Treatment of Bacterial Vaginosis (BV)
The recommended first-line treatment for bacterial vaginosis is oral metronidazole 500 mg twice daily for 7 days, which has demonstrated cure rates of up to 95%. 1, 2
First-Line Treatment Options
- Oral metronidazole 500 mg twice daily for 7 days is the preferred treatment with the highest efficacy (95% cure rate) 2, 1
- Metronidazole gel 0.75%, one full applicator (5g) intravaginally once daily for 5 days is equally effective as oral therapy but with fewer systemic side effects 2, 1
- Clindamycin cream 2%, one full applicator (5g) intravaginally at bedtime for 7 days is another effective first-line option 2
Alternative Treatment Options
- Oral metronidazole 2g as a single dose has lower efficacy (84% cure rate) compared to the 7-day regimen but may be useful when compliance is a concern 2, 1
- Oral clindamycin 300 mg twice daily for 7 days is an alternative when metronidazole cannot be used 2, 1
- Clindamycin ovules 100g intravaginally once at bedtime for 3 days 2
- Tinidazole has shown efficacy as either 2g once daily for 2 days or 1g once daily for 5 days 3
Special Populations
Pregnancy
- All symptomatic pregnant women should be tested and treated for BV 2, 1
- During first trimester: Clindamycin vaginal cream is preferred due to contraindication of metronidazole 2
- During second and third trimesters: Metronidazole 250 mg orally three times daily for 7 days is recommended 2, 4
- Treatment of BV in high-risk pregnant women (history of preterm delivery) may reduce risk of prematurity 1, 4
HIV Infection
- Patients with HIV and BV should receive the same treatment as persons without HIV 2
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 2, 1
- Clindamycin cream and ovules are oil-based and may weaken latex condoms and diaphragms 2, 1
- Metronidazole may cause gastrointestinal upset and unpleasant taste; intravaginal preparations have fewer systemic side effects 2
Allergy or Intolerance to Metronidazole
- Clindamycin cream or oral clindamycin is preferred for patients with allergy or intolerance to metronidazole 2, 1
- 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, affecting up to 50-80% of women 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
- Alternative regimen for recurrent BV: metronidazole vaginal gel 0.75% for 10 days, followed by twice weekly for 3-6 months 5
Management of Sex Partners
- 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 2, 4
- Treatment of sex partners in clinical trials has not influenced relapse or recurrence rates 2