Bacterial Vaginosis: What Do We Currently Know? Original paper

What Was Reviewed?

This review provides an in-depth exploration of bacterial vaginosis (BV), focusing on its etiology, diagnostic challenges, and treatment strategies. It explores the link between the vaginal microbiome and bacterial vaginosis, highlighting the shift from a Lactobacillus-dominated environment to one dominated by anaerobic bacteria like Gardnerella vaginalis and Atopobium vaginae. The review evaluates molecular and clinical diagnostic tools such as Amsel’s criteria, Nugent scoring, and PCR-based methods. Additionally, it highlights the limitations of antibiotic treatments due to high recurrence rates. It also explores emerging therapies, including probiotics, vaginal microbiota transplantation (VMT), and biofilm-targeting strategies​.

Who Was Reviewed?

This review synthesizes data from various studies examining the vaginal microbiome and its role in BV. It considers research on women of reproductive age from different geographic regions and ethnic backgrounds, recognizing the variability in vaginal microbiota composition. The review also addresses the broader clinical implications of BV, notably its links to sexually transmitted infections, pregnancy complications, and reproductive health​.

What Were the Most Important Findings?

The most significant finding is that BV is a polymicrobial shift, not an infection caused by a single pathogen. A healthy vaginal microbiome is dominated by Lactobacillusspp, but BV causes Lactobacilli decline and anaerobe overgrowth, including Gardnerella vaginalis and Prevotella spp. These bacteria form biofilms that contribute to antibiotic resistance and high recurrence rates.

The review highlights the flaws in traditional diagnostic methods. Amsel’s criteria and Nugent scoring are widely used but lack precision. PCR-based molecular diagnostics provide more accuracy and reliability. Emerging enzymatic and nanotechnology-based diagnostic tools offer potential advancements in BV detection.

Treatment challenges are another crucial aspect. Standard antibiotic therapies, including metronidazole and clindamycin, have a 50% recurrence rate within six months. This has driven interest in alternative approaches, including probiotics aimed at restoring Lactobacillus populations, vaginal microbiota transplantation (VMT) as a means of repopulating healthy microbiota, and biofilm-disrupting agents such as DNases and antimicrobial peptides. Additionally, the review explores the role of sexual transmission in BV persistence and the potential benefits of treating male partners​.

What Are the Implications of This Review?

The findings in this review emphasize the need for more effective diagnostic and therapeutic approaches for BV. The recognition of BV as a polymicrobial dysbiosis rather than a traditional infection suggests that future treatments should focus on restoring a healthy microbiome rather than eliminating bacteria. The high recurrence rate associated with antibiotic treatments highlights the need for strategies that address biofilm-associated resistance and microbiome resilience.

Probiotic-based interventions and vaginal microbiota transplantation could redefine BV treatment by offering long-term microbiome stability. Moreover, the identification of novel diagnostic biomarkers and rapid molecular techniques may enhance early detection and targeted interventions. Clinically, incorporating microbiome-focused therapies into gynecologic and obstetric care could improve reproductive health outcomes by reducing BV-related complications significantly. BV complications include increased susceptibility to sexually transmitted infections and adverse pregnancy events, emphasizing the need for innovative microbiome-based treatments urgently. The review ultimately advocates for a shift toward microbiome-informed medical strategies for managing BV.