The Journal of Infectious Diseases

SUPPLEMENT ARTICLE

Current Treatment of Bacterial Vaginosis—Limitations

and Need for Innovation
Catriona S. Bradshaw1,2,a and Jack D. Sobel3,a
1
Melbourne Sexual Health Centre, and 2Central Clinical School, Monash University, Clayton, Australia; and 3Division of Infectious Diseases, Department of Internal Medicine, Wayne State University
School of Medicine, Detroit, Michigan

Practitioners and patients alike widely recognize the limitations of current therapeutic approaches to the treatment of bacterial vag-
inosis (BV). Options remain extremely limited, and our inability to prevent the frequently, often relentless symptomatic recurrences
of BV and to reduce serious sequelae such as preterm delivery, remains an acknowledged but unresolved shortcoming. Our incom-
plete understanding of the pathophysiology of this unique form of vaginal dysbiosis has been a significant impediment to developing
optimal treatment and prevention approaches. New drugs have not been forthcoming and are not likely to be available in the im-
mediate future; hence, reliance on the optimal use of available agents has become essential as improvised often unproven regimens
are implemented. In this review, we will explore the limitations of currently recommended therapies, with a particular focus on the

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contribution of reinfection and pathogen persistence to BV recurrence, and the development of interventions that target these mech-
anisms. Ultimately, to achieve sustained cure and effectiveness against BV-associated sequelae, it is possible that we will need ap-
proaches that combine antimicrobials with biofilm-disrupting agents and partner treatments in those at risk of reinfection.
Keywords. bacterial vaginosis; treatment approaches; recurrence.

Bacterial vaginosis (BV) represents a profound shift in the vaginal
microbiota and is characterized by high bacterial species diversity;
increased loads of facultative anaerobes, including Gardnerella
vaginalis, Atopobium vaginae, and other fastidious BV-associated
bacteria, such as Megasphaera, Sneathia, and Clostridiales species;
increased production of volatile amines; and a rise in vaginal pH
to > 4.5 [1]. This change is accompanied by marked depletion of
key Lactobacillus species such as Lactobacillus crispatus, which
produces lactic acid, bacteriocins, and other antimicrobial mole-
cules, and is thought to play an important role in host defense
against pathogens [2, 3]. Recent studies have identified a polymi-
crobial biofilm dominated by G. vaginalis and A. vaginae that is
adherent to vaginal epithelial cells in women with BV and appears
to be absent in healthy controls [4, 5]. The initiating event that
results in this adverse shift in the vaginal microbiota remains un-
clear and has been a significant impediment to understanding the
pathogenesis of this common condition and to optimizing treat-
ment and prevention approaches. In this review, we explore the
limitations of currently recommended therapies, with a particular
focus on the contribution of reinfection and pathogen persistence
to BV recurrence.
Presented in part: Bacterial Vaginosis Technical Consultation Meeting of the Sexually Trans-
mitted Infections Clinical Trials Group, Washington D.C., 8–9 April 2015.
a
C. S. B. and J. D. S. contributed equally to this work.
Correspondence: C. S. Bradshaw, Melbourne Sexual Health Centre, 580 Swanston Street,
Carlton, Victoria 3053, Australia (cbradshaw@mshc.org.au).
The Journal of Infectious Diseases® 2016;214(S1):S14–20
© The Author 2016. Published by Oxford University Press for the Infectious Diseases Society of
America. All rights reserved. For permissions, e-mail journals.permissions@oup.com.
DOI: 10.1093/infdis/jiw159
BV is vaginal condition with a high global burden in women
of reproductive age. Prevalence estimates range from 12% in
Australian women [6] and 29% in North American women
[7, 8] to >50% of women affected in East/Southern Africa [9].
