Treatment of Bacterial Vaginosis (BV)
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 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
- Oral metronidazole 2g 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 for BV treatment as either 2g once daily for 2 days or 1g once daily for 5 days 3
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 2, 1
- Clindamycin cream and ovules are oil-based and may weaken latex condoms and diaphragms 2, 1
- Metronidazole may cause gastrointestinal upset; intravaginal preparations have fewer systemic side effects 1, 4
Allergy or Intolerance to Metronidazole
- Clindamycin cream or oral clindamycin is preferred for patients with allergy or intolerance to metronidazole 1, 5
- Patients allergic to oral metronidazole should not be administered metronidazole vaginally 1, 5
Special Populations
Pregnancy
- All symptomatic pregnant women should be tested and treated for BV 1, 5
- During first trimester: Clindamycin vaginal cream is preferred due to contraindication of metronidazole 1
- During second and third trimesters: Metronidazole 250 mg orally three times daily for 7 days is recommended 1, 6
- Treatment of BV in high-risk pregnant women (history of preterm delivery) may reduce risk of prematurity 2, 5
Breastfeeding Women
- Metronidazole is considered compatible with breastfeeding 1
- While small amounts of metronidazole are excreted in breast milk, the amount is not significant enough to cause harm to the infant 1
Follow-Up and Recurrence Management
- Follow-up visits are unnecessary if symptoms resolve 2, 1
- Recurrence is common, with 50-80% of women experiencing recurrence within a year of treatment 7, 8
- For recurrent BV, extended course of metronidazole treatment (500 mg twice daily for 10-14 days) is recommended; if ineffective, metronidazole vaginal gel 0.75% for 10 days, followed by twice weekly for 3-6 months 8
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, 1, 6
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, 5
- Treatment of BV with metronidazole has been shown to substantially reduce post-abortion PID 2