From the Guidelines
For the treatment of predominance of coccobacilli consistent with a shift in vaginal flora (bacterial vaginosis), I recommend oral metronidazole 500 mg twice daily for 7 days as first-line therapy. This recommendation is based on the most recent and highest quality study available, which suggests that metronidazole is an effective treatment for bacterial vaginosis 1. Alternative regimens include metronidazole gel 0.75% intravaginally once daily for 5 days or clindamycin cream 2% intravaginally at bedtime for 7 days. For pregnant patients, oral clindamycin 300 mg twice daily for 7 days is preferred, as suggested by previous guidelines 1.
Importance of Treatment
Treatment is important even if asymptomatic, as bacterial vaginosis increases the risk of pelvic inflammatory disease, post-surgical infections, and pregnancy complications. The condition results from an overgrowth of anaerobic bacteria and a reduction in protective Lactobacillus species, leading to an elevated vaginal pH above 4.5 1.
Recurrence and Prevention
After treatment, recurrence is common (up to 50% within 12 months), so patients should avoid douching, limit sexual partners, and consider probiotics containing Lactobacillus species to help restore normal vaginal flora. It is also important to note that treatment of the male sex partner has not been beneficial in preventing the recurrence of BV 1.
Key Considerations
When treating bacterial vaginosis, it is essential to advise patients to avoid consuming alcohol during treatment with metronidazole and for 24 hours thereafter, as well as to use caution with latex condoms and diaphragms when using clindamycin cream or ovules 1. By following these guidelines and recommendations, patients can effectively manage their symptoms and reduce the risk of complications associated with bacterial vaginosis.
From the FDA Drug Label
Gram’s stain results consistent with a diagnosis of bacterial vaginosis include (a) markedly reduced or absent Lactobacillus morphology, (b) predominance of Gardnerella morphotype, and (c) absent or few white blood cells.
The treatment for bacterial vaginosis with a predominance of coccobacilli consistent with a shift in vaginal flora is metronidazole 2.
- The indications and usage of metronidazole vaginal gel include the treatment of bacterial vaginosis, which is characterized by a homogeneous vaginal discharge with a pH of greater than 4.5, a "fishy" amine odor when mixed with a 10% KOH solution, and the presence of clue cells on microscopic examination.
- Gram's stain results consistent with a diagnosis of bacterial vaginosis include a predominance of Gardnerella morphotype, which is consistent with a shift in vaginal flora.
- Metronidazole is an antimicrobial agent active in vitro against most strains of the organisms associated with bacterial vaginosis, including Gardnerella vaginalis 2.
From the Research
Treatment of Bacterial Vaginosis
The predominance of coccobacilli consistent with a shift in vaginal flora is a characteristic of bacterial vaginosis (BV) 3. The treatment of BV typically involves the use of antimicrobial agents, with metronidazole and clindamycin being the most commonly recommended options 4, 5, 6, 3, 7.
Treatment Options
- Metronidazole: This is an oral antibiotic that is effective in treating BV 5, 6, 3, 7.
- Clindamycin: This is a vaginal cream or oral antibiotic that is also effective in treating BV 5, 6, 3, 7.
- Metronidazole vaginal gel: This is another option for treating BV, with similar efficacy to oral metronidazole and clindamycin vaginal cream 6.
Efficacy of Treatment Options
Studies have shown that these treatment options have similar efficacy in curing BV, with cure rates ranging from 72% to 87% 5, 6, 7. However, recurrence of the disease can be a problem 4, 3.
Adverse Reactions
Adverse reactions to these treatment options are generally mild and infrequent, with the most common side effects being non-bloody diarrhea and vulvovaginal candidiasis 5, 6, 7.