How to manage bacterial vaginosis?

From the Guidelines

Bacterial vaginosis (BV) is best managed with antibiotic treatment, typically metronidazole or clindamycin, with the first-line treatment being oral metronidazole 500mg twice daily for 7 days, or metronidazole gel 0.75% applied intravaginally once daily for 5 days, as recommended by the Centers for Disease Control and Prevention 1. The goal of treatment is to relieve vaginal symptoms and signs of infection, reduce the risk for infectious complications associated with BV, and restore the normal vaginal flora.

• The recommended regimens for BV treatment 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
• Patients should be advised to avoid consuming alcohol during treatment with metronidazole and for 24 hours thereafter, and to complete the full course of antibiotics even if symptoms resolve quickly.
• Lifestyle measures that may help prevent recurrence include avoiding douching, using unscented hygiene products, wearing cotton underwear, and limiting the number of sexual partners.
• For recurrent BV (three or more episodes in a year), extended regimens may be used, such as metronidazole gel twice weekly for 4-6 months after initial treatment, as suggested by the guidelines 1.
• BV during pregnancy is associated with adverse pregnancy outcomes, and treatment may reduce the risk for prematurity, as indicated by several investigations 1.
• The established benefit of therapy for BV in pregnant women is to relieve vaginal symptoms and signs of infection, and additional potential benefits include reducing the risk for infectious complications associated with BV during pregnancy and reducing the risk for other infections 1.

From the Research

Managing Bacterial Vaginosis

To manage bacterial vaginosis (BV), several treatment options are available, including:

• Oral and intravaginal metronidazole and clindamycin, as well as oral tinidazole 2
• Clindamycin cream as an alternative to oral metronidazole, with similar cure rates and fewer adverse reactions 3
• A 3-day regimen of clindamycin intravaginal ovules, which has been shown to be as effective as and better tolerated than a 7-day regimen of oral metronidazole 4

Treatment Options

The following treatment options have been studied:

• Oral metronidazole 500 mg twice daily for 7 days 3, 4, 5
• Metronidazole vaginal gel 0.75% for 5-10 days 2, 5
• Clindamycin vaginal cream 2% for 7 days 3, 4, 5
• Clindamycin intravaginal ovules 100 mg for 3 consecutive days 4
• Tinidazole, which may be an attractive new option due to one-time dosing 2

Recurrence Prevention

To prevent recurrence, the following strategies have been suggested:

• Extended course of metronidazole treatment (500 mg twice daily for 10-14 days) 2
• Metronidazole vaginal gel 0.75% for 10 days, followed by two times per week for 3-6 months 2
• Use of probiotics and prebiotics, which may have a significant role in improving efficacy and preventing recurrences 6
• Biofilm disruption and botanical treatments, which have shown some promise but require further study 2