What are the recommended treatments for bacterial vaginosis and yeast infections?

Medications for Bacterial Vaginosis and Yeast Infections

Bacterial Vaginosis Treatment

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

First-Line Options

• Oral metronidazole 500 mg twice daily for 7 days achieves 95% cure rates and is the gold standard treatment 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 (achieves less than 2% of standard oral dose serum concentrations) 1, 2
• Clindamycin cream 2%, one full applicator (5g) intravaginally at bedtime for 7 days is another effective first-line option 2, 1

Alternative Regimens

• Oral metronidazole 2g single dose has lower efficacy (84% cure rate) but may be used 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
• Tinidazole 2g once daily for 2 days or 1g once daily for 5 days demonstrates therapeutic cure rates of 27.4% and 36.8% respectively (compared to 5.1% for placebo) 3

Critical Treatment Precautions

• Patients must avoid alcohol during metronidazole treatment and for 24 hours afterward to prevent disulfiram-like reactions 2, 1
• Clindamycin cream is oil-based and weakens latex condoms and diaphragms for several days after use 1, 4
• Metronidazole may cause gastrointestinal upset and unpleasant taste; intravaginal preparations minimize these effects 2, 1

Special Populations

Pregnancy

• First trimester: Clindamycin vaginal cream is preferred because metronidazole is contraindicated 2, 1
• Second and third trimesters: Metronidazole 250 mg orally three times daily for 7 days is recommended 1, 5
• All symptomatic pregnant women should be tested and treated 1, 4
• Treatment in high-risk pregnant women (history of preterm delivery) may reduce prematurity risk 1, 4

Allergy or Intolerance

• Clindamycin cream or oral clindamycin is preferred for patients with metronidazole allergy or intolerance 2, 1
• Patients allergic to oral metronidazole should not receive metronidazole vaginally 2, 1

HIV Infection

• Patients with HIV and BV should receive the same treatment as persons without HIV 2, 1

Breastfeeding

• Standard CDC guidelines apply to breastfeeding women, as metronidazole is compatible with breastfeeding 1
• Intravaginal preparations minimize systemic absorption if preferred 1

Follow-Up and Partner Management

• Follow-up visits are unnecessary if symptoms resolve 2, 1
• Routine treatment of male sex partners is not recommended as it does not influence response to therapy or reduce recurrence rates 2, 1, 5
• Recurrence is common; the same treatment regimens can be used for recurrent disease 2

Recurrent Bacterial Vaginosis

• Extended metronidazole 500 mg twice daily for 10-14 days is recommended for recurrent BV 6
• If ineffective, metronidazole vaginal gel 0.75% for 10 days, followed by twice weekly for 3-6 months is an alternative suppressive regimen 6
• No long-term maintenance regimen beyond 3-6 months is currently recommended 7

Yeast Infection Treatment

Clotrimazole intravaginally treats vaginal yeast infections and relieves external itching and irritation. 8

Available Options

• Clotrimazole vaginal cream or tablets are FDA-approved for treating vaginal yeast infections 8
• The medication relieves both internal infection and external vulvar itching and irritation 8

Common Pitfall

• Posttreatment vulvovaginal candidiasis occurs in 12.5-30.4% of patients treated for bacterial vaginosis, with metronidazole vaginal gel showing the highest rate (30.4%) 9
• This is a potential complication to counsel patients about when treating bacterial vaginosis 9