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Evidence summaries

Probiotics for the Treatment of Bacterial Vaginosis

Probiotics in addition to metronidazole may be effective for bacterial vaginosis and may be effective for prevention of recurrence. Level of evidence: "C"

A Cochrane review [Abstract] 1 included 4 studies with a total of 422 subjects. Better microbiological cure was suggested with oral metronidazole plus probiotic regimen compared with oral metronidazole plus placebo (OR 0.09, 95% CI 0.03 to 0.26; 1 trial, n=106), and with probiotic plus estriol preparation vs placebo plus estriol (OR 0.02, 95% CI 0.00 to 0.47; 1 trial, n=15). Vaginal probiotic capsules compared to metronidazole vaginal gel were not different in microbiological cure (OR 0.27, 95% CI 0.07 to 1.10; 1 trial, n= 35), neither probiotic vs placebo given after open treatment with clindamycin ovules (OR 1.21, 95% CI 0.67 to 2.19; 1 trial, n=217).

A randomized, double-blind, placebo-controlled, phase 2b trial 2 assessed the effect of Lactobasillus to prevent recurrent bacterial vaginosis. Women (n=228) who had completed a course of vaginal metronidazole were randomly assigned, in a 2:1 ratio, to receive vaginally administered Lactin-V or placebo for 11 weeks. Recurrence of bacterial vaginosis by week 12 occurred in 46 participants (30%) in the Lactin-V group and in 34 participants (45%) in the placebo group (RR 0.66; 95% CI 0.44 to 0.87; P = 0.01). The risk ratio for recurrence by week 24 was 0.73 (95% CI 0.54 to 0.92).

In a prospective case-control study 3 250 women with diagnoses of BV were divided in Group A (125 patients assigned to standard treatment for BV-metronidazole 500 mg orally twice a day for 7 days) and Group B (125 women undergoing the same standard antibiotic regimen followed by vaginal tablets containing Lactobacillus rhamnosus BMX 54). Patients were evaluated after 2, 6, and 9 months in term of recurrences rates of BV, vaginal symptoms, re-establishment of healthy vaginal flora, vaginal pH, and treatment tolerability.Patients that underwent prophylactic therapy with with Lqctobasillus experienced significantly low rate of recurrences comparing with patients treated with antibiotics only (p < 0.001).

Comment: The quality of evidence is downgraded by various shortcomings in study quality and by imprecise results (limited study size for each comparison).

References

  • Senok AC, Verstraelen H, Temmerman M, Botta GA. Probiotics for the treatment of bacterial vaginosis. Cochrane Database Syst Rev 2009 Oct 7;(4):CD006289. [PubMed]
  • Cohen CR, Wierzbicki MR, French AL et al. Randomized Trial of Lactin-V to Prevent Recurrence of Bacterial Vaginosis. N Engl J Med 2020;382(20):1906-1915. [PubMed]
  • Recine N, Palma E, Domenici L et al. Restoring vaginal microbiota: biological control of bacterial vaginosis. A prospective case-control study using Lactobacillus rhamnosus BMX 54 as adjuvant treatment against bacterial vaginosis. Arch Gynecol Obstet 2016;293(1):101-107. [PubMed]

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