Diagnosis of vulvovaginitis: comparison of clinical and microbiological diagnosis

Phenylacetic acid, an anti-vaginitis metabolite produced by the vaginal symbiotic bacterium Chryseobacterium gleum

The human microbiome contains genetic information that regulates metabolic processes in response to host health and disease. While acidic vaginal pH is maintained in normal conditions, the pH level increases in infectious vaginitis. We propose that this change in the vaginal environment triggers the biosynthesis of anti-vaginitis metabolites. Gene expression levels of Chryseobacterium gleum, a vaginal symbiotic bacterium, were found to be affected by pH changes. The distinctive difference in the metabolic profiles between two C. gleum cultures incubated under acidic and neutral pH conditions was suggested to be an anti-vaginitis molecule, which was identified as phenylacetic acid (PAA) by spectroscopic data analysis. The antimicrobial activity of PAA was evaluated in vitro, showing greater toxicity toward Gardnerella vaginalis and Candida albicans, two major vaginal pathogens, relative to commensal Lactobacillus spp. The activation of myeloperoxidase, prostaglandin E2, and nuclear factor-κB, and the expression of cyclooxygenase-2 were reduced by an intravaginal administration of PAA in the vaginitis mouse model. In addition, PAA displayed the downregulation of mast cell activation. Therefore, PAA was suggested to be a messenger molecule that mediates interactions between the human microbiome and vaginal health.

Bacterial Vaginosis and Associated Factors Among Pregnant Women Attending Antenatal Care in Harar City, Eastern Ethiopia

Background

Bacterial vaginosis is one of the most common causes of abnormal vaginal discharge in women of reproductive age, especially pregnant women. It is characterized by the decrement of lactobacilli and increasing proliferation of diverse anaerobic bacteria. The prevalence of bacterial vaginosis and contributing factors vary between countries, within the same country, and among different populations.

Objective

The purpose of this study was to determine the prevalence of bacterial vaginosis and associated factors among pregnant women attending antenatal care from May 5-July 15, 2021 in health-care facilities found in Harar town, eastern Ethiopia.

Methods and Materials

An institutional-based cross-sectional study was conducted among 248 pregnant women attending antenatal care through systematic random sampling. Data were collected using a structured questionnaire and two vaginal swabs were collected using sterile swabs and transported to the microbiology laboratory. Samples were analyzed using Amsel's criteria or using Nugent scoring criteria and culture. Data were entered into EpiData version 3.1 and transferred to SPSS version 25 for analysis. Binary logistic regression was used to identify variables associated with bacterial vaginosis. P-value <0.05 was considered statistically significant.

Results

Altogether 248 pregnant women were included in the study. Overall, 21.4% (95% CI: 16, 27) of study participants had bacterial vaginosis. History of sexually transmitted infection (AOR = 6.0, 95% CI: 1.94, 19.07; P = 0.002), history of spontaneous abortion (AOR = 5.8, 95% CI: 1.55, 22.02; P = 0.009), multiple sex partners (AOR = 8.6, 95% CI: 2.93, 25.79; P = 0.000) and having vaginal discharge (AOR = 5.5, 95% CI: 2.48, 12.41; P = 0.000) were significantly associated with bacterial vaginosis.

Conclusion

The prevalence of bacterial vaginosis is higher among symptomatic pregnant women and associated with a history of sexually transmitted infection, vaginal discharge, multiple sexual partners and spontaneous abortion.

Understanding Women's Vaginal Douching Behaviors and Practices for Consideration in the Development of a Potential Future Vaginal Microbicide Douche for HIV Prevention: A Systematic Review of the Literature

Despite clinicians consistently advising against vaginal douching, 29-92% of women worldwide report douching. This review documents women's douching practices, motivations for douching, and specific associations (or absence of associations) between vaginal douche use and vaginal outcomes thought to be associated with douching. Understanding women's existing douching behaviors and vaginal health outcomes is critical for developing a safe vaginal microbicide douche that can be used as HIV pre-exposure prophylaxis (PrEP). A vaginal douche as PrEP could help prevent new HIV infections, since emerging evidence shows some women discontinue oral PrEP. We performed a systematic review of the literature using the guidelines for Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA). Articles included in the analysis (N = 48) were published 2009-2019 in English and focused on women's experiences with douching. Two trained independent reviewers assessed these articles for content on vaginal douching, including racial/ethnic focus of studies, study design, sampling, women's reasons for douching, contents of douche solutions, and associations between vaginal douching and vaginal health outcomes. Several studies focused on Black women (N = 12 studies) or had no racial/ethnic focus (N = 12). Just over half of all studies (N = 24) were cross-sectional and involved a self-reported questionnaire and lab samples. Studies sampled women from health clinics where they were (N = 13) or were not (N = 14) presenting for vaginal health complaints. Women's primary motivation for douching was for "general cleanliness" (N = 13), and most douche solutions contained water (N = 12). There was little empirical agreement between vaginal douche use and most vaginal health outcomes. Future studies of PrEP vaginal douches should be well controlled and prioritize safety to ensure positive vaginal health outcomes.

