What is the recommended treatment for a patient with intermediate bacterial vaginosis (BV) and spotting?

From the Guidelines

The recommended treatment for intermediate bacterial vaginosis (BV) with spotting is oral metronidazole 500 mg twice daily for 7 days. This treatment is based on the guidelines from the Centers for Disease Control and Prevention, as outlined in the 2002 sexually transmitted diseases treatment guidelines 1. Alternative regimens include oral clindamycin 300 mg twice daily for 7 days or metronidazole vaginal gel 0.75% applied once daily for 5 days.

Key Considerations

• Treatment is necessary even with intermediate BV to prevent complications such as increased risk of sexually transmitted infections and potential obstetric complications if pregnant.
• The spotting should be evaluated separately as it may be unrelated to the BV or could indicate other conditions requiring attention.
• Patients should abstain from alcohol during metronidazole treatment and for 24 hours afterward to avoid disulfiram-like reactions, as noted in the guidelines 1.

Additional Information

• Sexual partners typically don't require treatment as BV is not considered a sexually transmitted infection, though BV can recur, as discussed in the 1993 sexually transmitted diseases treatment guidelines 1.
• For recurrent cases, suppressive therapy with metronidazole gel twice weekly for 4-6 months may be considered.
• Treatment works by eliminating anaerobic bacteria that overgrow in BV while allowing normal vaginal flora to reestablish, as explained in the 2002 guidelines 1.

Follow-Up

• Follow-up visits are unnecessary if symptoms resolve, but because recurrence of BV is not unusual, women should be aware of the signs and symptoms of BV and seek medical attention if they recur, as advised in the treatment guidelines 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. A clinical diagnosis of bacterial vaginosis was based on Amsel's criteria and defined by the presence of an abnormal homogeneous vaginal discharge that (a) has a pH of greater than 4. 5, (b) emits a "fishy" amine odor when mixed with a 10% KOH solution, and (c) contains ≥20% clue cells on microscopic examination. Therapeutic cure was a composite endpoint, consisting of both a clinical cure and microbiologic cure 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 recommended treatment for a patient with intermediate bacterial vaginosis (BV) and spotting is tinidazole oral tablets given as either 2 g once daily for 2 days or 1 g once daily for 5 days 2.

• Key points:
  • The treatment is based on a clinical diagnosis of bacterial vaginosis using Amsel's criteria.
  • The treatment has demonstrated superior efficacy over placebo tablets in a randomized, double-blind, placebo-controlled clinical trial.
  • 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.

From the Research

Treatment Options for Intermediate Bacterial Vaginosis and Spotting

• The recommended treatment for bacterial vaginosis (BV) includes oral metronidazole (500 mg twice daily for 7 days) as the preferred treatment 3.
• Alternative 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), and oral clindamycin (300 mg twice daily for 7 days) 3.
• Clindamycin cream has been shown to be a safe, well-tolerated, and effective alternative to oral metronidazole for the treatment of BV, with no significant difference in cure rates 4.
• A 3-day regimen of clindamycin, given as intravaginal ovules, has been found to be as effective as and better tolerated than a 7-day regimen of oral metronidazole 500 mg, given twice daily, for the treatment of BV 5.
• Tinidazole has also been used to treat BV, with studies suggesting it is equivalent to oral metronidazole, intravaginal clindamycin cream, and intravaginal metronidazole tablets in efficacy, but with a more favorable side effect profile 6.
• Clindamycin has been shown to be a safe and effective alternative to metronidazole for treating women with BV, with no significant difference in failure rates and minimal adverse reactions 7.

Considerations for Treatment

• The treatment of BV during pregnancy should focus on the elimination of symptoms, as data on adverse pregnancy outcomes for women with BV remain insufficient to recommend treatment of asymptomatic patients 3.
• Before performing surgical abortion, treatment of BV (symptomatic or asymptomatic) should be considered to prevent pelvic inflammatory disease 3.
• Recurrent BV has been linked with persistence of Gardnerella vaginalis after treatment, and the clinical implications of the possible greater activity of tinidazole against G. vaginalis are not yet clear 6.