How should I manage a patient with recurrent bacterial vaginosis after completing standard treatment?

When managing a patient with recurrent bacterial vaginosis (BV) after completing standard treatment, it is important to advise the woman that recurrence of symptoms is common ¹.

• Reconfirm the diagnosis: Perform a speculum examination and take swabs for pH, microscopy, and culture ¹. Further examination and investigations may not be necessary if a previous episode of recognisably similar symptoms was diagnosed as BV, and symptoms/signs cleared after antibiotic treatment, and other conditions were absent ¹.
• Address contributing factors: Enquire about continued exposure to factors such as smoking, vaginal douching, and the use of antiseptics, bubble baths, or shampoos in the bath ¹.
• Review current contraception: For recurring BV in women with an intrauterine contraceptive device (IUD), consider removing the device and advising the use of an alternative form of contraception ¹.
• Treat the current episode: Prescribe a 7-day course of oral metronidazole 400 mg twice a day ¹. If a single 2g dose of metronidazole or an intravaginal preparation was used previously, an alternative treatment like oral metronidazole 400 mg twice a day for 7 days should be prescribed ¹.
• Consider suppressive treatment or referral for frequent recurrence: If the diagnosis is confirmed and symptoms recur frequently despite adequate management in primary care, and symptoms are adversely affecting the woman, consider prescribing metronidazole vaginal gel as suppressive treatment (off-label use) if experienced in treating recurrent BV in primary care ¹. Otherwise, discuss management with a gynaecologist or Genito-Urinary Medicine (GUM) specialist ¹.
• Partner treatment: Routine screening and treatment of male partners is not indicated ¹. However, consider testing and treating the female partner in a same-sex relationship ¹.
• Probiotics: Current guidelines do not recommend probiotics for the treatment or prevention of BV, as systematic reviews have not provided sufficient evidence for or against their use ¹.