Bacterial Vaginosis Empiric Therapy

The treatment regimens for bacterial vaginosis are provided below, including primary, alternative, and adjunctive treatments, as well as specific treatments for pregnant patients, patients allergic to metronidazole, and patients with recurrent infection.[1, 2, 3, 4, 5, 6]

Primary treatment

Metronidazole 500 mg PO BID for 7d ormetronidazole gel 0.75% (use one full applicator [5g] intravaginally daily for 5d) or clindamycin cream 2% (use one full applicator [5g] intravaginally at bedtime for 7d

Secnidazole 1 packet (2 gram) of granules PO q day, without regard to timing of meals

Alternative treatment

Tinidazole 2 g PO once daily for 2d or tinidazole 1 g PO once daily for 5d orclindamycin 300 mg PO BID for 7d or clindamycin ovules 100 mg intravaginally once at bedtime for 3d or metronidazole extended-release 750 mg PO once daily for 7d. Intravaginal dequalinium chloride 10 mg once daily for 6d also appears to be effective but is not FDA approved for use in the United States.[6]

Pregnant patients

Metronidazole 500 mg PO BID for 7d or metronidazole 250 mg PO TID for 7d or clindamycin 300 mg PO BID for 7d

Patients allergic to metronidazole

Intravaginal clindamycin cream is preferred in the presence of patient allergies or intolerance

Recurrent infection

Metronidazole gel 0.75% (after completion of recommended regimen, use one full applicator [5g] intravaginally twice weekly for 4-6mo or using a different treatment regimen is an option in patients with recurrent infections; re-treatment with the same topical regimen is also an acceptable approach in early stages of infection.

Treatment of partners has not been shown to decrease recurrence rates

Adjunctive therapy

Probiotic (Lactobacillus rhamnosus, L acidophilus, and Streptococcus thermophilus) vaginal capsule daily for 7d, repeat 7d later (not FDA approved)[5]

Organism-specific therapy

Specific etiology is not typically established for the diagnosis of bacterial vaginosis

CDC guidelines for the treatment of bacterial vaginosis

In 2021, the Centers for Disease Control and Prevention (CDC) updated its clinical practice guidelines on the treatment of sexually transmitted infections.[2]  These are some of the highlights of the recommendations for the treatment of bacterial vaginosis.

The recommended treatment regimens for bacterial vaginosis are as follows:

• Metronidazole at 500 mg PO BID for 7 days or
• Metronidazole gel 0.75% one full applicator (5 g) intravaginally once daily for 5 days or
• Clindamycin cream 2% one full applicator (5 g) intravaginally at bedtime for 7 days

Alternative treatment regimens for bacterial vaginosis are as follows:

• Clindamycin at 300 mg PO BID for 7 days or
• Clindamycin ovules 100 mg intravaginally once at bedtime for 3 days (oleaginous base used in ovules may weaken rubber or latex products [eg, condoms, diaphragms]; using such products ≤72 hours after treatment with clindamycin ovules not recommended) or
• Secnidazole 2 g oral granules in a single dose or
• Tinidazole at 2 g PO once daily for 2 days or
• Tinidazole at 1 g PO once daily for 5 days