Comparison of ofloxacin and metronidazole for the treatment of bacterial vaginosis

Why Do Different Criteria for ‘Cure’ Yield Different Conclusions in Comparing Two Treatments for Bacterial Vaginosis?

OBJECTIVE

The objective of this study was to determine why different criteria for response to treatment of bacterial vaginosis (BV) led to markedly different conclusions about treatment efficacy in a randomized trial comparing metronidazole gel versus metronidazole/nystatin ovules.

STUDY

We compared the impact of two treatment regimens on individual components of Amsel and Nugent criteria at follow-up visits 14, 42, and 104 days after initiating treatment.

RESULTS

Compared with gel, ovules more effectively eliminated amines, clue cells, and Gardnerella, Prevotella, or Mobiluncus morphotypes from vaginal fluid, thus achieving cure based on "usual" criteria (absence of BV by Amsel or Nugent criteria), but did not more effectively restore Lactobacillus morphotypes or lower vaginal pH, thus not meeting Federal Drug Administration (FDA) criteria for cure.

CONCLUSION

Because early vaginal recolonization by lactobacilli was poor after both gel and ovules, FDA draft criteria for cure missed marked differences in treatment efficacies against Gardnerella, clue cells, and amines. Cure defined more "usually" may give more useful information.

Antibiotic chemotherapy of bacterial sexually transmitted diseases in adults: a review

Treatment regimens for sexually transmitted infections continue to evolve. The natural history of syphilis in HIV-infected patients is leading to more aggressive policies in terms of both investigation and treatment. In particular, treatment protocols for late syphilis, especially neurosyphilis, are under scrutiny. Epidemiological change typified by the spread of penicillinase-producing Neisseria gonorrhoeae (PPNG) has led to a search for new agents to treat gonorrhoea, with a more extensive use of cephalosporin and quinolone antibiotics emerging. The problem of compliance with the antibiotic courses presently required for chlamydial infection may be close to being solved with the development of newer macrolide agents. Single dose azithromycin, although expensive, seems to be as effective as longer courses with other agents. Furthermore, its efficacy in gonococcal infection is also encouraging. Increased understanding of the pathogenesis and natural history of pelvic inflammatory disease (PID) and bacterial vaginosis (BV) has led to rationalization of treatment policies for these conditions.

Treatment of bacterial vaginosis

OBJECTIVE

The purpose of this article is to review the treatment options for bacterial vaginosis, including the newer topical antibiotics, metronidazole gel and clindamycin cream. The article also examines the controversies over whether bacterial vaginosis is a sexually transmitted disease and whether asymptomatic women should be treated.

DATA SOURCE

A MEDLINE search was conducted to identify pertinent literature, including review articles.

STUDY SELECTION

Emphasis was placed on those clinical trials using metronidazole gel or clindamycin cream. Studies addressing the complications of bacterial vaginosis in pregnancy, the risk of treatment in pregnancy, and the method of transmission of the disease also were reviewed.

DATA EXTRACTION

Clinical studies evaluating clindamycin cream and metronidazole gel were scarce; therefore, data from all available trials were reviewed. The objectives, methodology, and results from other studies were reviewed; those addressing complications of the disease and risks and benefits of treatment were included.

DATA SYNTHESIS

There is evidence both for and against bacterial vaginosis being a sexually transmitted disease. Potential complications of the disease may warrant treatment of certain asymptomatic women, especially during pregnancy. Treatment options include oral or vaginal metronidazole or clindamycin, all of which provide high cure rates. Vaginal antibiotics result in minimal risk to the fetus in pregnant patients.

CONCLUSIONS

Complications of bacterial vaginosis may be associated with significant morbidity, especially among pregnant women. Treatment of asymptomatic women with the disease is controversial, but may be justified in certain high-risk populations. The topical agents, clindamycin vaginal cream 2% and metronidazole vaginal gel 0.75% provide a safe, effective, but expensive alternative to oral antibiotic regimens for the treatment of bacterial vaginosis.

Quinolones in sexually transmitted diseases

The role of quinolones in the treatment of sexually transmitted diseases is assessed. Little is known of their activity against Treponema pallidum. These compounds are all highly active against Neisseria gonorrhoeae, and have produced good in vivo results with a single dose. Only the more recent compounds show useful antichlamydial activity in vitro. Clinical trials with ofloxacin demonstrate the efficacy of a single daily dose for 7 days for chlamydial genital infection in men and women. Results for treatment of bacterial vaginosis have so far been disappointing. Ciprofloxacin and fleroxacin are effective for chancroid. The potential for treating pelvic inflammatory disease with new quinolones is discussed.