Epidemiology of bacterial vaginosis

The evaluation of the Allplex™ BV molecular assay for the diagnosis of bacterial vaginosis in symptomatic South African females

Bacterial vaginosis (BV) is a dysbiosis of vaginal microbiota characterized by a shift from Lactobacillus species predomination to a heterogeneous mixture of anaerobes. We compared the performance characteristics of the Allplex ™ BV molecular assay with the reference test, Nugent score microscopy, for vaginal swab specimens from symptomatic South African women. A total of 213 patients were enrolled, of whom 99 (46.5%) and 132 (62.0%) were diagnosed with BV by Nugent and Allplex™, respectively. The Allplex™ BV assay displayed a sensitivity of 94.9% (95% CI, 88.7%-97.8%) and a specificity of 66.7% (95% CI, 57.6%-74.6%), with an agreement of 79.8% (95% CI, 73.9%-84.7%) (κ = 0.60). Assay design may be enhanced for improved specificity by accounting for differences in healthy and BV-associated vaginal microbiomes among women of different ethnicities.

Bacterial Vaginosis: A Comprehensive Narrative on the Etiology, Clinical Features, and Management Approach

Due to the intricate balance of the vaginal microbiota's ecology, bacterial vaginosis is documented in one-third of females globally at various times of their lives. It is a typical reason for unusual vaginal discharge and is linked to various health problems. Gardnerella vaginalis is one of the anaerobic microorganisms linked to bacterial vaginosis. bacterial vaginosis is diagnosed by Amsel's criteria as well as comparisons among Amsel's criteria, Nugent's criteria, and Hay/Ison's criteria. To scan and assess the degree of dysbiosis within the vaginal microbiome, researchers have upped their game by combining cutting-edge molecular methods, with a focus on how specific microbial populations fluctuate in comparison to a healthy condition. A clue cell can be detected on a simple wet mount of vaginal secretions. Despite receiving regular antibiotic therapy, a substantial risk of treatment failure and bacterial vaginosis recurrence persists. Researchers have revealed positive treatment effects and reduced the infection of the female reproductive system with harmful bacteria.

Bacterial vaginosis: An insight into the prevalence, alternative treatments regimen and it's associated resistance patterns

Bacterial Vaginosis (BV) is a complex polymicrobial infection of vagina that shifts the paradigms of vaginal flora from lactobacilli to opportunistic pathogens. BV is catagorized by greyish white discharge, pH greater than 4.5. It results in the preterm labor, abortion, pelvic inflammatory disorders, post cesarean infections. BV is associated with Sexually Transmitted Diseases (STDs) or immune deficiency disorders like Human Immunodeficiency Virus, Human Papilloma Virus, Herpes Simplex Virus 1 and 2, and Neisseria gonorrhoeae. The prevalence rate is about 21.2 million (29.2%) worldwide. BV is more frequent in black females as compared to white females, independent of geographical distribution. Globally, BV is treated with the current recommended antibiotic therapy including Metronidazole and Clindamycin. The recurrence rates are 76% and occur within 06 months of treatment due to antibiotic resistance against pathogenic bacteria and their biofilms. The antibiotic resistance is a global health issue which directs the attentions towards other treatments. One of these is the treatment of sex partners, thus helping to stop the recurrence rates in females. However, this method does not show any positive results. Probiotic therapy is an incorporation of Lactobacilli orally or intravaginally for the recolonization of healthy microbes. This therapy has exhibited promising results but some studies revealed that Probiotic therapy does not control the recurrence rate. The other methods are in trials period and none of them are used clinically or commercially available for the treatment. The thermoplastic polyurethane (TPU) intravaginal rings contain lactic acid and metronidazole showed promising results in trials of BV treatment. The vaginal acidifiers are used as an alternative method to maintain the vaginal pH but the process of douching is a major limitation. The activated charcoal is used to treat BV patients in clinical trials showed decrease in the pH with only 3.1% loss of lactobacilli. Phage therapy is a reemerging field to overcome the bacterial resistance. They are host specific and easier to handle. They can be used naturally, synthetically; phage cocktails and phage-antibiotics combination can be used. Phages show auspicious results for the treatment of bacterial infections as compared to antibiotics as they also treat biofilms. This is one of the promising therapy in future to treat infections with no side effects. Phage therapy can be used in pharmaceuticals according to Food and Drug Administration (FDA) guidelines. Taken together, it is suggested that large funding is required by pharmaceutical sector or government for further investigation of bacteriophages to be used against BV pathogenesis.

The Human Microbiome during Bacterial Vaginosis

Bacterial vaginosis (BV) is the most commonly reported microbiological syndrome among women of childbearing age. BV is characterized by a shift in the vaginal flora from the dominant Lactobacillus to a polymicrobial flora. BV has been associated with a wide array of health issues, including preterm births, pelvic inflammatory disease, increased susceptibility to HIV infection, and other chronic health problems. A number of potential microbial pathogens, singly and in combinations, have been implicated in the disease process. The list of possible agents continues to expand and includes members of a number of genera, including Gardnerella, Atopobium, Prevotella, Peptostreptococcus, Mobiluncus, Sneathia, Leptotrichia, Mycoplasma, and BV-associated bacterium 1 (BVAB1) to BVAB3. Efforts to characterize BV using epidemiological, microscopic, microbiological culture, and sequenced-based methods have all failed to reveal an etiology that can be consistently documented in all women with BV. A careful analysis of the available data suggests that what we term BV is, in fact, a set of common clinical signs and symptoms that can be provoked by a plethora of bacterial species with proinflammatory characteristics, coupled to an immune response driven by variability in host immune function.

