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Bacterial vaginosis - Management
Basis for recommendation
The recommendations for drug treatment in symptomatic women with bacterial vaginosis (BV) are consistent with recommendations from the British Association for Sexual Health and HIV [BASHH, 2006].
Antibiotics
- Oral metronidazole is a well-established treatment. It is usually well tolerated and is inexpensive.
- Evidence from a systematic review suggests that:
- Both intravaginal clindamycin and intravaginal metronidazole are more effective than placebo at curing BV.
- There are similar rates of cure with oral metronidazole (7-day regimen), intravaginal clindamycin, and intravaginal metronidazole.
- A single oral dose of metronidazole is associated with a significantly higher relapse rate than the 7-day regimen. However, some experts argue that in clinical practice the effectiveness of the single-dose regimen may be similar to that of the 7-day regimen because a higher adherence rate is expected for the single-dose regimen. CKS found no data to support this argument.
- Evidence from one randomized controlled trial suggests that there is no difference in efficacy between a 7-day regimen of metronidazole and a 7-day regimen of oral clindamycin; further evidence regarding the efficacy and safety of clindamycin is needed.
- The use of oral clindamycin is limited in primary care because of the rare but potentially serious risk of pseudomembranous colitis.
- CKS found no studies directly comparing tinidazole with other treatments for BV.
- Tinidazole has similar activity to metronidazole, but it is more expensive and it generally exhibits cross-resistance with metronidazole.
Vaginal acidification
- Several products containing intravaginal lactic acid are available over-the-counter; however, there is insufficient evidence to make a recommendation on the use of vaginal acidification for the treatment of BV.
- Evidence on the efficacy of vaginal acidification with lactic acid or acetic acid is conflicting and studies are generally small and of poor quality.
Test of cure if symptoms resolve
- The British Association for Sexual Health and HIV does not routinely recommend a test of cure in women who are not pregnant [BASHH, 2006].
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