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 or metronidazole gel 0.75% applied intravaginally once daily for 5 days as the first-line treatment. The choice of treatment regimen depends on patient preference, side effect profile, and potential interactions with other medications.

Treatment Options

• Metronidazole 500 mg orally twice a day for 7 days 1
• Metronidazole gel 0.75% applied intravaginally once daily for 5 days 1
• Clindamycin cream 2% applied intravaginally at bedtime for 7 days 1
• Clindamycin 300 mg orally twice a day for 7 days 1 It is essential to note that patients should avoid consuming alcohol during treatment with metronidazole and for 24 hours thereafter due to potential disulfiram-like reactions.

Special Considerations

• Pregnant women with bacterial vaginosis may benefit from treatment to reduce the risk of preterm labor and other complications 1
• Women who have previously delivered a premature infant may be at higher risk for preterm delivery and may benefit from treatment 1 Recurrence of bacterial vaginosis is common, affecting up to 50% of women within 12 months, and may require repeated or extended treatment courses.

Follow-Up

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.

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. Table 2 Efficacy of Tinidazole in the Treatment of Bacterial Vaginosis in a Randomized, Double-Blind, Double-Dummy, Placebo-Controlled Trial:

• Therapeutic Cure: 97.5% CI ‡ 36.8 31.7 (16.8,46.6) for 2g × 2 days, 27.4 22.3 (8.0,36.6) for 1g × 5 days
• Clinical Cure: 51.3 39.8 (23.3,56.3) for 2g × 2 days, 35.6 24.1 (7.8,40.3) for 1g × 5 days
• Nugent Score Cure: 38.2 33.1 (18.1,48.0) for 2g × 2 days, 27.4 22.3 (8.0,36.6) for 1g × 5 days

Tinidazole Treatment for Bacterial Vaginosis

• The recommended treatment for bacterial vaginosis is tinidazole oral tablets given as either 2 g once daily for 2 days or 1 g once daily for 5 days.
• Therapeutic cure rates were 97.5% for the 2g × 2 days regimen and 92.1% for the 1g × 5 days regimen 2.
• Clinical cure rates were 93.2% for the 2g × 2 days regimen and 87.7% for the 1g × 5 days regimen 2.
• Microbiologic cure rates (Nugent score) were 92.5% for the 2g × 2 days regimen and 85.4% for the 1g × 5 days regimen 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 a review of treatment options published in 1995 3.
• 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)
  • Oral clindamycin (300 mg twice daily for 7 days) 3
• Clindamycin may be a safe and effective alternative to metronidazole for treating women with bacterial vaginosis, with no significant difference in failure rates between the two treatments 4.
• Tinidazole has been used to treat bacterial vaginosis and has been shown to be equivalent to oral metronidazole, intravaginal clindamycin cream, and intravaginal metronidazole tablets in efficacy, with a more favorable side effect profile 5.

Comparison of Treatment Options

• A study comparing oral metronidazole, metronidazole vaginal gel, and clindamycin vaginal cream found no statistically significant differences in cure rates between the three treatments 6.
• The study also found that patients treated with intravaginal products reported being more satisfied with the treatment, but experienced similar rates of posttreatment vulvovaginal candidiasis as those treated with oral metronidazole 6.

Current Approaches to Treatment and Prevention

• The current and only FDA-approved treatment regimens for bacterial vaginosis are antibiotics, such as metronidazole and clindamycin 7.
• However, antibiotics provide a short-term cure for bacterial vaginosis, but 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 7.
• Current areas of investigation for bacterial vaginosis management include probiotics, vaginal microbiome transplantation, pH modulation, and biofilm disruption, as well as behavioral modifications such as smoking cessation, condom use, and hormonal contraception 7.