Vulvovaginal Candidosis: Current Concepts, Challenges and Perspectives

Vulvovaginal candidosis (VVC) is a frequently occurring infection of the lower female genital tract, mostly affecting immuno-competent women at childbearing age. Candida albicans is the most prevalent pathogenic yeast—apart from other non-albicans species—related to this fungal infection. Different virulence factors of C. albicans have been identified, which increase the risk of developing VVC. To initiate treatment and positively influence the disease course, fast and reliable diagnosis is crucial. In this narrative review, we cover the existing state of understanding of the epidemiology, pathogenesis and diagnosis of VVC. However, treatment recommendations should follow current guidelines.

Association of sexual function and psychological symptoms including depression, anxiety and stress in women with recurrent vulvovaginal candidiasis

Objective:

Recurrent vulvovaginal candidiasis (RVVC) is a common vaginal infection which could affect the quality of life, romantic relationships, and sexual performance. There is some evidence that psychological problems result in an increased incidence of RVVC by changing the immune systems of individuals. The aim of this study was to determine the association of sexual function and psychological factors including depression, anxiety, and stress in women with RVVC.

Material and Methods:

Study design was case controlled. Equal numbers of women with RVVC and uninfected women referred to gynecology clinics were selected, using convenience purposive sampling. Two samples of vaginal discharge were prepared from each person. One sample was examined microscopically and the second was cultured on Sabouraud Agar. Data collection tools used for this study included demographic questionnaire, Female Sexual Function Index, Depression Anxiety Stress Scales-21. Data were analyzed using SPSS software (version 19).

Results:

Less sexual satisfaction [odds ratio (OR): 0.608, 95% confidence interval (CI): 0.421-0.878] and less orgasm (OR: 0.741, 95% CI: 0.530-0.998) was associated with RVVC. In patients with RVVC, the levels of depression, anxiety and stress were significantly higher compared to those of healthy individuals.

Conclusion:

Depression, anxiety and stress in the past four weeks are related to an increased risk of RVVC. There is an association between depression, anxiety and stress, sexual satisfaction, and orgasm with RVVC. It may be that psychological interventions and sexual counseling can be effective in improving RVVC.

Fluconazole resistance in Candida albicans is induced by Pseudomonas aeruginosa quorum sensing

Microorganisms employ quorum sensing (QS) mechanisms to communicate with each other within microbial ecosystems. Emerging evidence suggests that intraspecies and interspecies QS plays an important role in antimicrobial resistance in microbial communities. However, the relationship between interkingdom QS and antimicrobial resistance is largely unknown. Here, we demonstrate that interkingdom QS interactions between a bacterium, Pseudomonas aeruginosa and a yeast, Candida albicans, induce the resistance of the latter to a widely used antifungal fluconazole. Phenotypic, transcriptomic, and proteomic analyses reveal that P. aeruginosa's main QS molecule, N-(3-Oxododecanoyl)-L-homoserine lactone, induces candidal resistance to fluconazole by reversing the antifungal's effect on the ergosterol biosynthesis pathway. Accessory resistance mechanisms including upregulation of C. albicans drug-efflux, regulation of oxidative stress response, and maintenance of cell membrane integrity, further confirm this phenomenon. These findings demonstrate that P. aeruginosa QS molecules may confer protection to neighboring yeasts against azoles, in turn strengthening their co-existence in hostile polymicrobial infection sites.

Recurrent vulvovaginal candidiasis

PURPOSE

Recurrent vulvovaginal candidiasis (RVVC), multiple episodes of vulvovaginal candidiasis (VVC; vaginal yeast infection) within a 12-month period, adversely affects quality of life, mental health, and sexual activity. Diagnosis is not straightforward, as VVC is defined by the combination of often nonspecific vaginal symptoms and the presence of yeast-which is a common vaginal commensal. Estimating the incidence and prevalence is challenging: most VVC is diagnosed and treated empirically, the availability for purchase of effective therapies over the counter enables self-diagnosis and treatment, and the duration of the relatively benign VVC symptoms is short, introducing errors into any estimates relying on medical records or patient recall.

