Abstract
Bacterial vaginosis is a common and distressing condition associated with serious comorbidities. Antibiotic treatment is usually clinically effective in the short term, but recurrence is common and side effects can occur. The objective is to assess whether or not intravaginal lactic acid gel is clinically effective and cost-effective for treating recurrent bacterial vaginosis compared with oral metronidazole (Flagyl, Sanofi). This was an open-label, multicentre, parallel-arm, randomised (1 : 1) controlled trial. This took place in one general practice and 19 sexual health centres in the UK. Women aged ≥ 16 years with bacterial vaginosis symptoms and one or more episode(s) within the past 2 years took part. The interventions were 5 ml of intravaginal lactic acid gel taken once daily for 7 days (intervention) or 400-mg oral metronidazole tablets taken twice daily for 7 days (control). The primary outcome was the resolution of bacterial vaginosis symptoms 14 days after randomisation. The secondary outcomes were time to first recurrence of symptoms; number of recurrences and treatment courses over 6 months; microbiological resolution on microscopy of vaginal smears at week 2; time to resolution of symptoms; tolerability, adherence and acceptability of the treatment; prevalence of concurrent sexually transmitted infections; quality of life; and cost-effectiveness. Recruitment stopped prior to reaching the target of 1900 participants on recommendation from the Data Monitoring Committee and Trial Steering Committee after a planned review of the results indicated that the research question had been answered. Overall, 518 participants were randomised and primary outcome data were available for 409 participants (79%; 204 in the metronidazole arm, 205 in the lactic acid gel arm). Participant-reported symptom resolution at week 2 was higher with metronidazole (143/204; 70%) than with lactic acid gel (97/205; 47%) (adjusted risk difference -23.2%, 95% confidence interval -32.3% to -14.0%). Recurrence in 6 months in a subset of participants who had initial resolution and were available for follow-up was similar across arms (metronidazole arm: 51/72, 71%; lactic acid gel arm: 32/46, 70%). A higher incidence of some side effects was reported with metronidazole than with lactic acid gel (nausea 32% vs. 8%; taste changes 18% vs. 1%; diarrhoea 20% vs. 6%, respectively). At week 2, the average cost per participant with resolved symptoms was £86.94 (metronidazole), compared with £147.00 (lactic acid gel). Some participants preferred using lactic acid gel even if they perceived it to be less effective than metronidazole. Loss to follow-up for collection of the primary outcome data was 21% and was similar in both arms. There is a risk of bias owing to missing outcome data at 3 and 6 months post treatment. A higher initial response was seen with metronidazole than with lactic acid gel, but subsequent treatment failure was common with both. Lactic acid gel was less cost-effective than metronidazole. In general, women disliked taking repeated courses of metronidazole and preferred lactic acid gel, even when they were aware that it was less likely to provide symptom resolution. In the absence of effective curative therapy, further evaluation of non-antibiotic treatments to control the symptoms of recurrent bacterial vaginosis is required to improve quality of life for these patients. Further microbiological analysis of vaginal samples would be useful to identify additional factors affecting response to treatment. Current Controlled Trials ISRCTN14161293. This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 2. See the NIHR Journals Library website for further project information.
Highlights
A higher incidence of some side effects was reported with metronidazole than with lactic acid gel
In the absence of effective curative therapy, further evaluation of non-antibiotic treatments to control the symptoms of recurrent bacterial vaginosis is required to improve quality of life for these patients
The early termination of recruitment into the trial limited the ability to obtain definitive evidence on the cost-effectiveness of intravaginal lactic acid gel compared with oral metronidazole
Summary
Bacterial vaginosis (BV) is a common condition that predisposes women to potentially serious comorbidities, such as human immunodeficiency virus (HIV) infections, other sexually transmitted infections (STIs), pelvic inflammatory disease (PID), and preterm birth, miscarriage and other adverse pregnancy outcomes.[1,2,3,4,5] Typical symptoms include vaginal discharge accompanied by an unpleasant fishy odour that frequently occurs in association with menstruation and can have a significant impact on the woman’s quality of life.[5]In women of reproductive age, the pH of the vagina is normally moderately acidic, in part because of the presence of lactobacilli species that produce lactic acid, which helps to prevent the overgrowth of other vaginal bacteria. The objective of the economic evaluation in the VITA trial was to compare the cost-effectiveness of intravaginal lactic acid gel with oral metronidazole in the treatment of recurrent BV.[25] In addition, given that the trial was investigating whether or not intravaginal lactic acid gel could be used to help reduce antibiotic exposure, exploratory analyses were included to investigate the costs associated with antibiotic resistance as a penalty cost for antibiotic use. Bacterial vaginosis affects 30–50% of women at some time in their lives and is a distressing condition that is associated with potentially serious comorbidities. Current antibiotic treatments, such as metronidazole (Flagyl, Sanofi), are usually effective, but they can result in side effects, and recurrence is common. The metronidazole Versus lactic acId for Treating bacterial vAginosis (VITA) trial aimed to investigate whether or not lactic acid gel is clinically effective and cost-effective for the treatment of recurrent bacterial vaginosis compared with metronidazole
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