A patient requires topical treatment for bacterial vaginosis. The patient is not pregnant. Which medicine is most appropriate for the presenting condition?

• A. Metronidazole
• B. Clindamycin
• C. Miconazole
• D. Nitrofurantoin

Answer: (A)

Topical therapy for bacterial vaginosis targets the anaerobic bacteria that predominate when normal lactobacilli are disrupted. Metronidazole is a nitroimidazole antibiotic that is highly active against anaerobes and, when used as a vaginal gel or cream, delivers effective concentrations directly to the site of infection with minimal systemic exposure. This makes it a standard first-line topical option for BV in a non-pregnant patient. Miconazole is an antifungal and treats Candida infections, not BV. Nitrofurantoin is aimed at urinary pathogens and isn’t used for BV. Clindamycin vaginal cream is a valid alternative, but metronidazole is typically preferred as the first-line topical choice in many guidelines and exam scenarios. If metronidazole is used, counsel to avoid alcohol during treatment and for 24 hours after completing therapy to prevent a disulfiram-like reaction.