What is the recommended treatment for bacterial vaginosis?

Recommended Treatment for Bacterial Vaginosis

Oral metronidazole 500 mg twice daily for 7 days is the preferred first-line treatment for bacterial vaginosis, achieving cure rates up to 95%. 1, 2

First-Line Treatment Options

The CDC recommends three equally effective first-line regimens 1, 2:

• Oral metronidazole 500 mg twice daily for 7 days - This achieves the highest cure rate (95%) and should be your default choice 1, 2
• Metronidazole gel 0.75% intravaginally (one full 5g applicator) once daily for 5 days - Equally efficacious as oral therapy but with fewer systemic side effects (no gastrointestinal upset or metallic taste) 1, 2
• Clindamycin cream 2% intravaginally (one full 5g applicator) at bedtime for 7 days - Another effective first-line option 2

Alternative Regimens

When compliance is a concern or first-line options fail 1, 2:

• Oral metronidazole 2g as a single dose - Lower efficacy (84% cure rate) but useful when adherence is questionable 1, 2
• Oral clindamycin 300 mg twice daily for 7 days - Use when metronidazole cannot be tolerated 1, 2
• Tinidazole 2g once daily for 2 days OR 1g once daily for 5 days - FDA-approved alternative with therapeutic cure rates of 27.4% and 36.8% respectively (though lower than metronidazole) 3

Special Populations

Pregnancy

All symptomatic pregnant women must be tested and treated 1, 2:

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

Breastfeeding Women

• Standard CDC guidelines apply - metronidazole is compatible with breastfeeding as only small amounts are excreted in breast milk 2
• Intravaginal preparations result in minimal systemic absorption (<2% of oral dose serum concentrations) 2

Metronidazole Allergy or Intolerance

• Use clindamycin cream or oral clindamycin instead 1, 2
• Critical pitfall: Patients allergic to oral metronidazole should NOT receive metronidazole vaginally 2

Essential Treatment Precautions

Alcohol Avoidance

• Patients must avoid alcohol during metronidazole treatment and for 24 hours afterward due to potential disulfiram-like reaction 1, 2

Contraceptive Considerations

• Clindamycin cream and ovules are oil-based and may weaken latex condoms and diaphragms 1, 2

Asymptomatic BV

• Do not treat asymptomatic BV unless the patient is undergoing surgical abortion or hysterectomy, where treatment reduces postoperative infectious complications 2

Follow-Up and Partner Management

• No follow-up visits are necessary if symptoms resolve 1, 2
• Do not routinely treat male sex partners - this has not been shown to influence treatment response or reduce recurrence rates 1, 2, 4
• Advise patients to return only if symptoms recur 1, 2

Recurrent BV Management

When BV recurs (occurs in up to 50% of women within one year) 5, 6:

• Extended metronidazole course: 500 mg twice daily for 10-14 days 5
• If ineffective: Metronidazole gel 0.75% for 10 days, then twice weekly for 3-6 months 5
• Recurrence may be due to biofilm formation that protects bacteria from antimicrobials 5, 7