Bacterial Vaginosis Treatment Guidelines

Current Recommendations

The Centers for Disease Control and Prevention (CDC) recommends that routine treatment of sex partners is not recommended for bacterial vaginosis, based on the fact that treatment of sex partners in clinical trials has historically not influenced the woman's response to therapy, nor has it influenced the relapse or recurrence rate 1, 2
The CDC guidelines state that the principal goal of BV therapy is to relieve vaginal symptoms in the affected woman, not to prevent transmission, although this may change with new evidence 1, 2

The American College of Obstetricians and Gynecologists may need to update their guidelines to reflect new evidence that treating male partners with combined oral metronidazole and topical 2% clindamycin cream for 7 days can reduce the recurrence rate of BV in women 1, 2
The treatment regimen for male partners, as suggested by new evidence, consists of metronidazole 400 mg orally twice daily for 7 days and 2% clindamycin cream applied topically to the glans penis and upper shaft twice daily for 7 days, with the warning that men must avoid alcohol during metronidazole treatment and for 24 hours afterward due to potential disulfiram-like reaction 3, 4

The CDC recommends that clinicians should not confuse BV with candidiasis (VVC), which does not require partner treatment, and should not use metronidazole gel for male partners, as the successful regimen used combination oral and topical treatment 3, 4

The CDC guidelines have consistently stated that treatment of male sex partners has not been beneficial in preventing BV recurrence in women, according to the American College of Family Physicians and the Centers for Disease Control and Prevention 5, 6
The principal goal of BV therapy is to relieve vaginal symptoms in the affected woman, not to prevent transmission, as stated by the American College of Family Physicians and the Centers for Disease Control and Prevention 7
Male partners are typically asymptomatic even when carrying BV-associated bacteria, as reported by the American College of Family Physicians and the Centers for Disease Control and Prevention 8
Women who have never been sexually active rarely develop BV, suggesting sexual transmission plays a role, according to the American Academy of Family Physicians and the Centers for Disease Control and Prevention 5, 6

Men must avoid alcohol during metronidazole treatment and for 24 hours afterward due to potential disulfiram-like reaction, as advised by the American College of Family Physicians and the Centers for Disease Control and Prevention 7, 9

Current CDC guidelines have not yet been updated to reflect the new evidence, as noted by the American College of Family Physicians and the Centers for Disease Control and Prevention 7

BV is not classified as a sexually transmitted infection that causes symptomatic disease in men, although BV‑associated bacteria are exchanged between sexual partners and can colonize the male genitalia. (Population: heterosexual couples; Intervention: sexual contact; Outcome: bacterial colonization without male symptoms) 10, 11 – Evidence: CDC expert recommendation (expert opinion).
BV‑associated bacteria can colonize the penis but do not produce clinical disease in men. (Population: male partners of women with BV; Outcome: asymptomatic colonization) 10, 11 – Evidence: CDC expert recommendation (expert opinion).
Women who have never been sexually active rarely develop BV, indicating that sexual activity contributes to the exchange of BV‑associated microbes, although BV itself results from disruption of the normal vaginal flora rather than acquisition of a single transmissible pathogen. (Population: nulliparous, sexually inactive women vs. sexually active women; Outcome: low BV prevalence in the former) 10, 11 – Evidence: CDC expert recommendation (expert opinion).

Routine evaluation or laboratory testing for BV‑associated bacteria in men is not required because men do not develop diagnostic criteria or symptomatic manifestations of BV. (Population: asymptomatic male partners; Intervention: no testing; Outcome: no clinical benefit) 10, 11 – Evidence: CDC expert recommendation (expert opinion).

CDC guidelines advise that routine treatment of male sex partners is not recommended, as historical data show that partner treatment does not improve the woman’s therapeutic response nor reduce relapse or recurrence rates. (Population: women treated for BV and their male partners; Intervention: partner treatment vs. no treatment; Outcome: no impact on cure or recurrence) 10, 11 – Evidence: CDC expert recommendation (expert opinion).
The primary objective of BV therapy is to alleviate vaginal symptoms in the affected woman, not to prevent bacterial transmission to the male partner. (Population: women with symptomatic BV; Outcome: symptom relief) 10, 11 – Evidence: CDC expert recommendation (expert opinion).

Do not equate BV transmission dynamics with classic sexually transmitted infections; BV reflects an ecological disturbance of vaginal flora rather than infection with a single pathogen, even though bacterial exchange between partners occurs. (Population: all patients with BV; Outcome: appropriate counseling) 10, 11 – Evidence: CDC expert recommendation (expert opinion).