From the Guidelines
The recommended treatment for recurrent bacterial vaginosis (BV) involves an initial intensive antibiotic course, but the most recent and highest quality study 1 suggests that metronidazole 500 mg orally twice a day for 7 days or metronidazole gel 0.75% one full applicator (5 g) intravaginally, once a day for 5 days, are the preferred initial treatment regimens. For recurrent BV, maintenance therapy may be considered to prevent recurrence, although the evidence is not strong for long-term maintenance regimens 1. Some options for maintenance therapy include metronidazole gel 0.75% twice weekly for 4-6 months or boric acid 600 mg vaginal suppositories daily for 21 days followed by twice weekly for several months. It is essential to note that treatment of the male sex partner has not been beneficial in preventing the recurrence of BV 1. Patients should be advised to avoid consuming alcohol during treatment with metronidazole and for 24 hours thereafter, and to avoid douching and use condoms during intercourse. Recurrent BV occurs because treatment may not fully eliminate the biofilm formed by BV-associated bacteria, allowing them to persist and regrow after treatment ends. Key points to consider in the treatment of recurrent BV include:
- Initial intensive antibiotic course with metronidazole or clindamycin
- Maintenance therapy to prevent recurrence, although evidence is limited
- Avoidance of douching and use of condoms during intercourse
- Consideration of vaginal probiotics containing Lactobacillus species to help restore normal vaginal flora.
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 recommended treatment for recurrent Bacterial Vaginosis (BV) is not explicitly stated in the provided drug label. However, for the treatment of BV, tinidazole can be given as either 2 g once daily for 2 days or 1 g once daily for 5 days 2.
- Key points:
- The drug label does not provide information on the treatment of recurrent BV.
- The provided treatment options are for the treatment of BV, not specifically recurrent BV.
From the Research
Treatment Options for Recurrent Bacterial Vaginosis (BV)
The recommended treatment for recurrent BV includes:
- An extended course of metronidazole treatment (500 mg twice daily for 10-14 days) 3
- Metronidazole vaginal gel 0.75% for 10 days, followed by two times per week for 3-6 months, as an alternate treatment regimen 3
- A combination pharmacotherapy long-term suppressive regimen, including oral nitroimidazole and simultaneous boric acid, followed by maintenance metronidazole gel 4
- Tinidazole as an alternative to metronidazole, with a more favorable side effect profile and equivalent efficacy 5
Considerations for Treatment
When treating recurrent BV, considerations include:
- The potential for resistance to antimicrobial therapy 3
- The formation of a biofilm that protects BV-causing bacteria from antimicrobial therapy 3
- The risk of posttreatment vaginal candidiasis, a potential complication of treating bacterial vaginosis 6
- The importance of adequate treatment to help avoid adverse patient outcomes, including the increased risk of acquiring sexually transmitted infections 7
Efficacy of Treatment Options
Studies have shown that:
- Oral metronidazole, metronidazole vaginal gel, and clindamycin vaginal cream achieve nearly equivalent cure rates for the treatment of bacterial vaginosis 6
- Tinidazole is equivalent to oral metronidazole, intravaginal clindamycin cream, and intravaginal metronidazole tablets in efficacy in treating BV 5
- A combination pharmacotherapy long-term suppressive regimen can achieve a satisfactory response in a high percentage of patients and prevent symptomatic BV recurrence in a significant proportion of compliant patients 4