Lessons from Suppressive Therapy and Periodic Presumptive Treatment for Bacterial Vaginosis
Purpose of Review
Suppressive therapy and periodic presumptive treatment (PPT) are distinct but related strategies that have been used to reduce the incidence of bacterial vaginosis (BV). Here, we review clinical trial evidence of the effectiveness of suppressive therapy and PPT to reduce BV, and discuss their roles for women who frequently experience symptomatic or asymptomatic BV.
Among women who were recently and successfully treated for symptomatic BV, suppressive therapy with twice-weekly metronidazole gel for 16 weeks reduces the likelihood of recurrent symptomatic BV and is currently recommended by the Centers for Disease Control and Prevention for prevention of recurrent BV. The premise of PPT is to provide regimens used to treat BV at regular intervals to reduce the overall frequency of BV, regardless of symptoms. Three PPT trials were conducted using different routes (oral or intravaginal), doses, and frequencies of administration. Each trial demonstrated a significant reduction in BV over the course 12 months, ranging from a 10 to 45% decrease. PPT regimens that substantially reduce the frequency of BV over time could be evaluated in clinical trials to assess whether a reduced frequency of BV leads to subsequent reductions in BV-associated sequelae. While both suppressive therapy and PPT reduce BV, their impact wanes following cessation of the regimen.
Given the high prevalence of BV globally and burden of adverse reproductive health outcomes among women with BV, there is a critical need for more effective treatments that produce durable shifts in the microbiota towards vaginal health.
KeywordsBacterial vaginosis Periodic presumptive treatment Suppressive therapy Symptomatic Asymptomatic
Compliance with Ethical Standards
Conflict of Interest
JEB has received honoraria for consulting from BD and Lupin Pharmaceuticals. RSM currently receives research funding from Hologic/Gen-Probe and has received honoraria for consulting from Lupin Pharmaceuticals.
All other authors declare that they have no conflict of interest.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
- 1.Hillier S. Bacterial Vaginosis. In: Holmes KKSP, Stamm W, Piot P, Wasserheit J, Corey L, Cohen M, Watts D, editors. Sexually transmitted diseases. New York: McGraw-Hill; 2008.Google Scholar
- 7.Tamarelle J, Thiebaut ACM, de Barbeyrac B, Bebear C, Ravel J, Delarocque-Astagneau E. The vaginal microbiota and its association with human papillomavirus, chlamydia trachomatis, Neisseria gonorrhoeae and mycoplasma genitalium infections: a systematic review and meta-analysis. Clin Microbiol Infect 2018.Google Scholar
- 15.Larsson PG, Platz-Christensen JJ, Thejls H, Forsum U, Pahlson C. Incidence of pelvic inflammatory disease after first-trimester legal abortion in women with bacterial vaginosis after treatment with metronidazole: a double-blind, randomized study. Am J Obstet Gynecol. 1992;166:100–3.PubMedGoogle Scholar
- 27.Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines. MMWR Recomm Rep. 2015;64:1–138.Google Scholar
- 28.Oduyebo OO, Anorlu RI, Ogunsola FT. The effects of antimicrobial therapy on bacterial vaginosis in non-pregnant women. Cochrane Database Syst Rev 2009:CD006055.Google Scholar
- 36.Swidsinski A, Mendling W, Loening-Baucke V, et al. An adherent Gardnerella vaginalis biofilm persists on the vaginal epithelium after standard therapy with oral metronidazole. Am J Obstet Gynecol. 2008;198(97):e1–6.Google Scholar
- 48.World Health Organization (WHO). Guideline for the management of sexually transmitted infections. Geneva: WHO; 2003. p. 1–91.Google Scholar
- 53.Sobel J. Bacterial vaginosis: treatment. www.uptodate.com; Accessed 1 July 2019 2019; Last updated Feb 21, 2019.Google Scholar
- 56.Fredricks DN, Fiedler TL, Marrazzo JM. Molecular identification of bacteria associated with bacterial vaginosis. N Engl J Med. 2005;353:1899–911.Google Scholar
- 57.Ravel J, Gajer P, Abdo Z, Schneider GM, Koenig SSK, McCulle SL, et al. Vaginal microbiome of reproductive-age women. Proc Natl Acad Sci U S A. 2011;108(Suppl 1):4680–7.Google Scholar
- 58.Ahmed A, Earl J, Retchless A, Hillier SL, Rabe LK, Cherpes TL, et al. Comparative genomic analyses of 17 clinical isolates of Gardnerella vaginalis provide evidence of multiple genetically isolated clades consistent with subspeciation into genovars. J Bacteriol. 2012;194:3922–37.PubMedPubMedCentralGoogle Scholar
- 62.Deng ZL, Gottschick C, Bhuju S, Masur C, Abels C, Wagner-Dobler I. Metatranscriptome analysis of the vaginal microbiota reveals potential mechanisms for protection against metronidazole in bacterial vaginosis. mSphere. 2018;3.Google Scholar
- 63.Schwebke JR, Desmond R. A randomized trial of metronidazole in asymptomatic bacterial vaginosis to prevent the acquisition of sexually transmitted diseases. Am J Obstet Gynecol. 2007;196:517 e1–6.Google Scholar
- 67.Balkus J, Srinivasan S, Andac C, et al. Impact of baseline vaginal bacterial colonization on subsequent development of bacterial vaginosis among women receiving periodic presumptive treatment for vaginal infections. Presented at the Infectious Dieseases Society of Obstetrics and Gynecology, Philadelphia, PA, 2018 2018.Google Scholar
- 68.Sobel JD, Kaur N, Woznicki NA, Boikov D, Aguin T, Gill G, Akins RA Prognostic indicators of recurrence of bacterial vaginosis. J Clin Microbiol 2019;57.Google Scholar
- 69.Marrazzo JM, Dombrowski JC, Wierzbicki MR, Perlowski C, Pontius A, Dithmer D, et al. Safety and efficacy of a novel vaginal anti-infective, TOL-463, in the treatment of bacterial vaginosis and vulvovaginal candidiasis: a randomized, single-blind, phase 2, controlled trial. Clin Infect Dis. 2019;68:803–9.PubMedGoogle Scholar