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The best way to prevent recurrent bacterial vaginosis is to treat the initial episode with the most effective regimen. Metronidazole (500 mg orally twice daily for 7 days) has the lowest recurrence rate among antimicrobial regimens for bacterial vaginosis (20% vs 34%–50% for other agents) (strength of recommendation [SOR]: A). Women should be treated if they are symptomatic (SOR: A), undergoing gynecologic surgery (SOR: B), or at risk for preterm labor (SOR: B).
When bacterial vaginosis recurs, providers should confirm the diagnosis (Table 1) (SOR: A), identify and control risk factors for recurrence ( Table 2) (SOR: B), and consider other causes while retreating bacterial vaginosis (SOR: C). If the diagnosis is confirmed and retreatment fails, consider suppression with metronidazole 0.75% vaginal gel for 10 days followed by twice weekly administration for 4 to 6 months (SOR: C, trial ongoing). No evidence supports treating sexual partners or administering oral or vaginal Lactobacillus acidophilus, but recolonization with vagina-specific lactobacilli (L crispatus and L jensenii) is undergoing Phase III clinical trials.
Evidence summary
No trials have tested or compared specific, comprehensive strategies for recurrent bacterial vaginosis. Given that bacterial vaginosis can also be asymptomatic, recurrence often cannot be differentiated from treatment failure. Accordingly, recurrent bacterial vaginosis may be prevented by using the most effective therapy for the initial episode. A 2002 meta-analysis by the Centers for Disease Control and Prevention’s (CDC) bacterial vaginosis working group reviewed the indications for therapy and best treatments for bacterial vaginosis.1 The group found 25 trials evaluating oral metronidazole therapy involving 2742 women. Although cure rates using either 500 mg twice daily for 5 to 7 days or 2 g as a single dose were similar at 2 weeks post follow-up (85%; range 67%–98%), the single-dose regimen led to higher relapse rates 1 month after treatment (35%–50% vs 20%–33%).
Six trials enrolling 946 women assessed the efficacy of various topical vaginal treatments. Metronidazole gel, clindamycin cream, and clindamycin ovules had a wide range of initial cure rates (50%–95%), but all had higher relapse rates at 4 weeks than did oral metronidazole for 1 week (34%–49%).1 A more complete discussion of the effectiveness of antibiotics for bacterial vaginosis can be found in a recent Clinical Inquiry.2
The CDC reviewers identified causal relationships between bacterial vaginosis and plasmacell endometritis, postpartum fever, and posthysterectomy vaginal-cuff cellulitis. They therefore concluded it is reasonable to try to prevent post-procedure infections by treating women who have asymptomatic bacterial vaginosis before hysterectomy or pregnancy termination. Although bacterial vaginosis has been associated with preterm labor, trials evaluating treatment of bacterial vaginosis to prevent preterm delivery are conflicting. A Cochrane review of bacterial vaginosis and preterm labor suggests treating women at high risk for preterm birth may reduce the risk of low birthweight and preterm prelabor rupture of membranes.3
Patients frequently try to self-diagnose vaginal complaints and ask for treatments and retreatments by phone. However, a prospective study of 253 women who underwent a structured telephone interview and subsequent physical exam found a poor correlation between telephone diagnosis and final clinical diagnosis (kappa coefficient of 0.12—very poor agreement).4 Accordingly, clinical and laboratory evaluation of vaginal discharge and especially recurrent symptoms is essential for diagnostic accuracy and treatment for bacterial vaginosis (Table 1).
For recurrent symptomatic bacterial vaginosis, 1 option is suppressive therapy with metronidazole gel 0.75%. After initial daily retreatment for 10 days, this can be used twice weekly for 4 to 6 months to decrease symptoms. This strategy is based on expert opinion but is currently undergoing clinical trial.
One small crossover randomized controlled trial of 46 women with bacterial vaginosis studied the consumption of live L acidophilus cultures.5 Only 20 of the women had recurrent bacterial vaginosis. The groups were randomized to eat yogurt with and without live L acidophilus cultures. While the results were encouraging (50% reduction in episodes of bacterial vaginosis and increase in detectable vaginal Lactobacillus), only 7 women actually completed the study protocol.
