What is the treatment for bacterial vaginosis (BV)?

Treatment for Bacterial Vaginosis

The recommended first-line treatment for bacterial vaginosis is oral metronidazole 500 mg twice daily for 7 days, which has a high efficacy rate of 95%. 1, 2

First-Line Treatment Options

• Oral metronidazole 500 mg twice daily for 7 days is the standard treatment with excellent clinical efficacy 2
• Alternative topical options with similar efficacy include:
  • Metronidazole gel 0.75%, one full applicator (5g) intravaginally twice daily for 5 days 2, 3
  • Clindamycin cream 2%, one full applicator (5g) intravaginally at bedtime for 7 days 2, 3

Alternative Treatment Options

• Metronidazole 2g orally in a single dose (lower efficacy of 84% but useful when compliance is a concern) 2
• Clindamycin 300 mg orally twice daily for 7 days 2
• Flagyl ER (metronidazole) 750 mg once daily for 7 days (FDA-approved but limited comparative data) 2

Important Precautions

• Patients must avoid consuming alcohol during metronidazole treatment and for 24 hours afterward to prevent disulfiram-like reactions 2
• Clindamycin cream is oil-based and may weaken latex condoms and diaphragms 2
• Patients allergic to oral metronidazole should not use metronidazole vaginally 2
• For metronidazole allergy, clindamycin cream is the preferred alternative 2

Special Considerations for Pregnancy

• For pregnant women, especially in the second trimester, metronidazole 250 mg orally three times daily for 7 days is recommended 2, 1
• Alternative regimens for pregnant women include:
  • Metronidazole 2g orally in a single dose 2
  • Clindamycin 300 mg orally twice daily for 7 days 2
• Treatment of BV in high-risk pregnant women (those with previous preterm birth) may reduce the risk of preterm delivery 1
• During the first trimester, clindamycin vaginal cream is preferred due to concerns about metronidazole 2

Follow-Up and Recurrence Management

• Follow-up visits are unnecessary if symptoms resolve 2
• Recurrence of BV is common, affecting up to 50% of women within one year of treatment 4
• For recurrent BV, an extended course of metronidazole treatment (500 mg twice daily for 10-14 days) is recommended 4
• If the extended course is ineffective, metronidazole vaginal gel 0.75% for 10 days, followed by twice weekly application for 3-6 months can be used 4

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 2, 5
• Treatment of sex partners has not influenced the woman's response to therapy in clinical trials 2

Clinical Pearls

• BV is associated with adverse pregnancy outcomes, including preterm delivery 2, 1
• Before surgical abortion or hysterectomy, screening and treating women with BV is recommended due to increased risk for postoperative infectious complications 1
• Comparative studies show similar efficacy between oral metronidazole and vaginal treatments (clindamycin cream and metronidazole gel) 6
• Patient satisfaction may be higher with intravaginal products despite similar efficacy rates 6
• Tinidazole is also FDA-approved for bacterial vaginosis treatment 7