Reviewer’s report
Title: 
Intravaginal lactic acid gel versus oral metronidazole for treating women
with recurrent bacterial vaginosis: the VITA randomised controlled trial
Version: 
1 
Date: 
20 Dec 2022
Reviewer's report:
Thank you for addressing my initial comments, however I have a few additional
comments and queries for consideration.
General comment:
The responses and additional text should be carefully proofed as there were a
number of grammatical errors. The following are examples of sentences that
need proofing.
"The most common additional treatments taken for BV were oral metronidazole,
lactic acid gel."
'… but there is a lack of evidence as to whether treating BV in this scenario can
improve outcome.' - outcome of what?
"Table S2 gives medians calculated using censoring for those with missing
resolution data."
Additionally, in several places the text jumps between having bacterial vaginosis
in full vs BV. 
Comment 2.1
My initial comment queried whether there might have been an overestimation of
BV recurrence specifically in the metronidazole arm given these women received
antibiotics and therefore might be more inclined to develop thrush rather than
BV. The response addresses the potential over estimation of BV, but not the
difference that might have occurred between the two arms. 
Comment 2.6
If meta-data were available, it would strengthen the paper if associations
between recurrence in the two arms and the presence of co-factors was included
as supplementary data. 
Comment 2.9
Thank you for updating the text. It would be helpful to include references in the
following sentence as indicated: Theoretically the effectiveness could differ if
factors such as the lactic acid isomer ratio [ref] or osmolality [ref] varied
between brands, but these are unknown and a specific randomised trial would be
needed to investigate this.
Comment 2.10
The authors have partially addressed this comment, however the limitation
suggested is that the absence of clinical and microbiological assessments at the
study endpoint may have led to an over-or under-estimation of true rates of
recurrence. Therefore, the interpretation should include a caution that the
effectiveness of lactic acid gels requires further evaluation.
Comment 2.14 
Please list the absence of meta-data on contraceptive methods, such as IUD use
as a limitation.
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