What is the treatment for a patient with a positive bacterial vaginosis (BV) swab?

Treatment of Bacterial Vaginosis

The first-line treatment for bacterial vaginosis is metronidazole 500 mg orally twice daily for 7 days, clindamycin cream 2% one full applicator (5 g) intravaginally at bedtime for 7 days, or metronidazole gel 0.75% one full applicator (5 g) intravaginally twice daily for 5 days. 1

First-Line Treatment Options for Non-Pregnant Women

The CDC recommends the following equally effective regimens for non-pregnant women with bacterial vaginosis:

• Metronidazole 500 mg orally twice daily for 7 days
• Metronidazole gel 0.75%, one full applicator (5 g) intravaginally twice daily for 5 days
• Clindamycin cream 2%, one full applicator (5 g) intravaginally at bedtime for 7 days 1

Clinical trials have demonstrated that oral metronidazole (7-day regimen) and clindamycin vaginal cream have similar cure rates of approximately 78-82%. Similarly, oral metronidazole and metronidazole vaginal gel have comparable cure rates of 84% and 75%, respectively. 1

Alternative Treatment Options

Alternative regimens include:

• Metronidazole 2 g orally in a single dose
• Clindamycin 300 mg orally twice daily for 7 days
• Clindamycin ovules 100 g intravaginally once at bedtime for 3 days 1

Treatment for Pregnant Women

For pregnant women, the recommended treatment is:

• Metronidazole 250 mg orally three times daily for 7 days 1, 2

This regimen balances efficacy with minimizing fetal exposure. The CDC recommends testing and treating all symptomatic pregnant women for bacterial vaginosis to prevent adverse pregnancy outcomes, including preterm birth. 1

Important Precautions and Patient Education

• Patients must avoid alcohol during metronidazole treatment and for 24 hours afterward to prevent disulfiram-like reactions 1
• Clindamycin cream and ovules are oil-based and may weaken latex condoms and diaphragms 1
• Routine follow-up is unnecessary if symptoms resolve, except in high-risk pregnant women 1

Management of Recurrent Bacterial Vaginosis

Recurrence is common, with 50-80% of women experiencing recurrence within a year of treatment 1, 3. For recurrent BV:

• Use another recommended treatment regimen different from the initial one 1
• For persistent recurrence, extended course of metronidazole treatment (500 mg twice daily for 10-14 days) is recommended 3
• An alternate regimen for persistent recurrence is metronidazole vaginal gel 0.75% for 10 days, followed by twice weekly for 3-6 months 3

Special Considerations

• Routine treatment of sex partners is not recommended, as clinical trials indicate that partner treatment does not affect a woman's response to therapy or likelihood of relapse/recurrence 1
• Screening and treating women with bacterial vaginosis before surgical abortion or hysterectomy may reduce post-operative infectious complications 1
• For high-risk pregnant women (with history of previous preterm birth), follow-up evaluation 1 month after treatment completion is recommended 1

Diagnostic Criteria

Bacterial vaginosis 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