What are the treatment options for bacterial vaginosis (BV), Mycoplasma genitalium, Mycoplasma hominis, Escherichia coli (E. coli), and Group B streptococcus (Group B strep) infections?

Treatment Options for Bacterial Vaginosis, Mycoplasma, E. coli, and Group B Strep Infections

For bacterial vaginosis (BV), the preferred treatment is oral metronidazole 500 mg twice daily for 7 days, which has the highest efficacy rate of 95%. 1

Bacterial Vaginosis (BV) Treatment

First-Line Options

• Oral metronidazole 500 mg twice daily for 7 days - highest efficacy (95% cure rate) 1
• Metronidazole gel 0.75%, one full applicator (5g) intravaginally once daily for 5 days - equally effective with fewer systemic side effects 1
• Clindamycin cream 2%, one full applicator (5g) intravaginally at bedtime for 7 days 1

Alternative Options

• Metronidazole 2g orally in a single dose - lower efficacy (84% cure rate) but useful when compliance is a concern 2, 1
• Clindamycin 300 mg orally twice daily for 7 days 2, 1
• Clindamycin ovules 100g intravaginally once at bedtime for 3 days 2

Special Considerations

• For patients allergic to metronidazole: Use clindamycin cream or oral clindamycin 2, 1
• Patients allergic to oral metronidazole should not use metronidazole vaginally 2, 1
• Avoid alcohol during metronidazole treatment and for 24 hours afterward due to potential disulfiram-like reaction 1
• Clindamycin cream and ovules may weaken latex condoms and diaphragms 1

Trichomoniasis Treatment

• Recommended regimen: Metronidazole 2g orally in a single dose 2
• Alternative regimen: Metronidazole 500 mg twice daily for 7 days 2
• Treatment of sex partners is recommended to increase cure rates and reduce transmission 2

Mycoplasma genitalium and Mycoplasma hominis Treatment

While specific guidelines for these infections are not provided in the evidence, the following treatments are generally effective:

• For Mycoplasma genitalium: Extended course of azithromycin or moxifloxacin may be effective
• For Mycoplasma hominis: Clindamycin 300 mg orally twice daily for 7 days is often effective

E. coli and Group B Streptococcus Treatment

• For urogenital E. coli infections: Appropriate antibiotics based on susceptibility testing
• For Group B Streptococcus: Penicillin or ampicillin are typically first-line treatments

Treatment in Pregnancy

• All symptomatic pregnant women should be tested and treated for BV 2, 1
• Recommended regimen: Metronidazole 250 mg orally three times daily for 7 days 2, 1
• Alternative regimen: Clindamycin 300 mg orally twice daily for 7 days 2
• During first trimester: Clindamycin vaginal cream is preferred due to contraindication of metronidazole 1
• Treatment of BV in high-risk pregnant women (history of preterm delivery) may reduce risk of prematurity 1

Follow-Up and Recurrence Management

• Follow-up visits are unnecessary if symptoms resolve 2, 1
• For recurrent BV: Extended course of metronidazole (500 mg twice daily for 10-14 days) 3
• Alternative for recurrent BV: Metronidazole vaginal gel 0.75% for 10 days, followed by twice weekly for 3-6 months 3
• Secnidazole 2g as a single dose has been shown to be as effective as multiple-dose metronidazole and may be convenient for patients with recurrence 4

Management of Sex Partners

• Routine treatment of male sex partners is not recommended for BV as it has not been shown to influence a woman's response to therapy or reduce recurrence rates 2, 1
• For trichomoniasis, treatment of sex partners is recommended 2

Clinical Pearls

• BV is associated with adverse pregnancy outcomes including preterm delivery 2, 1
• Metronidazole gel is not effective for trichomoniasis despite being effective for BV 2
• Cytolytic vaginosis can mimic BV symptoms but requires different treatment (sodium bicarbonate rather than antibiotics) 5
• Before surgical abortion or hysterectomy, screening and treating women with BV is recommended due to increased risk for postoperative infectious complications 1