What is the management of bacterial vaginosis?

Management of Bacterial Vaginosis

The first-line treatment for bacterial vaginosis is oral metronidazole 500 mg twice daily for 7 days, which has a 95% cure rate and is recommended by the CDC. 1

Diagnosis Confirmation

Before initiating treatment, confirm diagnosis using Amsel's criteria (3 of 4 required):

• Homogeneous vaginal discharge
• Clue cells on microscopic examination
• Vaginal fluid pH > 4.5
• Positive whiff test (fishy odor with 10% KOH) 1

First-Line Treatment Options

All of these options are considered equally effective by the CDC:

1. Oral Metronidazole:

   • 500 mg orally twice daily for 7 days (95% cure rate) 1

2. Topical Options:

   • 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

3. Alternative Option:

   • Tinidazole: FDA-approved for bacterial vaginosis in adult women
     • 2g once daily for 2 days OR
     • 1g once daily for 5 days 2

Special Considerations

Pregnancy

• First trimester: Clindamycin cream 2% applied intravaginally at bedtime for 7 days is preferred 1
• After first trimester: Metronidazole may be safely used 1
• Alternative: Amoxicillin-clavulanic acid is a safe option during pregnancy 1
• Treatment is important as untreated BV increases risk of preterm birth, low birth weight, and chorioamnionitis 1
• Follow-up evaluation 1 month after treatment is recommended for pregnant women 1

Important Precautions

• Patients using metronidazole should avoid alcohol during treatment and for 24 hours afterward to prevent disulfiram-like reactions 1
• Patients should abstain from sexual intercourse until completing the full course of treatment 1
• Unlike STIs, routine treatment of male sex partners is not recommended for BV 1

Management of Recurrent BV

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

• Use a different treatment regimen than the initial one 1
• Extended course options:
  • Metronidazole 500 mg twice daily for 10-14 days 4
  • If ineffective, metronidazole vaginal gel 0.75% for 10 days, followed by twice weekly for 3-6 months 4

Follow-up

• Follow-up visits are not necessary if symptoms resolve in non-pregnant women 1
• For pregnant women, follow-up evaluation 1 month after treatment completion is recommended 1

Common Pitfalls to Avoid

1. Inadequate diagnosis: Ensure all other potential causes of vulvovaginitis (Trichomonas, Candida, Chlamydia, Gonorrhea, Herpes) are ruled out 2
2. Poor adherence: Emphasize the importance of completing the full treatment course
3. Alcohol consumption: Warn patients about disulfiram-like reactions with metronidazole 1
4. Treating partners: Unlike STIs, partner treatment is not recommended and does not affect recurrence rates 1
5. Single-dose treatment: While convenient, metronidazole 2g as a single dose has a lower cure rate (84%) compared to the 7-day regimen (95%) 1