METHODS

We evaluate current estimates of VVC and RVVC and provide new prevalence estimates using data from a 2011 seven-country (n = 7345) internet panel survey on VVC conducted by Ipsos Health (https://www.ipsos.com/en). We also evaluate information on VVC-associated visits using the National Ambulatory Medical Care Survey.

RESULTS

The estimated probability of VVC by age 50 varied widely by country (from 23% to 49%, mean 39%), as did the estimated probability of RVVC after VVC (from 14% to 28%, mean 23%).

CONCLUSIONS

However estimated, the probability of RVVC was high suggesting RVVC is a common condition.

Syndromic Diagnosis in Evaluation of Women with Symptoms of Vaginitis

PURPOSE OF REVIEW

This review aims to determine the effectiveness of the use of syndrome diagnosis in the evaluation of vaginitis and to make suggestions based on the review findings.

RECENT FINDINGS

Vaginal discharge as the main symptom of vaginitis is unspecific. A randomized study of symptom-based diagnosis and treatment of vaginitis in the USA favored symptoms used for treatment; however, this was only a pilot study. Hence, a population-based study is necessary to validate these findings. Most of the study that assessed treatment of vaginitis in pregnancy reported low diagnostic sensitivity and specificity for bacterial vaginosis and vaginal candidiasis and a wide range for trichomonas vaginalis reflecting ineffectiveness of syndrome-based treatment in pregnancy. A systematic review of the web for relevant literature was made, and appropriate articles were extracted and reviewed. Sensitivity, specificity, and positive values were used, where applicable to determine effectiveness. Forty-three full articles and abstracts were reviewed. Studies that validated or applied WHO algorithm for treatment of vaginitis reported high sensitivity (91.5-100%) but moderate to low specificity (0-27.5%) among women with vaginal symptoms. Studies that focused on symptoms for diagnosis of the three main etiologic agents of vaginitis reported low sensitivity and specificity, while such studies in pregnancy reported sensitivity and specificity ranging from 35.4 to 54% for TV, 11 to 100% for BV, and 0 to 56.2% for trichomonas vaginalis, bacterial vaginosis, and vaginal candidiasis, respectively. Studies that added point of care test reported higher sensitivity and specificity and positive predictive value. The use of WHO syndrome-based algorithm or its modification for treatment of vaginitis though moderately effective has the potential for overtreatment and physician error. Point of care testing and laboratory investigation are essential for productive intervention especially in pregnancy.

Comparison of the therapeutic effects of Garcin(®) and fluconazole on Candida vaginitis

INTRODUCTION

This study aimed to determine and compare the effects of garlic tablets (Garcin(®)) and fluconazole on Candida vaginitis in women who presented to a health centre in Koohdasht, Iran, from August 2011 to March 2012.

METHODS

The clinical trial was conducted on 110 married women (aged 18-44 years) who had complaints of itching or a burning sensation in the vaginal area. Candida vaginitis was diagnosed by pH measurement of vaginal secretions, direct microscopic evaluation and Sabouraud dextrose agar cultures of the vaginal discharge. On confirmation of diagnosis, the patients were randomly divided into two groups (n = 55). One group received 1,500 mg of Garcin tablets daily and the other received fluconazole tablets 150 mg daily, over a period of seven days. Four to seven days after the completion of treatment, patients were examined for treatment response and possible side effects.

RESULTS

Complaints related to the disease improved by about 44% in the Garcin group and 63.5% in the fluconazole group (p < 0.05). The overall symptoms of the disease (i.e. redness of vulva and vagina, cheesy discharge, pustulopapular lesions and abnormal cervix) improved by about 60% in the Garcin group and 71.2% in the fluconazole group (p > 0.05). Results of microscopic evaluation and vaginal discharge culture showed significant differences before and after intervention in both groups (p < 0.05).

CONCLUSION

The present study shows that Garcin tablets could be a suitable alternative to fluconazole for the treatment of Candida vaginitis.

