Evolving issues in understanding and treating bacterial vaginosis.

Bacterial vaginosis is a synergistic polymicrobial syndrome characterized by depletion of Lactobacillus spp., especially those that produce hydrogen peroxide, and an intense increase in the quantity of commensal vaginal anaerobic bacteria to 100- to 1000-fold above normal levels. While the bacterial spectrum of these organisms has long been known to include Gardnerella vaginalis, Prevotella spp., anaerobic Gram-positive cocci, Mobiluncus spp. and Mycoplasma hominis, innovative use of molecular diagnostics has identified novel species apparently associated with this syndrome, including Atopobium vaginalis. Effecting resolution of bacterial vaginosis is important, in particular for the 8 to 23% of women afflicted with symptomatic disease during their reproductive years. Bacterial vaginosis has been consistently associated with numerous adverse sequelae related to the upper genital tract, including pelvic inflammatory disease and postsurgical infection in the setting of invasive gynecologic procedures, and may increase women's risk of acquiring HIV infection. Pregnant women with bacterial vaginosis experience a higher rate of preterm delivery and low-birth-weight infants. While antibiotics with activity against anaerobes--typically, metronidazole and clindamycin applied vaginally or taken orally--are the mainstays of therapy, bacterial vaginosis frequently recurs. For these reasons, innovative approaches to therapy are urgently required.