Rethinking Prevention of Recurrent Bacterial Vaginosis: A Comparative Effectiveness Network Meta-Analysis.

OBJECTIVE: Preventive strategies for bacterial vaginosis (BV) include sexual partner treatment, short-term consolidation therapy, and long-term maintenance interventions. This systematic review and network meta-analysis (NMA) compares the efficacy of these approaches and evaluates effect modification by baseline recurrence risk. PATIENTS AND METHODS: Randomized-controlled trials (from inception to January 31, 2026) evaluating interventions to prevent BV recurrence in nonpregnant women were categorized into 3 analyses: partner treatment (pairwise meta-analysis), consolidation therapy, and long-term prevention (random-effects NMA). Certainty of evidence was evaluated using GRADE and CINeMA. RESULTS: Partner treatment significantly reduced BV recurrence rates [incident rate ratio (IRR) =0.76, 95% CI=0.60-0.98; moderate-certainty evidence] compared with placebo/no treatment. In consolidation therapy, acidifying agents [risk ratio (RR)=0.22, 95% CI=0.08-0.62; moderate-certainty evidence], vaginal probiotics (RR=0.37, 95% CI=0.15-0.93; moderate-certainty evidence), and oral probiotics (RR=0.45, 95% CI=0.21-0.96; low-certainty evidence) reduced early recurrence or persistence compared with placebo. In long-term prevention, vaginal probiotics were the only intervention achieving statistical significance overall (IRR=0.74, 95% CI=0.58-0.96; moderate-certainty evidence). Among women at low baseline risk, oral probiotics (IRR = 0.49, 95% CI=0.28-0.85) and acidifying agents (IRR=0.48, 95% CI=0.24-0.96) were most effective. Among women at high baseline risk, vaginal probiotics (IRR=0.70, 95% CI=0.52-0.93) and intermittent antibiotic suppression (IRR=0.39, 95% CI=0.21-0.73) showed the greatest reduction in recurrence. CONCLUSIONS: Partner treatment, consolidation with probiotics or acidifying agents, and long-term vaginal probiotic maintenance reduce BV recurrence. Vaginal Lactobacillus preparations and acidifying agents represent the most evidence-supported nonantibiotic approaches for recurrence prevention.