What is the recommended treatment for bacterial vaginosis?

From the Guidelines

The recommended treatment for bacterial vaginosis is typically a course of antibiotics, with first-line treatment being metronidazole 500 mg orally twice daily for 7 days or metronidazole 0.75% vaginal gel applied once daily for 5 days, as supported by the Centers for Disease Control and Prevention guidelines 1. The goal of treatment is to relieve vaginal symptoms and signs of infection, reduce the risk for infectious complications, and restore the natural balance of vaginal bacteria dominated by Lactobacillus species.

• Metronidazole and clindamycin are the primary antibiotics used to treat bacterial vaginosis, with metronidazole being the preferred choice due to its higher efficacy 1.
• The recommended metronidazole regimens are equally efficacious, while the vaginal clindamycin cream appears less efficacious than the metronidazole regimens 1.
• Patients should be advised to avoid consuming alcohol during treatment with metronidazole and for 24 hours thereafter, and to use condoms or limit sexual intercourse to prevent potential disulfiram-like reactions and reduce the risk of transmission 1.
• For women who experience recurrent infections, extended antibiotic regimens may be necessary, such as metronidazole 500 mg twice daily for 10-14 days, followed by maintenance therapy 1.
• Treatment is important even for mild cases, as bacterial vaginosis can increase susceptibility to other infections and may lead to complications in pregnant women, including premature rupture of the membranes, preterm labor, and post-partum endometritis 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.

The recommended treatment for bacterial vaginosis is tinidazole given as either:

• 2 g once daily for 2 days
• 1 g once daily for 5 days 2 Key points:
• The treatment should be based on the presence of all four Amsel's criteria and a baseline Nugent score ≥4.
• Other pathogens commonly associated with vulvovaginitis should be ruled out before starting treatment.

From the Research

Treatment Options for Bacterial Vaginosis

The recommended treatment for bacterial vaginosis varies depending on the patient's pregnancy status and other factors.

• For nonpregnant women, treatment options include:
  • Metronidazole (500 mg orally twice daily for 7 days) 3
  • Clindamycin vaginal cream (2%, once daily for 7 days) 3, 4, 5
  • Metronidazole vaginal gel (0.75%, twice daily for 5 days) 3, 6
• For pregnant women, the treatment options are:
  • Metronidazole (250 mg orally three times a day for 7 days) for both high-risk and low-risk women 3

Recurrent Bacterial Vaginosis

For women with recurrent bacterial vaginosis, the recommended treatment includes:

• An extended course of metronidazole treatment (500 mg twice daily for 10-14 days) 7
• Metronidazole vaginal gel 0.75% for 10 days, followed by two times per week for 3-6 months, as an alternate treatment regimen 7

Comparison of Treatment Options

Studies have compared the efficacy of different treatment options for bacterial vaginosis, including:

• Oral metronidazole, metronidazole vaginal gel, and clindamycin vaginal cream, which achieved nearly equivalent cure rates 6
• Clindamycin cream and oral metronidazole, which had similar cure rates and adverse reaction profiles 4, 5