What is the treatment for Bacterial Vaginosis (BV)?

Treatment of Bacterial Vaginosis (BV)

Metronidazole 500 mg orally twice daily for 7 days is the recommended first-line treatment for bacterial vaginosis, with alternative options including clindamycin cream 2% intravaginally at bedtime for 7 days or metronidazole gel 0.75% intravaginally twice daily for 5 days. 1

Diagnosis of BV

BV is diagnosed when at least three of the following four clinical criteria (Amsel's criteria) are present:

• Homogeneous, white, non-inflammatory discharge that smoothly coats the vaginal walls 1
• Presence of clue cells on microscopic examination 1
• Vaginal fluid pH greater than 4.5 1
• Fishy odor of vaginal discharge before or after addition of 10% KOH (positive whiff test) 1

Alternatively, Gram stain of vaginal smear showing characteristic bacterial morphotypes can be used for diagnosis 1

Treatment Options

First-Line Treatment

• Metronidazole 500 mg orally twice daily for 7 days (95% cure rate) 1, 2
• Patients should avoid alcohol during treatment with metronidazole and for 24 hours afterward due to potential disulfiram-like reaction 1

Alternative Regimens

• Clindamycin cream 2%, one full applicator (5 g) intravaginally at bedtime for 7 days 1
  • Note: Clindamycin cream is oil-based and might weaken latex condoms and diaphragms 1
• Metronidazole gel 0.75%, one full applicator (5 g) intravaginally twice daily for 5 days 1
• Metronidazole 2 g orally in a single dose (lower efficacy than 7-day regimen) 1
• Clindamycin 300 mg orally twice daily for 7 days 1
• Tinidazole 2 g once daily for 2 days or 1 g once daily for 5 days 3

Treatment Considerations for Special Populations

Pregnant Women

• BV during pregnancy is associated with adverse pregnancy outcomes including preterm birth 1
• Treatment is recommended for all symptomatic pregnant women 1
• High-risk pregnant women (those with history of preterm delivery) with asymptomatic BV may benefit from evaluation and treatment 1

Before Invasive Procedures

• Consider treatment of women with symptomatic or asymptomatic BV before surgical abortion procedures 1
• BV has been associated with post-procedure infections including endometritis, PID, and vaginal cuff cellulitis 1

Management of Recurrent BV

• Recurrence rates of 50-80% within one year of treatment are common 4, 5
• Extended course of metronidazole treatment (500 mg twice daily for 10-14 days) is recommended for recurrent BV 5
• If ineffective, metronidazole vaginal gel 0.75% for 10 days, followed by twice weekly for 3-6 months can be considered 5

Important Clinical Considerations

• Treatment of male sex partners has not been shown to prevent recurrence of BV and is not recommended 1, 6
• All symptomatic women should be treated, regardless of pregnancy status 1
• Follow-up visits are not necessary if symptoms resolve 7
• Laboratory testing fails to identify the cause of vaginitis in a substantial minority of women 1, 7

Common Pitfalls to Avoid

• Treating asymptomatic women unnecessarily (except in specific high-risk situations) 1, 7
• Failing to treat before invasive gynecological procedures, which may increase risk of post-procedure infections 1
• Premature discontinuation of therapy leading to treatment failure 8
• Failing to advise patients about alcohol avoidance during metronidazole treatment 1
• Treating male partners, which has not been shown to be beneficial in preventing recurrence 1, 6