Douching is the best-studied risk factor for bacterial vaginosis. A recent multicenter cross-sectional study of 1200 women assessed douching practices and found that recent douching increased the risk of bacterial vaginosis twofold (odds ratio=2.1; 95% confidence interval, 1.3–3.1).6 Evidence for the other risk factors listed in Table 2 is based on smaller studies or expert opinion.7,8
For women who continue to have recurrent or unresolved vaginal symptoms not explained by candidiasis or sexually transmitted infections such as trichomoniasis, consider less common causes such as atrophic vaginitis, chemical/irritant vaginitis, allergic vaginitis, Behçets disease, desquamative interstitial vaginitis, or erosive lichen planus vaginitis.9
TABLE 1
Amsel criteria for diagnosis of bacterial vaginosis
| Patient must have 3 of the 4 criteria for diagnosis. |
|
| Source: Based on Amsel et al 1983.11 |
TABLE 2
Risk factors for bacterial vaginosis
| Use of vaginal foreign bodies, perfumed soaps, or douching |
| Cigarette smoking |
| Intrauterine device |
| New male sexual partner |
| Sex with another woman |
| No condom use (trend toward association) |
| Source: Based on Marrazzo et al 20027; CDC 2002.8 |
Recommendations from others
No organizations have developed guidelines for treating recurrent bacterial vaginosis. In 2002, the Association for Genitourinary Medicine and the Medical Society for the Study of Venereal Diseases released national guidelines on the management of bacterial vaginosis,10 which generally agrees with the previously described CDC recommendations.
Take a detailed history, make sure clinical findings support the diagnosis
Jon O. Neher, MD
Valley Medical Center, Renton, Wash
Patients with recurrent bacterial vaginosis are often embarrassed, frustrated, or angry with the failure of prior medical therapy. Our challenge is to listen empathetically and avoid blaming the patient for the failure. It is critical to take another detailed history (again reviewing sexual and perineal hygiene habits), consider an expanded differential, and make sure clinical findings continue to support the diagnosis. A discussion about the (current lack of) evidence on pharmacologic therapy for recurrent cases must also be included in the visit. A collaborative plan of action will help the patient regain a sense of control over her health.
1. Koumans EH, Markowitz LE, Hogan V. Indications for therapy and treatment recommendations for bacterial vaginosis in nonpregnant and pregnant women: a synthesis of data. Clin Infect Dis 2002;35(Suppl 2):S152-172.
2. Kane KY, Pierce R. What are the most effective treatments for bacterial vaginosis in nonpregnant women? J Fam Pract 2001;50:399-400.
3. McDonald H, Brocklehurst P, Parsons J, Vigneswaran R. Cochrane Pregnancy and Childbirth Group. Antibiotics for treating bacterial vaginosis in pregnancy. Cochrane Database Syst Rev 1, 2004. Last accessed May 18, 2004.
4. Allen-Davis JT, Beck A, Parker R, Ellis JL, Polley D. Assessment of vulvovaginal complaints: accuracy of telephone triage and in-office diagnosis. Obstet Gynecol 2002;99:18-22.
5. Shalev E, Battino S, Wiener E, Colodner R, Keness Y. Ingestion of yogurt containing Lactobacillus acidophilus compared with pasteurized yogurt as prophylaxis for recurrent candidal vaginitis and bacterial vaginosis. Arch Fam Med 1996;5:593-596.
6. Ness RB, Hillier SL, Richter HE, Soper DE, Stamm C, McGregor J, et al. Douching in relation to bacterial vaginosis, lactobacilli, and facultative bacteria in the vagina. Obstet Gynecol 2002;100:765-772.
7. Marrazzo JM, Koutsky LA, Eschenbach DA, Agnew K, Stine K, Hillier SL. Characterization of vaginal flora and bacterial vaginosis in women who have sex with women. J Infect Dis 2002;185:1307-1313.
8. Sexually transmitted diseases treatment guidelines 2002. Centers for Disease Control and Prevention. MMWR Recomm Rep 2002;51(RR-6):1-78.
9. Sobel J. Overview of Vaginitis. In: UpToDate, Rose, BD (Ed). Wellesley, Mass: UpToDate, 2003. (This topic was last changed on July 24, 2003).
10. National guideline for the management of bacterial vaginosis. Clinical Effectiveness Group (Association of Genitourinary Medicine and the Medical Society for the Study of Venereal Diseases). Sex Transm Infect 1999;75 Suppl 1:S16-18.
11. Amsel R, Totten PA, Spiegel CA, Chen KC, Eschenbach D, Holmes KK. Nonspecific vaginitis. Diagnostic criteria and microbial and epidemiologic associations. Am J Med 1983;74:14-22.
