Local treatment for bacterial vaginosis.
Authors: C A Ison, R F Taylor, C Link, P Buckett, J R Harris, C S Easmon
Journal: BMJ (1987)

Local treatment for bacterial vaginosisBacterial vaginosis (non-specific vaginitis) is a mild but common condition.O'Dowd et al reported that organisms associated with vaginosis could be isolated from 37% of women who presented with vaginal symptoms.The current treatment of choice is an oral nitroimidazole (metronidazole or tinidazole), given either as a single large dose or as a twice daily regimen for five to seven days.A problem with any treatment for vaginosis is the high rate of recurrence.2This study compares the efficacy ofmetronidazole given as a single oral 2 g dose with that of local treatment in the form of chlorhexidine pessaries in curing vaginosis and preventing recurrence. Patients, methods, and resultsPremenopausal women attending the Praed Street Clinic, London, with vaginosis were entered into a randomised single blind study.One group was allocated to receive a single 2 g oral dose ofmetronidazole and the other to receive intravaginal chlorhexidine as a single pessary containing 150 mg active drug on two consecutive days.A diagnosis of vaginosis was based on finding three of the following: "clue" cells, an abnormal vaginal discharge, a positive amine test result, and a vaginal pH>4-5.3Cervical and vaginal samples were taken for culture of Neisseria gonorrhoeae, Gardnerella vaginalis, lactobacilli, and anaerobic cocci and curved rods.Quantitative bacterial cultures were done on vaginal washings.Seventy nine women entered into the trial reattended for assessment at seven days.Forty three received chlorhexidine and 36 metronidazole.There was no significant difference in age, ethnic origin, parity, past history of sexually transmitted diseases, or forms of contraception between the two groups.Differences in results of treatment were analysed by x2 test.Chlorhexidine and metronidazole had similar efficacy in reducing both symptoms and signs of vaginosis (table).Metronidazole eradicated vaginal colonisation by G vaginalis in more patients than did chlorhexidine, but this was the only significant difference between the two regimens.When G vaginalis persisted there was no difference between the treatment groups in the numbers of organisms found (mean 107 colony forming units/g vaginal exudate).Of the 79 women assessed seven days after treatment, 63 (80%) returned at 28 days.Thirty four had been treated with chlorhexidine and 29 with metronidazole, of whom 26 and 20, respectively, had no discharge at seven days.Of these patients, 10 (38%) in the chlorhexidine group and 4 (20%) in the metronidazole group had a recurrence of vaginal discharge at 28 days.This difference was not significant (p=0 3).With regard to signs of vaginosis (raised pH and presence of amines, clue cells, and abnormal discharge), 27 of the chlorhexidine group had two or fewer at seven days, as did 25 of the metronidazole group.By day 28, 13 (48%) ofthe 27 patients in the chlorhexidine group and 10 (40%) ofthe 25 in the metronidazole group had signs of recurrence (three or four findings positive).Again this difference was not significant (p=0 7), a finding matched by the colonisation rates of G vaginalis and anaerobes in the two groups.