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

Recommended Treatment for Bacterial Vaginosis (BV)

For non-pregnant women with bacterial vaginosis, first-line treatment is metronidazole 500 mg orally twice daily for 7 days, clindamycin cream 2% intravaginally at bedtime for 7 days, or metronidazole gel 0.75% intravaginally twice daily for 5 days. 1

First-Line Treatment Options for Non-Pregnant Women

The following regimens are considered equally effective for treating BV:

• Oral options:

  • Metronidazole 500 mg orally twice daily for 7 days (78-82% cure rate) 1
  • Clindamycin 300 mg orally twice daily for 7 days 1

• Vaginal options:

  • Metronidazole gel 0.75%, one full applicator (5g) intravaginally once daily for 5 days (75% cure rate) 1
  • Clindamycin cream 2%, one full applicator (5g) intravaginally at bedtime for 7 days (78-82% cure rate) 1
  • Clindamycin ovules 100g intravaginally once at bedtime for 3 days 1

• Alternative regimen:

  • Metronidazole 2g orally in a single dose 1

Treatment for Pregnant Women

• First-line treatment: Metronidazole 250 mg orally three times daily for 7 days 1
• This regimen balances efficacy with minimizing fetal exposure
• All symptomatic pregnant women should be tested and treated to prevent adverse pregnancy outcomes 1
• High-risk pregnant women (history of previous preterm birth) should be screened and treated, preferably in early second trimester 1

Management of Recurrent BV

Recurrence is common, affecting 50-80% of women within a year of treatment 1. For recurrent BV:

• Use a different treatment regimen from the initial one 1
• Extended course of metronidazole (500 mg twice daily for 10-14 days) 2
• If ineffective, consider metronidazole vaginal gel 0.75% for 10 days, followed by twice weekly for 3-6 months 2

Emerging Treatment Option

Recent research (2024) shows that dequalinium chloride vaginal tablets (10 mg once daily for 6 days) is non-inferior to oral metronidazole for BV treatment, with similar efficacy but better tolerability and fewer adverse events 3. This antiseptic option may help reduce antibiotic consumption.

Important Precautions and Follow-up

• Alcohol warning: Patients must avoid alcohol during metronidazole treatment and for 24 hours afterward to prevent disulfiram-like reactions 1
• Barrier contraception: Clindamycin cream and ovules are oil-based and may weaken latex condoms and diaphragms 1
• Follow-up: Routine follow-up is unnecessary if symptoms resolve, except in high-risk pregnant women 1
• Partner treatment: Routine treatment of sex partners is not recommended as clinical trials indicate it does not affect treatment response or recurrence likelihood 1

Diagnostic Criteria

BV diagnosis requires confirming at least three of the following clinical criteria:

• Homogeneous, white, non-inflammatory discharge adhering to vaginal walls
• Presence of clue cells on microscopic examination
• Vaginal fluid pH greater than 4.5
• Fishy odor of vaginal discharge before or after addition of 10% KOH (whiff test) 1