The best way to prevent recurrent bacterial vaginosis is to treat the initial episode with the most effective regimen. Metronidazole (500 mg orally twice daily for 7 days) has the lowest recurrence rate among antimicrobial regimens for bacterial vaginosis (20% vs 34%–50% for other agents) (strength of recommendation [SOR]: A). Women should be treated if they are symptomatic (SOR: A), undergoing gynecologic surgery (SOR: B), or at risk for preterm labor (SOR: B).
When bacterial vaginosis recurs, providers should confirm the diagnosis (Table 1) (SOR: A), identify and control risk factors for recurrence ( Table 2) (SOR: B), and consider other causes while retreating bacterial vaginosis (SOR: C). If the diagnosis is confirmed and retreatment fails, consider suppression with metronidazole 0.75% vaginal gel for 10 days followed by twice weekly administration for 4 to 6 months (SOR: C, trial ongoing). No evidence supports treating sexual partners or administering oral or vaginal Lactobacillus acidophilus, but recolonization with vagina-specific lactobacilli (L crispatus and L jensenii) is undergoing Phase III clinical trials.
Evidence summary
No trials have tested or compared specific, comprehensive strategies for recurrent bacterial vaginosis. Given that bacterial vaginosis can also be asymptomatic, recurrence often cannot be differentiated from treatment failure. Accordingly, recurrent bacterial vaginosis may be prevented by using the most effective therapy for the initial episode. A 2002 meta-analysis by the Centers for Disease Control and Prevention’s (CDC) bacterial vaginosis working group reviewed the indications for therapy and best treatments for bacterial vaginosis.1 The group found 25 trials evaluating oral metronidazole therapy involving 2742 women. Although cure rates using either 500 mg twice daily for 5 to 7 days or 2 g as a single dose were similar at 2 weeks post follow-up (85%; range 67%–98%), the single-dose regimen led to higher relapse rates 1 month after treatment (35%–50% vs 20%–33%).
Six trials enrolling 946 women assessed the efficacy of various topical vaginal treatments. Metronidazole gel, clindamycin cream, and clindamycin ovules had a wide range of initial cure rates (50%–95%), but all had higher relapse rates at 4 weeks than did oral metronidazole for 1 week (34%–49%).1 A more complete discussion of the effectiveness of antibiotics for bacterial vaginosis can be found in a recent Clinical Inquiry.2
The CDC reviewers identified causal relationships between bacterial vaginosis and plasmacell endometritis, postpartum fever, and posthysterectomy vaginal-cuff cellulitis. They therefore concluded it is reasonable to try to prevent post-procedure infections by treating women who have asymptomatic bacterial vaginosis before hysterectomy or pregnancy termination. Although bacterial vaginosis has been associated with preterm labor, trials evaluating treatment of bacterial vaginosis to prevent preterm delivery are conflicting. A Cochrane review of bacterial vaginosis and preterm labor suggests treating women at high risk for preterm birth may reduce the risk of low birthweight and preterm prelabor rupture of membranes.3
Patients frequently try to self-diagnose vaginal complaints and ask for treatments and retreatments by phone. However, a prospective study of 253 women who underwent a structured telephone interview and subsequent physical exam found a poor correlation between telephone diagnosis and final clinical diagnosis (kappa coefficient of 0.12—very poor agreement).4 Accordingly, clinical and laboratory evaluation of vaginal discharge and especially recurrent symptoms is essential for diagnostic accuracy and treatment for bacterial vaginosis (Table 1).
For recurrent symptomatic bacterial vaginosis, 1 option is suppressive therapy with metronidazole gel 0.75%. After initial daily retreatment for 10 days, this can be used twice weekly for 4 to 6 months to decrease symptoms. This strategy is based on expert opinion but is currently undergoing clinical trial.
One small crossover randomized controlled trial of 46 women with bacterial vaginosis studied the consumption of live L acidophilus cultures.5 Only 20 of the women had recurrent bacterial vaginosis. The groups were randomized to eat yogurt with and without live L acidophilus cultures. While the results were encouraging (50% reduction in episodes of bacterial vaginosis and increase in detectable vaginal Lactobacillus), only 7 women actually completed the study protocol.
