Treatment of Bacterial Vaginosis
The recommended first-line treatment for bacterial vaginosis is oral metronidazole 500 mg twice daily for 7 days, which has a cure rate of 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 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 4, 1
Alternative Treatment Options
- Oral metronidazole 2g as a single dose has lower efficacy (84% cure rate) compared to the 7-day regimen (95%) but may be useful when compliance is a concern 1, 5
- Oral clindamycin 300 mg twice daily for 7 days is an alternative when metronidazole cannot be used 4, 1
- Tinidazole has shown efficacy in bacterial vaginosis treatment, with therapeutic cure rates of 36.8% for 1g daily for 5 days and 27.4% for 2g daily for 2 days 5
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 4, 1
- Clindamycin cream and ovules are oil-based and may weaken latex condoms and diaphragms 4, 2
- Metronidazole may cause gastrointestinal upset and unpleasant taste; intravaginal preparations have fewer systemic side effects (mean peak serum concentrations less than 2% of oral doses) 4, 1
Allergy or Intolerance to Metronidazole
- Clindamycin cream is preferred for patients with allergy or intolerance to metronidazole 4, 1
- Patients allergic to oral metronidazole should not be administered metronidazole vaginally 4, 2
Special Populations
Pregnancy
- For pregnant women, recommended regimens include metronidazole 250 mg orally three times daily for 7 days 4, 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 4, 6
- The use of clindamycin vaginal cream during pregnancy is not recommended due to increased risk of preterm deliveries 4
HIV Infection
- Patients who have BV and are infected with HIV should receive the same treatment regimen as those who are HIV-negative 4, 1
Follow-Up and Recurrence Management
- Follow-up visits are unnecessary if symptoms resolve 4, 2
- Recurrence of BV is common, with 50-80% of women experiencing recurrence within a year of treatment 7, 8
- For recurrent BV, an extended course of metronidazole treatment (500 mg twice daily for 10-14 days) is recommended; if ineffective, metronidazole vaginal gel 0.75% for 10 days, followed by twice weekly for 3-6 months 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, 2, 6
Special Clinical Situations
- Before surgical abortion or hysterectomy, screening and treating women with BV is recommended due to increased risk for postoperative infectious complications 4, 1
- Treatment of BV with metronidazole has been shown to substantially reduce post-abortion PID 4
Emerging Approaches
- Current areas of investigation for BV management include probiotics, vaginal microbiome transplantation, pH modulation, and biofilm disruption, though these are not yet standard of care 8