Treatment of Bacterial Vaginosis
For non-pregnant women with bacterial vaginosis, the recommended first-line treatment is metronidazole 500 mg orally twice daily for 7 days, which has demonstrated the highest cure rates of approximately 95%. 1
First-Line Treatment Options
Three equally effective first-line regimens are recommended:
- Oral metronidazole: 500 mg twice daily for 7 days
- Metronidazole gel 0.75%: one full applicator (5g) intravaginally once daily for 5 days
- Clindamycin cream 2%: one full applicator (5g) intravaginally at bedtime for 7 days
Among these options, oral metronidazole has the most extensive evidence supporting its efficacy, with cure rates of approximately 95% 1. The vaginal preparations offer the advantage of fewer systemic side effects, with metronidazole gel resulting in serum concentrations less than 2% of those achieved with standard oral dosing 1.
Alternative Regimens (Lower Efficacy)
These options have demonstrated lower efficacy but may be considered in certain situations:
- Metronidazole 2g orally in a single dose (84% cure rate) 1
- Clindamycin 300 mg orally twice daily for 7 days
- Clindamycin ovules 100g intravaginally once at bedtime for 3 days
Special Considerations
Pregnancy
- First trimester: Clindamycin vaginal cream 2% is preferred due to concerns about metronidazole 1
- Second/third trimesters: Metronidazole 250 mg orally three times daily for 7 days 1
- Treatment is particularly important for high-risk pregnant women (history of preterm birth) as BV is associated with adverse pregnancy outcomes 1
Allergy or Intolerance to Metronidazole
- Clindamycin cream or oral clindamycin is the preferred alternative 1
- Note: Patients allergic to oral metronidazole should not use metronidazole vaginally 1
Important Precautions
- Patients should avoid alcohol during metronidazole treatment and for 24 hours afterward 1
- Clindamycin cream and ovules are oil-based and may weaken latex condoms and diaphragms 1
Follow-Up and Recurrence
- Follow-up visits are unnecessary if symptoms resolve 1
- Recurrence is common (50-80% within one year) 2, 3
- For recurrent BV, extended metronidazole treatment (500 mg twice daily for 10-14 days) is recommended 3
- An alternative for recurrent BV is metronidazole gel 0.75% for 10 days, followed by twice weekly for 3-6 months 3
Management of Sex Partners
- Routine treatment of sex partners is not recommended as clinical trials have not shown this to influence the woman's response to therapy or recurrence rates 1, 4
Emerging Approaches
Recent research is exploring additional strategies for managing recurrent BV, including:
- Biofilm disruption techniques
- Probiotics and prebiotics
- Vaginal microbiome transplantation
- pH modulation 2
However, these approaches require further study before clinical implementation, and antimicrobial therapy remains the mainstay of treatment 3.