Sobel JD, et al. - Researchers examined the efficacy of high dose vaginal metronidazole therapy (HDM) in treating recurrent bacterial vaginosis (RBV) patients who fail after standard of care (SOC) therapy. In addition, they determined the predictive value of diagnostic test scores proximal to the HDM for clinical outcome, and investigated the influences of menses, coitus, or race on therapy outcome. Seventy-four patients who were given SOC were tracked for up to 9 months; of these, 57 patients who were refractory or showed recurrence with symptomatic bacterial vaginosis (BV) were provided HDM and followed for up to 8 months. HDM led to the attainment of at least short-term remission in 68% of the patients and afforded a 10-day increase in the mean duration of remission among patients who eventually recurred. Following subsequent HDM, recurrence was more frequent among patients with prolonged dysbiosis (pH >5 or Amsel 4) before symptomatic recurrence. Within 10 days of menses, they noted most recurrence, however, sex in this cohort was not correlated with clinical outcome. African American patients in remission showed inferior mean diagnostic BV scores to those of a small cohort of Caucasian patients in remission. HDM thus led to the achievement of encouraging results that justify a prospective, randomized study to ascertain if follow-up HDM is useful among a broader cohort of women failing conventional oral metronidazole therapy.