J Am Board Fam Pract: first published as 10.3122/jabfm.7.5.431 on 1 September 1994. Downloaded from http://www.jabfm.org/ on 27 June 2023 by guest.

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Recurrent Bacterial Vaginosis Unresponsive To
Metronidazole: Successful Treatment With Oral
Clindamycin
Robyn Schuler Tepper, MD, Timothy]. lues, PharmD, MPH,
and Mizanu Kebede, MS, MT (ASep)

Bacterial vaginosis is known to be a polymicrobial the incomplete resolution of the vaginal dis-
condition that can include infections with Gard- charge with the characteristic foul-smelling odor.
nerella vaginalis, Mycoplasma hominis, Mobiluncus, Mter the patient experienced repeated treat-
Bacteroides, and Peptococcus. 1 Currently, many ment failures with metronidazole in spite of total
physicians consider oral metronidazole to be monogamy and the strict use of condoms during
the drug of choice for the treatment of bacterial the treatment period, a vaginal swab was cultured
vaginosis. Cure rates of up to 91 percent have on agar containing 5 percent defibrinated horse
been reported after 7 days of pharmacotherapy2; blood at 37°C with incubation in an anaerobic en-
however, it is common and often frustrating for vironment. 3 Moderate normal genital tract flora
the clinician to see a lack of response after this were identified. Of note, however, G. vaginalis
standard treatment regimen. As recurrences are was also identified, with sensitivities as follows:
often attributed to poor compliance, cultures and penicillin G, 90 percent minimum inhibitory
sensitivity testing are not used routinely to ad- concentration (MIC90) <0.06 f.Lg/mL; clindamy-
dress the possibility of resistant organisms. A case cin, <0.12 f.Lg/mL; chloramphenicol, <2 f.Lg/mL;
of recurrent bacterial vaginosis that contained a metronidazole, > 32 f.Lg/mL; and tetracycline,
strain of G. vaginalis that was resistant to metro- > 16 f.Lg/mL; the presence of a strain of G. vaginalis
nidazole is presented. Oral clindamycin was an was resistant to both metronidazole and tetracy-
effective alternative treatment. cline but sensitive to clindamycin. No other
anaerobic bacteria were identified. The patient was
Case Report treated with oral clindamycin, 300 mg twice daily
During a 5-year period, a 23-year-old patient was for 10 days. After 5 months, she remained asympto-
prescribed multiple courses of oral metronida- matic and was culture negative for G. vaginalis at
zole 500 mg twice daily for 7 or 10 days for bac- that point. She remained asymptomatic for 1 year,
terial vaginosis. Initial treatment failures had a longer recurrence-free period than any of the
been attributed to poor compliance, which was previous treatment courses with metronidazole.
unsubstantiated. These infections were diag-
nosed by the characteristic vaginal discharge, Discussion
presence of clue cells and absence of other patho- The standard MIC 90 of metronidazole for
gens on microscopic examination of the normal G. vaginalis is 32 f.Lg/mL,3 but serum metronida-
saline preparation on wet mounts, pH>4.5, and zole concentrations of only 11.5 f.Lg/mL have been
an amine odor after the addition of 10 percent found after administration of a 500-mg oral dose.4
potassium hydroxide to the specimen. The pa- Ralph, et aU demonstrated that 30 percent of
tient continued to return to the clinic because of Gardnerella strains were resistant under anaerobic
conditions at a metronidazole MIC90 of 16 f.Lgl
mL.s Jones, et al. 2 found that 54.5 percent of
strains had MICs ~32 f.Lg/mL, but no correlation
Submitted, revised, 4 March 1994.
From the Student Health Service (RSl), The Department of with treatment failures in relation to these strains
Family Medicine, School of Medicine, (I'JI and MK), and the has been made. Further studies examining the cur-
School of Pharmacy (TJI), University of North Carolina at rent sensitivity of G. vaginalis and other microbial
Chapel Hill. Address reprint requests to Timothy J. lves,
PharmD, MPH, Department of Family Medicine, Box 7595,
organisms associated with bacterial vaginosis
University of North Carolina at Chapel Hill, Chapel Hill, NC to metronidazole, as well as 1(2-hydroxyethyl)-
27599-7595. 2-hydroxymethyl-5-nitroimidazole, its active

Bacterial Vaginosis 431

J Am Board Fam Pract: first published as 10.3122/jabfm.7.5.431 on 1 September 1994. Downloaded from http://www.jabfm.org/ on 27 June 2023 by guest. Protected by copyright.
further the role of resistance in recurrent cases. GR, Duerden BI. In-vitro and in-vivo activity of
metronidazole against Gardnerella vaginalis, Bacte-
The use of clindamycin could be advantageous
roides spp and Mobiluncus spp in bacterial vaginosis.
because of its high bacteriocidal activity against J Antimicrob Chemother 1985; 16: 189-97.
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nal organisms,6-IO whereas metronidazole has dards. Methods for antimicrobial susceptibility test-
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NCCLS; 1989.
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consume ethanol, because of the disulfiram-like WMM. Pharmacokinetics of metronidazole as
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Inhibition of Haemophilus vaginalis (Cornehacterium
tis) is considered to be low, and metronidazole has
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432 JABFP Sept.-Oct.1994 Vol. 7 No.5