What treatment is recommended for a patient with bacterial vaginosis (BV) presenting with a malodorous smell, who has tried boric acid capsules and over-the-counter (OTC) Canesten (clotrimazole) with some relief?

Treatment for Bacterial Vaginosis with Malodorous Smell

For bacterial vaginosis presenting with malodorous smell and partial response to boric acid and OTC clotrimazole, the recommended first-line treatment is metronidazole 500 mg orally twice daily for 7 days. 1

Diagnosis Confirmation

Before initiating treatment, confirm the diagnosis of bacterial vaginosis by assessing for:

• 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 (positive whiff test) 1

Treatment Options

First-line treatments (equally effective):

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

Alternative regimens:

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

Route of Administration Considerations

Intravaginal metronidazole is as effective as oral metronidazole but with significantly fewer side effects:

• Nausea: 10.2% (intravaginal) vs. 30.4% (oral)
• Abdominal pain: 16.8% (intravaginal) vs. 31.9% (oral)
• Metallic taste: 8.8% (intravaginal) vs. 17.9% (oral) 2

Important Precautions

• Avoid alcohol during metronidazole treatment and for 24 hours afterward to prevent disulfiram-like reactions 1
• Clindamycin cream and ovules are oil-based and might weaken latex condoms and diaphragms 1
• If using metronidazole while breastfeeding, consider temporary discontinuation of nursing or the medication 1

Management of Recurrent BV

If symptoms recur (common in 50-80% of women within a year):

1. Extended course of metronidazole: 500 mg twice daily for 10-14 days
2. If ineffective, metronidazole vaginal gel 0.75% for 10 days, followed by twice weekly for 3-6 months 3

Follow-up

• Routine follow-up is unnecessary if symptoms resolve 1
• If symptoms persist after treatment, consider alternative diagnosis or treatment failure

Common Pitfalls to Avoid

1. Mistaking candidiasis for BV: The patient's partial response to Canesten (clotrimazole) might indicate a mixed infection. Consider testing for both conditions.

2. Inadequate treatment duration: Complete the full course of antibiotics even if symptoms improve quickly.

3. Partner treatment: Routine treatment of sex partners is not recommended as clinical trials indicate it does not affect a woman's response to therapy or likelihood of recurrence 1

4. Using boric acid as primary treatment: While boric acid may provide some symptom relief, it is not a first-line treatment for BV according to guidelines.