Treatment of Bacterial Vaginosis
The recommended first-line treatment for bacterial vaginosis is oral metronidazole 500 mg twice daily for 7 days, which has the highest efficacy with a 95% cure rate. 1
First-Line Treatment Options
- Oral metronidazole 500 mg twice daily for 7 days - most effective regimen with highest cure rate 2, 1
- Metronidazole gel 0.75%, one full applicator (5g) intravaginally twice daily for 5 days - equally effective with fewer systemic side effects 2, 1
- Clindamycin cream 2%, one full applicator (5g) intravaginally at bedtime for 7 days - another effective first-line option 2, 1
Alternative Treatment 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 - alternative when metronidazole cannot be used 2, 1
- Tinidazole 2g once daily for 2 days or 1g once daily for 5 days - shown to be superior to placebo in clinical trials 3
Special Populations
Pregnancy
- First trimester: Clindamycin vaginal cream is preferred due to contraindication of metronidazole 2, 1
- Second and third trimesters: Oral metronidazole can be used 2, 1
- Treatment of BV in high-risk pregnant women (history of preterm delivery) may reduce risk of prematurity 1
HIV Infection
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 2, 1
- Clindamycin cream is oil-based and might weaken latex condoms and diaphragms 2, 1
- 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) 2
Allergy or Intolerance to Metronidazole
- Clindamycin cream or oral clindamycin is preferred for patients with allergy or intolerance to metronidazole 2, 1
- Patients allergic to oral metronidazole should not be administered metronidazole vaginally 2, 1
Management of Recurrent BV
- Extended course of metronidazole treatment (500 mg twice daily for 10-14 days) is recommended for recurrent BV 4
- If ineffective, metronidazole vaginal gel 0.75% for 10 days, followed by twice weekly for 3-6 months can be used 4
- Recurrence is common, with 50-80% of women experiencing recurrence within a year of treatment 4, 5
Follow-Up and Sex Partner Management
- Follow-up visits are unnecessary if symptoms resolve 2, 1
- Routine treatment of sex partners is not recommended as it has not been shown to influence a woman's response to therapy or reduce recurrence rates 2, 1
Special Clinical Situations
- Before surgical abortion or hysterectomy, screening and treating women with BV is recommended due to increased risk for postoperative infectious complications 2, 1
- Treatment of BV with metronidazole has been shown to substantially reduce post-abortion PID 2, 1
Important Distinctions
- BV should not be confused with cytolytic vaginosis, which involves excessive growth of lactobacilli and requires different treatment (sodium bicarbonate douches rather than antibiotics) 6
- BV is characterized by an elevated vaginal pH above 4.5, while cytolytic vaginosis typically has a pH below 4.0 6