Over 50% of women with BV experience an unpleasant vaginal
malodor and discharge, with qualitative studies showing that
BV is associated with a significant negative impact on self-
esteem, sexual relationships, and quality of life [10]. This dysbi-
otic state is associated with an approximate 2-fold increased risk
of acquiring a broad range of sexually transmitted infections, in-
cluding chlamydial infection, gonorrhea, herpes simplex type 2
infection, and human immunodeficiency virus (HIV) infection
[11–14], and increases the risk of HIV-infected women trans-
mitting HIV to male partners [15]. BV is associated with impor-
tant reproductive and obstetric sequelae, increasing women’s
risk of pelvic inflammatory disease, spontaneous abortion, pre-
term delivery, low birth weight, and postpartum endometritis
[16–18].
Current clinical approaches to the management of BV are
somewhat empirical and involve the use of either nitroimida-
zoles or clindamycin, antimicrobials with broad-spectrum an-
aerobic coverage. Recommended first-line regimens include
oral metronidazole 500 mg twice daily for 7 days, intravaginal
2% clindamycin cream once daily for 7 days, or intravaginal
metronidazole gel once daily for 5 days [19]. Single doses and
short courses of metronidazole, tinidazole, and intravaginal
clindamycin are less effective [19]. While short-term cure
rates following first-line recommended regimens are equivalent
and approach 80% [20], studies with extended follow-up show
that recurrence rates in excess of 50% occur within 6–12 months

S14 • JID 2016:214 (Suppl 1) • Bradshaw and Sobel

[21, 22]. These high rates of recurrence have led investigators to
evaluate a range of alternative therapeutic approaches, including
extended and suppressive antimicrobial regimens [23–27], com-
bination first-line regimens [28], and adjunctive intravaginal
and oral probiotic therapies [28, 29]. While some of these ap-
proaches appear promising and are under further evaluation,
overall there has been limited progress in achieving sustained
long-term cure following cessation of these regimens. This
lack of success is a reflection of our poor understanding of
the pathogenesis of both recurrent and incident BV. Higher
baseline loads of some BV-associated bacteria have been associ-
ated with an increased risk of recurrence in one study [30], and
2 studies showed that BV-associated biofilm re-accumulates fol-
lowing antibiotic therapy [31, 32]. These data indicate that per-
sistence of certain BV-associated bacteria and biofilm may be a
determinant of recurrence following antimicrobials and raises
the question as to whether antimicrobial resistance also plays
a role. While there have been data indicating that clindamycin
use can result in the emergence of clindamycin-resistant anaer-
obic gram-negative rods [33], in a panel of 865 anaerobic species
obtained from women with BV, resistance to metronidazole was
rare (0.3%) [34]. Despite evidence that there may be differences
in antimicrobial susceptibility between the 2 first-line agents,
overall BV cure rates following clindamycin and metronidazole
have been equivalent [19, 35]. Intriguingly, however, recent
whole-metagenome sequencing studies have identified at least
4 clades of G. vaginalis [36, 37], with preliminary studies show-
ing that 2 of these clades may be intrinsically resistant to met-
ronidazole, providing one possible mechanism for BV persistence
after treatment [38]. There are also tantalizing data suggesting
that reintroduction of BV-associated bacteria through sexual in-
tercourse may be contributing to BV recurrence and that sexual
transmission or exchange of BV-associated bacteria may play an
integral role in the pathogenesis of BV and recurrence. Making
significant progress in achieving sustained long-term cure of
BV, in reducing BV-associated sequelae, and in developing pre-
vention strategies necessitates investigating the contribution of
reinfection, organism/biofilm persistence, and antimicrobial re-
sistance to the pathogenesis of BV recurrence.
EVIDENCE FOR SEXUAL TRANSMISSION OF
BV-ASSOCIATED BACTERIA AND IMPLICATIONS
FOR TREATMENT AND PREVENTION STRATEGIES
FOR BV RECURRENCE
The proposition that BV may be sexually transmitted has been
evident in published literature for several decades [39–44].
