A large retrospective analysis of more than 6,000 patients has identified a significant association between sexually transmitted infections—particularly gonorrhea—and bacterial vaginosis recurrence, with implications for clinical management and patient counseling.

Researchers at the University of Illinois Hospital analyzed electronic medical records from January 1, 2015 through September 9, 2023 and found that patients with a history of gonorrhea infection had dramatically increased odds of developing multiple bacterial vaginosis (BV) episodes within a year. Specifically, patients with gonorrhea positivity before BV diagnosis demonstrated adjusted odds ratios of 5.49 for recurrent BV compared with patients who had a single episode of BV. 

Key Findings

The research included 6,217 patients diagnosed with BV via gram stain, categorized as either single BV (4,882 patients) or recurrent BV (1,335 patients with two or more positive tests within 1 year). The researchers further categorized sexually transmitted infection (STI) history into three temporal relationships: positive ever, positive before BV, and positive after BV. The 8-year study period provided sufficient temporal scope to capture multiple BV episodes and various STI occurrences within individual patient records, which supported the robust statistical analysis that identified the significant associations between gonorrhea and chlamydia with BV recurrence. Bivariate analysis revealed significant differences in STI history between the two groups.

For gonorrhea, the data showed striking disparities: 37% of patients with recurrent BV had ever tested positive for gonorrhea vs only 11% of patients with single BV. Even more pronounced was the difference in gonorrhea positivity before BV diagnosis—34% in the recurrent BV group compared with 6.9% in the single BV group.

Chlamydia infection also demonstrated significant associations with BV recurrence, though they were less dramatic than gonorrhea. The researchers found that 43% of patients with recurrent BV had ever tested positive for chlamydia compared with 23% of patients who had a single episode of BV.

Statistical Analysis

In a multivariate analysis that controlled for confounding variables, two gonorrhea-related factors emerged as independently predictive of BV recurrence. History of gonorrhea infection yielded an adjusted odds ratio of 4.04, while gonorrhea positivity before BV diagnosis produced an even more substantial adjusted odds ratio of 5.49.

The researchers evaluated five STIs in total: chlamydia, gonorrhea, human papillomavirus (HPV), human immunodeficiency virus (HIV), and syphilis. However, the authors noted in their conclusions that "[n]o results regarding HPV, HIV, or syphilis were statistically significant, possibly due to smaller sample sizes."

Clinical Implications

The research builds upon established understanding of the bidirectional relationship between BV and STIs, while providing new quantitative evidence that specifically links STI history to BV recurrence patterns.

"Despite this relationship," the investigators noted, "few studies have linked BV recurrence to STI history." Their work therefore addresses a significant gap in the current literature. The substantial sample size—which represents one of the larger analyses of this relationship—strengthened the statistical power of the findings.

Study Methodology

The study design allowed for comprehensive temporal analysis of STI occurrence relative to BV episodes, which enabled the researchers to distinguish between pre-existing infections and those that occurred subsequent to initial BV diagnosis.

These findings were presented at the ACOG Annual Clinical and Scientific Meeting and suggest potential modifications to clinical practice patterns, particularly regarding STI screening protocols and counseling for patients with recurrent BV, while highlighting the complex interplay between vaginal dysbiosis and STIs in gynecologic health management.

The authors declared no conflicts of interest.

Source: Obstetrics & Gynecology