Recommended Treatment for Bacterial Vaginosis (BV)
For bacterial vaginosis, oral metronidazole 500 mg twice daily for 7 days is the preferred first-line treatment with the highest efficacy (95% cure rate). 1
First-Line Treatment Options
- Oral metronidazole 500 mg twice daily for 7 days - considered the gold standard treatment with highest efficacy 1, 2
- Metronidazole gel 0.75%, one full applicator (5g) intravaginally once daily for 5 days - 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 - another effective first-line option 4, 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 4, 1, 2
- Oral clindamycin 300 mg twice daily for 7 days - an alternative when metronidazole cannot be used 4, 1
Treatment Considerations and Side Effects
- Patients using metronidazole should avoid alcohol during treatment and for 24 hours afterward due to potential disulfiram-like reaction 4, 1
- Clindamycin cream is oil-based and may weaken latex condoms and diaphragms 4, 1
- Oral metronidazole commonly causes gastrointestinal upset (30.4% report nausea) and unpleasant metallic taste (17.9%) 3
- Intravaginal preparations have significantly fewer systemic side effects (10.2% nausea with intravaginal vs. 30.4% with oral administration) 3
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, 5
- Treatment of BV in high-risk pregnant women (history of preterm delivery) may reduce risk of prematurity 1, 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
Follow-Up and Recurrence Management
- Follow-up visits are unnecessary if symptoms resolve 4, 1
- Recurrence is common, with 50-80% of women experiencing a BV recurrence within a year of completing antibiotic treatment 6, 7
- For recurrent BV, recommended treatment consists of an extended course of metronidazole (500 mg twice daily for 10-14 days) 7
- If ineffective, metronidazole vaginal gel 0.75% for 10 days, followed by twice weekly for 3-6 months, is an alternate treatment regimen 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 4, 1, 5