What is the recommended treatment for bacterial vaginosis?

Treatment of Bacterial Vaginosis

The recommended first-line treatment for bacterial vaginosis is oral metronidazole 500 mg twice daily for 7 days, which has shown cure rates of up to 95%. 1

First-Line Treatment Options

• Oral metronidazole 500 mg twice daily for 7 days - This regimen has demonstrated high efficacy with cure rates of approximately 95% and is considered a first-line treatment 1
• Metronidazole gel 0.75% - One full applicator (5g) intravaginally once daily for 5 days; equally efficacious as oral metronidazole but with fewer systemic side effects 1, 2
• Clindamycin cream 2% - One full applicator (5g) intravaginally at bedtime for 7 days; slightly less efficacious than metronidazole regimens but still an effective option 1, 3

Alternative Treatment Options

• Oral metronidazole 2g as a single dose - Lower efficacy (84% cure rate) compared to the 7-day regimen (95%), but may be useful when compliance is a concern 1
• Oral clindamycin 300 mg twice daily for 7 days - An alternative when metronidazole cannot be used 1
• Clindamycin ovules 100g intravaginally once at bedtime for 3 days - Another alternative option with similar efficacy to clindamycin cream 1
• Tinidazole - FDA-approved for bacterial vaginosis; can be given as 2g once daily for 2 days or 1g once daily for 5 days 4

Treatment Considerations

Side Effects and Precautions

• Patients using metronidazole should avoid alcohol during treatment and for 24 hours afterward due to potential disulfiram-like reaction 1
• Oral metronidazole commonly causes gastrointestinal side effects (nausea in 30.4%, abdominal pain in 31.9%) and metallic taste (17.9%) 2
• Intravaginal treatments have significantly fewer systemic side effects than oral regimens (nausea: 10.2% vs 30.4%, p<0.001) 2
• Clindamycin cream and ovules are oil-based and may weaken latex condoms and diaphragms 1

Special Populations

Pregnancy

• All symptomatic pregnant women should be tested and treated 1
• For pregnant women, recommended regimens include:
  • Metronidazole 250 mg orally three times daily for 7 days 1
  • Clindamycin 300 mg orally twice daily for 7 days 1
• Treatment of BV in high-risk pregnant women (history of preterm delivery) may reduce risk of prematurity 1
• Topical treatments are generally not recommended during pregnancy 1

Allergy or Intolerance to Metronidazole

• Clindamycin cream or oral clindamycin is preferred 1
• Metronidazole gel can be considered for patients who don't tolerate systemic metronidazole, but should be avoided in those with true allergy to oral metronidazole 1

Management of Recurrent BV

• Recurrence rates are high, with 50-80% of women experiencing recurrence within a year of treatment 5, 6
• For recurrent BV, extended course of metronidazole (500 mg twice daily for 10-14 days) is recommended 5
• Alternative approach for recurrent cases: metronidazole vaginal gel 0.75% for 10 days, followed by twice weekly application for 3-6 months 5

Follow-Up and Partner Treatment

• Follow-up visits are unnecessary if symptoms resolve 1
• Routine treatment of male sex partners is not recommended as it has not been shown to influence a woman's response to therapy or reduce recurrence rates 1, 7
• Patients should be advised to return for additional therapy if symptoms recur 1

Common Pitfalls to Avoid

• Failing to advise patients to avoid alcohol during and 24 hours after metronidazole treatment 1
• Not considering treatment of asymptomatic BV before invasive gynecological procedures, particularly surgical abortion, which has been shown to reduce post-procedure infections 1
• Treating male partners, which studies have consistently shown does not improve outcomes or prevent recurrence 1, 7
• Using topical treatments during pregnancy, which may be associated with adverse outcomes 1