What is the treatment for Bacterial Vaginosis (BV)?

From the Guidelines

The treatment of bacterial vaginosis should involve metronidazole 500 mg orally twice a day for 7 days as the first-line option. This recommendation is based on the guidelines provided by the Centers for Disease Control and Prevention 1. Alternatively, metronidazole gel 0.75% can be applied intravaginally once daily for 5 days, or clindamycin cream 2% can be used intravaginally at bedtime for 7 days. For patients who cannot tolerate metronidazole, oral clindamycin 300 mg twice daily for 7 days is an effective alternative.

During treatment, patients should avoid alcohol consumption while taking metronidazole and for 24 hours afterward due to potential disulfiram-like reactions. Sexual abstinence or condom use is recommended during treatment. Bacterial vaginosis occurs when the normal vaginal flora, dominated by Lactobacillus species, is disrupted and replaced by an overgrowth of anaerobic bacteria like Gardnerella vaginalis. The antibiotics work by targeting these anaerobic bacteria, allowing the normal Lactobacillus-dominant flora to be restored.

Some key points to consider in the treatment of bacterial vaginosis include:

• The benefits of therapy for BV in pregnant women are to relieve vaginal symptoms and signs of infection, reduce the risk for infectious complications associated with BV during pregnancy, and reduce the risk for other infections 1.
• The benefits of therapy for BV in nonpregnant women are to relieve vaginal symptoms and signs of infection and reduce the risk for infectious complications after abortion or hysterectomy 1.
• Treatment of the male sex partner has not been beneficial in preventing the recurrence of BV 1.
• Follow-up visits are unnecessary if symptoms resolve, but recurrence is not unusual and patients should return for additional treatment if symptoms recur 1.

While recurrence is common (affecting up to 50% of women within a year), maintaining good vaginal hygiene, avoiding douching, and completing the full course of antibiotics can help prevent recurrence.

From the FDA Drug Label

A randomized, double-blind, placebo-controlled clinical trial in 235 non-pregnant women was conducted to evaluate the efficacy of tinidazole for the treatment of bacterial vaginosis. In patients with all four Amsel's criteria and with a baseline Nugent score ≥4, tinidazole oral tablets given as either 2 g once daily for 2 days or 1 g once daily for 5 days demonstrated superior efficacy over placebo tablets as measured by therapeutic cure, clinical cure, and a microbiologic cure. The therapeutic cure rates reported in this clinical study conducted with tinidazole were based on resolution of 4 out of 4 Amsel's criteria and a Nugent score of <4.

The treatment of bacterial vaginosis with tinidazole is effective, with therapeutic cure rates of:

• 97.5% for the 2 g once daily for 2 days regimen
• 97.5% for the 1 g once daily for 5 days regimen Both regimens demonstrated superior efficacy over placebo, with p-values <0.001 for therapeutic, clinical, and microbiologic cure rates 2. Tinidazole is indicated for the treatment of bacterial vaginosis in adult women 2.

From the Research

Treatment Options for Bacterial Vaginosis

• The current and only FDA-approved treatment regimens for bacterial vaginosis are antibiotics, such as metronidazole and clindamycin 3.
• Oral metronidazole, metronidazole vaginal gel, and clindamycin vaginal cream have been shown to be effective in treating bacterial vaginosis, with similar cure rates 4.
• Recommended treatment for recurrent bacterial vaginosis consists of an extended course of metronidazole treatment (500 mg twice daily for 10-14 days); if ineffective, metronidazole vaginal gel 0.75% for 10 days, followed by two times per week for 3-6 months, is an alternate treatment regimen 5.
• Other effective treatment regimens include single-dose metronidazole (2 g orally), 2% clindamycin vaginal cream (once daily for 7 days), 0.75% metronidazole vaginal gel (twice daily for 5 days), and oral clindamycin (300 mg twice daily for 7 days) 6.

Alternative Strategies for Treatment and Prevention

• Alternative strategies to replace or combine with standard therapies include antimicrobial substances, probiotics, prebiotics, acidifying agents, and substances that aim to reestablish the physiologic vaginal environment 7.
• Current areas of investigation for bacterial vaginosis management include probiotics, vaginal microbiome transplantation, pH modulation, and biofilm disruption 3.
• Behavioral modifications that may help include smoking cessation, condom use, and hormonal contraception 3.
• Additional strategies considered by many people include dietary modification, non-medical vaginally applied products, choice of lubricant, and treatments from medical practices outside of allopathic medicine 3.

Challenges and Limitations of Current Treatments

• Antibiotics provide a short-term cure for bacterial vaginosis; however, fail to provide a consistent long-term cure for many women, with 50-80% of women experiencing a recurrence within a year of completing antibiotic treatment 3.
• The treatment with antibiotics is associated with high levels of failure and recurrence rates, which may be associated with antibiotic resistance, the inability to eradicate the polymicrobial biofilms, and failure to reestablish acidic pH and the lactobacillus-dominated commensal flora 7.
• Persistence of residual infection, resistance, and possibly reinfection from either male or female partners may also contribute to recurrence 5.