Bacterial Vaginosis Treatment Regimens
Treatment of symptomatic bacterial vaginosis (BV) is recommended for women with symptoms. [1]
Recommended first-line options include oral metronidazole, intravaginal metronidazole gel, or intravaginal clindamycin cream. [1]
Medication Selection Algorithm
Preferred regimens for nonpregnant women with symptomatic BV include the following: [1]
- Oral metronidazole (500 mg orally 2 times/day for 7 days). [1]
- Intravaginal metronidazole (0.75% gel, 5 g intravaginally once daily for 5 days). [1]
- Intravaginal clindamycin cream (2% clindamycin, 5 g intravaginally at bedtime for 7 days). [1]
Alternative regimens include the following: [1]
- Oral clindamycin (300 mg orally 2 times/day for 7 days). [1]
- Intravaginal clindamycin ovules (100 mg intravaginally once at bedtime for 3 days). [1]
- Oral secnidazole (2 g orally as a single dose). [1]
- Oral tinidazole (2 g orally once daily for 2 days). [1]
- Oral tinidazole (1 g orally once daily for 5 days). [1]
Core Treatment for Nonpregnant Women
Symptomatic BV in nonpregnant women should be treated with one of the recommended regimens: [1]
- Metronidazole 500 mg orally 2 times/day for 7 days. [1]
- Metronidazole gel 0.75%, 5 g intravaginally once daily for 5 days. [1]
- Clindamycin cream 2%, 5 g intravaginally at bedtime for 7 days. [1]
Monotherapy Versus Combination Therapy
BV treatment is recommended as monotherapy with a single recommended regimen rather than antibiotic combination regimens. [1]
Data are limited and no data directly compare the efficacy of oral versus topical medications for BV cure. [1]
Treatment in Pregnancy
Treatment is recommended for all symptomatic pregnant women with BV because symptomatic BV has been associated with adverse pregnancy outcomes. [1]
Pregnant women can be treated with any recommended nonpregnant regimens. [1]
Tinidazole should be avoided during pregnancy. [1]
S e c n i d a z o l e , Clindesse 2% vaginal cream, metronidazole 1.3% vaginal gel, and 750-mg vaginal metronidazole tablets should be avoided during pregnancy due to insufficient efficacy and safety data. [1]
Oral metronidazole administered as 500 mg orally 2 times/day for 7 days can be used in pregnancy. [1]
Oral clindamycin (300 mg orally 2 times/day for 7 days) can be used in pregnancy as an alternative regimen. [1]
Recurrent or Persistent BV Management
After a first recurrence, retreatment with the same recommended regimen is acceptable. [1]
For women with multiple recurrences after completion of a recommended regimen, suppressive options include: [1]
- 0.75% metronidazole gel intravaginally. [1]
- 750 mg metronidazole vaginal suppositories twice weekly for more than 3 months. [1]
For women with multiple recurrences, an option that has limited supporting data includes: [1]
- Oral nitroimidazole (metronidazole or tinidazole 500 mg orally 2 times/day for 7 days) followed by intravaginal boric acid 600 mg daily for 21 days and then suppressive 0.75% metronidazole gel twice weekly for 4–6 months. [1]
Partner Management and Counseling
Routine treatment of sex partners is not recommended because a woman’s response to therapy and likelihood of relapse or recurrence are not affected by treatment of sex partners. [1]
Women should be advised to refrain from sexual activity or to use condoms consistently and correctly during the BV treatment regimen. [1]
Douching should be avoided because it might increase the risk for relapse. [1]
Drug Safety and Practical Considerations
Intravaginal clindamycin cream should be preferred in case of allergy or intolerance to metronidazole or tinidazole. [1]
Intravaginal metronidazole gel can be considered for women who are not allergic to metronidazole but do not tolerate oral metronidazole. [1]
Refraining from alcohol use while taking metronidazole (or tinidazole) is unnecessary. [1]
Clindamycin cream is oil based and might weaken latex condoms and diaphragms for 5 days after use. [1]
Follow-Up
Follow-up visits are unnecessary if symptoms resolve. [1]
Women should return for evaluation if symptoms recur because persistent or recurrent BV is common. [1]
Targets of Therapy
Treatment benefits among nonpregnant women include relief of vaginal symptoms and signs of infection. [1]
Additional potential benefits include reduction in risk for acquisition of several STIs and HIV and HSV-2, plus reduction of BV recurrence in some contexts. [1]