Check treatment options for bacterial vaginosis
Check treatment options for bacterial vaginosis
After taking the necessary diagnostic steps, the results are clear: The patient sitting in front of you needs to be treated for bacterial vaginosis (BV). The most common vaginal infection in women of childbearing age, women with BV may present with a white or gray discharge, odor, pain, or burning during urination. Symptoms aren't always present, though. More than 50% of women with BV may be asymptomatic.1
Clinicians are concerned with BV due to its link to such adverse pregnancy outcomes as preterm delivery and low birth weight, postpartum and postabortal endometritis, and acquisition of sexually transmitted infections (STIs), including HIV.2,3 A new review looks at current evidence on antimicrobial treatments of bacterial vaginosis.4
"Treating BV could help reduce susceptibility of women to HIV," says lead researcher Oyinlola Oduyebo, MD, lead author of the review and a senior lecturer in the Department of Medical Microbiology and Parasitology at the University of Lagos in Nigeria. "Therefore it is important, particularly in the developing world, to establish the most effective and appropriate forms of treatment."
There is a need for larger, better-designed studies of BV treatment, says Oduyebo. Many studies were excluded from the review because they did not meet the review's criteria, she notes.
"Mainly the methods of diagnosis in such studies were not acceptable because at the time the studies were carried out, the methods of diagnosis had not been standardized and the current methods were not available," Oduyebo states.
The best options for treatment of BV remain topical clindamycin, topical metronidazole gel, oral metronidazole, or tinidazole, says Sharon Hillier, PhD, professor of obstetrics, gynecology and reproductive sciences, and molecular genetics and biochemistry at the University of Pittsburgh, and senior investigator at the Magee-Womens Research Institute, both in Pittsburgh. All are good at effective treatment, she notes.
She points to the 2006 edition of the Centers for Disease Control and Prevention's (CDC) Sexually Transmitted Diseases Treatment Guidelines, which recommends the following regimens:
- metronidazole, 500 mg, orally twice a day for seven days;
- or metronidazole gel, 0.75%, one full applicator (5 g) intravaginally, once a day for five days;
- or clindamycin cream, 2%, one full applicator (5 g) intravaginally at bedtime for seven days.5
Look for the 2010 edition of the CDC guidance to include the use of oral tinidazole (Tindamax; Mission Pharmacal, San Antonio). The drug was approved for use in treatment of BV in 2007.
Tindamax is administered as 1 g (two tablets) once daily for five days or 2 g (four tablets) once daily for two days, compared to the twice-daily, seven-day oral dosing of metronidazole. Results from Tindamax's clinical trial indicate both regimens of the drug were effective.6
How about treatment of sex partners? According to the CDC, results of clinical trials indicate that a woman's response to therapy and the likelihood of relapse or recurrence are not affected by partner treatment.5 Therefore, it is not recommended.
Although most women will respond to initial treatment, about 20%-25% will have recurrence of infection following treatment, observes Hillier. The CDC recommends that women be advised to return for additional therapy if symptoms recur, with another round of treatment. Although there are limited data, treatment with the same drug again appears to result in the same level of cure as when re-treatment with a different drug regimen is used for recurrent infection.7 Women with multiple recurrences should be managed in consultation with a specialist, the CDC notes.5 Results from a randomized trial for persistent BV indicate that metronidazole gel 0.75% twice per week for six months after completion of a recommended regimen was effective in maintaining a clinical cure for six months.8
"The best data suggests that recurrence is not due to antimicrobial resistance," Hillier notes. "We don't really know why women have high rate of recurrence."
The need for a clear understanding of the pathogenesis of BV is acute, states a 2009 overview of the condition.9 Hillier agrees with this assessment. "As someone who has worked in vaginitis research my entire life, I am very frustrated with the lack of good answers we have for clinicians taking care of women with bacterial vaginosis," she states. "Our answers are not yet satisfactory."
References
- Centers for Disease Control and Prevention, Workowski KA, Berman SM. Sexually transmitted diseases treatment guidelines, 2006. MMWR Recomm Rep 2006; 55(RR-11):1-94.
- Koumans EH, Kendrick JS, CDC Bacterial Vaginosis Working Group. Preventing adverse sequelae of bacterial vaginosis: A public health program and research agenda. Sex Transm Dis 2001; 28:292-297.
- Schwebke JR, Desmond R. Risk factors for bacterial vaginosis in women at high risk for sexually transmitted diseases. Sex Transm Dis 2005; 32:654-658.
- Oduyebo OO, Anorlu RI, Ogunsola FT. The effects of antimicrobial therapy on bacterial vaginosis in nonpregnant women. Cochrane Database Syst Rev 2009; 3:CD006055.
- Centers for Disease Control and Prevention, Workowski KA, Berman SM. Sexually transmitted diseases treatment guidelines, 2006. MMWR Recomm Rep 2006; 55(RR-11):1-94.
- Livengood CH 3rd, Ferris DG, Wiesenfeld HC, et al. Effectiveness of two tinidazole regimens in treatment of bacterial vaginosis: A randomized controlled trial. Obstet Gynecol 2007; 110(2 Pt 1):302-309.
- Bunge KE, Beigi RH, Meyn LA, et al. The efficacy of re-treatment with the same medication for early treatment failure of bacterial vaginosis. Sex Transm Dis 2009 Jul 31. [Epub ahead of print.] Doi: 10.1097/OLQ.0b013e3181af6cfd.
- Sobel JD, Ferris D, Schwebke J, et al. Suppressive antibacterial therapy with 0.75% metronidazole vaginal gel to prevent recurrent bacterial vaginosis. Am J Obstet Gynecol 2006; 194:1,283-1,289.
- Livengood CH 3rd. Bacterial vaginosis: An overview for 2009. Rev Obstet Gynecol 2009; 2:28-37.
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