Treatment of bacterial vaginosis in pregnancy in order to reduce the risk of spontaneous preterm delivery - a clinical recommendation.
BACKGROUND
Bacterial vaginosis (BV) is characterized by a dysbiosis of the vaginal microbiota with a depletion of Lactobacillus spp. In pregnancy, prevalence's between 7 and 30% have been reported depending on the study population and the definition. BV may be associated with an increased risk of spontaneous preterm delivery (sPTD). However, it is controversial whether or not BV-positive pregnant women will benefit from treatment to reduce the risk of sPTD. We could not identify any good-quality guideline addressing this issue. Consequently we aimed to produce this clinical recommendation based on GRADE.


METHODS
Systematic literature searches were conducted in the following databases: Guidelines International Network: G-I-N, Medline, Embase, The Cochrane Database of Systematic Reviews, Web of Science and http://www.clinicaltrials.gov from 1999 to 3 October 2014. Hence, nine guidelines, 34 reviews, 18 randomized controlled trials and 12 observational studies were included.


RESULTS
The GRADE quality of evidence was consistently low or very low, primarily because none of the risk ratios (RR) for the risk of sPTD at <37 weeks were statistically significant. Concerning treatment with metronidazole, RR was 1.11 (95% CI 0.93-1.34) in low-risk pregnancies and 0.96 (95% CI 0.78-1.18) in high risk pregnancies. Concerning treatment with clindamycin at any gestational age, the RR was 0.87 (95% CI 0.73-1.05).


CONCLUSIONS
This systematic review gives a strong recommendation against treatment with metronidazole and a weak recommendation against treatment with clindamycin to reduce the sPTD rate in both high-risk and low-risk pregnancies with BV.
The Fertility Clinic, Skive Regional Hospital, Copenhagen, Denmark.
Thor
T
Haahr
Department of Obstetrics, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark.
Anne S
AS
Ersbøll
Department of Obstetrics, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark.
Mona A
MA
Karlsen
Department of Obstetrics and Gynecology, Copenhagen University Hospital Herlev Gentofte, Herlev, Denmark.
Jens
http://orcid.org/0000-0003-4554-2455
J
Svare
Department of Obstetrics and Gynecology, Vendsyssel Hospital, Aalborg University, Aalborg, Denmark.
Kirstine
K
Sneider
Department of Obstetrics and Gynecology, Nordsjaellands Hospital, Hillerød, Denmark.
Lene
L
Hee
Department of Gynecology and Obstetrics, Odense University Hospital, Odense, Denmark.
Louise K
http://orcid.org/0000-0001-5027-5027
LK
Weile
Department of Clinical Pharmacology, Aarhus University Hospital, Aarhus, Denmark.
Agnes
A
Ziobrowska-Bech
Department of Clinical Microbiology, Vejle Hospital, Vejle, Denmark.
Claus
C
Østergaard
Statens Serum Institute, Copenhagen, Denmark.
Jørgen S
JS
Jensen
Department of Obstetrics and Gynecology, Aarhus University Hospital, Skejby, Denmark.
Rikke B
RB
Helmig
Department of Obstetrics and Gynecology, Aarhus University Hospital, Skejby, Denmark.
Niels
N
Uldbjerg
D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D002981:Clindamycin / Q000627:therapeutic use*; D005260:Female; D006801:Humans; D008795:Metronidazole / Q000627:therapeutic use*; D011247:Pregnancy; D011251:Pregnancy Complications, Infectious / Q000188:drug therapy* / Q000628:therapy; D047928:Premature Birth / Q000209:etiology / Q000517:prevention & control*; D019936:Probiotics / Q000627:therapeutic use; D012307:Risk Factors; D016896:Treatment Outcome; D016585:Vaginosis, Bacterial / Q000188:drug therapy* / Q000628:therapy
D000900:Anti-Bacterial Agents; D008795:Metronidazole; D002981:Clindamycin
Bacterial vaginosis; GRADE; clindamycin; guideline; metronidazole; preterm birth; preterm delivery; probiotics