What is the recommended treatment for bacterial vaginosis?

Treatment of Bacterial Vaginosis

The recommended first-line treatment for bacterial vaginosis is metronidazole 500 mg orally twice daily for 7 days, which has demonstrated a 95% cure rate compared to 84% for single-dose therapy. 1

First-Line Treatment Options

• Oral metronidazole regimen:

  • Metronidazole 500 mg orally twice daily for 7 days 1, 2
  • Patients should avoid alcohol during treatment and for 24 hours afterward 1

• Alternative first-line options:

  • Metronidazole gel 0.75%, one full applicator (5 g) intravaginally once daily for 5 days 1, 2, 3
  • Clindamycin cream 2%, one full applicator (5 g) intravaginally at bedtime for 7 days 1, 2

Second-Line Treatment Options

• Metronidazole 2 g orally in a single dose (lower efficacy at 84%) 1
• Clindamycin 300 mg orally twice daily for 7 days 1, 2
• Clindamycin ovules 100 g intravaginally once at bedtime for 3 days 1, 2
• Tinidazole has shown efficacy when given as either 2 g once daily for 2 days or 1 g once daily for 5 days 4

Treatment Selection Considerations

• Efficacy comparison:

  • The 7-day oral metronidazole regimen (95% cure rate) is more effective than the single 2 g dose (84% cure rate) 1
  • Vaginal metronidazole gel once daily is as effective as twice daily application 3
  • Clindamycin cream appears slightly less efficacious than metronidazole regimens 1

• Special situations:

  • Allergy/intolerance to metronidazole: Use clindamycin cream 1, 2
  • Pregnancy: Different recommendations apply, particularly for high-risk pregnant women with history of preterm birth 1, 5

Important Clinical Considerations

• Only women with symptomatic disease require treatment 1
• Treatment of male sex partners has not been shown to alter clinical course or reduce recurrence rates, so it is not recommended 1, 5
• Clindamycin cream and ovules are oil-based and may weaken latex condoms and diaphragms 1, 2
• Follow-up visits are unnecessary if symptoms resolve 1, 2

Management of Recurrent BV

• Recurrence is common, affecting 50-80% of women within one year of treatment 6, 7
• For recurrent BV, extended course of metronidazole treatment (500 mg twice daily for 10-14 days) is recommended 7
• If ineffective, consider metronidazole vaginal gel 0.75% for 10 days, followed by twice weekly for 3-6 months 7

Emerging Approaches

Research is ongoing for alternative approaches to prevent recurrence, including probiotics, vaginal microbiome transplantation, pH modulation, and biofilm disruption, but these are not yet part of standard treatment recommendations 6, 7.