Clinician instructions for BV partner treatment

BV causes

Bacterial vaginosis (BV) is a polymicrobial infection associated with a loss of vaginal lactobacilli and an increase in anaerobic and facultative anaerobic bacteria such as Gardnerella, Prevotella and Sneathia species (termed BV-associated bacteria). Global prevalence is 30%, with some populations recording a prevalence in excess of 50%. Importantly, BV recurrence occurs in over 50% of women and other people with a vagina within 6 months of recommended antibiotic treatment. 

BV is most common among sexually active people and data show that BV has the profile of a sexually transmitted infection (STI). BV is predominantly detected after onset of sexual activity and is associated with a new or change in partner, a history of multiple partners and lack of condom use. BV-associated bacteria are detected in the penile urethra as well as on penile skin, particularly in the sub-preputial space under the foreskin. Penile carriage of BV-associated bacteria is more common in individuals with a partner with BV and is usually asymptomatic¹.

Clinical presentation and diagnosis

Please refer to our BV guidelines. 

Reducing BV recurrence through partner treatment 

A recent randomised controlled trial found that BV cure is greatly improved when partners with a penis are treated with antibiotics administered concurrently with standard antibiotic treatment for the person with BV². Partner treatment involved oral metronidazole 400mg twice daily AND 2% clindamycin cream applied twice daily to the glans, sub-preputial space and upper shaft of the penis, both for 7 days. Couples were advised to synchronise treatment and abstain from all sexual contact throughout the treatment period. The intervention, trialled in monogamous couples, resulted in a >60% reduction in risk of BV recurrence over 12 weeks. This is the first intervention in decades to demonstrate a very significant improvement in BV cure.  

The Melbourne Sexual Health Centre has provided this website to assist with the prescription of partner treatment for BV in the community. 

Recommendations for couples where both partners have a vagina remain unchanged (see BV treatment guidelines), however a partner treatment trial for LGBTQIA+ couples is currently recruiting (see PACT study). 

Discussing BV partner treatment 

When offering partner treatment for BV to a couple, it can be helpful to explain the following concepts: 

• BV-associated bacteria are commonly detected in the penile urethra and on the penile skin in the absence of symptoms  
• BV-associated bacteria can be exchanged during sex 
• This strategy of partner treatment is the same approach that is used for STIs such as chlamydia, where partners and ongoing sexual contacts of an index case need to be treated simultaneously to achieve cure.  

Involving a partner with a penis in BV treatment

There is no current diagnostic test for the carriage of BV-associated bacteria on the penis, but concordance for BV-associated bacteria in heterosexual couples is very high.

As BV-associated bacteria are found within the penile urethra and on the penile skin, particularly in the sub-preputial space, successful partner treatment depends on the partner with a penis taking an oral antibiotic and using a topical antibiotic cream, twice daily for 7 days. It is important to explain that both antibiotics are needed, and that the cream is just as important as the oral tablets. Partner treatment should be taken when the female or person diagnosed with BV is being treated with first line therapy (7 days of oral metronidazole OR 7 nights of intravaginal clindamycin cream OR 5 nights of intravaginal metronidazole gel³). Couples that are 100% adherent to treatment have the highest level of BV cure, and it should be strongly recommended that both partners take all of their prescribed medication. Furthermore, it is important to advise couples to avoid all sexual contact throughout the treatment period as sexual transmission of bacteria risks treatment failure. If engaging in any sexual activity, use of barrier methods (condoms) is strongly recommended, but couples should be aware that recently applied clindamycin cream can weaken latex. 

Treatment guidelines 

Involving a partner with a vagina in BV treatment

If your patient has a regular sexual partner who has a vagina, then concordance for BV is very high and it is common practice to also test them for BV and treat BV in the partner if it is detected. While there is no clinical trial to inform this practice, BV can be accurately diagnosed in people with vaginas and most clinicians feel this practice is acceptable. There is however a clinical trial currently underway for LGBTQIA+ couples; the PACT partner treatment study. This trial is examining the impact of treating both partners with a vagina for BV even if only one individual has BV detected. PACT is currently recruiting monogamous LGBTQIA+ couples where at least one partner has confirmed BV.

Treatment guidelines 

Treating BV with multiple partners 

As all partners in a sexual relationship need treatment, couples where either partner has additional sexual partners are less likely to derive benefit from partner treatment. This is due to the potential reintroduction of BV-associated bacteria by untreated sex partners if they are carriers or infected. It is important to explain this to individuals with BV seeking partner treatment. Multiple partners may be treated simultaneously if appropriate to individual circumstances.  

Treatment guidelines 

Information for prescribing partner treatment in Australia

Oral metronidazole can be prescribed to eligible patients through the PBS or a private script. The PBS lists metronidazole for use in anaerobic infections. 

Topical clindamycin is packaged as Dalacin – V Cream 2% and comes with 7 vaginal applicators. It requires a private script for all patients, at an expense of approximately $30 AUD.  

The partner medication instructions provide detailed directions for use.  

The abbreviated example of partner treatment instructions can be used in your prescription: 

Treatment guidelines 

Resources

As mentioned above, we have provided downloadable and printable medication instructions for the correct use of the clindamycin cream and metronidazole tablets.  

We have also provided a pharmacy letter which can be printed and signed with the script, so a pharmacist knows how to correctly dispense the medication.

The information sheets for couples where one partner has a penis, couples where both partners have a vagina, and individuals seeking guidance on raising the conversation with a partner, promote easy communication between couples and answer some common questions. Please provide this information to your patient(s) with the medication instructions, to assist couples in understanding the rationale for partner treatment, how to take the medication correctly, and the importance of high adherence to improve BV cure.  

The clinician instructions can also be downloaded and saved as a PDF.