The right bug in the right place: opportunities for bacterial vaginosis treatment Original paper

What was Reviewed?

This review examines the current understanding of the vaginal microbiome and its relationship to bacterial vaginosis (BV). It discusses how microbial dysbiosis contributes to the onset and persistence of BV and evaluates the potential therapeutic strategies that could leverage microbiome science to treat and prevent the condition. The authors explore the complexity of vaginal microbial communities, particularly focusing on the imbalance between health-associated Lactobacillus species and BV-associated anaerobic bacteria. They review both existing antibiotic treatments and emerging microbiome-informed interventions, including live biotherapeutics and vaginal microbiota transplants (VMT).

Who was Reviewed?

The review focused on published research involving women diagnosed with bacterial vaginosis, as well as healthy women with Lactobacillus-dominated vaginal microbiota. The authors synthesized data from clinical studies, in vitro experiments, and microbiome profiling studies that examined microbial composition, treatment responses, and microbial dynamics in BV-affected and healthy populations. They also reviewed preclinical studies exploring potential microbial therapeutics, including specific bacterial strains and vaginal microbiome restoration strategies.

What were the Most Important Findings?

The review highlighted that bacterial vaginosis is characterized by a distinct microbial signature: a depletion of Lactobacillus species (notably L. crispatus, L. jensenii, and L. gasseri) and an overgrowth of anaerobic bacteria. This microbial imbalance leads to elevated vaginal pH and inflammation, contributing to symptoms and increasing susceptibility to other infections.

The authors emphasized that standard antibiotic treatments, like metronidazole and clindamycin, often result in high recurrence rates and can disrupt both pathogenic and beneficial bacterial populations. They reviewed emerging microbiome-based therapies aimed at correcting vaginal dysbiosis without harming commensal microbes. These include probiotic formulations containing Lactobacillus strains, VMT, and precision antimicrobials targeting specific BV-associated pathogens. Notably, they discussed the importance of strain-specific effects, showing that not all Lactobacillus strains equally promote vaginal health, and that strain selection is critical for therapeutic success.

A key finding was that sustained remission from BV is linked to successful re-establishment of a Lactobacillus-dominant community, specifically L. crispatus. The review also addressed how host factors, sexual activity, and antibiotic exposure influence microbial dynamics, indicating the need for personalized, microbiome-informed approaches to BV treatment.

What are the Implications of this Review?

This review carries significant implications for clinicians managing bacterial vaginosis. It highlights the limitations of antibiotic-centric treatments and underscores the need for microbiome-conscious strategies that restore and maintain vaginal microbial balance. The evidence supports moving toward targeted interventions such as live biotherapeutics and VMT, which can selectively suppress BV-associated pathogens while promoting beneficial lactobacilli. Clinicians should consider that effective, long-term BV management may depend not only on pathogen eradication but also on rebuilding a resilient, health-associated vaginal microbiome. The review points to the potential of precision microbial therapies tailored to individual microbial profiles, marking a shift toward personalized vaginal microbiome medicine. For microbiome signatures research, the paper enriches the understanding of the specific bacterial players involved in BV dysbiosis and recovery.