However, confusion regarding the etiology of BV, difficulties
in identifying a single causative agent, and absence of a clear
disease counterpart in males have all been significant impedi-
ments in determining whether BV is sexually transmitted. In
the 1950s, a highly unethical study demonstrated that women
inoculated with secretions from women with BV but not a
Bacterial Vaginosis, Need for Innovation
pure culture of G. vaginalis developed BV [45]. This led to
the belief that BV was likely to be sexually transmitted, and
the study was followed by 6 randomized, controlled male-
partner-treatment trials that were conducted from the mid-
1980s to the 1990s [39] that have recently been systematically
reviewed [46]. Three trials found male partner treatment to be
associated with a reduction in either BV recurrence or BV
symptoms in women [47–49], although this was statistically sig-
nificant in only 1 trial, by Mengel et al [46, 48]. Mengel et al re-
ported a significant increase in symptom resolution and BV
cure by Gram stain in women whose partners received either
a 7-day course or a 2-g dose of metronidazole, but data were
presented graphically, and no effect sizes were reported [48].
Vutyanavic et al reported a 13% increase in clinical cure of
BV among women at 4 weeks whose male partners had been
treated with 2 g of tinidazole [47], and Vejtorp et al found a
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15% reduction in BV and a 36% reduction in culture of G. vag-
inalis at 5 weeks in women whose male partners were treated
with two 2-g doses of metronidazole; neither finding was stat-
istically significant [49]. Two trials found no effect on BV recur-
rence from treating male partners with a single dose or 7-day
course of metronidazole [50] or with oral clindamycin for 1
week [51]. One trial found BV recurrence to be higher among
women whose partners were treated with two 2-g doses of met-
ronidazole, compared with those who were not [52].
The apparent incongruity between the strong evidence for
sexual transmission and the failure of these trials now appears
likely to be due to issues in trial design that have been detailed in
a rigorous systematic review by Mehta [46]. Importantly, Mehta
found that none of the trials had sufficient power to detect rea-
sonable effect sizes, that randomization methods were deficient
or insufficiently reported, and that adherence to therapy was
not reported in women and was only reported in men in 2 trials.
Five trials used treatment regimens in women that are now con-
sidered to be less effective, such as single-dose regimens, and 5
trials used regimens in men that are now known to be subopti-
mal in women. Mehta concluded that the trial findings were in-
conclusive by the current clinical trial standards and
recommended that sufficiently powered trials using recom-
mended therapies be conducted to determine whether antibiot-
ic treatment in men can reduce BV and to generate an accurate
evidence base for guidelines [46].
A mounting body of epidemiologic and microbiologic data
suggest that sexual transmission is likely to be integral to the
pathogenesis of BV. Detection of BV has been associated with
inconsistent condom use and exposure to increased numbers of
recent and lifetime sex partners, by meta-analysis [43]. Women
with BV have an earlier median age of sexual debut than women
without BV [53]. While 2 studies identified BV in “virgins,”
both restricted the definition of ‘virgin’ to absence of a past his-
tory of penile-vaginal sex [54, 55]. In contrast, a study of young
female students that collected detailed data on sexual behaviors
• JID 2016:214 (Suppl 1) • S15
found that BV was not detected in women without a history of
sexual activity with others, was uncommon in women who re-
ported having only ever engaged in noncoital sexual activities,
and was significantly associated with the practice of penile-
vaginal sex [56]. Consistent epidemiological data show high
rates of concordance of BV within female partnerships [40,
57–60], and BV has been associated with practices that implicate
sexual transmission between women, including increased num-
ber of female partners, a female partner with BV, and receptive
oral sex [58, 60–62]. Marrazzo et al showed that women who
have sex with women, in monogamous relationships, shared
Lactobacillus strain types [63], and Vodstrcil et al found that in-
cident BV was associated with exposure to a new female sex part-
ner and a female partner with symptoms of BV in a 2-year cohort
[60]. These data suggest that dynamic exchange of both protec-
tive and detrimental vaginal bacterial species is occurring
between women in sexual relationships.
Published data also support the fact that reintroduction of
BV-associated bacteria through sexual intercourse is likely to be
contributing to BV recurrence after treatment. Treated women
with ongoing exposure to an untreated male partner had twice
the risk of recurrence, after adjustment for sex frequency, con-
dom use, and contraception, in 2 studies [22, 64]. Several studies
have found that inconsistent condom use during penile-vaginal
sex increased the risk of recurrence following treatment [64–66].
