What is the recommended treatment for a vaginal culture showing high levels of Gardnerella vaginalis and Enterococcus faecalis bacteria?

From the Guidelines

The recommended treatment for a vaginal culture showing high levels of Gardnerella vaginalis and Enterococcus faecalis typically involves targeted antibiotic therapy, with metronidazole as the first-line treatment for Gardnerella vaginalis and amoxicillin or ampicillin for Enterococcus faecalis, if the strain is sensitive. For Gardnerella vaginalis, which causes bacterial vaginosis (BV), metronidazole is the preferred treatment, either as oral tablets (500mg twice daily for 7 days) or as a vaginal gel (0.75%, applied once daily for 5 days) 1. Alternatively, clindamycin cream (2%, applied intravaginally at bedtime for 7 days) can be effective, although it appears less efficacious than the metronidazole regimens 1.

For Enterococcus faecalis, which represents a secondary infection, amoxicillin (500mg three times daily for 7 days) or ampicillin may be prescribed if the strain is sensitive. In cases where both organisms need simultaneous treatment, a combination approach may be necessary. It's essential to complete the full course of antibiotics even if symptoms improve quickly. During treatment, patients should avoid alcohol with metronidazole due to potential severe reactions, abstain from sexual intercourse or use condoms, and consider probiotic supplements to help restore normal vaginal flora. This dual infection suggests disruption of the normal vaginal microbiome, where Gardnerella overgrowth creates conditions favorable for opportunistic pathogens like Enterococcus to establish infection.

Key considerations in treatment include:

• Completing the full course of antibiotics to ensure effective treatment and prevent recurrence
• Avoiding alcohol consumption during metronidazole treatment to prevent adverse reactions
• Practicing safe sex or abstaining from sexual intercourse during treatment to prevent transmission or reinfection
• Considering probiotic supplements to aid in restoring the normal vaginal flora, as suggested by the association between BV and the disruption of the vaginal microbiome 1.

Given the potential for BV to be associated with adverse pregnancy outcomes, as noted in the guidelines for treating STDs 1, it is crucial to manage these infections effectively, especially in pregnant women, to reduce the risk of complications. However, the provided evidence does not directly address the treatment of Enterococcus faecalis in the context of vaginal infections, emphasizing the need to rely on general principles of antibiotic therapy for secondary infections.

From the FDA Drug Label

Infections of the Genitourinary Tract: Amoxicillin for oral suspension is indicated in the treatment of infections due to susceptible (ONLY β-lactamase–negative) isolates of Escherichia coli, Proteus mirabilis, or Enterococcus faecalis The recommended treatment for a vaginal culture showing high levels of Gardnerella vaginalis is not directly addressed in the label, however, for Enterococcus faecalis, the treatment is amoxicillin (PO), but only if the isolate is β-lactamase–negative 2.

• Gardnerella vaginalis treatment is not mentioned in the label.
• Enterococcus faecalis can be treated with amoxicillin (PO) if the isolate is susceptible.

From the Research

Treatment for Gardnerella Vaginalis and Enterococcus Faecalis

• The recommended treatment for a vaginal culture showing high levels of Gardnerella vaginalis is metronidazole, as it is effective in decreasing the levels of anaerobic bacteria and G. vaginalis, and restoring the normal vaginal flora dominated by lactobacilli 3, 4, 5.
• However, there is a growing concern about the increasing resistance of G. vaginalis to metronidazole, with some studies showing that up to 68.7% of strains are resistant to this antibiotic 6.
• For Enterococcus faecalis, the treatment is not well established, but it is recommended to use a combination of therapy, including antibacterial (antiseptic and antibiotic), hormonal, non-steroidal anti-inflammatory, and/or probiotics 7.
• Topical antibiotics, such as clindamycin, may be effective against E. faecalis, and metronidazole may also be used in combination with other treatments 4, 7.
• It is essential to note that the treatment of aerobic vaginitis caused by E. faecalis should be based on microscopic or microbiological findings, and a topical steroid may be used to reduce inflammation, and estrogen to treat atrophy 7.

Considerations for Treatment

• The development of biofilms by G. vaginalis can protect the bacteria from antibiotics, and the use of lysozyme as a cotreatment may improve the effectiveness of antibiotics, such as metronidazole 4.
• The presence of E. faecalis in the vaginal flora can increase the risk of cervical intraepithelial lesion (CIN) and cervical cancer, and intensive treatment of aerobic vaginitis may be important in preventing the onset of precancerous lesions and cervical cancer 7.
• The treatment of G. vaginalis and E. faecalis infections should be tailored to the individual patient, taking into account the severity of symptoms, the presence of other infections, and the patient's medical history 3, 5, 7.