What is the dose and duration of Augmentin (amoxicillin/clavulanate) for treating bacterial vaginosis with a positive culture for Escherichia coli and Enterococcus faecalis?

Augmentin is Not Recommended for Bacterial Vaginosis with E. coli and Enterococcus faecalis

Metronidazole 500 mg orally twice daily for 7 days is the recommended first-line treatment for bacterial vaginosis, not Augmentin, even with positive cultures for E. coli and Enterococcus faecalis. 1

Correct Treatment Options for Bacterial Vaginosis

The CDC guidelines clearly outline the following recommended treatment regimens for bacterial vaginosis:

First-line options:

• Metronidazole 500 mg orally twice daily for 7 days
• Metronidazole gel 0.75%, one full applicator (5 g) intravaginally once daily for 5 days
• Clindamycin 300 mg orally twice daily for 7 days
• Clindamycin ovules 100 g intravaginally once at bedtime for 3 days 1

Alternative options:

• Metronidazole 2 g orally in a single dose (lower efficacy)
• Clindamycin cream 2%, one full applicator (5 g) intravaginally at bedtime for 7 days 1

Important Clinical Considerations

Diagnostic Confirmation

Before initiating treatment, confirm the diagnosis of bacterial vaginosis using clinical criteria:

• Homogeneous, white discharge adhering to vaginal walls
• Presence of clue cells on microscopic examination
• Vaginal fluid pH greater than 4.5
• Positive whiff test (fishy odor with 10% KOH) 1

Why Not Augmentin?

1. Augmentin (amoxicillin/clavulanate) is not included in any guideline recommendations for bacterial vaginosis
2. Augmentin may actually worsen BV by further disrupting vaginal flora
3. Despite positive cultures for E. coli and Enterococcus faecalis, these organisms are likely secondary colonizers rather than primary pathogens in BV

Treatment Considerations

• Patients taking metronidazole must avoid alcohol during 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
• Oral metronidazole commonly causes mild-to-moderate gastrointestinal disturbance and unpleasant taste 1

Follow-up and Recurrence Management

• Routine follow-up is unnecessary if symptoms resolve 1
• Recurrence is common (50-80% of women experience recurrence within a year) 1, 2
• For recurrent BV, an extended course of metronidazole treatment (500 mg twice daily for 10-14 days) is recommended 2
• Alternative for recurrent cases: metronidazole vaginal gel 0.75% for 10 days, followed by twice weekly for 3-6 months 2

Common Pitfalls to Avoid

• Using single-dose regimens as first-line therapy (lower efficacy) 1
• Failing to warn patients about alcohol interaction with metronidazole 1
• Treating male sex partners (not shown to improve outcomes or prevent recurrence) 1
• Using antibiotics not recommended in guidelines, such as Augmentin, which may disrupt vaginal flora further

Despite the presence of E. coli and Enterococcus faecalis in cultures, standard BV treatment with metronidazole or clindamycin remains the appropriate approach according to current guidelines.