Version July 2025
This figure summarizes our suggested approach to the initial treatment of BV. Please refer to related UpToDate content for additional detail.
Treatment of sex partners varies by anatomy and symptoms. Male sex partners should receive dual-antibiotic treatment with metronidazole 400 mg orally and clindamycin 2% cream applied to penile skin, both twice daily for 7 days; female sex partners should monitor for BV symptoms and test if they occur.‡
BV: bacterial vaginosis.
* We do not routinely treat asymptomatic individuals, including pregnant and lactating persons. However, others may reasonably elect to treat asymptomatic pregnant individuals as the supporting data conflict, particularly for those with a history of preterm birth.
¶ As treatment efficacy is similar between metronidazole and clindamycin, the choice of medication is based on availability, patient preference, side effects, cost, and history of response or adverse reactions.
Δ For additional treatment options, including secnidazole and tinidazole, please refer to related UpToDate content on treatment of BV.
◊ Pregnant individuals who are unable to tolerate metronidazole 500 mg twice daily because of gastrointestinal symptoms may be able to tolerate metronidazole 250 mg 3 times daily.
§ Use of oral metronidazole 500 mg twice daily for 7 days results in a low drug concentration in breast milk and is considered compatible with breastfeeding.
¥ Breastfeeding infants may develop side effects from maternal clindamycin treatment and should be monitored for possible symptoms, including diarrhea, candidiasis (thrush, diaper rash), or, rarely, colitis.
‡ Until definitive data are available, we treat patients who have undergone gender-affirming surgery based on their revised anatomy. As an example, patients with neovaginas are treated as female, and those with neophalluses are treated as male.
