From the Guidelines
Recurrent bacterial vaginosis (BV) infections can be effectively managed with a combination of treatments, prioritizing metronidazole or clindamycin as the first line of treatment. For immediate relief, metronidazole is typically prescribed, 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 supported by the CDC guidelines 1. Alternatively, clindamycin 2% cream applied vaginally at bedtime for 7 days can be effective, with cure rates comparable to metronidazole 1.
Treatment Options
- 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 maintenance regimen may not be necessary, as no long-term maintenance regimen with any therapeutic agent is recommended 1. Instead, women should be advised to return for additional therapy if symptoms recur. To prevent recurrence, it is essential to avoid douching, use condoms during sex, wear cotton underwear, and maintain proper hygiene without using scented products in the genital area. Probiotics containing Lactobacillus species, either orally or vaginally, may help restore healthy vaginal flora.
Prevention of Recurrence
- Avoid douching
- Use condoms during sex
- Wear cotton underwear
- Maintain proper hygiene without using scented products in the genital area
- Consider probiotics containing Lactobacillus species
Recurrent BV occurs because the normal acidic vaginal environment becomes disrupted, allowing overgrowth of anaerobic bacteria. The condition is not considered a sexually transmitted infection but can be triggered by sexual activity. If symptoms persist despite treatment, consult a healthcare provider as recurrent infections may require longer treatment courses or different approaches 1.
From the FDA Drug Label
The percentage of patients with clinical response was also consistently higher in both trials in the SOLOSEC arm compared to placebo among all subsets of patients: number of prior episodes of bacterial vaginosis (≤ 3 episodes and ≥ 4 episodes) in past 12 months, baseline Nugent score (score 4-6 and score 7-10), and race (Black/African American and White)
The treatment options for recurrent bacterial vaginosis (BV) infection include secnidazole (SOLOSEC), which has been shown to be effective in treating BV in clinical trials, including patients with recurrent episodes.
- Key findings:
- Statistically significant results for clinical response, Nugent score cure, and therapeutic response at 21-30 days following a single dose of SOLOSEC compared to placebo.
- Efficacy was consistent across different subsets of patients, including those with prior episodes of BV. 2
From the Research
Treatment Options for Recurrent Bacterial Vaginosis (BV)
The treatment options for recurrent bacterial vaginosis (BV) include:
- Antimicrobial therapy, such as metronidazole and clindamycin, which provide a short-term cure but often fail to provide a consistent long-term cure 3
- Extended courses of metronidazole treatment, such as 500 mg twice daily for 10-14 days, followed by metronidazole vaginal gel 0.75% for 10 days, and then twice weekly for 3-6 months 4
- Combination pharmacotherapy, including oral nitroimidazole and simultaneous vaginal boric acid, followed by maintenance metronidazole gel to prevent recurrence 5
- Lactic acid gel, which has been compared to metronidazole in a randomized controlled trial, showing a higher initial response with metronidazole but similar recurrence rates with both treatments 6
- Other potential approaches, including probiotics, vaginal microbiome transplantation, pH modulation, and biofilm disruption, which are being explored but require further research 3, 4
Considerations for Clinicians
When managing recurrent BV, clinicians should consider:
- The high recurrence rate within 12 months of treatment, which can be as high as 50-80% 3, 4
- The potential for antimicrobial resistance and the need for alternative treatment options 4
- The importance of patient adherence to treatment and the potential for loss to follow-up 5, 6
- The need for further research into the epidemiology, pathogenesis, diagnosis, and treatment of recurrent BV 7
Ongoing Research and Future Directions
Ongoing research is focused on:
- Developing new treatment options, such as secnidazole, which has the advantage of one-time dosing 4
- Exploring non-antibiotic treatments, such as lactic acid gel, to control symptoms and improve quality of life for patients with recurrent BV 6
- Investigating the role of biofilm disruption, probiotics, and prebiotics in the treatment and prevention of recurrent BV 3, 4