What is the recommended antibiotic treatment and management plan for a woman with aerobic vaginitis, who is trying to conceive, with a microbiome profile showing no Lactobacillus, high levels of E. coli (Escherichia coli), and high levels of Enterococcus faecalis?

Treatment of Aerobic Vaginitis with E. coli and Enterococcus faecalis in a Woman Trying to Conceive

For aerobic vaginitis with high E. coli and Enterococcus faecalis levels in a woman attempting conception, treat with oral amoxicillin-clavulanate 875/125 mg twice daily for 7-10 days, followed by vaginal probiotic restoration with Lactobacillus species. 1

Antibiotic Selection

• Amoxicillin-clavulanate (Augmentin) is the preferred oral antibiotic because it provides broad-spectrum coverage against both E. coli and Enterococcus faecalis, the two dominant pathogens in this case 1

• The recommended dosing is 875 mg/125 mg orally twice daily for 7-10 days 1

• This regimen is pregnancy category B and safe for women attempting conception, unlike fluoroquinolones which should be avoided 2

• Alternative option: Oral moxifloxacin can be used for severe cases, but amoxicillin-clavulanate is preferred in reproductive-age women 1

Why Not Local Antibiotics Alone

• While local kanamycin is effective for aerobic vaginitis, oral antibiotics are specifically indicated when dealing with deep colonization by enteric organisms like E. coli and Enterococcus faecalis 1

• The extremely high bacterial loads (150 × 10⁵ CFU/ml for E. coli and 75 × 10⁵ CFU/ml for Enterococcus) suggest deep tissue involvement requiring systemic therapy 3, 1

• Local antibiotics alone may not adequately penetrate to eradicate these high bacterial burdens 1

Post-Antibiotic Lactobacillus Restoration

• After completing antibiotics, immediately begin vaginal probiotic therapy with Lactobacillus reuteri or Lactobacillus rhamnosus to restore protective vaginal flora 4

• Probiotics have demonstrated efficacy in preventing recurrence of aerobic vaginitis caused by Enterococcus faecalis 4

• Use vaginal probiotic suppositories or capsules containing at least 10⁸-10⁹ CFU daily for 2-4 weeks 2

• This step is critical because the absence of Lactobacillus creates the permissive environment for aerobic pathogen overgrowth 5

Monitoring and Follow-Up

• Recheck vaginal pH and wet mount microscopy 2-3 weeks after completing antibiotic therapy 5

• Successful treatment should show: pH normalization to <4.5, reduction in inflammatory cells, and restoration of Lactobacillus-dominant flora 5

• If symptoms persist or recur, consider adding local estrogen therapy (if atrophic changes present) or extending probiotic duration 1, 5

Critical Considerations for Conception

• Untreated aerobic vaginitis significantly increases risk of chorioamnionitis, preterm birth, and fetal infection 5

• Treatment should be completed before attempting conception to optimize pregnancy outcomes 3, 5

• Enterococcus faecalis specifically has been associated with increased risk of cervical dysplasia and may harbor HPV genes, making eradication particularly important 3

• The complete absence of Lactobacillus indicates severe dysbiosis requiring aggressive restoration efforts 5

Common Pitfalls to Avoid

• Do not treat this as bacterial vaginosis with metronidazole alone - metronidazole targets anaerobes and will be ineffective against E. coli and Enterococcus faecalis 2, 5

• Do not use fluoroquinolones (ciprofloxacin, levofloxacin) in women of reproductive age attempting conception due to potential fetal risks 2

• Do not skip the probiotic restoration phase - antibiotics alone without Lactobacillus replacement leads to high recurrence rates 4, 5

• Do not rely on vaginal culture results alone for diagnosis - wet mount microscopy showing inflammation, toxic leukocytes, and immature epithelial cells confirms aerobic vaginitis 1, 5