From the Guidelines
For recurrent bacterial vaginosis (BV), the recommended treatment is metronidazole 500 mg orally twice a day for 7 days, as it is the most efficacious regimen. This recommendation is based on the guidelines from the Centers for Disease Control and Prevention 1. The treatment options for recurrent BV 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 be advised to avoid consuming alcohol during treatment with metronidazole and for 24 hours thereafter, as stated in the guidelines 1. Additionally, clindamycin cream and ovules are oil-based and might weaken latex condoms and diaphragms, so patients should be informed about this potential interaction 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 BV treatment and are not recommended as the first line of treatment 1.
Follow-up visits are unnecessary if symptoms resolve, but because recurrence of BV is not unusual, women should be aware of the potential for recurrence and the need for maintenance therapy or repeated treatment 1.
From the FDA Drug Label
2.6 Bacterial Vaginosis The recommended dose is a 2 g oral dose once daily for 2 days taken with food or a 1 g oral dose once daily for 5 days taken with food. The recommended dosing for bacterial vaginosis (BV) treatment is:
- A 2 g oral dose once daily for 2 days taken with food
- Or a 1 g oral dose once daily for 5 days taken with food 2 There is no specific information for recurrent BV dosing.
From the Research
Recurrent Bacterial Vaginosis (BV) Treatment
The recommended dosing for recurrent bacterial vaginosis (BV) treatment includes:
- An extended course of metronidazole treatment (500 mg twice daily for 10-14 days) 3
- If ineffective, metronidazole vaginal gel 0.75% for 10 days, followed by two times per week for 3-6 months, is an alternate treatment regimen 3
- Oral tinidazole has been used to treat bacterial vaginosis for over 25 years, with longer courses of treatment (e.g., 1 g daily for 5 days) appearing to be more effective than a 2 g oral single dose 4
- Secnidazole may be an attractive new option due to one-time dosing, with a single-dose secnidazole regimen shown to be at least as effective as the multiple-dose metronidazole regimen 5
Comparison of Treatment Options
Different treatment options for bacterial vaginosis have been compared, including:
- Oral metronidazole, metronidazole vaginal gel, and clindamycin vaginal cream, which achieved nearly equivalent cure rates for the treatment of bacterial vaginosis 6
- Once-daily and twice-daily dosing of 0.75% metronidazole gel, which yielded efficacy, safety, and tolerance equivalent to the currently used twice-daily dosing in the treatment of bacterial vaginosis 7
Treatment Considerations
Treatment considerations for recurrent BV include:
- Persistence of residual infection, resistance, and possibly reinfection from either male or female partners 3
- The formation of a biofilm that protects BV-causing bacteria from antimicrobial therapy 3
- Poor adherence to treatment among patients with genitourinary infections, which may lead to resistance 3