From the Guidelines
The first-line treatment for bacterial vaginosis (BV) is oral metronidazole (Flagyl) 500 mg taken twice daily for 7 days. This systemic therapy is generally preferred as it achieves high cure rates and treats both vaginal and potential upper genital tract infections 1. Alternative first-line options include metronidazole gel 0.75% (one full applicator vaginally once daily for 5 days) or clindamycin cream 2% (one full applicator vaginally at bedtime for 7 days) 1. These topical treatments are equally effective for uncomplicated BV and may be preferred in cases where oral therapy is contraindicated or poorly tolerated.
Key Considerations
- Oral metronidazole works by disrupting DNA synthesis in anaerobic bacteria that cause BV, such as Gardnerella vaginalis.
- Patients should avoid alcohol during treatment with metronidazole and for 24 hours afterward to prevent disulfiram-like reactions.
- Treatment is important even in asymptomatic cases during pregnancy to reduce risk of preterm birth and other complications 1.
Treatment Options
- Metronidazole 500 mg orally twice a day for 7 days
- Metronidazole gel 0.75%, one full applicator (5 g) intravaginally, once a day for 5 days
- Clindamycin cream 2%, one full applicator (5 g) intravaginally at bedtime for 7 days It is essential to note that the recommended metronidazole regimens are equally efficacious, and the vaginal clindamycin cream appears less efficacious than the metronidazole regimens 1. Follow-up visits are unnecessary if symptoms resolve, but recurrence is not unusual, and patients should return for additional treatment if symptoms recur 1.
From the FDA Drug Label
INDICATIONS AND USAGE Metronidazole vaginal gel is indicated in the treatment of bacterial vaginosis The first line treatment for BV is Metronidazole gel 0.75% 1 full applicator (5g) vaginally once daily x 5 days 2.
From the Research
Treatment Options for Bacterial Vaginosis
The first line of treatment for bacterial vaginosis (BV) is:
- Metronidazole (Flagyl) 500 mg PO bid x 7 days, as suggested by 3, 4 Other effective treatment regimens include:
- Metronidazole gel 0.75% 1 full applicator (5g) vaginally once daily x 5 days, as mentioned in 3, 5, 4
- Clindamycin cream 2% 1 full applicator (5g) vaginally qhs x 7 days, as noted in 3, 5, 4, 6
Comparison of Treatment Regimens
Studies have compared the efficacy of these treatment regimens, with results showing:
- No statistically significant differences in cure rates for oral metronidazole, metronidazole vaginal gel, and clindamycin vaginal cream, as reported in 5
- Similar rates of posttreatment vulvovaginal candidiasis among the different treatment groups, as found in 5
- The effectiveness of treatment may vary, with some studies suggesting that standard treatment methods may not always be effective, as noted in 7