Point-of-care (POC) diagnosis of bacterial vaginosis (BV) using VGTest™ ion mobility spectrometry (IMS) in a routine ambulatory care gynecology clinic

PURPOSE

A new CE-marked portable desktop ion mobility spectrometer (VGTest) was used for detection of malodorous biogenic amines indicative of bacterial vaginosis (BV). This study aimed to assess the performance of this testing method for the first time in a routine ambulatory care clinic and to determine the relative levels of biogenic amines in vaginal fluid of BV.

METHODS

Vaginal and cervical swabs (n = 57) were surveyed for infections. Cases of BV (n = 18) confirmed positive according to "Amsel" criteria and normal controls (n = 39) showing no infection under clinical examination and testing negative in wet mount microscopy were included in the IMS analysis.

RESULTS

The trimethylamine (TMA) content in vaginal fluid of the BV-positive cases, AUCTMA/AUCTotal [mean 0.215 (range 0.15-0.35)] was significantly higher than normal controls [mean 0.06 (range 0.048-0.07)] p < 0.0001. The putrescine (1,4-diaminobutane, PUT) and cadaverine (1,5-diaminopentane, CAD) of BV-positive cases were above controls at borderline significance. The AUCTMA/AUCTotal ratios correlated neither with AUCPUT/AUCTotal nor AUCCAD/AUCTotal among BV-positive patients. In contrast, among normal controls all the biogenic amines were at a low level and the linear regression analysis revealed striking positive correlations of AUCTMA/AUCTotal with AUCPUT/AUCTotal (p < 0.05) and AUCCAD/AUCTotal (p < 0.001). The test shows 83 % sensitivity and 92 % specificity at a cut-off of AUCTMA/AUCTotal = 0.112 and AUC of receiver operator characteristic = 0.915 (0.81-0.97, 95 % CI).

CONCLUSIONS

VGTest-IMS is accurate and feasible for point-of-care testing of BV in the ambulatory care setting. Further evaluations are in progress to assess the utility of VGTest-IMS for differential diagnosis of candidosis, non-BV infection and common inflammatory conditions.

Biomedical applications of fermenticin HV6b isolated from Lactobacillus fermentum HV6b MTCC10770

Fermenticin HV6b is a class IIa antimicrobial peptide produced by Lactobacillus fermentum HV6b MTCC 10770 isolated from human vaginal ecosystem. It shows growth inhibition of a wide range of opportunistic pathogens of humans, for example, Bacteroides, Gardnerella vaginalis, Mobiluncus, Staphylococci, and Streptococci, associated with bacterial vaginosis in humans. It does possess an impressive sperm immobilization and spermicidal activity tested against human sperms which makes it an attractive proposition for formulating antibacterial vaginosis and contraceptive products. Apart from this, in vitro studies conducted against four different tissue models have indicated its potential to be used as a component of anticancerous drug therapy as it is reported to induce apoptosis in cancerous cells. This information could be integrated in future studies focusing on in vivo assessment of anticancerous activity of lactic acid bacterial toxins or bacteriocins.

Vaginal health in contraceptive vaginal ring users - A review

BACKGROUND

To provide an overview of the available data from clinical studies of vaginal conditions in women who use a vaginal ring as a contraceptive.

METHODS

A systematic review of the literature.

RESULTS

Millions of women have already used the ethylene vinyl acetate vaginal ring that releases ethinylestradiol and etonogestrel for contraception. Because of its small size, more than four out of five women using the ring report that they do not feel it, even during sexual intercourse. No colposcopic or cytological changes have been observed in users, although approximately 10% have increased vaginal discharge. While in vitro studies have shown adhesion of Candida yeasts to the vaginal ring surface, clinical studies have not demonstrated a greater incidence of Candida infections compared to users of equivalent oral contraceptives. Some clinical studies suggest a lower incidence of bacterial vaginosis. No interaction exists between concomitant use of the vaginal ring and other drugs or products for vaginal use.

CONCLUSION

The use of a contraceptive vaginal ring does not alter the vaginal ecosystem and therefore does not substantially affect vaginal health.

Stress, bacterial vaginosis, and the role of immune processes

Bacterial vaginosis (BV), the most common lower genital tract infection in women of reproductive age, is associated with adverse gynecologic and reproductive health outcomes. Women at highest risk for BV are young, unmarried, low income, undereducated, and African American. Behaviors such as vaginal douching, numerous sexual partners, frequent sexual intercourse, receptive oral sex, and substance use may contribute to risk, but they account for only a modest proportion of the observed race/ethnicity variance in BV. These subpopulations are also exposed to more social disadvantages or "stressors" such as poverty, poor housing, crime-infested neighborhoods, and discrimination than other groups. Growing physiologic evidence links psychosocial stress to the development of disease. Evidence supports a statistically significant, independent effect of stress on the risk and observed racial/ethnic disparity in the rate of BV. This paper reviews such evidence.

Comparison of local metronidazole and a local antiseptic in the treatment of bacterial vaginosis

OBJECTIVE

Bacterial vaginosis (BV) is characterized by a mixed flora of pathogenic anaerobic bacteria and associated with risks of pathologic conditions. In the present study, therapy with a local antiseptic spray (octenidine hydrochloride/phenoxyethanol, OHP) for 7 or 14 days is compared against the standard local therapy of BV (metronidazole) in a Serbian patient population.

METHODS

As much as 450 women were treated in groups with either 7 days metronidazole vaginal tablets, 7 days OHP, or 14 days OHP. Control smears were taken after each treatment period.

RESULTS

In total, 63.2% of the women were without indications of BV after therapy (metronidazole: 61.0%, OHP 7 days: 57.6%, and OHP 14 days: 71.0%). Significantly fewer women were affected from infections after treatment with 14 days OHP compared to OHP for 7 days.

