Bacterial vaginosis: Treatment of recurrent infection

There is no single data-driven approach to the management of recurrent BV. For each regimen, treatment consists of antibiotic induction phase followed by maintenance therapy.

We select among the regimens based on the patient's preference, prior response to therapy, and potential adverse effects of treatment.
Generally, we prefer an extended metronidazole regimen because it is well tolerated and easy to use. We educate patients that vaginal candidiasis may develop as a result.
Given the potential toxicity of boric acid, we reserve vaginal boric acid treatment for patients who do not respond to, or cannot tolerate, the extended metronidazole regimen.

BV: bacterial vaginosis.

* Discussion of testing options to confirm bacterial vaginosis and/or other causes of abnormal vaginal discharge are presented in related UpToDate content on abnormal vaginal discharge.

¶ Choice of metronidazole or tinidazole is based on prior patient response (if any), availability, and cost.

Δ If response to a drug was inadequate in the past, then we select a different drug if available.

◊ Patients often prefer oral rather than vaginal treatment but both are effective.

§ Critical warning: Boric acid is for vaginal use only. Boric acid can cause death if taken orally. Commercially available vaginal suppository preparation is preferred but compounded products are an acceptable alternative. Vaginal boric acid should not be used by people who are pregnant or attempting conception. Boric acid should be stored safely away from children. Optimal treatment duration is not known.

Courtesy of Jack Sobel, MD.

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Bacterial vaginosis: Treatment of recurrent infection