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 rate of approximately 95%. 1
First-Line Treatment Options
- Oral metronidazole 500 mg twice daily for 7 days is the preferred treatment with the highest efficacy 1
- 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, 2
- Clindamycin cream 2%, one full applicator (5g) intravaginally at bedtime for 7 days is another effective first-line option 2, 1
Alternative Treatment Options
- Metronidazole 2g orally in a single dose has lower efficacy (84% cure rate) compared to the 7-day regimen but may be useful when compliance is a concern 2, 1, 3
- Oral clindamycin 300 mg twice daily for 7 days is an alternative when metronidazole cannot be used 2
- Clindamycin ovules 100g intravaginally once at bedtime for 3 days 2
- Tinidazole has shown efficacy in clinical trials when given as either 2g once daily for 2 days or 1g once daily for 5 days 4
Special Considerations
Pregnancy
- All symptomatic pregnant women should be tested and treated for BV due to associated adverse pregnancy outcomes 2, 1
- For pregnant women, metronidazole 250 mg orally three times daily for 7 days is recommended 1, 5
- Systemic therapy is preferred over topical therapy during pregnancy to treat possible subclinical upper genital tract infections 2, 3
- Clindamycin vaginal cream is not recommended during pregnancy due to increased risk of preterm deliveries 3
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
Treatment Precautions
- Patients using metronidazole should avoid alcohol during treatment and for 24 hours afterward due to potential disulfiram-like reaction 2, 1
- Clindamycin cream and ovules are oil-based and may weaken latex condoms and diaphragms 2, 1
- Metronidazole may cause gastrointestinal upset and unpleasant taste; intravaginal preparations have fewer systemic side effects 2, 1
Recurrent Bacterial Vaginosis
- For recurrent BV, an extended course of metronidazole treatment (500 mg twice daily for 10-14 days) is recommended 6
- If ineffective, metronidazole vaginal gel 0.75% for 10 days, followed by twice weekly for 3-6 months, is an alternative regimen 6
- Longer courses of therapy are recommended for women with documented multiple recurrences 7
Follow-Up and Management of Sex Partners
- Follow-up visits are unnecessary if symptoms resolve 2, 1
- Patients should be advised to return for additional therapy if symptoms recur 2, 1
- 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 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
Treatment Efficacy Comparison
- The 7-day regimen of oral metronidazole and clindamycin vaginal cream have similar cure rates (78% vs. 82%) 2
- The 7-day regimen of oral metronidazole and metronidazole vaginal gel have similar cure rates (84% vs. 75%) 2
- Vaginal clindamycin cream appears less efficacious than the metronidazole regimens 2