CONCLUSIONS

Octenidine hydrochloride/phenoxyethanol spray was as effective as the standard therapy with metronidazole. Patients stated that OHP was more comfortable, easier to apply, and side effects were lesser.

Bacterial vaginosis and lower genital tract infections in women attending out-patient clinics at a tertiary institution serving a developing community

The prevalence of bacterial vaginosis and other lower genital tract infections were determined in women from a developing community. Patients were recruited from four out-patient clinics of a large urban tertiary referral hospital serving the indigent Black population of KwaZulu/Natal, South Africa. A total of 208 women attending the sexually transmitted diseases (STD) (n = 51), colposcopy (n =50), family planning (n = 52) and antenatal (n = 55) clinics were investigated. Endocervical and vaginal specimens were collected for microbiological investigation of recognised sexually transmitted pathogens. Estimation of vaginal pH, amine test and wet smear microscopy were performed at the bedside. Peripheral venous blood was obtained for serological tests for syphilis, hepatitis B surface antigen and antibody to the human immunodeficiency virus (HIV). Vaginal infections were detected in a total of 50% (104) of women, endocervical infections alone in 9% (18) and concurrent vagino-endocervical infections in 20% (41). Bacterial vaginosis (BV) was diagnosed in 35% (73) and its prevalence amongst different clinic populations ranged from 25% to 41% with no significant differences between any groups. Trichomoniasis was detected significantly more often in women attending the STD and antenatal clinics. Endocervical infections were found mainly in women attending the STD clinic, though the prevalence of Chlamydia trachomatis amongst the other clinic attenders ranged from 13% to 20%. Micro-organisms such as Gardnerella vaginalis, Mycoplasma hominis, anaerobes and curved Gram-negative rods were found in significantly higher number of women with BV. This study confirms the high prevalence of vaginal, endocervical and mixed vagino-endocervical infections in women from developing communities. The high prevalence of bacterial vaginosis as a single infection and its association with other recognised sexually transmitted pathogens in a large proportion of women, is of significance since such infections not only predispose to ascending upper genital tract infections but are also associated with complications in pregnancy such as premature rupture of membranes, preterm labour and endometritis.

Prevalence of bacterial vaginosis among young women in low-income populations of coastal Peru

The goal of this study was to determine the prevalence of bacterial vaginosis (BV) in Peruvian women from socioeconomically deprived populations and to determine the association between BV and risk factors for sexually transmitted diseases (STDs). Women were administered an epidemiologic survey to determine sexual risk behaviour and they provided biological samples to test for BV and STDs. The prevalence of BV was high (27%) and was significantly associated with having a bacterial STD or trichomoniasis. Age, marital status, and a history of sex work, but not of sexual experience, frequency of intercourse, and unprotected intercourse, were associated with BV. As BV may be a marker for STDs, screening for STDs should be performed in individuals with BV to promote early detection and treatment of co-infecting sexually transmitted pathogens.

Perfil epidemiológico de mulheres com vaginose bacteriana, atendidas em um ambulatório de doenças sexualmente transmissíveis, em São Paulo, SP

FUNDAMENTOS - A vaginose bacteriana é doença de grande relevância devido à sua alta prevalência e suas complicações obstétricas e ginecológicas. OBJETIVO - Descrever o perfil epidemiológico das pacientes com diagnóstico de vaginose bacteriana, atendidas em um ambulatório de São Paulo, segundo variáveis de interesse social, demográfico e clínico. MÉTODOS - Estudo transversal descritivo, baseado nos prontuários de 658 mulheres atendidas de janeiro de 1999 a dezembro de 2004. Foram coletadas as seguintes informações: idade, cor, estado civil, procedência, grau de escolaridade, preferência sexual, número de parceiros e presença de doença sexualmente transmissível associada. RESULTADOS - A prevalência encontrada foi de 29%. Com relação ao perfil da mulher com vaginose bacteriana, observou-se maior ocorrência em jovens entre 10 e 19 anos (40%), negras (37,1%), viúvas (62,5%), com segundo grau incompleto (39,5%), heterossexuais (29,5%), com dois ou mais parceiros sexuais nos últimos 30 dias (50%) e nos últimos cinco anos (32,3%). A associação com outras doenças sexualmente transmissíveis, concomitante, foi encontrada em 31,9% dos casos. CONCLUSÃO - A distribuição dos casos segundo faixa etária, raça, número de parceiros sexuais e associação com outras doenças encontradas nas pacientes com diagnóstico de vaginose bacteriana foi semelhante aos dados encontrados na literatura. A ocorrência está dentro dos limites descritos (10 e 36%).

Pregnancy outcome after early detection of bacterial vaginosis

OBJECTIVE

To assess if detecting bacterial vaginosis either in early pregnancy or at midtrimester may predict adverse pregnancy outcome in women at risk for preterm delivery.

STUDY DESIGN

242 pregnant women with a previous preterm delivery were evaluated for bacterial vaginosis either in the first trimester (prior to 10+0 weeks) or in the second one (24-26 weeks). Adverse outcome was intended as miscarriage (< or =25 weeks), or premature delivery (< or =36+6).

RESULTS

The risk of adverse pregnancy outcome was significantly increased in women diagnosed at first trimester with bacterial vaginosis (OR: 4.56; 95% CI: 2.54-8.93); the same finding at midtrimester did not increase significantly the risk of preterm delivery.

CONCLUSIONS

Early screening for bacterial vaginosis in pregnant women who experienced a preterm delivery may help in predicting the risk of adverse outcome.

