Treatment of Bacterial Vaginosis with Flagyl (Metronidazole) Tablets

For non-pregnant women with bacterial vaginosis, the recommended treatment is oral metronidazole (Flagyl) 500 mg twice daily for 7 days. 1

First-line Treatment Options

Oral metronidazole (Flagyl) 500 mg twice daily for 7 days is the standard recommended regimen for BV treatment in non-pregnant women 1
Alternative topical options include:
- Metronidazole gel 0.75%, one full applicator (5g) intravaginally once daily for 5 days 1
- Clindamycin cream 2%, one full applicator (5g) intravaginally at bedtime for 7 days 1

Metronidazole 2g orally in a single dose - Note that this is considered an alternative regimen due to lower efficacy compared to the 7-day course 1
Clindamycin 300 mg orally twice daily for 7 days 1
Clindamycin ovules 100g intravaginally once at bedtime for 3 days 1
Flagyl ER (metronidazole) 750 mg once daily for 7 days - FDA approved but clinical equivalency data with other regimens is limited 1

Oral metronidazole (500 mg twice daily) is highly effective for BV treatment, resulting in relief of symptoms and improvement in clinical course 1
Based on randomized controlled trials, cure rates for the 7-day regimen of oral metronidazole and clindamycin vaginal cream were comparable (78% vs. 82%) 1
Similarly, cure rates for oral metronidazole and metronidazole vaginal gel were not significantly different (84% vs. 75%) 1, 2
Intravaginal metronidazole application has been shown to be as effective as oral administration with significantly fewer side effects 3

Patients must avoid consuming alcohol during treatment with metronidazole and for 24 hours afterward to prevent disulfiram-like reactions 1
Clindamycin cream and ovules are oil-based and may weaken latex condoms and diaphragms 1
Common side effects of oral metronidazole include:
- Nausea (30.4% with oral vs. 10.2% with vaginal administration) 3
- Abdominal pain (31.9% with oral vs. 16.8% with vaginal administration) 3
- Metallic taste (17.9% with oral vs. 8.8% with vaginal administration) 3

For pregnant women, different dosing is recommended:
- Metronidazole 250 mg orally three times daily for 7 days is the recommended regimen 1
- Metronidazole is contraindicated in the first trimester of pregnancy 1
- For high-risk pregnant women (those with history of preterm delivery), treatment of asymptomatic BV may reduce risk of preterm delivery 1

For recurrent BV, an extended course of metronidazole treatment (500 mg twice daily for 10-14 days) is recommended 4
If ineffective, metronidazole vaginal gel 0.75% for 10 days, followed by twice weekly for 3-6 months can be considered 4

Clindamycin cream or oral clindamycin is preferred in case of allergy or intolerance to metronidazole 1
Metronidazole gel can be considered for patients who don't tolerate systemic metronidazole 1
Patients allergic to oral metronidazole should not use metronidazole vaginally 1

Follow-up visits are unnecessary if symptoms resolve 1
Recurrence of BV is not unusual and patients should return for additional therapy if symptoms recur 1, 4
Routine treatment of sex partners is not recommended as clinical trials indicate that a woman's response to therapy and likelihood of relapse are not affected by treatment of her partner(s) 1

Oral metronidazole is particularly effective against anaerobic bacteria, which play a major role in causing BV symptoms 5
Intravaginal treatments may be preferred by some patients due to fewer systemic side effects 3, 2
Patient satisfaction is generally higher with intravaginal products compared to oral metronidazole 2