What is the treatment for bacterial vaginosis (BV) with a predominance of coccobacilli?

From the Guidelines

The first-line treatment for bacterial vaginosis (BV) with a predominance of coccobacilli is oral metronidazole 500 mg twice daily for 7 days. Alternative regimens include metronidazole 0.75% vaginal gel applied once daily for 5 days, or clindamycin 2% vaginal cream applied at bedtime for 7 days 1. For patients who cannot tolerate metronidazole, oral clindamycin 300 mg twice daily for 7 days is recommended. Treatment is important even in asymptomatic cases during pregnancy to prevent complications. BV results from an imbalance in vaginal flora where normal lactobacilli are replaced by anaerobic bacteria, including coccobacilli such as Gardnerella vaginalis. The antibiotics work by targeting these anaerobic organisms while allowing restoration of normal lactobacilli. Patients should avoid alcohol during treatment with metronidazole and for 24 hours afterward due to potential disulfiram-like reactions 1. Sexual partners typically do not require treatment, but patients should be advised to abstain from intercourse or use condoms during the treatment period. Recurrence is common (30-50% within 3-12 months), and may require repeated or extended treatment courses 1.

Some key points to consider when treating BV include:

• The importance of treating symptomatic disease to relieve vaginal symptoms and signs of infection
• The use of oral or topical metronidazole or clindamycin cream as recommended treatment regimens
• The need for follow-up visits only if symptoms recur, as recurrence is not unusual
• The recommendation to avoid alcohol during treatment with metronidazole and for 24 hours afterward
• The advice to abstain from intercourse or use condoms during the treatment period to prevent transmission

It is also important to note that BV is associated with having multiple sex partners, douching, and lack of vaginal lactobacilli, and that treatment of the male sex partner has not been beneficial in preventing the recurrence of BV 1. Overall, the goal of therapy is to relieve vaginal symptoms and signs, and to reduce the risk of infectious complications.

From the FDA Drug Label

A microbiologic diagnosis of bacterial vaginosis was based on Gram stain of the vaginal smear demonstrating (a) markedly reduced or absent Lactobacillus morphology, (b) predominance of Gardnerella morphotype, and (c) absent or few white blood cells, with quantification of these bacterial morphotypes to determine the Nugent score, where a score ≥4 was required for study inclusion and a score of 0 to 3 considered a microbiologic cure.

The treatment for bacterial vaginosis (BV) with a predominance of coccobacilli, such as Gardnerella, is tinidazole oral tablets given as either 2 g once daily for 2 days or 1 g once daily for 5 days 2. This treatment has demonstrated superior efficacy over placebo in achieving therapeutic cure, clinical cure, and microbiologic cure in patients with all four Amsel's criteria and a baseline Nugent score ≥4.

• Therapeutic cure rates for tinidazole were 97.5% for the 2-day regimen and 97.5% for the 5-day regimen.
• Clinical cure rates for tinidazole were 51.3% for the 2-day regimen and 35.6% for the 5-day regimen.
• Microbiologic cure rates for tinidazole were 38.2% for the 2-day regimen and 27.4% for the 5-day regimen.

From the Research

Treatment for Bacterial Vaginosis (BV) with a Predominance of Coccobacilli

The treatment for bacterial vaginosis (BV) with a predominance of coccobacilli, consistent with a shift in vaginal flora, involves several options:

• Oral metronidazole (500 mg twice daily for 7 days) 3
• Intravaginal 2% clindamycin cream (one applicatorful at bedtime for 7 days) 4, 3
• Intravaginal metronidazole gel (one to two applicatorfuls per day for 5 days) 3
• Alternative regimens include a single 2-g oral dose of metronidazole or a 7-day course of oral clindamycin, 300 mg twice daily 3
• Oral tinidazole, which has been shown to be equivalent to oral metronidazole and intravaginal clindamycin cream in efficacy, with a more favorable side effect profile 5

Recurrence of BV

Recurrence of BV can be a problem, and recommended treatment for recurrent BV consists of an extended course of metronidazole treatment (500 mg twice daily for 10-14 days); 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 6

Mechanisms of Recurrent Etiology of BV

The underlying mechanisms of recurrent etiology of BV are not known, but persistence may occur due to the formation of a biofilm that protects BV-causing bacteria from antimicrobial therapy, and poor adherence to treatment among patients with genitourinary infections may lead to resistance 6