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.

The alternative regimens, such as metronidazole 2 g orally in a single dose, clindamycin 300 mg orally twice a day for 7 days, or clindamycin ovules 100 g intravaginally once at bedtime for 3 days, have lower efficacy for BV and should only be considered when the first-line treatment is not tolerated or contraindicated 1.

Follow-up visits are unnecessary if symptoms resolve, but women should be aware that recurrence of BV is not unusual, and treatment may need to be repeated 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 treatment options for bacterial vaginosis using tinidazole are:

• 2 g once daily for 2 days
• 1 g once daily for 5 days Both regimens have been shown to be effective in achieving therapeutic cure, clinical cure, and microbiologic cure in patients with bacterial vaginosis, with cure rates of 97.5% and 92.3% for the 2-day and 5-day regimens, respectively 2.

From the Research

Treatment Options for Bacterial Vaginosis

• Oral metronidazole (500 mg twice daily for 7 days) is a preferred treatment for bacterial vaginosis, as suggested by 3 and 4.
• Other effective treatment regimens include:
  • Single-dose metronidazole (2 g orally) 3, 5
  • 2% clindamycin vaginal cream (once daily for 7 days) 3, 4, 6
  • 0.75% metronidazole vaginal gel (twice daily for 5 days) 3, 4, 6
  • Oral clindamycin (300 mg twice daily for 7 days) 3, 5
• Tinidazole is also an effective treatment for bacterial vaginosis, with a more favorable side effect profile than oral metronidazole, as noted in 7.

Special Considerations

• Treatment of bacterial vaginosis during pregnancy should focus on eliminating symptoms, with metronidazole (250 mg orally three times a day for 7 days) being a recommended option for pregnant women, as stated in 4.
• Routine treatment of male sex partners is not recommended, according to 3 and 4.
• Treatment of bacterial vaginosis before surgical abortion should be considered to prevent pelvic inflammatory disease, as suggested in 3.

Comparison of Treatment Options

• A study comparing oral metronidazole, metronidazole vaginal gel, and clindamycin vaginal cream found no statistically significant differences in cure rates, as reported in 6.
• Patients treated with intravaginal products reported being more satisfied with the treatment, as noted in 6.