A 28-year-old female presents with thin, grey discharge and fishy odour consistent with BV. What is the most appropriate treatment?

A 28-year-old female presents with thin, grey discharge and fishy odour consistent with BV. What is the most appropriate treatment?

• A. Oral metronidazole 400 mg twice daily for 7 days
• B. Topical clindamycin
• C. Oral fluconazole
• D. Metronidazole gel 0.75% once daily for 5 days

Answer: (A)

Bacterial vaginosis arises from a shift in vaginal flora with overgrowth of anaerobic bacteria and a loss of protective lactobacilli. Metronidazole is highly effective against anaerobes, which is why it’s the preferred treatment. The oral regimen given—metronidazole taken twice daily for about a week—provides good vaginal and pelvic tissue concentrations and cures a high proportion of cases, making it a standard first‑line choice. The topical metronidazole gel is also effective and can be used as an alternative if you want to avoid systemic exposure, but oral therapy is commonly chosen for simplicity and has comparable efficacy. Topical clindamycin is another option if metronidazole isn’t suitable, but it isn’t the first-line in most guidelines. Fluconazole targets fungi and won’t treat BV, so it’s not appropriate.

Bacterial vaginosis arises from a shift in vaginal flora with overgrowth of anaerobic bacteria and a loss of protective lactobacilli. Metronidazole is highly effective against anaerobes, which is why it’s the preferred treatment. The oral regimen given—metronidazole taken twice daily for about a week—provides good vaginal and pelvic tissue concentrations and cures a high proportion of cases, making it a standard first‑line choice.

The topical metronidazole gel is also effective and can be used as an alternative if you want to avoid systemic exposure, but oral therapy is commonly chosen for simplicity and has comparable efficacy. Topical clindamycin is another option if metronidazole isn’t suitable, but it isn’t the first-line in most guidelines. Fluconazole targets fungi and won’t treat BV, so it’s not appropriate.