The association of psychosocial stress and bacterial vaginosis in a longitudinal cohort

OBJECTIVE

The purpose of this study was to assess the association of psychosocial stress with bacterial vaginosis in a longitudinal sample of nonpregnant women.

STUDY DESIGN

A 1-year prospective longitudinal design was used. Nonpregnant women (n = 3614) aged 15 to 44 years were recruited at routine health care visits. Assessments were conducted quarterly for 1 year and included a standardized pelvic examination, an assessment of clinical symptoms, and an extensive self-report interview.

RESULTS

Psychosocial stress was associated with overall prevalence of (adjusted odds ratio, 1.10; 95% CI, 1.01-1.20) and an increased incidence of (adjusted odds ratio, 1.29; 95% CI, 1.12-1.48) bacterial vaginosis. The association between stress and bacterial vaginosis incidence was not changed appreciably by the control for behavioral and demographic characteristics and was magnified (odds ratio, 2.05; 95% CI, 1.15-3.66) in a case-crossover analysis.

CONCLUSION

Increased psychosocial stress is associated with greater bacterial vaginosis prevalence and incidence independent of other risk factors.

Effect of bacterial vaginosis on premature rupture of membranes and related complications in pregnant women with a gestational age of 37-42 weeks

BACKGROUND

The most serious outcome of term, premature rupture of membrane and chorioamnionitis is often associated with adverse maternal and infant outcomes related to infection. This study was undertaken to determine the prevalence of bacterial vaginosis (BV) at 37-42 gestational weeks and its relationship to premature rupture of membranes.

METHOD

During an analytical descriptive prospective study, 425 pregnant women with a gestational age of 37-42 weeks were studied for prevalence of BV. Then, 304 women on the basis of having BV or not were followed up until 48 h after delivery for premature rupture of membranes.

RESULT

The rate of BV in this population was 30.5%. No significant association was found between BV and premature rupture of membranes (odds ratio 1.6, 95% CI 0.9-2.8).

CONCLUSION

BV is a common vaginitis in term pregnancy, but we could not find any relationship between BV and premature rupture of membranes at term.

Bacterial vaginosis - a laboratory and clinical diagnostics enigma. Review article II

Diagnosing bacterial vaginosis (BV) has long been based on the clinical criteria of Amsel et al., whereby three of four defined criteria must be satisfied. Though there are other criteria and scoring methods which function well in comparison (i.e. Nugent scoring), it is not certain that they will always identify the same category of patients. Point-of-care methods based on various combinations of microbial products, presence of RNA, or more complex laboratory instrumentations such as sensor arrays, have also been introduced for the diagnosis of BV. No method for diagnosing BV can at present be regarded as the best. It could be that--based partly on tacit knowledge on the part of the clinical investigators scoring in the clinic--various scoring systems have been chosen to fit a particular BV-related problem in a particular population. In this review we critically examine these pertinent issues influencing clinical scoring and laboratory diagnostics of BV.

Risk factors for bacterial vaginosis

OBJECTIVE

To analyse risk factors for bacterial vaginosis (BV).

STUDY DESIGN

We conducted a case-control study on risk factors for BV, in several first-level gynecological centers in Italy. Cases were women aged 18-70 years with confirmed diagnosis of BV (using test for proline iminopeptidase (PIP) activity). Control were the first patients observed in the same center without any symptom suggesting vaginal infection, and a negative PIP activity test. A total of 476 cases and 450 controls entered the study.

RESULTS

The number of sexual partners in the month before interview, but not the number of intercourses, was associated with an increased risk of BV. The risk of BV with vaginal douching or tight jeans/trousers once or more a week was 2.0 (95% CI 1.0-3.9) and 1.5 (95% CI 1.0-2.2), respectively, compared to never users.

CONCLUSION

The findings are consistent with previous data and suggest that daily habits play an important role in risk of BV.

Bacterial vaginosis and miscarriage

PURPOSE OF REVIEW

This review aims to summarize current knowledge about the relationship between bacterial vaginosis and miscarriage.

RECENT FINDINGS

Studies investigating the relationship between bacterial vaginosis and infertility, implantation and early pregnancy loss have produced conflicting results. One study demonstrated a beneficial effect of colonization with hydrogen peroxide producing lactobacilli. A community based study found no association between bacterial vaginosis and first trimester loss, but a positive association with early second trimester loss. In a randomized controlled trial, treatment of bacterial vaginosis with oral clindamycin was associated with a fivefold reduction in the incidence of late miscarriage.

SUMMARY

The relationship between bacterial vaginosis and infertility and first trimester loss needs further elucidation. Measures to support a healthy lactobacillus flora such as probiotic therapy warrant study. The randomized controlled trials of clindamycin treatment need to be replicated in different settings.

Socioeconomic and environmental risk factors of bacterial vaginosis in early pregnancy

The main aim of this prospective study was to determine the socioeconomic, demographic and environmental factors that may be associated with the occurrence of bacterial vaginosis at early pregnancy in an indigent population from Central Poland. A group of 196 pregnant women was selected randomly from the patients of 10 district maternity units in the Lodz region, Central Poland. Only singleton pregnancies between 8 and 16 week of gestation were qualified for inclusion in the survey. A standard questionnaire covering medical, socioeconomic, demographic, constitutional and environmental items was administered to every subject and was verified with medical records. Cervico-vaginal swabs were collected from the women under study and tested for bacterial vaginosis (BV) according to Spiegel's criteria. Based on the results of Gram stain, BV was diagnosed in 51 women (28.5%), grade I microflora among 66 (36.9%) and grade II among 62 women (34.6%). In the univariate analysis, only single marital status proved to be an important risk factor associated with BV during pregnancy, this was confirmed in the multivariate analysis. Pregnant women who present risk factors for abnormal cervico-vaginal microflora should be covered by comprehensive prenatal surveillance, which enables early detection and treatment of this pathology. Research that identifies the causal pathways and mechanisms through which social disadvantage leads to a higher risk of preterm birth may help to reduce current socioeconomic and demographic disparities and improve pregnancy outcome.

