What is the recommended treatment for Bacterial Vaginosis (BV)?

Treatment of Bacterial Vaginosis

Metronidazole 500 mg orally twice daily for 7 days is the recommended first-line treatment for bacterial vaginosis (BV), with cure rates of approximately 95%. 1

First-Line Treatment Options

For non-pregnant women with symptomatic BV, the following regimens are recommended:

1. Oral therapy:

   • Metronidazole 500 mg orally twice daily for 7 days 1

2. Intravaginal therapy options:

   • Metronidazole gel 0.75%, one full applicator (5 g) intravaginally once daily for 5 days 1
   • Clindamycin cream 2%, one full applicator (5 g) intravaginally at bedtime for 7 days 1

Alternative Treatment Regimens

These regimens have lower efficacy for BV but may be considered in certain situations:

• Metronidazole 2 g orally in a single dose (84% cure rate vs. 95% for 7-day regimen) 1
• Clindamycin 300 mg orally twice daily for 7 days 1
• Clindamycin ovules 100 g intravaginally once at bedtime for 3 days 1

Special Considerations

Pregnancy

• First trimester: Clindamycin vaginal cream is preferred due to contraindication of metronidazole 1
• Second and third trimesters: Oral metronidazole can be used, though vaginal preparations may be preferable 1
• High-risk pregnant women (those with previous preterm birth) with asymptomatic BV may benefit from treatment to reduce risk of prematurity 1

Allergy or Intolerance to Metronidazole

• Clindamycin cream or oral clindamycin is preferred 1
• Patients allergic to oral metronidazole should not use metronidazole vaginally 1

Important Precautions

• Patients should avoid alcohol during treatment with metronidazole and for 24 hours afterward 1
• Clindamycin cream and ovules are oil-based and may weaken latex condoms and diaphragms 1

Recurrent BV

Recurrence is common. Treatment options include:

• Using another recommended treatment regimen 1
• For persistent cases, extended metronidazole treatment (10-14 days) may be considered 2

Follow-Up

• Follow-up visits are unnecessary if symptoms resolve 1
• Patients should return for additional therapy if symptoms recur 1

Management of Sex Partners

• Routine treatment of sex partners is not recommended as it does not influence the woman's response to therapy or affect relapse/recurrence rates 1

Clinical Efficacy Comparison

• Oral metronidazole (7-day regimen): ~95% cure rate 1
• Metronidazole gel: Similar efficacy to oral metronidazole with fewer systemic side effects 3, 4
• Clindamycin cream: Similar efficacy but may be slightly less effective than metronidazole regimens 1

Common Pitfalls to Avoid

1. Undertreating with single-dose therapy when 7-day regimen has superior efficacy
2. Not warning patients about alcohol interaction with metronidazole
3. Unnecessarily treating sexual partners
4. Failing to consider treatment before invasive gynecological procedures to reduce risk of post-procedure infections
5. Using metronidazole in first trimester of pregnancy when clindamycin cream is preferred

The most recent high-quality evidence confirms that oral metronidazole, metronidazole gel, and clindamycin cream all achieve similar cure rates, but oral metronidazole remains the standard first-line therapy with the highest documented efficacy 1, 5.