What is the treatment for bacterial vaginosis?

Treatment of Bacterial Vaginosis

First-Line Treatment Regimens

Oral metronidazole 500 mg twice daily for 7 days is the preferred treatment for bacterial vaginosis, achieving a 95% cure rate and representing the highest efficacy among available options. 1, 2, 3

The following regimens are equally acceptable first-line options for non-pregnant women:

• 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 (mean peak serum concentrations <2% of oral doses) 4, 1

• Clindamycin cream 2%, one full applicator (5g) intravaginally at bedtime for 7 days 4, 1

Critical Patient Counseling

• Patients must avoid all alcohol during metronidazole treatment and for 24 hours after completion to prevent disulfiram-like reactions 4, 1, 3

• Clindamycin cream is oil-based and will weaken latex condoms and diaphragms—patients must use alternative contraception during treatment 4, 1, 3

Alternative Regimens (Lower Efficacy)

Use these only when compliance is a major concern or first-line options cannot be used:

• Metronidazole 2g orally as a single dose has significantly lower efficacy (84% cure rate vs. 95% for 7-day regimen) 4, 1, 2

• Oral clindamycin 300 mg twice daily for 7 days 4, 2

• Tinidazole 2g once daily for 2 days OR 1g once daily for 5 days (FDA-approved alternative with therapeutic cure rates of 27-37%) 5

Treatment for Special Populations

Pregnancy

• All symptomatic pregnant women should be tested and treated 1, 2

• First trimester: Clindamycin vaginal cream is preferred due to metronidazole contraindication concerns 1

• Second and third trimesters: Metronidazole 250 mg orally three times daily for 7 days 1, 6

• High-risk pregnant women (history of preterm delivery) should receive treatment even if asymptomatic, as this may reduce prematurity risk 4, 2, 3

Metronidazole Allergy or Intolerance

• Use clindamycin cream 2% intravaginally OR oral clindamycin 300 mg twice daily for 7 days 1, 2

• Never administer metronidazole vaginally to patients allergic to oral metronidazole 1, 2

HIV-Positive Patients

• Treat identically to HIV-negative patients—no regimen modifications needed 1

Clinical Context Requiring Treatment

Beyond symptom relief, treatment is particularly important in these situations:

• Before surgical abortion or hysterectomy: Screen and treat all women with BV in addition to routine prophylaxis, as treatment reduces postabortion PID by 10-75% 4, 3

• Before other invasive procedures (endometrial biopsy, IUD placement, cesarean section, uterine curettage): Consider screening and treatment due to association with endometritis, PID, and vaginal cuff cellulitis 4

Follow-Up and Partner Management

• No follow-up visit is necessary if symptoms resolve 4, 1, 2, 3

• Do not treat male sex partners routinely—clinical trials demonstrate no effect on cure rates, relapse, or recurrence 3, 6

• Advise patients to return only if symptoms recur, as recurrence occurs in 50-80% of women within one year despite initial cure 7, 8

Recurrent Bacterial Vaginosis

• For recurrence: Use metronidazole 500 mg orally twice daily for 10-14 days (extended course) 8

• If extended course fails: Metronidazole gel 0.75% for 10 days, then twice weekly for 3-6 months as suppressive therapy 8

• Recurrence may be due to biofilm formation protecting bacteria from antimicrobials, though biofilm disruption strategies remain investigational 8, 9