Colposcopic and Cytologic Findings Among Women with Abnormal Vaginal Flora

OBJECTIVE

The purpose of our study was to evaluate the association of abnormal vaginal flora with pathological colposcopic and cytological findings.

MATERIALS AND METHODS

A total of 100 women of reproductive age were examined. Pregnant women were excluded. Each patient completed a self-administered questionnaire regarding sexual history and vaginal symptoms. All participants underwent a gynecological examination and colposcopy. Pap smear of the cervix and samples of vaginal discharge for microbiological analysis were obtained before the colposcopic examination. Statistical analysis was performed using Fisher exact test, chi test, and multifactorial analysis of variance.

RESULTS

Results of colposcopic examination were normal in more than 70% of all examined women, except in women with bacterial vaginosis where < 30% had normal results. Of all the women examined only 1 did not have normal (class II) Pap smear results.

CONCLUSIONS

Our study indicates that women with abnormal vaginal flora more often have pathological colposcopic findings, such as leukoplakia, vaginal hyperemia, and chronic cervicitis.

Bacterial vaginosis in pregnancy

Bacterial vaginosis is associated with adverse pregnancy outcomes across all gestational ages. It is linked to first and second trimester fetal loss, chorioamnionitis, preterm delivery, low-birthweight infants and maternal/neonatal infectious morbidity. Infants who survive preterm birth are at an increased risk of subsequent neurodevelopmental delays and handicap, more so if there was underlying choriomnionitis. The exact mechanisms and pathways through which bacterial vaginosis exerts these adverse effects are incompletely understood. Not surprisingly, intervention studies in bacterial vaginosis-positive pregnant women have shown conflicting results, both in women at high and low risk of preterm birth. A much better understanding of the pathobiology of bacterial vaginosis in pregnancy is required to focus the designs of intervention studies on the disturbed cellular and biochemical pathways. Such studies may address the benefits of the treatment of bacterial vaginosis before conception and during early pregnancy, to determine whether treatment in populations of pregnant women may be beneficial.

Bacterial vaginosis in early pregnancy and adverse pregnancy outcome

OBJECTIVE

To assess the prevalence of bacterial vaginosis (BV) in asymptomatic pregnant women and its association with preterm birth (PTB) and premature rupture of membranes (PROM).

METHODS

In a cohort study 1,006 pregnant women between 16-28 weeks' gestation were screened for BV (Nugent's criteria) and for lower genital tract infection. Women were followed to confirm pregnancy outcome. Data were analyzed using STATA software. Univariate and multivariate methods were used to investigate the association between bacterial vaginosis and adverse pregnancy outcome.

RESULTS

Prevalence of BV was 11.53%. Baseline characteristics were similar for both groups, 6.8% women were lost to follow-up. Incidence of PTB was higher in BV positive women compared to BV negative women (p = 0.001). On multiple logistic regression (MLR), BV was associated with an increased risk of PTB (p = 0.001) and PROM (p = 0.001), other correlates being previous PTB (p = 0.003) and the presence of enteropharyangeal organisms in vagina (p = 0.03). BV accounted for 82.53% of the attributable risk for PTB.

CONCLUSION

Presence of BV in early pregnancy is associated with an increased risk of PTB and PROM. Multicentric interventional study is recommended.

Bacterial vaginosis and contraceptive methods

OBJECTIVES The aim of this study was to investigate if bacterial vaginosis is associated with the use of specific contraceptives.

METHODS

The study population consisted of 1314 women attending for periodical preventive examinations at our gynecology unit at the II Institute of Obstetrics and Gynecology of the University 'La Sapienza' in Rome. The patient's history and any current genital symptom were recorded on a structured protocol. Current users of contraceptives were compared with non-users. The chi(2) test and the t-test were used in the statistical analysis; a stepwise logistic regression analysis was performed to assess the simultaneous effect of more than one variable and to identify for possible confounding factors.

RESULTS

Both oral contraceptive and condom use showed a significant protective effect against bacterial vaginosis. Our results also showed a significant increase of BV among IUD users, either before or after adjustments.

CONCLUSIONS

This study showed a significant negative association between BV and OC and condom use, respectively, and a significant positive association between BV and IUD use. Therefore, we suggest that it is advisable to carry out a systematic microscopic evaluation in order to identify BV for IUD users.

Bacterial vaginosis

Bacterial vaginosis is the most common cause of vaginitis, affecting over 3 million women in the United States annually. Depopulation of lactobacilli from the normal vaginal flora and overgrowth of Gardnerella vaginalis and other anaerobic species are the presumed etiology. To date, no scientific evidence shows that bacterial vaginosis is a sexually transmitted disease. Malodorous vaginal discharge is the most common symptom. Differential diagnoses include trichomoniasis, moniliasis, and allergic or chemical dermatitis. The diagnosis is confirmed when at least three of the following four findings are present (Amsel's criteria): 1) thin, homogenous discharge, 2) pH greater than 4.5, 3) positive amine test, and 4) presence of clue cells. The sensitivity and positive predictive value are both 90%. Vaginal Gram stain is also reliable and allows for permanent record. Cultures are nonspecific because G. vaginalis resides in normal vaginal flora as well. Papanicolaou smears are not particularly sensitive, but their positive predictive value is very high. The Centers for Disease Control and Prevention recommend three treatment regimens in nonpregnant patients: oral metronidazole (500 mg twice daily for 7 days), intravaginal 2% clindamycin cream (one applicatorful at bedtime for 7 days), or intravaginal metronidazole gel (one to two applicatorfuls per day for 5 days). Alternative regimens include a single 2-g oral dose of metronidazole or a 7-day course of oral clindamycin, 300 mg twice daily. The association between bacterial vaginosis and adverse pregnancy outcomes has satisfied many criteria for a causal inference. Treatment of bacterial vaginosis in women with previous history of preterm labor results in fewer preterm deliveries than in untreated women from the same population.

