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What is the best approach for managing recurrent bacterial vaginosis? — The Journal of Family Practice

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August 2004 · Vol. 53, No. 8

Clinical Inquiries
FROM THE FAMILY PRACTICE INQUIRIES NETWORK

What is the best approach for
managing recurrent bacterial
vaginosis?
Grace A. Alfonsi, MD; JudithC. Shlay, MD, MSPH
Denver Health and Hospital Authority, University of Colorado Health Sciences Center;
Sandi Parker, MLS
Denison Memorial Library, University of Colorado Health Sciences Center, Denver

EVIDENCE-BASED ANSWER
The best way to prevent recurrent bacterial vaginosis is to treat the initial episode with the most effective
regimen. Metronidazole (500 mg orally twice daily for 7days) has the lowest recurrence rate among
antimicrobial regimens for bacterial vaginosis (20% vs 34%–50% for other agents) (strength of
recommendation [SOR]: A). Women should be treated if they are symptomatic (SOR: A), undergoing
gynecologic surgery (SOR: B), or at risk for preterm labor (SOR: B).
When bacterial vaginosis recurs, providers should confirm the diagnosis (Table 1) (SOR: A),identify and
control risk factors for recurrence ( Table 2) (SOR: B), and consider other causes while retreating
bacterial vaginosis (SOR: C). If the diagnosis is confirmed and retreatment fails, consider suppression with
metronidazole 0.75% vaginal gel for 10 days followed by twice weekly administration for 4 to 6 months
(SOR: C, trial ongoing). No evidence supports treating sexual partners oradministering oral or vaginal
Lactobacillus acidophilus , but recolonization with vagina-specific lactobacilli (L crispatus and L jensenii) is
undergoing Phase III clinical trials.

EVIDENCE SUMMARY
No trials have tested or compared specific, comprehensive strategies for recurrent bacterial vaginosis.
Given that bacterial vaginosis can also be asymptomatic, recurrence often cannot bedifferentiated from
treatment failure. Accordingly, recurrent bacterial vaginosis may be prevented by using the most effective
therapy for the initial episode. A 2002 meta-analysis by the Centers for Disease Control and Prevention’s

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What is the best approach for managing recurrent bacterial vaginosis? — TheJournal of Family Practice
(CDC) bacterial vaginosis working group reviewed the indications for therapy and best treatments for
bacterial vaginosis. 1 The group found 25 trials evaluating oral metronidazole therapy involving 2742
women. Although cure rates using either 500 mg twice daily for 5 to 7 days or 2 g as a single dose were
similar at 2 weeks post follow-up (85%; range 67%–98%), thesingle-dose regimen led to higher relapse
rates 1 month after treatment (35%–50% vs 20%–33%).
Six trials enrolling 946 women assessed the efficacy of various topical vaginal treatments. Metronidazole
gel, clindamycin cream, and clindamycin ovules had a wide range of initial cure rates (50%–95%), but all
had higher relapse rates at 4 weeks than did oral metronidazole for 1 week (34%–49%). 1 Amore
complete discussion of the effectiveness of antibiotics for bacterial vaginosis can be found in a recent
Clinical Inquiry. 2
The CDC reviewers identified causal relationships between bacterial vaginosis and plasmacell
endometritis, postpartum fever, and posthysterectomy vaginal-cuff cellulitis. They therefore concluded it is
reasonable to try to prevent post-procedure infections by treatingwomen who have asymptomatic
bacterial vaginosis before hysterectomy or pregnancy termination. Although bacterial vaginosis has been
associated with preterm labor, trials evaluating treatment of bacterial vaginosis to prevent preterm delivery
are conflicting. A Cochrane review of bacterial vaginosis and preterm labor suggests treating women at
high risk for preterm birth may reduce the risk...