What are the treatment options for recurrent Bacterial Vaginosis (BV)?

From the Guidelines

For recurrent Bacterial Vaginosis (BV), the recommended treatment is a longer course of antibiotics, typically metronidazole or clindamycin, followed by maintenance therapy. Initial treatment options include:

• Metronidazole 500 mg orally twice daily for 7 days,
• Metronidazole gel 0.75%, one full applicator (5 g) intravaginally, once a day for 5 days,
• Clindamycin cream 2%, one full applicator (5 g) intravaginally at bedtime for 7 days 1. It is essential to note that patients should be advised to avoid consuming alcohol during treatment with metronidazole and for 24 hours thereafter, and clindamycin cream and ovules are oil-based and might weaken latex condoms and diaphragms 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. Additional measures such as avoiding douching and use of scented products in the vaginal area, using condoms during sexual intercourse, and considering boric acid suppositories as an adjunct therapy can further support treatment 1. Chronic BV is often due to biofilm formation by bacteria, which makes it resistant to standard short-course treatments, and the extended antibiotic course helps to break down this biofilm, while maintenance therapy prevents recurrence by maintaining a healthy vaginal microbiome. If symptoms persist or recur frequently despite these measures, further evaluation for other underlying conditions or resistant strains may be necessary.

From the FDA Drug Label

Metronidazole vaginal gel is indicated in the treatment of bacterial vaginosis In a randomized, single-blind clinical trial of non-pregnant women with bacterial vaginosis who received metronidazole vaginal gel daily for 5 days, the clinical cure rates for evaluable patients determined at 4 weeks after completion of therapy for the QD and BID regimens were 98/185 (53%) and 109/190 (57%), respectively.

The treatment option for recurrent Bacterial Vaginosis (BV) is metronidazole vaginal gel. The clinical cure rates for metronidazole vaginal gel are 53% for the QD regimen and 57% for the BID regimen at 4 weeks after completion of therapy 2 2.

From the Research

Treatment Options for Recurrent Bacterial Vaginosis (BV)

The treatment options for recurrent BV include:

• Oral and intravaginal metronidazole and clindamycin, and oral tinidazole 3
• An extended course of metronidazole treatment (500 mg twice daily for 10-14 days) 3
• Metronidazole vaginal gel 0.75% for 10 days, followed by two times per week for 3-6 months, as an alternate treatment regimen 3
• Combination pharmacotherapy long-term suppressive regimen, including oral nitroimidazole and simultaneous boric acid vaginal therapy, followed by twice-weekly vaginal metronidazole gel 4
• Intravaginally applied metronidazole, which is as effective as orally applied metronidazole but exhibits significantly less side effects 5
• Other effective treatment regimens, including single-dose metronidazole, 2% clindamycin vaginal cream, 0.75% metronidazole vaginal gel, and oral clindamycin 6

Rationale for Treatment Options

The rationale for these treatment options is based on the fact that:

• Recurrent BV is a major challenge to effective therapy, and women experiencing intractable and frequent recurrences are ill-served by available treatment options 4
• The current and only FDA-approved treatment regimens for BV are antibiotics, such as metronidazole and clindamycin, which provide a short-term cure but fail to provide a consistent long-term cure for many women 7
• The use of probiotics, vaginal microbiome transplantation, pH modulation, and biofilm disruption are being explored as potential approaches to treatment and prevention 7

Considerations for Treatment

Considerations for treatment include:

• The need for a prolonged drug-intensive antimicrobial regimen incorporating antibiofilm activity until newer measures are available 4
• The potential for vaginal candidiasis to complicate prolonged antibiotic prophylaxis, requiring frequent antifungal rescue or prophylaxis 4
• The importance of patient compliance and satisfaction with treatment, which may be improved with intravaginal application of metronidazole 5