How is bacterial vaginosis (BV) treated?

Treatment of Bacterial Vaginosis

Bacterial vaginosis (BV) should be treated with metronidazole 500 mg orally twice daily for 7 days as the first-line treatment due to its high efficacy rate of 95%. Oral metronidazole 500 mg twice daily for 7 days is the recommended first-line treatment for bacterial vaginosis. 1, 2

First-Line Treatment Options

• Metronidazole 500 mg orally twice daily for 7 days (95% cure rate) 1, 2
• Metronidazole gel 0.75%, one full applicator (5g) intravaginally once daily for 5 days 1, 2
• Clindamycin cream 2%, one full applicator (5g) intravaginally at bedtime for 7 days 1, 2

Alternative Treatment Options

• Metronidazole 2g orally as a single dose (lower efficacy of 84% compared to the 7-day regimen) 1
• Clindamycin 300 mg orally twice daily for 7 days 1
• Clindamycin ovules 100g intravaginally once at bedtime for 3 days 1
• Tinidazole has also shown efficacy for BV treatment in clinical trials 3

Important Clinical Considerations

• Patients using metronidazole should avoid alcohol during treatment and for 24 hours afterward due to potential disulfiram-like reaction 1
• Clindamycin cream and ovules are oil-based and might weaken latex condoms and diaphragms 1, 2
• Intravaginal treatments may cause fewer systemic side effects than oral metronidazole (such as gastrointestinal upset and unpleasant taste) 1, 2
• Follow-up visits are unnecessary if symptoms resolve 1, 2

Special Populations

Pregnancy

• All symptomatic pregnant women should be tested and treated for BV 1, 2
• First trimester: Clindamycin vaginal cream is preferred due to contraindication of metronidazole 1, 4
• Second and third trimesters: Oral metronidazole can be used 1, 4
• Treatment of BV in high-risk pregnant women (history of preterm delivery) may reduce risk of prematurity 2, 5

Allergy or Intolerance to Metronidazole

• 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

Management of Recurrent BV

• Recurrence is common, affecting 50-80% of women within a year of completing antibiotic treatment 6, 7
• For recurrent BV, an extended course of metronidazole treatment (500 mg twice daily for 10-14 days) is recommended 7
• If ineffective, metronidazole vaginal gel 0.75% for 10 days, followed by twice weekly for 3-6 months, is an alternative regimen 7
• Emerging approaches for recurrent BV include probiotics, biofilm disruption, and pH modulation, though more research is needed 6, 7

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

Special Clinical Situations

• Consider treatment of BV (symptomatic or asymptomatic) before surgical abortion procedures, as treatment with metronidazole has been shown to substantially reduce post-abortion PID 1
• Some specialists recommend screening and treating women with BV before hysterectomy due to increased risk for postoperative infectious complications 1, 8

Clinical Pitfalls to Avoid

• Treating asymptomatic women unnecessarily (except before certain invasive procedures) 1, 8
• Using single-dose metronidazole when higher efficacy is needed (7-day regimen has higher cure rate) 1, 2
• Failing to warn patients about alcohol interaction with metronidazole 1
• Not considering treatment before invasive gynecological procedures, which may increase risk of post-procedure infections 1, 8
• Not addressing recurrent BV with extended treatment regimens 7