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 treating bacterial vaginosis and are not recommended as first-line treatments 1. Recurrence of bacterial vaginosis is common, affecting up to 50% of women within 12 months, and may require repeated or extended treatment courses 1. Pregnant women with symptomatic bacterial vaginosis should be treated to prevent complications such as preterm birth, with oral metronidazole or clindamycin being safe options 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. Table 2 Efficacy of Tinidazole in the Treatment of Bacterial Vaginosis in a Randomized, Double-Blind, Double-Dummy, Placebo-Controlled Trial: Outcome Tinidazole 1 g × 5 days (n=76) Tinidazole 2 g × 2 days (n=73) Placebo (n=78) % Cure % Cure % Cure Therapeutic Cure Difference 97.5% CI 36.8 31.7 (16.8,46.6) 27.4 22.3 (8.0,36.6) 5.1 Clinical Cure Difference 97.5% CI 51.3 39.8 (23.3,56.3) 35.6 24.1 (7.8,40.3) 11.5 Nugent Score Cure Difference 97.5% CI 38.2 33.1 (18.1,48.0) 27.4 22.3 (8.0,36.6) 5. 1

Tinidazole Treatment for Bacterial Vaginosis

• The therapeutic cure rates for tinidazole were 97.5% for the 2 g × 2 days regimen and 92.1% for the 1 g × 5 days regimen.
• Key Findings:
  • Tinidazole demonstrated superior efficacy over placebo for the treatment of bacterial vaginosis.
  • The 2 g × 2 days and 1 g × 5 days regimens of tinidazole were effective in achieving therapeutic cure, clinical cure, and microbiologic cure.
  • The cure rates for tinidazole were higher than those for placebo. 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 studies 3, 4.
• Other effective treatment regimens include:
  • Single-dose metronidazole (2 g orally) 3.
  • 2% clindamycin vaginal cream (once daily for 7 days) 3, 5.
  • 0.75% metronidazole vaginal gel (twice daily for 5 days) 3, 4.
  • Oral clindamycin (300 mg twice daily for 7 days) 3, 5.
• Tinidazole is also an effective treatment option, with a more favorable side effect profile than oral metronidazole 6.
• For pregnant women, the treatment objective is to eliminate symptoms and prevent adverse outcomes of pregnancy 4.
• The use of probiotics, prebiotics, and acidifying agents may be considered as alternative strategies to reestablish the physiologic vaginal environment and improve treatment efficacy 7.

Special Considerations

• Treatment of bacterial vaginosis during pregnancy should focus on the elimination of symptoms, and data on adverse pregnancy outcomes remain insufficient to recommend treatment of asymptomatic patients 3, 4.
• Routine treatment of male sex partners is not recommended 3, 4.
• Recurrent bacterial vaginosis may be linked to persistence of Gardnerella vaginalis after treatment, and alternative treatment options such as tinidazole may be considered 6.