From the Guidelines
Recurrent bacterial vaginosis (BV) infections can be effectively managed with a combination of treatments, prioritizing metronidazole as the first-line treatment, either as a 500mg oral dose twice daily for 7 days or as a 0.75% vaginal gel applied once daily for 5 days, as recommended by the most recent guidelines 1. The treatment options for recurrent BV infection include:
- Metronidazole 500mg oral dose twice daily for 7 days
- Metronidazole 0.75% vaginal gel applied once daily for 5 days
- Clindamycin 2% cream applied vaginally at bedtime for 7 days For recurrent cases, a suppressive regimen may be necessary, such as twice-weekly metronidazole gel for 4-6 months after the initial treatment, although no long-term maintenance regimen with any therapeutic agent is recommended 1. Lifestyle modifications are also important, including:
- Avoiding douching
- Using condoms during sex
- Wearing cotton underwear
- Avoiding tight-fitting clothes Maintaining vaginal pH balance with probiotics containing Lactobacillus (either oral supplements or vaginal suppositories) can help restore healthy vaginal flora, as the condition involves an imbalance where healthy Lactobacillus bacteria are replaced by an overgrowth of anaerobic bacteria, disrupting the vaginal environment and raising the pH above the normal 3.8-4.5 range 1. It is essential to note that follow-up visits are unnecessary if symptoms resolve, but recurrence is not unusual, and patients should return for additional treatment if symptoms recur, as recommended by the guidelines 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 treatment options for bacterial vaginosis (BV) include:
- Tinidazole 2 g once daily for 2 days
- Tinidazole 1 g once daily for 5 days These regimens have been shown to be effective in achieving therapeutic cure, clinical cure, and microbiologic cure in patients with BV 2.
From the Research
Treatment Options for Recurrent Bacterial Vaginosis (BV)
- Antimicrobial therapy is the mainstay of treatment for recurrent BV, with options including oral and intravaginal metronidazole and clindamycin, as well as oral tinidazole 3
- An extended course of metronidazole treatment (500 mg twice daily for 10-14 days) is recommended for recurrent BV, with 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 vaginal boric acid, has been shown to be effective in preventing recurrence of BV 4
- Lactic acid gel has been compared to metronidazole for the treatment of recurrent BV, with metronidazole showing a higher initial response rate, but similar recurrence rates at 6 months 5
- Hydrogen peroxide (3%) has been used as a single vaginal washout to treat recurrent BV, with symptoms clearing completely in 78% of women and improving in 13% 6
Considerations for Treatment
- The formation of a biofilm that protects BV-causing bacteria from antimicrobial therapy may contribute to the persistence of infection and recurrence of BV 3, 7
- Poor adherence to treatment among patients with genitourinary infections may lead to resistance to antimicrobial therapy 3
- The use of probiotics and prebiotics, as well as botanical treatments, has shown some promise in the treatment of recurrent BV, but requires further study 3, 7
- Vaginal candidiasis may frequently complicate prolonged antibiotic prophylaxis, requiring frequent antifungal rescue or prophylaxis 4