Treatment of Bacterial Vaginosis
The recommended first-line treatment for bacterial vaginosis is oral metronidazole 500 mg twice daily for 7 days, which has the highest efficacy with cure rates 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) 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, 3
- Clindamycin cream 2%, one full applicator (5g) intravaginally at bedtime for 7 days is another effective first-line option 2, 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 2, 1
- Clindamycin ovules 100g intravaginally once at bedtime for 3 days 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
- Intravaginal preparations have significantly fewer systemic side effects compared to oral metronidazole 3
- Common side effects of oral metronidazole include nausea (30.4%), abdominal pain (31.9%), and metallic taste (17.9%), while intravaginal application has significantly lower rates of these side effects (nausea 10.2%, abdominal pain 16.8%, metallic taste 8.8%) 3
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, 1
Special Populations
Pregnancy
- All symptomatic pregnant women should be tested and treated for BV 1, 2
- During pregnancy, metronidazole 250 mg orally three times daily for 7 days is recommended 2
- Treatment of BV in high-risk pregnant women (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 deliveries 2
Before Surgical Procedures
- Screening and treating women with BV before surgical abortion or hysterectomy is recommended due to increased risk for postoperative infectious complications 2
- Treatment of BV with metronidazole has been shown to substantially reduce post-abortion PID 2
Follow-Up and Recurrence Management
- Follow-up visits are unnecessary if symptoms resolve 2, 1
- Recurrence of BV is common, and patients should be advised to return for additional therapy if symptoms recur 2, 1
- No long-term maintenance regimen with any therapeutic agent is recommended 2
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, 1, 4
Comparative Efficacy of Treatment Options
- A randomized controlled trial found that once-daily dosing of metronidazole gel 0.75% for 5 days is as effective as twice-daily dosing (77% vs 80% cure rate) 5
- Another study comparing oral metronidazole, metronidazole vaginal gel, and clindamycin vaginal cream found no statistically significant differences in cure rates (84.2%, 75.0%, and 86.2% respectively) 6
- Intravaginal application of metronidazole has been shown to be as effective as oral administration (92.5% vs 89.9% cure rate) with significantly fewer adverse events 3