Douching is the best-studied risk factor for bacterial vaginosis. A recent multicenter cross-sectional study of 1200 women assessed douching practices and found that recent douching increased the risk of bacterial vaginosis twofold (odds ratio=2.1; 95% confidence interval, 1.3–3.1).6 Evidence for the other risk factors listed in Table 2 is based on smaller studies or expert opinion.7,8
For women who continue to have recurrent or unresolved vaginal symptoms not explained by candidiasis or sexually transmitted infections such as trichomoniasis, consider less common causes such as atrophic vaginitis, chemical/irritant vaginitis, allergic vaginitis, Behçets disease, desquamative interstitial vaginitis, or erosive lichen planus vaginitis.9
TABLE 1
Amsel criteria for diagnosis of bacterial vaginosis
| Patient must have 3 of the 4 criteria for diagnosis. |
|
| Source: Based on Amsel et al 1983.11 |
TABLE 2
Risk factors for bacterial vaginosis
| Use of vaginal foreign bodies, perfumed soaps, or douching |
| Cigarette smoking |
| Intrauterine device |
| New male sexual partner |
| Sex with another woman |
| No condom use (trend toward association) |
| Source: Based on Marrazzo et al 20027; CDC 2002.8 |
Recommendations from others
No organizations have developed guidelines for treating recurrent bacterial vaginosis. In 2002, the Association for Genitourinary Medicine and the Medical Society for the Study of Venereal Diseases released national guidelines on the management of bacterial vaginosis,10 which generally agrees with the previously described CDC recommendations.
Take a detailed history, make sure clinical findings support the diagnosis
Jon O. Neher, MD
Valley Medical Center, Renton, Wash
Patients with recurrent bacterial vaginosis are often embarrassed, frustrated, or angry with the failure of prior medical therapy. Our challenge is to listen empathetically and avoid blaming the patient for the failure. It is critical to take another detailed history (again reviewing sexual and perineal hygiene habits), consider an expanded differential, and make sure clinical findings continue to support the diagnosis. A discussion about the (current lack of) evidence on pharmacologic therapy for recurrent cases must also be included in the visit. A collaborative plan of action will help the patient regain a sense of control over her health.
The best way to prevent recurrent bacterial vaginosis is to treat the initial episode with the most effective regimen. Metronidazole (500 mg orally twice daily for 7 days) has the lowest recurrence rate among antimicrobial regimens for bacterial vaginosis (20% vs 34%–50% for other agents) (strength of recommendation [SOR]: A). Women should be treated if they are symptomatic (SOR: A), undergoing gynecologic surgery (SOR: B), or at risk for preterm labor (SOR: B).
When bacterial vaginosis recurs, providers should confirm the diagnosis (Table 1) (SOR: A), identify and control risk factors for recurrence ( Table 2) (SOR: B), and consider other causes while retreating bacterial vaginosis (SOR: C). If the diagnosis is confirmed and retreatment fails, consider suppression with metronidazole 0.75% vaginal gel for 10 days followed by twice weekly administration for 4 to 6 months (SOR: C, trial ongoing). No evidence supports treating sexual partners or administering oral or vaginal Lactobacillus acidophilus, but recolonization with vagina-specific lactobacilli (L crispatus and L jensenii) is undergoing Phase III clinical trials.
Evidence summary
No trials have tested or compared specific, comprehensive strategies for recurrent bacterial vaginosis. Given that bacterial vaginosis can also be asymptomatic, recurrence often cannot be differentiated from treatment failure. Accordingly, recurrent bacterial vaginosis may be prevented by using the most effective therapy for the initial episode. A 2002 meta-analysis by the Centers for Disease Control and Prevention’s (CDC) bacterial vaginosis working group reviewed the indications for therapy and best treatments for bacterial vaginosis.1 The group found 25 trials evaluating oral metronidazole therapy involving 2742 women. Although cure rates using either 500 mg twice daily for 5 to 7 days or 2 g as a single dose were similar at 2 weeks post follow-up (85%; range 67%–98%), the single-dose regimen led to higher relapse rates 1 month after treatment (35%–50% vs 20%–33%).