Current concepts on the pathogenesis and markers of preterm births

Preterm births remain a major cause of neonatal morbidity and mortality despite our efforts over the past several decades. Our improved understanding of the complex mechanisms surrounding preterm labor, however, has resulted in the development of numerous biologic and clinical predictors of spontaneous preterm births. These developments offer the exciting prospect for the creation of specific interventions that are directed toward the various pathways involved with preterm births.

A clinical test of women's self-diagnosis of genitourinary infections

Vaginitis and cystitis result in 8 million ambulatory health care visits annually. For military women deployed to austere environments, gynecological problems are more likely to occur yet unlikely to be adequately diagnosed and managed. The Institute of Medicine has recommended that self-care kits be made available to military women under these circumstances. In this clinical comparative study, women's (N = 86) self-diagnoses of vaginitis and cystitis using an investigator-designed, self-diagnostic decision-making guide and kit were compared with clinical diagnoses by advanced practice nurses (APN). The vaginitis guide had a sensitivity of 84% for candida vaginitis (CV) and 91.3% for bacterial vaginosis (BV) and a specificity of 81.5% for CV and 82.8% for BV. The women consistently agreed with the APN's diagnosis of presence or absence of cystitis. These findings suggest that women are capable of making reliable self-diagnostic decisions given appropriate cues. Continued development of a self-diagnosis and treatment kit for military women deployed to austere environments is warranted.

Vaginal douching and preterm birth: an intriguing hypothesis

The rate of preterm birth has risen in recent years and is twice as high among black women as among white women. Neither the underlying causes nor the reasons for the racial disparity are clearly understood. Further, preventable risk factors have not been identified. We hypothesize that vaginal douching plays a key role in the risk of infection-related spontaneous preterm birth. Vaginal douching is a common behavior, twice as prevalent among black women as among white women. Douching may be an important mechanism by which vaginal pathogens gain access to the upper genital tract. Douching increases the risk of acquiring bacterial vaginosis. It may also facilitate the ascent of microorganisms into the upper genital tract, resulting in a chronic bacterial colonization inside the uterus. During pregnancy, the host inflammatory response is initiated, which stimulates preterm labor and birth. Douching, a potentially preventable risk factor, may explain a substantial proportion of the black-white disparity in preterm birth.

Prevalence of bacterial vaginosis and correlation of clinical to Gram stain diagnostic criteria in low risk pregnant women

The present study aimed to evaluate the prevalence of bacterial vaginosis, and the correlation of clinical Amsel criteria with Gram Nugent criteria for the diagnosis of bacterial vaginosis in a low risk population of pregnant women. Pregnant women under 28 weeks of gestation who were followed in the low risk clinics at two centers were evaluated for the presence of bacterial vaginosis using the Amsel clinical criteria, and underwent vaginal samples for Gram staining. Gram smears were examined for the diagnosis of bacterial vaginosis on the basis of Nugent's criteria. A total of 492 women were included in the study. Bacterial vaginosis was diagnosed in 1.6% (8/492) women on the basis of clinical criteria, and in 4.5% (22/492) according to Gram stain. The sensitivity and specificity of Amsel criteria compared with Gram stain were 35% and 99%, respectively. In accordance with other recent reports, the prevalence of bacterial vaginosis appears to be much lower in certain areas than figures previously suggested. In these populations, the correlation of composite clinical criteria defined in groups with high prevalence of bacterial vaginosis appears to be also poor.

The influence of bacterial vaginosis on in-vitro fertilization and embryo implantation during assisted reproduction treatment

There is growing evidence that the pathogenic effects of bacterial vaginosis may not be confined to the lower genital tract. Possible associations with infertility and effects on fertilization and implantation were studied in patients undergoing in-vitro fertilization (IVF) treatment. High vaginal swabs taken at the time of oocyte collection were assessed by Gram staining. The prevalence of bacterial vaginosis and of intermediate and normal flora in 301 patients was 25.6, 14.0 and 60.4% respectively. Bacterial vaginosis was more prevalent in patients with tubal (31.5%, n = 149) compared with non-tubal (19.7%, n = 152) infertility (odds ratio (OR) 1.87, CI 1.11-3.18, P = 0.02). Bacterial vaginosis did not have an adverse effect on fertilization rate. Further, no significant difference in implantation rates was seen when comparing bacterial vaginosis (15. 8%, OR 1.03, CI 0.66-1.61) and intermediate flora (13.1%, OR 0.82, CI 0.45-1.52) with normal flora (15.5%). Though confidence intervals around the observations were relatively wide, the findings suggest that routine screening for bacterial vaginosis in the hope of improving the success of IVF treatment is not justified. The prevention of complications in pregnancy associated with bacterial vaginosis might be a more relevant indication for screening at the time of IVF treatment, in particular patients with tubal disease, if treatment were shown to be effective for that particular purpose. However, antibiotic treatment before IVF has been shown to be positively disadvantageous for IVF by encouraging other organisms.

