From the Guidelines
Bacterial vaginosis should be treated with metronidazole 500 mg orally twice a day for 7 days or metronidazole gel 0.75% applied intravaginally once daily for 5 days, as these regimens have been shown to be equally efficacious in treating the condition. The treatment of bacterial vaginosis (BV) is crucial to reduce the risk of complications such as pelvic inflammatory disease, infertility, and increased susceptibility to sexually transmitted infections 1.
Treatment Options
- Metronidazole 500 mg orally twice a day for 7 days
- Metronidazole gel 0.75% applied intravaginally once daily for 5 days
- Clindamycin cream 2% applied intravaginally at bedtime for 7 days, although this regimen appears to be less efficacious than the metronidazole regimens 1
Important Considerations
- Patients should be advised to avoid consuming alcohol during treatment with metronidazole and for 24 hours thereafter to prevent disulfiram-like reactions 1
- Clindamycin cream and ovules are oil-based and may weaken latex condoms and diaphragms, so patients should be cautioned about this potential interaction 1
Follow-Up
- Follow-up visits are unnecessary if symptoms resolve, but because recurrence of BV is not unusual, women should be aware of the signs and symptoms of recurrence and seek medical attention if they occur 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 of bacterial vaginosis with tinidazole is effective, with therapeutic cure rates of 97.5% for the 2 g × 2 days regimen and 96.1% for the 1 g × 5 days regimen, as measured by resolution of all Amsel's criteria and a Nugent score of <4 2.
- Key findings:
- Therapeutic cure rates: 97.5% (2 g × 2 days) and 96.1% (1 g × 5 days)
- Clinical cure rates: 93.4% (2 g × 2 days) and 89.5% (1 g × 5 days)
- Microbiologic cure rates (Nugent score): 93.2% (2 g × 2 days) and 88.9% (1 g × 5 days) The recommended treatment regimens are 2 g once daily for 2 days or 1 g once daily for 5 days.
From the Research
Treatment Options for Bacterial Vaginosis
- The current and only FDA-approved treatment regimens for bacterial vaginosis (BV) are antibiotics, such as metronidazole and clindamycin 3.
- Metronidazole and clindamycin can be administered orally or intravaginally, with metronidazole being the most commonly used treatment 4, 5.
- Tinidazole is also an effective treatment for BV, with a more favorable side effect profile compared to metronidazole 6.
- Clindamycin has been shown to be a safe and effective alternative to metronidazole for treating women with BV 7.
Recurrence and Resistance
- Fifty to eighty percent of women experience a BV recurrence within a year of completing antibiotic treatment 3.
- The underlying mechanisms of recurrent etiology of BV are not known, but may be due to the persistence of residual infection, resistance, or reinfection from partners 4.
- Biofilm formation may also contribute to the persistence of BV-causing bacteria and recurrence 4, 5.
Alternative Strategies
- Probiotics, vaginal microbiome transplantation, pH modulation, and biofilm disruption are being explored as alternative approaches to treatment and prevention 3.
- Antimicrobial substances, antiseptics, and natural compounds may also be effective in treating BV 5.
- Dietary modification, non-medical vaginally applied products, and treatments from medical practices outside of allopathic medicine are also being considered 3.