Six trials enrolling 946 women assessed the efficacy of various topical vaginal treatments. Metronidazole gel, clindamycin cream, and clindamycin ovules had a wide range of initial cure rates (50%–95%), but all had higher relapse rates at 4 weeks than did oral metronidazole for 1 week (34%–49%).1 A more complete discussion of the effectiveness of antibiotics for bacterial vaginosis can be found in a recent Clinical Inquiry.2
The CDC reviewers identified causal relationships between bacterial vaginosis and plasmacell endometritis, postpartum fever, and posthysterectomy vaginal-cuff cellulitis. They therefore concluded it is reasonable to try to prevent post-procedure infections by treating women who have asymptomatic bacterial vaginosis before hysterectomy or pregnancy termination. Although bacterial vaginosis has been associated with preterm labor, trials evaluating treatment of bacterial vaginosis to prevent preterm delivery are conflicting. A Cochrane review of bacterial vaginosis and preterm labor suggests treating women at high risk for preterm birth may reduce the risk of low birthweight and preterm prelabor rupture of membranes.3
Patients frequently try to self-diagnose vaginal complaints and ask for treatments and retreatments by phone. However, a prospective study of 253 women who underwent a structured telephone interview and subsequent physical exam found a poor correlation between telephone diagnosis and final clinical diagnosis (kappa coefficient of 0.12—very poor agreement).4 Accordingly, clinical and laboratory evaluation of vaginal discharge and especially recurrent symptoms is essential for diagnostic accuracy and treatment for bacterial vaginosis (Table 1).
For recurrent symptomatic bacterial vaginosis, 1 option is suppressive therapy with metronidazole gel 0.75%. After initial daily retreatment for 10 days, this can be used twice weekly for 4 to 6 months to decrease symptoms. This strategy is based on expert opinion but is currently undergoing clinical trial.
One small crossover randomized controlled trial of 46 women with bacterial vaginosis studied the consumption of live L acidophilus cultures.5 Only 20 of the women had recurrent bacterial vaginosis. The groups were randomized to eat yogurt with and without live L acidophilus cultures. While the results were encouraging (50% reduction in episodes of bacterial vaginosis and increase in detectable vaginal Lactobacillus), only 7 women actually completed the study protocol.
Douching is the best-studied risk factor for bacterial vaginosis. A recent multicenter cross-sectional study of 1200 women assessed douching practices and found that recent douching increased the risk of bacterial vaginosis twofold (odds ratio=2.1; 95% confidence interval, 1.3–3.1).6 Evidence for the other risk factors listed in Table 2 is based on smaller studies or expert opinion.7,8
For women who continue to have recurrent or unresolved vaginal symptoms not explained by candidiasis or sexually transmitted infections such as trichomoniasis, consider less common causes such as atrophic vaginitis, chemical/irritant vaginitis, allergic vaginitis, Behçets disease, desquamative interstitial vaginitis, or erosive lichen planus vaginitis.9
TABLE 1
Amsel criteria for diagnosis of bacterial vaginosis
| Patient must have 3 of the 4 criteria for diagnosis. |
|
| Source: Based on Amsel et al 1983.11 |
TABLE 2
Risk factors for bacterial vaginosis
| Use of vaginal foreign bodies, perfumed soaps, or douching |
| Cigarette smoking |
| Intrauterine device |
| New male sexual partner |
| Sex with another woman |
| No condom use (trend toward association) |
| Source: Based on Marrazzo et al 20027; CDC 2002.8 |
Recommendations from others
No organizations have developed guidelines for treating recurrent bacterial vaginosis. In 2002, the Association for Genitourinary Medicine and the Medical Society for the Study of Venereal Diseases released national guidelines on the management of bacterial vaginosis,10 which generally agrees with the previously described CDC recommendations.
Take a detailed history, make sure clinical findings support the diagnosis
Jon O. Neher, MD
Valley Medical Center, Renton, Wash
Patients with recurrent bacterial vaginosis are often embarrassed, frustrated, or angry with the failure of prior medical therapy. Our challenge is to listen empathetically and avoid blaming the patient for the failure. It is critical to take another detailed history (again reviewing sexual and perineal hygiene habits), consider an expanded differential, and make sure clinical findings continue to support the diagnosis. A discussion about the (current lack of) evidence on pharmacologic therapy for recurrent cases must also be included in the visit. A collaborative plan of action will help the patient regain a sense of control over her health.
1. Koumans EH, Markowitz LE, Hogan V. Indications for therapy and treatment recommendations for bacterial vaginosis in nonpregnant and pregnant women: a synthesis of data. Clin Infect Dis 2002;35(Suppl 2):S152-172.
2. Kane KY, Pierce R. What are the most effective treatments for bacterial vaginosis in nonpregnant women? J Fam Pract 2001;50:399-400.
3. McDonald H, Brocklehurst P, Parsons J, Vigneswaran R. Cochrane Pregnancy and Childbirth Group. Antibiotics for treating bacterial vaginosis in pregnancy. Cochrane Database Syst Rev 1, 2004. Last accessed May 18, 2004.
