Treatment of Bacterial Vaginosis
For bacterial vaginosis, oral metronidazole 500 mg twice daily for 7 days is the recommended first-line treatment with the highest efficacy (95% cure rate). 1, 2
First-Line Treatment Options
- Oral metronidazole 500 mg twice daily for 7 days is considered the preferred treatment for bacterial vaginosis in non-pregnant women 1, 2
- 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, 3
- Clindamycin cream 2%, one full applicator (5g) intravaginally at bedtime for 7 days is another effective first-line option 4, 1
Alternative Treatment Options
- Oral metronidazole 2g as a single dose has lower efficacy (84% cure rate) compared to the 7-day regimen (95%) but may be useful when compliance is a concern 4, 1, 2
- Oral clindamycin 300 mg twice daily for 7 days is an alternative when metronidazole cannot be used 4, 1
- Tinidazole has been FDA-approved for bacterial vaginosis treatment, with options of 2g once daily for 2 days or 1g once daily for 5 days 5
Special Populations
Pregnancy
- For pregnant women, metronidazole 250 mg orally three times daily for 7 days is recommended 1, 6
- During first trimester, clindamycin vaginal cream is preferred due to theoretical concerns about metronidazole 1
- Treatment of BV in high-risk pregnant women (history of preterm delivery) may reduce risk of prematurity 1, 6
Breastfeeding Women
- Standard treatment regimens can be used for breastfeeding women, as metronidazole is considered compatible with breastfeeding 1
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 4, 1, 2
- Clindamycin cream is oil-based and might weaken latex condoms and diaphragms 4, 1
- Metronidazole may cause gastrointestinal upset and unpleasant taste; intravaginal preparations have fewer systemic side effects 4, 1
Allergy or Intolerance to Metronidazole
- Clindamycin cream or oral clindamycin is preferred for patients with allergy or intolerance to metronidazole 4, 1
- Patients allergic to oral metronidazole should not be administered metronidazole vaginally 1
Recurrent Bacterial Vaginosis
- For recurrent BV, an extended course of metronidazole treatment (500 mg twice daily for 10-14 days) is recommended 7
- If ineffective, metronidazole vaginal gel 0.75% for 10 days, followed by twice weekly application for 3-6 months is an alternate regimen 7
- Recurrence rates are high, with 50-80% of women experiencing recurrence within a year of treatment 8, 7
Follow-Up and Partner Management
- Follow-up visits are unnecessary if symptoms resolve 4, 1, 2
- 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 4, 1, 6