What is the treatment for Bacterial Vaginosis (BV)?

From the Guidelines

Bacterial vaginosis should be treated with metronidazole 500 mg orally twice a day for 7 days as the first-line treatment. This recommendation is based on the Centers for Disease Control and Prevention's guidelines 1. The treatment options for bacterial vaginosis include:

• Metronidazole 500 mg orally twice a day 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

It is essential to note that patients should avoid consuming alcohol during treatment with metronidazole and for 24 hours thereafter, as it may cause disulfiram-like reactions 1. Additionally, clindamycin cream and ovules are oil-based and may weaken latex condoms and diaphragms, so patients should be advised to use alternative forms of contraception during treatment 1.

Alternative regimens, such as metronidazole 2 g orally in a single dose or clindamycin 300 mg orally twice a day for 7 days, have lower efficacy for BV and are not recommended as first-line treatments 1. Recurrence of BV is common, affecting about 30% of women within 3 months after treatment, and may require repeated or extended antibiotic courses. Follow-up visits are unnecessary if symptoms resolve, but women should be aware of the potential for recurrence and seek medical attention if symptoms persist or recur 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. 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 Treatment for Bacterial Vaginosis

• The recommended treatment for bacterial vaginosis is tinidazole 2 g once daily for 2 days or 1 g once daily for 5 days.
• Therapeutic Cure Rates:
  • 2 g once daily for 2 days: 97.5%
  • 1 g once daily for 5 days: 97.5%
• Clinical Cure Rates:
  • 2 g once daily for 2 days: 51.3%
  • 1 g once daily for 5 days: 36.8%
• Nugent Score Cure Rates:
  • 2 g once daily for 2 days: 38.2%
  • 1 g once daily for 5 days: 33.1% 2

From the Research

Treatment Options for Bacterial Vaginosis

• Oral metronidazole (500 mg twice daily for 7 days) is the preferred treatment for bacterial vaginosis, as suggested by 3 and 4.
• Other effective treatment regimens include:
  • Single-dose metronidazole (2 g orally) 3
  • 2% clindamycin vaginal cream (once daily for 7 days) 3, 4, 5
  • 0.75% metronidazole vaginal gel (twice daily for 5 days) 3, 4, 5
  • Oral clindamycin (300 mg twice daily for 7 days) 3
  • Oral tinidazole, which has been shown to be equivalent to oral metronidazole and intravaginal clindamycin cream in efficacy, but with a more favorable side effect profile 6

Treatment During Pregnancy

• Treatment of bacterial vaginosis during pregnancy should focus on the elimination of symptoms, as data on adverse pregnancy outcomes for women with bacterial vaginosis remain insufficient to recommend treatment of asymptomatic patients 3.
• For pregnant high-risk women, the objective of treatment is to prevent adverse outcomes of pregnancy, in addition to relief of symptoms, and metronidazole (250 mg orally three times a day for 7 days) is recommended 4.
• 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 4.

Recurrence and Alternative Strategies

• Bacterial vaginosis is associated with high rates of recurrence, and appropriate management of such recurrences can prove difficult 6.
• Alternative strategies to replace or combine with standard therapies are being studied, including antimicrobial substances, probiotics, prebiotics, and acidifying agents, as well as new dosage forms and drug delivery systems 7.