4. Allen-Davis JT, Beck A, Parker R, Ellis JL, Polley D. Assessment of vulvovaginal complaints: accuracy of telephone triage and in-office diagnosis. Obstet Gynecol 2002;99:18-22.
5. Shalev E, Battino S, Wiener E, Colodner R, Keness Y. Ingestion of yogurt containing Lactobacillus acidophilus compared with pasteurized yogurt as prophylaxis for recurrent candidal vaginitis and bacterial vaginosis. Arch Fam Med 1996;5:593-596.
6. Ness RB, Hillier SL, Richter HE, Soper DE, Stamm C, McGregor J, et al. Douching in relation to bacterial vaginosis, lactobacilli, and facultative bacteria in the vagina. Obstet Gynecol 2002;100:765-772.
7. Marrazzo JM, Koutsky LA, Eschenbach DA, Agnew K, Stine K, Hillier SL. Characterization of vaginal flora and bacterial vaginosis in women who have sex with women. J Infect Dis 2002;185:1307-1313.
8. Sexually transmitted diseases treatment guidelines 2002. Centers for Disease Control and Prevention. MMWR Recomm Rep 2002;51(RR-6):1-78.
9. Sobel J. Overview of Vaginitis. In: UpToDate, Rose, BD (Ed). Wellesley, Mass: UpToDate, 2003. (This topic was last changed on July 24, 2003).
10. National guideline for the management of bacterial vaginosis. Clinical Effectiveness Group (Association of Genitourinary Medicine and the Medical Society for the Study of Venereal Diseases). Sex Transm Infect 1999;75 Suppl 1:S16-18.
11. Amsel R, Totten PA, Spiegel CA, Chen KC, Eschenbach D, Holmes KK. Nonspecific vaginitis. Diagnostic criteria and microbial and epidemiologic associations. Am J Med 1983;74:14-22.
1. Koumans EH, Markowitz LE, Hogan V. Indications for therapy and treatment recommendations for bacterial vaginosis in nonpregnant and pregnant women: a synthesis of data. Clin Infect Dis 2002;35(Suppl 2):S152-172.
2. Kane KY, Pierce R. What are the most effective treatments for bacterial vaginosis in nonpregnant women? J Fam Pract 2001;50:399-400.
3. McDonald H, Brocklehurst P, Parsons J, Vigneswaran R. Cochrane Pregnancy and Childbirth Group. Antibiotics for treating bacterial vaginosis in pregnancy. Cochrane Database Syst Rev 1, 2004. Last accessed May 18, 2004.
4. Allen-Davis JT, Beck A, Parker R, Ellis JL, Polley D. Assessment of vulvovaginal complaints: accuracy of telephone triage and in-office diagnosis. Obstet Gynecol 2002;99:18-22.
5. Shalev E, Battino S, Wiener E, Colodner R, Keness Y. Ingestion of yogurt containing Lactobacillus acidophilus compared with pasteurized yogurt as prophylaxis for recurrent candidal vaginitis and bacterial vaginosis. Arch Fam Med 1996;5:593-596.
6. Ness RB, Hillier SL, Richter HE, Soper DE, Stamm C, McGregor J, et al. Douching in relation to bacterial vaginosis, lactobacilli, and facultative bacteria in the vagina. Obstet Gynecol 2002;100:765-772.
7. Marrazzo JM, Koutsky LA, Eschenbach DA, Agnew K, Stine K, Hillier SL. Characterization of vaginal flora and bacterial vaginosis in women who have sex with women. J Infect Dis 2002;185:1307-1313.
8. Sexually transmitted diseases treatment guidelines 2002. Centers for Disease Control and Prevention. MMWR Recomm Rep 2002;51(RR-6):1-78.
9. Sobel J. Overview of Vaginitis. In: UpToDate, Rose, BD (Ed). Wellesley, Mass: UpToDate, 2003. (This topic was last changed on July 24, 2003).
10. National guideline for the management of bacterial vaginosis. Clinical Effectiveness Group (Association of Genitourinary Medicine and the Medical Society for the Study of Venereal Diseases). Sex Transm Infect 1999;75 Suppl 1:S16-18.
11. Amsel R, Totten PA, Spiegel CA, Chen KC, Eschenbach D, Holmes KK. Nonspecific vaginitis. Diagnostic criteria and microbial and epidemiologic associations. Am J Med 1983;74:14-22.
Evidence-based answers from the Family Physicians Inquiries Network