Screening of vulvovaginal infections during pregnancy in resource constrained settings: Implications on preterm delivery

The present study was undertaken to evaluate the efficacy of clinical and microbiological investigations available in limited resource settings for an effective diagnosis of vaginal infections/abnormal vaginal microbiota among pregnant women. As an outcome of the study we intended to find the association of various vaginal infections during pregnancy with preterm delivery. Pregnant women presenting for routine antenatal care at an antenatal clinic in south India were enrolled in the study. Each participant underwent clinical and microbiological examinations for the diagnosis of vaginal infections such as bacterial vaginosis (BV), vulvovaginal candidiasis (VVC) and trichomoniasis. In addition, Gram's stained high-vaginal smears were evaluated for the presence of partial BV and vaginitis. Diagnostic accuracies of clinical diagnosis for the aforementioned infections was determined in comparison with gold standard microbiological diagnosis. Proportion of women with vulvovaginal infections were estimated using descriptive statistics and incidence risk ratio for preterm delivery with each form of the infection was estimated using univariate analysis. A total of 790 pregnant women were recruited in the study. Positive predictive values of clinical diagnosis for BV, VVC and Trichomoniasis in comparison with reference method were 72.7, 33.5 and 37.6% respectively. Partial BV (3.2%) and vaginitis due to mixed bacterial etiology (9.4%) were per exclusionem diagnosed using the microbiological smear examination. Microbiological diagnosis of BV and vaginitis were found to have a statistically significant association with preterm delivery. Effective diagnosis of vaginal infections/abnormal vaginal microbiota associated with preterm delivery can be achieved by the adjunct of microbiological smear examination of the vaginal smears to the clinical examination in limited resource settings.

Vulvovaginal candidiasis: Epidemiology, microbiology and risk factors

Vulvovaginal candidiasis (VVC) is an infection caused by Candida species that affects millions of women every year. Although Candida albicans is the main cause of VVC, the identification of non-Candida albicans Candida (NCAC) species, especially Candida glabrata, as the cause of this infection, appears to be increasing. The development of VVC is usually attributed to the disturbance of the balance between Candida vaginal colonization and host environment by physiological or nonphysiological changes. Several host-related and behavioral risk factors have been proposed as predisposing factors for VVC. Host-related factors include pregnancy, hormone replacement, uncontrolled diabetes, immunosuppression, antibiotics, glucocorticoids use and genetic predispositions. Behavioral risk factors include use of oral contraceptives, intrauterine device, spermicides and condoms and some habits of hygiene, clothing and sexual practices. Despite a growing list of recognized risk factors, much remains to be elucidated as the role of host versus microorganisms, in inducing VVC and its recurrence. Thus, this review provides information about the current state of knowledge on the risk factors that predispose to VVC, also including a revision of the epidemiology and microbiology of VVC, as well as of Candida virulence factors associated with vaginal pathogenicity.

Vaginal films for drug delivery

Vaginal dosage forms have been studied in relation to many drugs as the vagina presents several advantages as a site for drug delivery, such as large surface area, rich blood supply, avoidance of the first-pass effect, relatively high permeability to several drugs, and self-insertion. Traditional vaginal dosage forms have been associated with disadvantages such as low residence time and discomfort and have been surpassed by newly designed drug delivery systems, particularly those based on bioadhesive polymers. Vaginal films are solid dosage forms that rapidly dissolve in contact with vaginal fluids and are unlikely to be associated with leakage and messiness. They have been studied for some female genital problems, aiming either contraceptive, antimicrobial, or microbicide effects. Precise and complex processes of manufacturing and characterization are required to achieve successful film formulation. Although scarce, the available user's acceptability studies show promising results. Vaginal films gather a lack of opportunities for both therapeutic and prophylactic actions, and therefore should be considered when designing and developing new vaginal drug delivery systems.

Importance of Candida-bacterial polymicrobial biofilms in disease

Candida albicans is the most prevalent human fungal pathogen, with an ability to inhabit diverse host niches and cause disease in both immunocompetent and immunocompromised individuals. C. albicans also readily forms biofilms on indwelling medical devices and mucosal tissues, which serve as an infectious reservoir that is difficult to eradicate, and can lead to lethal systemic infections. Biofilm formation occurs within a complex milieu of host factors and other members of the human microbiota. Polymicrobial interactions will probably dictate the cellular and biochemical composition of the biofilm, as well as influence clinically relevant outcomes, such as drug and host resistance and virulence. In this manuscript, we review C. albicans infections in the context of in vivo polymicrobial biofilms and implications for pathogenesis.