Deep-sequencing studies have shown that the subprepucial
space and distal urethra of males can harbor a broad range of
BV-associated bacteria and that these bacteria are more preva-
lent among the male partners of females with BV than among
those of females without BV [67]. The composition of the sulcus
microbiota also appears to be strongly influenced by circumci-
sion and sexual activity [68], with male circumcision prospec-
tively associated with a significant reduction in BV-associated
genera [69, 70] and a 40%–60% reduction in the development
of BV in female partners [71]. BV-associated biofilm has re-
cently been detected in male urine and semen and is more
commonly found in the male partners of females with BV
than in healthy controls [4, 72, 73].
Collectively, these findings provide evidence of carriage of
BV-associated bacteria in males and broad support for the ex-
change of BV-associated bacteria within sexual partnerships be-
tween men and women, and women and women. They strongly
suggest that sexual transmission is integrally involved in the
pathogenesis of both incident and recurrent BV and highlight
the need to fund and conduct sufficiently powered partner-
treatment trials to determine whether this strategy reduces BV
recurrence and associated sequelae. They also provide compel-
ling evidence for an unforeseen benefit from male circumcision
and for promotion of condom use in strategies to reduce the risk
of BV acquisition and recurrence. There is 1 registered male-
partner-treatment trial enrolling couples in North America, in
which men are randomly assigned to receive a 7-day course of
S16 • JID 2016:214 (Suppl 1) • Bradshaw and Sobel
oral metronidazole versus oral placebo, and these data are ea-
gerly awaited (ClinicalTrials.gov identifier NCT02209519). Tri-
als involving the use of topical antimicrobials in addition to oral
agents are planned and may be required to eradicate cutaneous
carriage of BV-associated bacteria from the penile skin. Female-
partner-treatment trials are clearly needed, and because they
will be logistically challenging, the design of such studies will
require innovative thinking and careful planning.
BIOFILM DISRUPTION
As summarized above, there is compelling evidence for the ex-
istence of pathogen-containing biofilm in the vagina of women
and the urethra and subpreputial surface of the glans penis of
males, which provides a rational explanation for microbial per-
sistence after therapy [32, 73–76]. Moreover, biofilm has been
shown to persist after putatively successful antimicrobial thera-
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py in females [32, 77]. Biofilm may serve to reduce antimicrobial
penetration, allowing antibiotic-susceptible microbes to persist,
creating a carrier state. Biofilm sanctuary function may well ex-
plain the failure of effective antimicrobial therapy. Understand-
ing biofilm production provides insight into expression of
bacterial virulence factors [78–80]. It may be necessary to
break down biofilm to achieve optimal efficacy of antimicrobial
therapies, and novel strategies to eliminate biofilm have
emerged that target women with recurrent BV.
The first evidence of a potential therapeutic benefit from bio-
film disruption emerged in a multicenter, long-term study of
maintenance suppressive therapy for the prevention of recurrent
BV, in which Reichman et al used topical boric acid 600 mg daily
following a 1-week course of systemic nitroimidazole therapy
[81]. Previous unpublished studies performed by Sobel et al
had demonstrated that boric acid alone was inadequate in
even achieving a satisfactory clinical response in BV, reflecting
its weak antimicrobial potency. In the study by Reichman et al,
after a 1-month course of daily boric acid treatment, asymptom-
atic women were additionally prescribed suppressive twice
weekly metronidazole for 4 months. The overall combination
regimen dramatically reduced BV recurrence on treatment, al-
though recurrence late after treatment was common [81]. Un-
fortunately, study design precluded objective evaluation of the
unique contribution of boric acid. Ongoing research is also eval-
uating boric acid enhanced with an ethylenediaminetetraacetic
acid excipient, which boosts antimicrobial activity and retains
activity against vaginal biofilm [82].
