What is the recommended treatment for Bacterial Vaginosis (BV)?

Treatment of Bacterial Vaginosis

Oral metronidazole 500 mg twice daily for 7 days is the recommended first-line treatment for bacterial vaginosis with the highest efficacy rate of 95%. 1, 2

First-Line Treatment Options

• Oral metronidazole 500 mg twice daily for 7 days is the preferred treatment recommended by the Centers for Disease Control and Prevention due to its high efficacy (95% cure rate) 1, 2
• Metronidazole gel 0.75%, one full applicator (5g) intravaginally once daily for 5 days is an effective alternative with fewer systemic side effects 1
• Clindamycin cream 2%, one full applicator (5g) intravaginally at bedtime for 7 days is another effective first-line option 1, 3

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 1, 3
• Oral clindamycin 300 mg twice daily for 7 days is an alternative when metronidazole cannot be used 1, 2
• Tinidazole has shown efficacy in bacterial vaginosis treatment, with therapeutic cure rates of 36.8% for the 1g × 5 days regimen and 27.4% for the 2g × 2 days regimen 4

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 1, 2, 3
• Metronidazole may cause gastrointestinal upset and unpleasant taste; intravaginal preparations have fewer systemic side effects (mean peak serum concentrations following intravaginal administration are less than 2% of standard oral doses) 1, 3
• Clindamycin cream and ovules are oil-based and may weaken latex condoms and diaphragms 1

Allergy or Intolerance to Metronidazole

• For patients allergic or intolerant to metronidazole, clindamycin cream or oral clindamycin is the preferred alternative 1, 2
• Patients allergic to oral metronidazole should not be administered metronidazole vaginally 1, 2

Special Populations

Pregnancy

• All symptomatic pregnant women should be tested and treated for BV 1
• 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, 2
• Treatment of BV in high-risk pregnant women (history of preterm delivery) may reduce risk of prematurity 1, 2

HIV Infection

• Patients with HIV and BV should receive the same treatment as persons without HIV 1

Follow-Up and Recurrence Management

• Follow-up visits are not necessary if symptoms resolve 1, 3
• Recurrence of BV is common (50-80% within one year of treatment) 5, 6
• For recurrent BV, an 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 is an alternative regimen 6

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 1, 3, 7

Special Clinical Situations

• Before surgical abortion or hysterectomy, screening and treating women with BV is recommended due to increased risk for postoperative infectious complications 1, 3
• Treatment of BV with metronidazole has been shown to substantially reduce post-abortion PID 3

Emerging Approaches for Recurrent BV

• Current areas of investigation for managing recurrent BV include probiotics, vaginal microbiome transplantation, pH modulation, and biofilm disruption 5
• Behavioral modifications that may help include smoking cessation, condom use, and hormonal contraception 5