From the Guidelines
Bacterial vaginosis should be treated with metronidazole 500 mg orally twice a day for 7 days as the first-line treatment. This recommendation is based on the Centers for Disease Control and Prevention's guidelines 1. The treatment options for bacterial vaginosis include:
- Metronidazole 500 mg orally twice a day for 7 days
- Metronidazole gel 0.75% intravaginally once a day for 5 days
- Clindamycin cream 2% intravaginally at bedtime for 7 days
It is essential to note that patients should avoid consuming alcohol during treatment with metronidazole and for 24 hours thereafter, as it may cause disulfiram-like reactions. Additionally, clindamycin cream and ovules are oil-based and may weaken latex condoms and diaphragms 1.
Alternative regimens, such as metronidazole 2 g orally in a single dose or clindamycin 300 mg orally twice a day for 7 days, have lower efficacy for treating bacterial vaginosis and are not recommended as first-line treatments. Follow-up visits are unnecessary if symptoms resolve, but recurrence is common, affecting about 30% of women within 3 months after treatment 1.
In terms of prevention, there is no evidence to support the use of non-vaginal lactobacilli or douching for the treatment of bacterial vaginosis. However, studies are currently underway to evaluate the efficacy of vaginal lactobacilli suppositories in addition to oral metronidazole for the treatment of bacterial vaginosis 1.
From the FDA Drug Label
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. Tinidazole is indicated for the treatment of bacterial vaginosis (formerly referred to as vaginitis, vaginitis, nonspecific vaginitis, or anaerobic vaginosis) in adult women [see Use in Specific Populations ( 8.1) and Clinical Studies ( 14.5)].
The recommended treatment for bacterial vaginosis is tinidazole given as either:
From the Research
Treatment Options for Bacterial Vaginosis
- The current and only FDA-approved treatment regimens for BV are antibiotics, such as metronidazole and clindamycin 4.
- Other treatment options include oral and intravaginal metronidazole and clindamycin, and oral tinidazole 5, 6, 7.
- Recommended treatment for recurrent BV consists of an extended course of metronidazole treatment or metronidazole vaginal gel 5.
Efficacy of Treatment Options
- Cure rates for oral metronidazole, metronidazole vaginal gel, and clindamycin vaginal cream are nearly equivalent, with no statistically significant differences 6.
- Tinidazole has been shown to be equivalent to oral metronidazole, intravaginal clindamycin cream, and intravaginal metronidazole tablets in efficacy in treating BV 7.
- However, treatment with these antibiotics is associated with high levels of failure and recurrence rates 4, 5, 8.
Alternative Strategies
- Alternative strategies to replace or combine with standard therapies include antimicrobial substances, probiotics, prebiotics, and acidifying agents 8.
- Biofilm disruption, use of probiotics and prebiotics, and botanical treatments have shown some promise, but must be studied further before use in the clinic 4, 5.
- Development of formulation strategies and new dosage forms and drug delivery systems can improve treatment efficacy and overcome some limitations associated with conventional products 8.
Recurrence and Management
- Fifty to eighty percent of women experience a BV recurrence within a year of completing antibiotic treatment 4.
- Recurrent BV has been linked with persistence of Gardnerella vaginalis after treatment 7.
- Management of recurrences can prove difficult, and repeated courses of oral metronidazole may be poorly tolerated 7.