What is the recommended treatment for bacterial vaginosis?

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 95%. 1

First-Line Treatment Options

• Oral metronidazole 500 mg twice daily for 7 days is the preferred treatment with the highest efficacy 2, 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 2, 1
• 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 as 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
• Oral clindamycin 300 mg twice daily for 7 days is an alternative when metronidazole cannot be used 2, 1
• Clindamycin ovules 100g intravaginally once at bedtime for 3 days 2
• 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 3

Treatment Considerations

Side Effects and Precautions

• Patients using metronidazole should avoid consuming alcohol during treatment and for 24 hours afterward due to potential disulfiram-like reaction 2, 1
• Clindamycin cream and ovules are 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 1

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

Special Populations

Pregnancy

• All symptomatic pregnant women should be tested and treated for BV 2, 1
• During pregnancy, metronidazole 250 mg orally three times daily for 7 days is recommended 1, 4
• Systemic therapy is preferred over topical therapy during pregnancy to treat possible subclinical upper genital tract infections 2, 5
• Treatment of BV in high-risk pregnant women (history of preterm delivery) may reduce risk of prematurity 1, 5
• Clindamycin vaginal cream is not recommended during pregnancy due to increased risk of preterm deliveries 5

Follow-Up and Recurrence Management

• Follow-up visits are unnecessary if symptoms resolve 2, 1
• Recurrence of BV is not unusual, with 50-80% of women experiencing recurrence within a year of treatment 6, 7
• For recurrent BV, an extended course of metronidazole treatment (500 mg twice daily for 10-14 days) is recommended 7
• If the extended course is ineffective, metronidazole vaginal gel 0.75% for 10 days, followed by twice weekly for 3-6 months, is an alternate treatment regimen 7
• No long-term maintenance regimen with any therapeutic agent is consistently recommended 2

Management of Sex Partners

• 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
• BV has been associated with adverse pregnancy outcomes (e.g., premature rupture of the membranes, chorioamnionitis, preterm labor, preterm birth) 2, 5