These clinical studies, together with the biofilm studies by
Swidsinski et al, have enhanced interest in the identification
of more-potent agents capable of biofilm disruption, including
octenidine, DNAses, retrocyclin, and the naturally occurring
antimicrobials subtilosin, ploy-L-lysine, and lauramide arginine
ethyl ester. There is also interest in quorum-sensing inhibitors
[77, 83–86]. Octenidine and boric acid are the only agents to
have been evaluated in human studies. Octenidine, an antiseptic
with broad-spectrum antimicrobial activity, is effective against
biofilms involved in oral, wound, and orthopedic-implant infec-
tions. Swidsinski et al recently reported on its use in 24 women
with recurrent BV [77]. With application of octenidine daily for
7 days and, in women with further recurrence, daily for 28 days
and weekly for 60 days, initial cure rates looked promising,
but the efficacy of prolonged and repeated treatment was poor,
and BV recurrence was observed in a significant proportion of
women [77].
G. vaginalis biofilms contain extracellular DNA (eDNA),
which is integral to their structural integrity, and enzymatic dis-
ruption of this eDNA by DNase has been shown to inhibit
G. vaginalis biofilm formation and to disrupt established bio-
films in vitro [84]. Hymes et al recently reported that low con-
centrations of DNase and metronidazole were more efficacious
against G. vaginalis biofilm, compared with either agent alone,
in vitro, perhaps due to increased susceptibility of G. vaginalis
to the antibiotic when liberated from the biofilm [84]. The syn-
thetic agent, retrocyclin (RC-101), an antimicrobial peptide
with antiviral activity, has also been shown to inhibit the forma-
tion of G. vaginalis biofilms in vitro [83, 87]. RC101 is a potent
inhibitor of vaginolysin, a toxin produced by G. vaginalis. Vag-
inolysin inhibition has been proposed as a potential strategy for
BV treatment [83, 87], and while it is not clear whether the ac-
tion of RC101 is entirely mediated through inhibition of vagi-
nolysin, it may be another potential candidate for studies of BV
in humans. A final, highly novel and emergent area of biofilm
research involves inhibition of quorum sensing, a strategy that
some bacterial species use to coordinate expression of genes in-
volved in virulence, biofilm formation, and pathogenicity [88].
While quorum-sensing inhibitors have not yet been evaluated
in human studies, they have been shown to be active in vitro
against biofilms produced by Pseudomonas aeruginosa and
Staphylococcus species [88, 89]. There has been much successful
recent research on biofilm prevention and removal in the field
of intravascular catheter and prosthetic device infections, using
a variety of in vitro models. BV research lags behind, and one
significant impediment has been the lack of a suitable animal
model, with vaginal primate and other animal models being
less optimal owing to significant differences in their microbiota
and pH compared to humans [90, 91]. There is urgent need for
progress in the development and evaluation of safe and effective
topical vaginal agents capable of disrupting and eliminating
genitourinary tract biofilm that could be included in combina-
tion therapy with antimicrobials.
ANTIMICROBIAL RESISTANCE
There remains scant knowledge regarding the role of anti-
microbial resistance in contributing to both initial clinical and
bacteriologic failures and recurrence [92]. Clinical experience
indicates that the former is uncommon, whereas relapse after
initial improvement is much more common. Beigi et al performed
Bacterial Vaginosis, Need for Innovation
one of the few studies examining in vitro resistance to culti-
vatable BV-associated bacteria, concluding that, in contrast to
clindamycin, anaerobic gram-negative bacterial resistance to
metronidazole was rare [33, 34]. Similar in vitro studies that
focus specifically on women with refractory or recurrent BV
have not been performed. A major limitation of such studies
in general is that the majority of BV-associated bacteria cannot
be grown in vitro and thus cannot be tested for antimicrobial
susceptibility. It should also be emphasized that BV represents
a functional dysbiosis with a community of contributing path-
ogens, reflecting a model that is difficult if not impossible to
evaluate in vitro by use of traditional methods of antimicrobial
susceptibility testing.
