What medication can be used for bacterial vaginosis if Metronidazole is not effective?

1.

Elsevier ClinicalKey Clinical Overview

Treatment Antibiotic treatment is recommended for symptomatic patients Asymptomatic patients to consider for treatment Male sexual partners do not require treatment Probiotics According to the CDC, first line agents are metronidazole (oral tablet or intravaginal gel) and clindamycin (intravaginal cream) Alternative medications include tinidazole (oral tablet), secnidazole (oral granules), and clindamycin (oral tablet or intravaginal ovule) Single-dose oral therapy using metronidazole is no longer recommended owing to high failure rates More than 50% of patients with bacterial vaginosis are asymptomatic Those scheduled to undergo genital tract procedures (eg, cesarean delivery, hysterectomy) before undergoing procedure The role of probiotics in therapy of bacterial vaginosis remains unclear Evidence for probiotics in bacterial vaginosis treatment, either as monotherapy or in combination with antibiotics, is mixed, though some analyses have suggested possible benefit

Treatment For multiple recurrences, an oral nitroimidazole, followed by intravaginal boric acid with suppressive metronidazole gel for 4 to 6 months may be an option. Clindamycin Intravaginal dosage (cream - standard formulations) Clindamycin Phosphate Vaginal cream; Adolescents†: 1 applicatorful (100 mg/5 g cream) intravaginally every night at bedtime for 7 days. Clindamycin Phosphate Vaginal cream; Adults: 1 applicatorful (100 mg/5 g cream) intravaginally every night at bedtime for 7 days; FDA-approved duration is 3 to 7 consecutive days in nonpregnant patients and for 7 days in pregnant patients for most formulations. Intravaginal dosage (cream - Clindesse) Clindamycin Phosphate Vaginal cream; Adults: 1 applicatorful (100 mg clindamycin/5 g cream) intravaginally as a single dose. Alternative agents Tinidazole for the initial treatment of bacterial vaginosis Tinidazole Oral tablet; Adults: 2 g PO once daily for 2 days or 1 g PO once daily for 5 days. Clindamycin Oral dosage Clindamycin Hydrochloride Oral capsule; Adolescents: 300 mg PO twice daily for 7 days. Clindamycin Hydrochloride Oral capsule; Adults: 300 mg PO twice daily for 7 days. Intravaginal dosage (ovules/suppositories) Note: clindamycin ovules might weaken latex condoms and diaphragms for up to 5 days after treatment Clindamycin Phosphate Vaginal suppository; Adolescents (post-menarchal): 1 ovule (100 mg) intravaginally every night at bedtime for 3 days.

2.

Elsevier ClinicalKey Derived Clinical Overview

• Recommended regimens (similar efficacy): 1.000000000000000e+00 Metronidazole 500 mg PO bid for 7 daysor 2.000000000000000e+00 Metronidazole 0.75% gel, one full applicator (5 g) intravaginally daily for 5 daysor 3.000000000000000e+00 Clindamycin 2% cream, one full applicator (5 g) intravaginally at bedtime for 7 days • Alternative regimens: 1.000000000000000e+00 Clindamycin 300 mg PO bid for 7 days or clindamycin 100 mg ovules intravaginally once at bedtime for 3 days. • May be associated with antimicrobial resistance 1.000000000000000e+00 Tinidazole 1g PO once daily for 5 days • Longer half-life than metronidazole (∼12 to 14 hr vs. ∼6 to 7 hr) 1.000000000000000e+00 Secnidazole 2 g PO once • Longer half-life than metronidazole (∼17 hr vs. ∼8 hr). Shown to be superior to placebo in phase 3 trial and at least as effective as metronidazole 500 mg PO bid in noninferiority trial. Single 1-g oral dose appears to be effective also. Single dose improves compliance but is more expensive than multidose metronidazole therapy. • Disulfiram-type reactions may occur while taking oral or topical metronidazole, and patients should be advised to avoid alcohol while undergoing treatment. • Sexual partners: It is not necessary to treat male partners of affected females; however, females who partner with females need to be aware of the signs and symptoms of BV, and treatment is indicated in this population if symptoms occur. • Follow-up visits after treatment and resolution of symptoms are unnecessary, but patients are advised to return if symptoms recur. • Not enough evidence for or against probiotic use for treatment and prevention. • Clindamycin cream may weaken latex condoms if used together.

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Swygard, Heidi, Cohen, Myron S. (2024). In Goldman-Cecil Medicine (pp. 1878). DOI: 10.1016/B978-0-323-93038-3.00264-1

Treatment of asymptomatic women who are not at high risk for preterm delivery appears to confer no benefit. For symptomatic women, treatment against the anaerobic flora consists of metronidazole (500 mg orally twice daily for 7 days or 0.75% gel at 5 g intravaginally daily for 5 days), secnidazole (2 g of oral granules in a single dose), tinidazole (2 g orally daily for 2 days or 1 gram orally once daily for 5 days), or clindamycin (2% cream as 5 g intravaginally at bedtime for 7 days, 300 mg orally twice daily for 7 days, or 100 mg ovules intravaginally at bedtime for 3 days). The relapse rate is about 30%, and treatment of male sexual partners offers no benefit. However,Lactobacillus crispatusCTV-05 administered vaginally can significantly reduce recurrences of bacterial vaginosis after treatment with vaginal metronidazole gel.

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Elsevier ClinicalKey Drug Monograph

Content last updated: September 5, 2023.

Description Secnidazole is an oral nitroimidazole antimicrobial indicated for the treatment of bacterial vaginosis and trichomoniasis in adults and pediatric patients 12 years and older. Sexual partners should be simultaneously treated for trichomoniasis to avoid reinfection. Secnidazole is approved as single-dose therapy. It was found to be at least as effective as a 7-day course of metronidazole for bacterial vaginosis. In a double-dummy, double-blind, noninferiority study (n = 577), therapeutic success, a composite of clinical and bacteriological cure, rates at day 28 were similar, 60.1% and 59.5% for single-dose secnidazole vs. multiple-dose metronidazole (500 mg PO twice daily for 7 days), respectively. For trichomoniasis, secnidazole had cure rates ranging from 91.7% to 100%. Single-dose therapy increases convenience and promotes compliance.