What is the recommended treatment for bacterial vaginosis (B.V.)?

Treatment for Bacterial Vaginosis (B.V.)

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 of approximately 95%. 1, 2, 3

First-Line Treatment Options

• Oral metronidazole 500 mg twice daily for 7 days is the preferred treatment with the highest documented efficacy (95% cure rate) 1, 2, 3
• 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, 4
• Clindamycin cream 2%, one full applicator (5g) intravaginally at bedtime for 7 days is another effective first-line option 1, 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 1, 2, 3
• Oral clindamycin 300 mg twice daily for 7 days is an alternative when metronidazole cannot be used 1, 2
• Clindamycin ovules 100g intravaginally once at bedtime for 3 days 1

Treatment Considerations and Precautions

• Patients using metronidazole should avoid alcohol during treatment and for 24 hours afterward due to potential disulfiram-like reaction 1, 2, 3
• Clindamycin cream and ovules are oil-based and may weaken latex condoms and diaphragms 1, 2
• Intravaginal treatments generally cause fewer systemic side effects (like gastrointestinal upset and metallic taste) compared to oral metronidazole 4, 5
• Common side effects with oral metronidazole include nausea (30.4%), abdominal pain (31.9%), and metallic taste (17.9%), which occur significantly less frequently with intravaginal application 4

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, 2
• During second and third trimesters: Oral metronidazole can be used, although vaginal preparations may be preferable 1, 2
• Treatment of BV in high-risk pregnant women (history of preterm delivery) may reduce risk of prematurity 2, 6

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, 2

Follow-Up and Recurrence Management

• Follow-up visits are unnecessary if symptoms resolve 1, 2, 3
• Recurrence of BV is common, affecting 50-80% of women within one year of treatment 7, 8
• For recurrent BV, extended course of metronidazole treatment (500 mg twice daily for 10-14 days) is recommended 8
• Alternative for recurrent BV: metronidazole vaginal gel 0.75% for 10 days, followed by twice weekly for 3-6 months 8

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, 3

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, 2
• Treatment of BV with metronidazole has been shown to substantially reduce post-abortion PID 1

Emerging Approaches

• Areas of investigation for improving BV management include probiotics, vaginal microbiome transplantation, pH modulation, and biofilm disruption 7
• These approaches are still experimental and not yet recommended for routine clinical practice 7