Treatment of Bacterial Vaginosis (BV)

Metronidazole 500 mg orally twice daily for 7 days is the first-line treatment for bacterial vaginosis, with cure rates of up to 95%. 1

First-Line Treatment Options

Oral metronidazole 500 mg twice daily for 7 days is highly effective for BV treatment 2, 1
Metronidazole gel 0.75%, one full applicator (5g) intravaginally once daily for 5 days is equally efficacious as oral metronidazole but with fewer systemic side effects 2, 1, 3
Clindamycin cream 2%, one full applicator (5g) intravaginally at bedtime for 7 days, though this appears less efficacious than the metronidazole regimens 2

Metronidazole 2g orally in a single dose (lower efficacy of approximately 84% compared to the 7-day regimen) 2, 1, 4
Clindamycin 300 mg orally twice daily for 7 days 2, 1
Clindamycin ovules 100g intravaginally once at bedtime for 3 days 2
Tinidazole has FDA approval for BV treatment with demonstrated efficacy in clinical trials 5

Patients using metronidazole should avoid consuming alcohol during treatment and for 24 hours afterward due to potential disulfiram-like reaction 2, 1
Intravaginal metronidazole results in significantly fewer side effects compared to oral administration, with less nausea (10.2% vs. 30.4%), abdominal pain (16.8% vs. 31.9%), and metallic taste (8.8% vs. 17.9%) 3
Clindamycin cream and ovules are oil-based and might weaken latex condoms and diaphragms 2, 1

All symptomatic pregnant women should be tested and treated for BV 2
For pregnant women, metronidazole 250 mg orally three times daily for 7 days is recommended 2, 6
Treatment of BV in high-risk pregnant women (those with history of preterm delivery) may reduce risk of prematurity 2, 1
Clindamycin vaginal cream is not recommended during pregnancy due to increased risk of preterm delivery 2

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 visits are unnecessary if symptoms resolve 2, 1
Recurrence of BV is common, with 50-80% of women experiencing recurrence within a year of treatment 7, 8
For recurrent BV, an extended course of metronidazole treatment (500 mg twice daily for 10-14 days) is recommended; if ineffective, metronidazole vaginal gel 0.75% for 10 days, followed by twice weekly for 3-6 months 7
Patients should be advised to return for additional therapy if symptoms recur, and another recommended treatment regimen may be used 2, 1

Routine treatment of male 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 sex partner(s) 2, 1, 6

Current areas of investigation for BV management include probiotics, vaginal microbiome transplantation, pH modulation, and biofilm disruption, though these require further study before clinical implementation 8