What is the management of Bacterial Vaginosis (BV)?

From the Guidelines

Bacterial vaginosis should be treated with oral metronidazole 500 mg twice daily for 7 days as first-line therapy. Alternative regimens include metronidazole gel 0.75% intravaginally once daily for 5 days, or clindamycin cream 2% intravaginally at bedtime for 7 days 1. For pregnant patients, oral therapy is preferred, using the same metronidazole regimen. Treatment is recommended for all symptomatic women to relieve symptoms like vaginal discharge and odor, and to prevent complications such as increased risk of STIs and obstetric complications in pregnant women.

Key Considerations

• Partners typically don't require treatment as BV isn't considered a sexually transmitted infection.
• Recurrence is common (30-50% within 3-12 months), and may require repeated treatment courses or suppressive therapy with metronidazole gel twice weekly for 4-6 months.
• Patients should avoid douching, use condoms consistently, and maintain good hygiene practices.
• BV results from an imbalance in vaginal flora with overgrowth of anaerobic bacteria and reduction in protective lactobacilli, leading to an elevated vaginal pH above 4.5 and the characteristic fishy odor due to volatile amines.

Treatment Benefits

• Relieve vaginal symptoms and signs of infection
• Reduce the risk for infectious complications associated with BV during pregnancy
• Reduce the risk for other infections (e.g., other STDs or HIV) 1

Special Considerations for Pregnant Women

• High-risk pregnant women who have asymptomatic BV may be evaluated for treatment to reduce the risk for prematurity 1
• The established benefit of therapy for BV in pregnant women is to relieve vaginal symptoms and signs of infection, and additional potential benefits include reducing the risk for infectious complications associated with BV during pregnancy and reducing the risk for other infections 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. Therapeutic cure was a composite endpoint, consisting of both a clinical cure and microbiologic cure 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 management of Bacterial Vaginosis (BV) is with tinidazole given as either:

• 2 g once daily for 2 days
• 1 g once daily for 5 days 2

From the Research

Treatment Options for Bacterial Vaginosis (BV)

• For nonpregnant women, the preferred treatment for BV includes:
  • Metronidazole (500 mg orally twice daily for 7 days) 3
  • Clindamycin vaginal cream (2%, once daily for 7 days) 3, 4
  • Metronidazole vaginal gel (0.75%, twice daily for 5 days) 3, 4
• For pregnant women, the treatment of BV depends on the risk of preterm birth:
  • For high-risk pregnant women (with a prior preterm birth), metronidazole (250 mg orally three times a day for 7 days) is recommended 3
  • For low-risk pregnant women (without a prior preterm birth) with symptomatic disease, metronidazole (250 mg orally three times a day for 7 days) is recommended 3
• For recurrent BV, an extended course of metronidazole treatment (500 mg twice daily for 10-14 days) is recommended; 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 5
• Other effective treatment regimens for BV include:
  • Single-dose metronidazole (2 g orally) 4
  • Oral clindamycin (300 mg twice daily for 7 days) 4
  • Tinidazole, which has been shown to be equivalent to oral metronidazole, intravaginal clindamycin cream, and intravaginal metronidazole tablets in efficacy, with a more favorable side effect profile 6

Special Considerations

• Data do not support the practice of routine treatment of male sex partners of infected females 3, 4
• Treatment of BV during pregnancy should focus on the elimination of symptoms, and data on adverse pregnancy outcomes for women with BV remain insufficient to recommend treatment of asymptomatic patients 3, 4
• For women with documented multiple recurrences of BV, longer courses of therapy are recommended 7