What is the diagnosis and treatment for Bacterial Vaginosis (BV)?

From the Guidelines

Bacterial vaginosis (BV) should be treated with oral metronidazole or clindamycin in symptomatic pregnant women to reduce the risk of premature rupture of the membranes, preterm labor, and post-partum endometritis. The treatment of BV is crucial in preventing adverse pregnancy outcomes, and the benefits of therapy include relieving vaginal symptoms and signs of infection, reducing the risk for infectious complications associated with BV during pregnancy, and reducing the risk for other infections 1.

Treatment Options

The recommended treatment regimens for BV include:

• Oral metronidazole 250 mg three times a day for 7 days 1
• Oral metronidazole 2 g in a single dose 1
• Clindamycin 300 mg orally twice a day for 7 days 1
• Clindamycin cream 2% intravaginally at bedtime for 7 days 1

Prevention and Risk Factors

BV occurs when the normal vaginal pH increases above 4.5, allowing harmful bacteria to flourish. Risk factors include douching, new or multiple sexual partners, and lack of condoms. Prevention strategies include avoiding douches, using condoms, and maintaining good hygiene. Probiotics containing lactobacilli may help restore vaginal flora, though they're not a replacement for antibiotic treatment when infection is present.

Follow-up and Recurrence

Follow-up visits are unnecessary if symptoms resolve, but recurrence is not unusual, and patients should return for additional treatment if symptoms recur 1. A follow-up evaluation should be done one month after completion of treatment to verify that therapy was effective, especially in pregnant women 1.

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. Therapeutic cure required a return to normal vaginal discharge and resolution of all Amsel's criteria 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.

Tinidazole is effective for the treatment of bacterial vaginosis.

• The therapeutic cure rates for tinidazole were 97.5% for the 2 g × 2 days regimen and 96.1% for the 1 g × 5 days regimen.
• Clinical cure rates were 93.4% for the 2 g × 2 days regimen and 87.7% for the 1 g × 5 days regimen.
• Microbiologic cure rates were 93.2% for the 2 g × 2 days regimen and 87.0% for the 1 g × 5 days regimen 2.

From the Research

Treatment Options for Bacterial Vaginosis

• The preferred treatment for bacterial vaginosis in nonpregnant women includes metronidazole (500 mg orally twice daily for 7 days), clindamycin vaginal cream (2%, once daily for 7 days), or metronidazole vaginal gel (0.75%, twice daily for 5 days) 3, 4.
• For pregnant high-risk women, the recommended treatment is metronidazole (250 mg orally three times a day for 7 days) to prevent adverse outcomes of pregnancy and relieve symptoms 3.
• For pregnant low-risk women with symptomatic disease, the main objective of treatment is to relieve symptoms, and metronidazole (250 mg orally three times a day for 7 days) is recommended 3.
• Other effective treatment regimens include single-dose metronidazole (2 g orally), oral clindamycin (300 mg twice daily for 7 days), and 0.75% metronidazole vaginal gel (twice daily for 5 days) 4, 5.

Comparison of Treatment Efficacy

• A study comparing oral metronidazole, metronidazole vaginal gel, and clindamycin vaginal cream found no statistically significant differences in cure rates among the three treatments 5.
• Clindamycin has been shown to be a safe and effective alternative to metronidazole for treating women with bacterial vaginosis, with a similar failure rate and mild adverse reactions 6.
• Tinidazole has been found to be equivalent to oral metronidazole, intravaginal clindamycin cream, and intravaginal metronidazole tablets in efficacy, with a more favorable side effect profile and better gastrointestinal tolerability 7.

Special Considerations

• Data do not support routine treatment of male sex partners of infected females 3, 4.
• Treatment of bacterial vaginosis during pregnancy should focus on eliminating symptoms, and data on adverse pregnancy outcomes for women with bacterial vaginosis remain insufficient to recommend treatment of asymptomatic patients 4.
• Before performing surgical abortion, treatment of bacterial vaginosis (symptomatic or asymptomatic) should be considered to prevent pelvic inflammatory disease 4.