke, J. R., Hillier, S. L., Sobel, J. D., McGregor, J. A., & Sweet, R. L. (January 01, 1996). Validity of the vaginal gram stain for the diagnosis of bacterial vaginosis. Obstetrics and Gynecology, 88, 4, 573-6.
U.S Preventive Services Task Force (2020, April 07). Bacterial Vaginosis in Pregnant Persons to Prevent Preterm Delivery: Screening. Retrieved from https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/bacterial-vaginosis-in-pregnancy-to-prevent-preterm-delivery-screening#:~:text=Recommendation%20Summary&text=The%20USPSTF%20recommends%20against%20screening,increased%20risk%20for%20preterm%20delivery.