Both G. vaginalis and A. vaginae demonstrate well-described
intrinsic resistance to nitroimidazole agents. Nevertheless, in
vivo these organisms are dramatically reduced in population
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numbers following conventional nitroimidazole therapy, indi-
cating an effective in situ effect, possibly reflecting the effect
of more-potent antimicrobial intermediate or degradation
products [93]. It has always been assumed that the currently rec-
ommended regimens of oral and topical nitroimidazoles
achieve concentrations in vaginal secretions far above concen-
trations needed to eradicate BV pathogens [94]. Nevertheless,
some investigators have opined that higher concentrations
may be more effective and essential, especially given the possi-
bility of microbial pathogen persistence in biofilm. The use of
available topical formulations of metronidazole result in vaginal
fluid drug concentrations 10–30-fold higher than achievable
with the oral drug, and several uncontrolled noncomparative
pilot studies using higher-dose topical metronidazole have re-
ported achieving improved cure and control rates [95, 96].
There is a need to perform studies comparing high-dose topical
metronidazole with conventional dose commercially available
metronidazole, especially given the availability and documented
safety of the high-concentration/dose preparations.
CONCLUSION
Practitioners and patients alike widely recognize the current
limitations in achieving successful therapy of BV. Therapeutic
options remain extremely limited, and our inability to prevent
frequent symptomatic recurrences of BV remains an acknowl-
edged but unresolved shortcoming. New drugs have not been
forthcoming and are not likely to be available in the near future.
Thus, despite the limitations, we recommend adhering to cur-
rent treatment guidelines rather than relying on unproven
alternative regimens. Probiotics, although attractive as sup-
plementary agents, have not consistently been shown to be ad-
vantageous. Our lack of progress is the direct result of our
continuing incomplete understanding of the pathophysiology
of this unique form of vaginal dysbiosis. On the other hand, in-
creasing recognition of the potential role of pathogen-rich bio-
film in facilitating disease persistence, together with the future
• JID 2016:214 (Suppl 1) • S17
introduction of effective antibiofilm agents, results in hope for
improved therapeutic success in the future. It is also important
to acknowledge the likelihood that reinfection from partners
may be contributing to recurrence and may obscure the benefits
of new therapeutic approaches. Rigorous partner-treatment tri-
als, conducted in accordance with current clinical trial stan-
dards, are essential to not only determine the contribution of
reinfection to recurrence, but also to provide an accurate evi-
dence base for developing new treatment guidelines. Ultimately
optimization of future BV treatment strategies may require
combination approaches, such as antibiotics given along with bi-
ofilm-disrupting agents and in conjunction with partner treat-
ment. Future research also should focus on the possibility that
BV is a heterogeneous condition involving subtly different vag-
inal microbiomes. Such putative BV subtypes might respond
differently to treatment regimens. In the field of HIV, ambitious
goals have been set and result in intense coordinated efforts be-
tween clinicians and researchers, accompanied by advocacy
from the public sector, to attempt to meet these targets. BV is
a condition that is strikingly common but largely hidden from
public view. Our collective goal needs to be the achievement of
sustained cure for women if we are to reduce the global burden
of this common and distressing condition and impact on its se-
rious sequelae such as preterm delivery and HIV transmission.
Notes
Supplement sponsorship. This article appears as part of the supplement
“Proceedings of the 2015 NIH/NIAID Bacterial Vaginosis Expert Consulta-
tion,” sponsored by the Division of Microbiology and Infectious Diseases of
the National Institute of Allergy and Infectious Diseases in partnership with
the University of Alabama at Birmingham Sexually Transmitted Infections
Clinical Trials Group; contract HHSN272201300012I.
Acknowledgments. We thank the University of Alabama Clinical Trials
Group for funding to attend a meeting at which some of this content was
presented.
Potential conflict of interest. Both authors: No reported conflicts. Both
authors have submitted the ICMJE Form for Disclosure of Potential Con-
flicts of Interest. Conflicts that the editors consider relevant to the content
of the manuscript have been disclosed.
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