Sexually transmitted diseases and gynecologic symptoms and signs in women with a history of induced abortion

OBJECTIVE

To investigate associations between a history of induced abortion and current or previous sexually transmitted diseases and other gynecologic infections.

METHODS

A cohort study was performed at two family planning clinics and one youth clinic. Of 996 women, 192 (19.3%) admitted a history of induced abortion, whereas the remaining 804 women served as a control group. A structured, personal interview which included details on previous genital infections and gynecologic symptoms and a gynecologic examination was performed. Genital chlamydial infection, gonorrhea, genital herpes, genital warts, cervical human papillomavirus infection, bacterial vaginosis, candidiasis, and bacteria associated with bacterial vaginosis were diagnosed.

RESULTS

Both a history of genital infections, with the exception of vulvovaginal candidiasis, and current genital symptoms were more common in women with a history of induced abortion, compared with the control group. Age-adjusted odds ratios ranged from 1.5 (history of genital warts, 95% confidence interval (95% CI 0.9-2.5) to 5.0 (history of gonorrhea, 95% CI 2.6-9.7). Odds ratios for current bacterial vaginosis was 1.9 (95% CI 1.2-2.9) and for vulvovaginal candidiasis 1.8 (95% CI 1.1-2.7).

CONCLUSION

Women attending a clinic for an induced abortion could be a target group for sexually transmitted disease information programs.

Bacterial vaginosis: sequelae and management

The prevalence and complications of bacterial vaginosis are population dependent. In pregnancy, bacterial vaginosis is associated with late miscarriages and infection driven pre-term delivery. Regardless of the aetiology of pre-term delivery, surviving infants are at increased risk of subsequent neurodevelopmental handicap. Intervention studies in bacterial vaginosis positive pregnant women at high risk of pre-term delivery demonstrate the benefits of antibiotic treatment. Current evidence suggests that bacterial vaginosis may increase the efficiency of heterosexual HIV transmission. Metronidazole remains the mainstay of treatment of bacterial vaginosis. No treatment prevents relapse, which occurs in 20-30% of cases within 1 month. New approaches that are based on a better understanding of the pathophysiology of bacterial vaginosis are required to improve the clinical management of recurrent bacterial vaginosis.

Acquisition of iron by Gardnerella vaginalis

Six Gardnerella vaginalis strains were examined for the ability to utilize various iron-containing compounds as iron sources. In a plate bioassay, all six strains acquired iron from ferrous chloride, ferric chloride, ferrous sulfate, ferric ammonium citrate, ferrous ammonium sulfate, bovine and equine hemin, bovine catalase, and equine, bovine, rabbit, and human hemoglobin. All six strains also acquired iron from human lactoferrin, but not from human transferrin, as determined by a liquid broth growth assay. Siderophore production was detected in eight G. vaginalis strains by the chrome azurol S universal chemical assay. Sodium dodecyl sulfate-polyacrylamide gel electrophoresis of the cytoplasmic membrane proteins isolated from G. vaginalis 594 grown under iron-replete and iron-restricted conditions revealed several iron-regulated proteins ranging in molecular mass from 33 to 94 kDa. These results indicate that G. vaginalis may acquire iron from iron salts and host iron compounds.

Treatment of bacterial vaginosis with oral or vaginal ornidazole, secnidazole and metronidazole

OBJECTIVE

To evaluate the clinical efficacy and tolerance of oral or vaginal ornidazole, secnidazole and metronidazole or their combinations for treatment of bacterial vaginosis.

METHOD

In an open, randomized, prospective study, 152 patients with bacterial vaginosis according to Amsel's criteria were included into the study. The patients were divided into eight groups: (1) oral ornidazole 2 x 500 mg/day for 5 days; (2) vaginal ornidazole 500 mg/day for 5 days; (3) oral and vaginal ornidazole for 5 days; (4) oral secnidazole 2 g in a single dose; (5) oral secnidazole 2 g in a single dose and vaginal ornidazole 500 mg/day for 5 days; (6) oral secnidazole 2 g in a single dose and vaginal metronidazole 2 x 500 mg/day for 7 days; (7) oral ornidazole 2 x 500 mg/day for 5 days and vaginal metronidazole 2 x 500 mg/day for 7 days; and (8) vaginal metronidazole 2 x 500 mg/day for 7 days. None of the partners received any treatment.

RESULT

We found a 100% cure rate in both oral and vaginal ornidazole and oral secnidazole-vaginal metronidazole groups.

CONCLUSION

Vaginal treatments including ornidazole and metronidazole are not as effective as both oral and vaginal drug combinations.

Sexually transmitted diseases in pregnancy

Sexually transmitted diseases are common complications of pregnancy and may have significant maternal/fetal effects. Knowledge of the symptoms and physical examination features, methods of diagnosis, indications for screening, and appropriate treatment options are essential for obstetric/gynecologic health care providers.

Treatment of vaginal infections: candidiasis, bacterial vaginosis, and trichomoniasis

OBJECTIVE

To describe the signs and symptoms of and recommend treatments for Candida vulvovaginitis, bacterial vaginosis, and Trichomonas vaginitis.

DATA SOURCES

Current clinical literature.

DATA SYNTHESIS

Patients with candidal vulvovaginitis often present with itching, burning, white discharge, vulvar or vaginal erythema, painful intercourse, and stinging on urination. It is treated with oral or topical antifungal agents. Bacterial vaginosis is characterized by a musty or fishy vaginal odor and a thin, white vaginal discharge. It is treated with oral or topical metronidazole or clindamycin. Patients with trichomoniasis usually complain of profuse, yellow-green discharge and vaginal or vulvar irritation. The standard treatment is a single 2 gram dose of oral metronidazole for both the patient and sexual partners.

