Recommended Treatment for Bacterial Vaginosis (BV)
The Centers for Disease Control and Prevention recommends oral metronidazole 500 mg twice daily for 7 days as the preferred treatment for bacterial vaginosis with the highest efficacy (95% cure rate). 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) 1, 2
- 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 1, 2
- Clindamycin cream 2%, one full applicator (5g) intravaginally at bedtime for 7 days is another effective first-line option 1
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 1, 2
- Oral clindamycin 300 mg twice daily for 7 days is an alternative when metronidazole cannot be used 1, 2
- Tinidazole 2g once daily for 2 days or 1g once daily for 5 days has demonstrated superior efficacy over placebo in clinical trials 3
Treatment in Special Populations
Pregnancy
- All symptomatic pregnant women should be tested and treated for BV 1, 2
- During first trimester: Clindamycin vaginal cream is preferred due to contraindication of metronidazole 1
- During second and third trimesters: Metronidazole 250 mg orally three times daily for 7 days is recommended 1, 4
- Treatment of BV in high-risk pregnant women (history of preterm delivery) may reduce risk of prematurity 1, 2, 4
Patients with Metronidazole Allergy or Intolerance
- Clindamycin cream or oral clindamycin is preferred for patients with allergy or intolerance to metronidazole 1, 2
- Patients allergic to oral metronidazole should not be administered metronidazole vaginally 1
Important 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, 2
- Clindamycin cream and ovules are oil-based and may weaken latex condoms and diaphragms 1, 2
- Metronidazole may cause gastrointestinal upset and unpleasant taste; intravaginal preparations have fewer systemic side effects 1
Follow-Up and Recurrence Management
- Follow-up visits are unnecessary if symptoms resolve 1, 2
- For recurrent BV (which affects up to 50% of women within one year of treatment), extended course of metronidazole treatment (500 mg twice daily for 10-14 days) is recommended 5
- An alternative regimen for recurrent BV is 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 1, 2, 4
Special Clinical Situations
- Before surgical abortion or hysterectomy, screening and treating women with BV is recommended due to increased risk for postoperative infectious complications 1
- Treatment of BV with metronidazole has been shown to substantially reduce post-abortion pelvic inflammatory disease 1
Emerging Treatment Approaches
- Current areas of investigation for BV management include probiotics, vaginal microbiome transplantation, pH modulation, and biofilm disruption, though these are not yet part of standard treatment guidelines 6