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

Treatment for Bacterial Vaginosis

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

First-Line Treatment Options

The CDC establishes three equally acceptable first-line regimens for non-pregnant women 1, 2:

• Metronidazole 500 mg orally twice daily for 7 days - This is the preferred regimen with superior efficacy (95% cure rate) 1, 2
• Metronidazole gel 0.75%, one full applicator (5g) intravaginally once daily for 5 days - Equally effective as oral therapy but with fewer systemic side effects 3, 1
• Clindamycin cream 2%, one full applicator (5g) intravaginally at bedtime for 7 days - Another effective first-line option, though appears less efficacious than metronidazole regimens 3, 1

Alternative Regimens (Lower Efficacy)

When compliance is a major concern, consider these options with reduced efficacy 1, 2:

• Metronidazole 2g orally as a single dose - Lower cure rate of 84% compared to 95% for the 7-day regimen 1, 2
• Oral clindamycin 300 mg twice daily for 7 days - Alternative when metronidazole cannot be used 3, 1
• Clindamycin ovules 100g intravaginally once at bedtime for 3 days 3

Tinidazole is FDA-approved for BV with regimens of either 2g once daily for 2 days or 1g once daily for 5 days, showing therapeutic cure rates of 27.4% and 36.8% respectively (compared to 5.1% for placebo) 4. However, these cure rates are notably lower than metronidazole due to stricter study criteria requiring resolution of all 4 Amsel's criteria plus Nugent score normalization 4.

Critical Patient Counseling

Patients must avoid all alcohol during metronidazole treatment and for 24 hours after completion to prevent disulfiram-like reactions 3, 1, 2.

Additional precautions include 3, 1, 2:

• Clindamycin cream and ovules are oil-based and will weaken latex condoms and diaphragms
• Metronidazole may cause gastrointestinal upset and unpleasant taste; intravaginal preparations have fewer systemic side effects 1

Special Populations

Pregnancy

All symptomatic pregnant women should be tested and treated for BV 1:

• First trimester: Clindamycin vaginal cream is preferred due to metronidazole contraindication 1
• Second and third trimesters: Metronidazole 250 mg orally three times daily for 7 days 1, 2, 5
• High-risk pregnant women (history of preterm delivery): Treatment may reduce risk of prematurity 3, 1

The established benefit in pregnancy is relief of vaginal symptoms, with additional potential benefits including reducing risk for infectious complications and preterm birth 3.

HIV Infection

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

Breastfeeding

CDC guidelines apply to breastfeeding women, as metronidazole is considered compatible with breastfeeding, with only small amounts excreted in breast milk 1.

Perimenopausal Women

Treatment approach remains consistent with standard BV management regardless of menopausal status 1.

Allergy or Intolerance to Metronidazole

Clindamycin cream or oral clindamycin is preferred for patients with metronidazole allergy 1, 6. Patients allergic to oral metronidazole should not be administered metronidazole vaginally 1, 6.

Management of Sex Partners

Routine treatment of male sex partners is NOT recommended, as clinical trials demonstrate no effect on cure rates, relapse, or recurrence 2, 5.

Follow-Up

Follow-up visits are unnecessary if symptoms resolve 3, 1, 2. Women should be advised to return for additional therapy if symptoms recur, as recurrence is not unusual 3.

Special Clinical Situations

Before Surgical Procedures

Screen and treat women with BV before surgical abortion or hysterectomy in addition to providing routine prophylaxis, due to increased risk for postoperative infectious complications 3, 2. Treatment with metronidazole substantially reduces postabortion PID by 10-75% 3, 2.

BV increases risk for 3, 2:

• Postabortion PID
• Post-hysterectomy infectious complications
• Endometritis and vaginal cuff cellulitis after invasive procedures

Recurrent BV

For recurrent BV, recommended treatment consists of an extended course of metronidazole 500 mg twice daily for 10-14 days 7. If ineffective, metronidazole vaginal gel 0.75% for 10 days, followed by twice per week for 3-6 months is an alternate regimen 7. As many as 50% of women experience recurrence within 1 year of treatment 7, 8.

Common Pitfalls

• Do not confuse BV with cytolytic vaginosis: BV has elevated pH >4.5, while cytolytic vaginosis has pH <4.0 and would worsen with antibiotics 6
• Boric acid is NOT a first-line treatment for BV and should only be considered as adjunctive treatment in recurrent BV after standard antimicrobial therapy has failed 6
• Single-dose metronidazole regimens have lower efficacy and should be reserved for compliance concerns only 1, 2