CONCLUSION

Given the potential adverse effects of the drugs used to treat these conditions, pharmacists are in a unique position to recommend appropriate therapies and to refer patients to other health care providers as needed.

Treatment of male partners and recurrence of bacterial vaginosis: a randomised trial

OBJECTIVE

To test the efficacy of treatment with clindamycin of a partner on the recurrence rate of bacterial vaginosis in women within 3 months from diagnosis.

SUBJECTS

Eligible for the study were sexually active women with one current sexual partner, who were aged 18-45 years, with a clinical diagnosis of bacterial vaginosis and whose partner agreed to be treated.

METHODS

A double blind, randomised, controlled trial was conducted comparing the effect of treating the partner with either clindamycin capsules or placebo on the reduction of the recurrence rate of bacterial vaginosis. Women were treated with clindamycin 2% vaginal cream, administered intravaginally once daily at bedtime for 7 consecutive days. The partners were randomly allocated to clindamycin hydrochloride capsules, 150 g by mouth four times daily for 7 consecutive days, or a placebo. A total of 139 couples were randomised--69 were treated with clindamycin vaginal cream group and 70 with placebo. One, 4, and 12 weeks after the end of treatment the patients and their partners were examined; vaginal discharges were examined to check for clue cells, vaginal pH was determined, and a KOH test carried out.

RESULTS

Overall, 131 women out of the 139 who entered the study were cured (94.2%, lower 95% confidence interval 79.8, based on Poisson's approximation). There was no difference in the cure rate among women whose partner received clindamycin or placebo (chi(2) p = not significant). A total of 55 couples (26 in the clindamycin and 29 in the placebo group) withdrew from the study during the follow up period. Of the 69 women whose partner received clindamycin, 22 (31.9%) reported "recurrence" or persistence. The corresponding number was 21 (30%) of the 70 women whose partner received placebo (chi(2) p = not significant). Of the 84 couples in which the woman was cured by the first week's visit and who completed the study; there were five recurrences (11.6%) among the 43 women whose partner received clindamycin and nine (22.0%) of the 41 whose partner received placebo (chi(2) p = not significant).

CONCLUSION

This study indicates that vaginal clindamycin is effective and safe in the treatment of bacterial vaginosis, but it does not support the suggestion that male treatment markedly reduces the short term recurrence rate.

Evaluation of a fast test to identify the presence of proline aminopeptidase in women with bacterial vaginosis

Objective: The purpose of this study was to evaluate the activity of proline aminopeptidase by a rapid paper strip test in women with bacterial vaginosis (BV).

Methods: Vaginal secretions of 1,387 voluntary patients attending the Obstetrics and Gynecology Infectious Diseases Clinic at Juárez Hospital of Mexico City were collected and examined. Patients were assigned into 2 groups: 483 with BV according to clinical and laboratory criteria and 604 without BV as the control group. For the purposes of this study, 300 patients with trichomonas and/or yeast were excluded from the BV group. The strips were prepared by using L-proline β-naphthylamide and L-proline p-nitroanilide as the substrates to detect proline aminopeptidase activity in concentrated vaginal secretions. In parallel, all samples were also analyzed with the standard methods in microplates containing either sustrate as a control of the rapid strip test. The test was interpreted after 3–5 min of incubation.

Results: The results in the strip and microplate assays were similar in 95% of the samples. Sensitivity was 91.7% and specificity was 94.2%; probability of BV if the test is positive was 92.6% and negative predictive value was 93.4%.

Conclusions: These findings indicate that this aminopeptidase rapid strip assay provides a 3–5 min identification of activity of the enzyme in women with BV. The procedure is a rapid, non-expensive, sensitive, and useful test at the gynecologic clinic.

Bacterial vaginosis and associated infections in pregnancy

OBJECTIVE

To assess the role of bacterial vaginosis (BV) on pregnancy complications in a developing community where mixed cervico-vaginal infections are common.

SETTING

The antenatal clinic at King Edward VIII Hospital (KEH), Durban, South Africa, which is a large urban tertiary hospital serving mainly a Black underprivileged population of KwaZulu/Natal.

METHODS

Asymptomatic pregnant women < or = 30 weeks gestation were recruited at their first antenatal visit. Clinical data including the sexual history were recorded. Swab specimens were collected from the vagina and endocervix for diagnosing BV, trichomoniasis, candidiasis, gonorrhea and chlamydial infection. Venous blood specimens were tested for antibody to syphilis and human immunodeficiency virus (HIV). All women continued standard antenatal care and hospital records were reviewed following delivery to evaluate pregnancy outcome.

RESULTS

BV was found in 52% of the women studied and was the commonest infection diagnosed. Mixed vaginal infections of BV and trichomoniasis were diagnosed in 14%. Only 29% of asymptomatic women did not have any microbiological evidence of a lower genital tract infection. A total of 46% of women studied had poor pregnancy outcome as measured by obstetrical complications, pregnancy loss and/or neonatal morbidity. There was a significant difference in outcome in women with BV (55 of 88) compared to those having infections other than BV (13 of 31), or no infection (5 of 9)-P = 0.005. This difference was for obstetrical complications of preterm delivery, premature rupture of membranes and intrauterine infection, but not for pregnancy losses and neonatal morbidity.

CONCLUSIONS

The high prevalence of BV and concomitant lower genital tract infections among asymptomatic pregnant women and the resultant adverse pregnancy outcome associated with BV, confirms reports from developed countries of the need for screening for BV at the initial antenatal clinic visit. Whether pregnancy outcome was worse in the presence of BV and other infections than BV alone could not be determined. Future studies with appropriate interventions are needed to evaluate the unique problems of developing countries.