Treatment of Bacterial Vaginosis (BV)
The first-line treatment for bacterial vaginosis is oral metronidazole 500 mg twice daily for 7 days, which has cure rates of up to 95%. 1
First-Line Treatment Options
- Oral metronidazole 500 mg twice daily for 7 days 2, 1
- Metronidazole gel 0.75%, one full applicator (5g) intravaginally once daily for 5 days 2, 1
- Clindamycin cream 2%, one full applicator (5g) intravaginally at bedtime for 7 days 2
Alternative Treatment Options
- Metronidazole 2g orally in a single dose (note: lower efficacy than 7-day regimen) 2, 1
- Clindamycin 300 mg orally twice daily for 7 days 2, 1
- Clindamycin ovules 100g intravaginally once at bedtime for 3 days 2
- Tinidazole has shown efficacy in bacterial vaginosis treatment at doses of 2g once daily for 2 days or 1g once daily for 5 days 3
Important Precautions
- Patients using metronidazole should avoid alcohol during treatment and for 24 hours afterward due to potential disulfiram-like reaction 2, 1
- Clindamycin cream and ovules are oil-based and may weaken latex condoms and diaphragms 2, 1
Special Populations
Pregnancy
- All symptomatic pregnant women should be tested and treated for BV 2
- For pregnant women, recommended regimen is metronidazole 250 mg orally three times daily for 7 days 2, 1
- Treatment of BV in high-risk pregnant women (those with history of preterm delivery) may reduce risk of prematurity 1
- Systemic therapy is preferred for pregnant women to treat possible subclinical upper genital tract infections 2, 4
Allergy or Intolerance to Metronidazole
- Clindamycin cream or oral clindamycin is preferred for patients with allergy or intolerance to metronidazole 2, 1
- Metronidazole gel can be considered for patients who do not tolerate systemic metronidazole, but patients allergic to oral metronidazole should not be administered metronidazole vaginally 2
Follow-Up and Recurrence Management
- Follow-up visits are unnecessary if symptoms resolve 2, 1
- Recurrence of BV is common, with 50-80% of women experiencing recurrence within one year of treatment 5, 6
- For recurrent BV, an extended course of metronidazole treatment (500 mg twice daily for 10-14 days) is recommended 5
- If the extended course is ineffective, metronidazole vaginal gel 0.75% for 10 days, followed by twice weekly for 3-6 months, is an alternative regimen 5
Partner Management
- Routine treatment of sex partners is not recommended as clinical trials indicate that a woman's response to therapy and likelihood of relapse or recurrence are not affected by treatment of her partner(s) 2, 1
Emerging Approaches
- Areas of investigation for BV management include probiotics, vaginal microbiome transplantation, pH modulation, and biofilm disruption 6
- Initial studies on biofilm disruption and use of probiotics have shown promise but require further research before clinical implementation 5, 6