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

Treatment of Bacterial Vaginosis (BV)

The first-line treatment for bacterial vaginosis in non-pregnant women is metronidazole 500 mg orally twice daily for 7 days, as recommended by the CDC. 1

First-Line Treatment Options

Several equally effective regimens are available:

• Oral options:

  • Metronidazole 500 mg orally twice daily for 7 days
  • Clindamycin 300 mg orally twice daily for 7 days

• Vaginal options:

  • Metronidazole gel 0.75%, one full applicator (5 g) intravaginally once daily for 5 days
  • Clindamycin ovules 100g intravaginally once at bedtime for 3 days 1

Alternative Regimens

• Metronidazole 2 g orally in a single dose (note: lower efficacy than 7-day regimen) 1
• Clindamycin cream 2%, one full applicator (5 g) intravaginally at bedtime for 7 days 1
• Tinidazole 2 g once daily for 2 days or 1 g once daily for 5 days (shown superior efficacy over placebo) 2

Important Precautions

• Alcohol interaction: Patients must avoid alcohol during metronidazole treatment and for 24 hours afterward to prevent disulfiram-like reactions 1
• Condom compatibility: Clindamycin cream and ovules are oil-based and may weaken latex condoms and diaphragms 1
• Side effects: Oral metronidazole commonly causes mild-to-moderate gastrointestinal disturbance and unpleasant taste 1

Treatment During Pregnancy

• Metronidazole 250 mg orally three times daily for 7 days (lower dose to minimize fetal exposure) 1
• Alternative: metronidazole 2 g orally in a single dose 1
• All symptomatic pregnant women should be treated to prevent adverse pregnancy outcomes 1
• High-risk pregnant women (history of previous preterm birth) should be screened and treated, preferably in the early second trimester 1

Follow-up and Recurrence

• Routine follow-up is unnecessary if symptoms resolve, except in high-risk pregnant women 1
• Recurrence is common (50-80% of women within a year) 1, 3
• For recurrent BV:
  • Extended course of metronidazole (500 mg twice daily for 10-14 days)
  • If ineffective, metronidazole vaginal gel 0.75% for 10 days, followed by twice weekly for 3-6 months 4

Common Pitfalls to Avoid

1. Using single-dose regimen as first-line therapy: The 2 g single-dose metronidazole has lower efficacy than the 7-day regimen 1, 5
2. Failing to warn patients about alcohol interaction with metronidazole 1
3. Treating male sex partners: Not recommended as clinical trials show no improvement in outcomes or prevention of recurrence 1, 6
4. Not considering treatment before procedures: Screening and treating women with BV before surgical abortion or hysterectomy may reduce post-operative infectious complications 1

Diagnosis Reminder

BV diagnosis requires three of the following clinical criteria:

• Homogeneous, white 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