My first-line treatment for bacterial vaginosis (BV) is topical clindamycin (Clindesse) (Item 104-10). This one-day, single-dose vaginal gel offers superior patient comfort and efficacy as well as easy compliance. Because the gel adheres to the vaginal environment for several days, there is no need for repeat applications. The cost is fairly comparable with that of topical metronidazole (Metrogel), particularly when you consider the greater efficay with first-time use of Clindesse, which often eliminates the possibility of recurrence.
While metronidazole is an effective treatment, many patients find a five-day topical regimen difficult to tolerate. For some insurance formularies, however, this is a more cost-effective topical treatment. The systemic treatments are ideal for patients who have an aversion to topicals or when out-of-pocket cost is a concern.
Metronidazole 500 mg p.o. b.i.d. for seven days is effective and should be used for first-line treatment if the infection is severe or in cases where ascent to the upper pelvis is a concern (e.g., severe infection, presence of an intrauterine device or system). An alternative dosing regimen is 2 g of metronidazole taken once daily for two days. This dosing can cause more frequent GI side effects but is highly effective and a good choice for patients with questionable compliance to a seven-day regimen. If trichomoniasis is concomitant or suspected, this is an ideal regimen, as both BV and trichomoniasis can be effectively eliminated with this two-day dosing.
A second choice is now available for p.o. treatment of BV and Trichomonas. Tinidazole (Tindamax) has been approved by the FDA as a single-dose treatment for the management of trichomonal infection. Though use of tinidazole in the treatment of BV is still off-label, the company has released compelling peer-reviewed studies that demonstrate its superior efficacy and side-effect profile compared with metronidazole.
—Mary Ana McGlasson, MN, ARNP, FNP, Seattle
The easiest topical treatment for BV is Clindesse, a combination of 5 g clindamycin and a bioadhesive. This is a single dose and can be initiated at any time of the day.
—James A. McGregor, MD, visiting professor of maternal fetal medicine, University of Southern California Keck School of Medicine, Los Angeles (107-17)