What are the treatment options for recurrent Bacterial Vaginosis (BV)?

From the Guidelines

Recurrent bacterial vaginosis (BV) can be effectively managed with metronidazole 500mg orally twice daily for 7 days as the first-line treatment, with alternatives including metronidazole gel 0.75% intravaginally once daily for 5 days or clindamycin cream 2% intravaginally at bedtime for 7 days. For women with frequent recurrences (3 or more episodes per year), suppressive therapy with metronidazole gel 0.75% twice weekly for 4-6 months can reduce recurrence rates, as suggested by 1.

Some key points to consider in the management of recurrent BV include:

• The use of oral metronidazole 500mg daily for 4-6 months as another suppressive option 1
• Adjunctive measures such as using boric acid vaginal suppositories (600mg daily for 21 days) and probiotics containing Lactobacillus species, particularly L. crispatus and L. rhamnosus, to help restore normal vaginal flora
• Lifestyle modifications that may help include avoiding douching, using condoms during intercourse, limiting sexual partners, and wearing cotton underwear
• The fact that BV recurs frequently because treatment may not fully eliminate the biofilm formed by BV-associated bacteria, and because the normal protective Lactobacillus-dominant vaginal microbiome may not be adequately restored after antibiotic treatment, as noted in 1

It is also important to note that follow-up visits are unnecessary if symptoms resolve, but a follow-up evaluation at 1 month after completion of treatment should be considered to evaluate whether therapy was successful, especially in high-risk pregnant women who are asymptomatic, as recommended by 1.

From the FDA Drug Label

INDICATIONS AND USAGE Metronidazole vaginal gel is indicated in the treatment of bacterial vaginosis Clinical Studies In a randomized, single-blind clinical trial of non-pregnant women with bacterial vaginosis who received metronidazole vaginal gel daily for 5 days, the clinical cure rates for evaluable patients determined at 4 weeks after completion of therapy for the QD and BID regimens were 98/185 (53%) and 109/190 (57%), respectively.

The treatment of recurrent bacterial vaginosis (BV) is not directly addressed in the provided drug labels. However, metronidazole vaginal gel is indicated for the treatment of bacterial vaginosis (BV), and the clinical cure rates for evaluable patients determined at 4 weeks after completion of therapy were 53% and 57% for the QD and BID regimens, respectively 2 2.

• Recurrent BV may be managed with repeated courses of metronidazole, but the optimal treatment strategy is not specified in the provided labels.
• Clinical judgment should be used to determine the best course of treatment for recurrent BV.

From the Research

Recurrent Bacterial Vaginosis (BV) Treatment Options

• Recurrent BV is a major challenge to effective therapy, with women experiencing intractable and frequent recurrences being ill-served by available treatment options 3.
• 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 4.
• 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 4.

Alternative Strategies for Recurrent BV Treatment

• Alternative strategies may include antimicrobial substances (other antimicrobials, antiseptics, and natural compounds) or substances that aim to reestablish the physiologic vaginal environment (probiotics, prebiotics, and acidifying agents) while improving the local immunity response 5.
• The development of formulation strategies and new dosage forms and drug delivery systems can improve treatment efficacy and overcome some limitations associated with conventional products 5.
• Secnidazole may be an attractive new option due to one-time dosing, and initial studies on biofilm disruption, use of probiotics and prebiotics, and botanical treatments have shown some promise 4.

Comparison of Treatment Options

• Oral metronidazole, metronidazole vaginal gel, and clindamycin vaginal cream achieved nearly equivalent cure rates for the treatment of bacterial vaginosis 6.
• Posttreatment vulvovaginal candidiasis was experienced by 12.5% of subjects treated with oral metronidazole, 14.8% of subjects treated with clindamycin vaginal cream, and 30.4% of subjects treated with metronidazole vaginal gel 6.
• A combination pharmacotherapy long-term suppressive regimen, including oral nitroimidazole and simultaneous boric acid, achieved a satisfactory response in 92 of 93 available patients, and a maintenance metronidazole gel prevented symptomatic BV recurrence in 69.6% of compliant patients at 6-month follow-up 3.