Bacterial vaginosis and surgical site infections

Metronidazole and cefazolin vs cefazolin alone for surgical site infection prophylaxis in gynecologic surgery at a comprehensive cancer center

BACKGROUND

Surgical site infection is one of the most common complications of gynecologic cancer surgery. Current guidelines recommend the administration of cefazolin preoperatively to reduce surgical site infection rates for patients undergoing clean-contaminated surgeries such as hysterectomy.

OBJECTIVE

To evaluate the impact of a quality improvement project adding metronidazole to cefazolin for antibiotic prophylaxis on surgical site infection rate for women undergoing gynecologic surgery at a comprehensive cancer center.

STUDY DESIGN

This retrospective, single-center cohort study included patients who underwent surgery in the gynecologic oncology department from May 2017 to June 2023. Patients with penicillin allergies and those undergoing concomitant bowel resections and/or joint cases were excluded. The preintervention group patients had surgery from May 2017 to April 2022, and the postintervention group patients had surgery from April 2022 to June 2023. The primary outcome was a 30-day surgical site infection rate. Sensitivity analyses were performed to compare surgical site infection rates on the basis of actual antibiotics received and for those who had a hysterectomy. Factors independently associated with surgical site infection were identified using a multivariable logistic regression model adjusting for confounding variables.

RESULTS

Of 3343 patients, 2572 (76.9%) and 771 (23.1%) were in the pre-post intervention groups, respectively. Most patients (74.7%) had a hysterectomy performed. Thirty-four percent of cases were for nononcologic (benign) indications. Preintervention patients were more likely to receive appropriate preoperative antibiotics (95.6% vs 90.7%; P<.001). The overall surgical site infection rate before the intervention was 4.7% compared with 2.6% after (P=.010). The surgical site infection rate for all patients who underwent hysterectomy was 4.9% (preintervention) vs 2.8% (postintervention) (P=.036); a similar trend was seen for benign cases (4.4% vs 2.4%; P=.159). On multivariable analysis, the odds ratio for surgical site infection was 0.49 (95% confidence interval, 0.38-0.63) for the postintervention compared with the preintervention group (P<.001). In a sensitivity analysis (n=3087), the surgical site infection rate was 4.5% for those who received cefazolin alone compared with 2.3% for those who received cefazolin plus metronidazole, with significantly decreased odds of surgical site infection for the cefazolin plus metronidazole group (adjusted odds ratio, 0.40 [95% confidence interval, 0.30-0.53]; P<.001). Among only those who had a hysterectomy performed, the odds of surgical site infection were significantly reduced for those in the postintervention group (adjusted odds ratio, 0.63 [95% confidence interval, 0.47-0.86]; P=.003).

CONCLUSION

The addition of metronidazole to cefazolin before gynecologic surgery decreased the surgical site infection rate by half, even after accounting for other known predictors of surgical site infection and differences in practice patterns over time. Providers should consider this combination regimen in women undergoing gynecologic surgery, especially for cases involving hysterectomy.

Screening for Bacterial Vaginosis Prior to Delivery: A Cost-Effectiveness Study

OBJECTIVE

 The objective of this study was to compare the cost and effectiveness of three strategies for screening and/or treating bacterial vaginosis (BV) during pregnancy prior to delivery: (1) the current standard of care was neither test nor treat for BV (Treat None); (2) test all patients for BV at 36 weeks' gestation; treat if positive (Test Treat); and (3) treat all patients undergoing cesarean delivery with intravenous metronidazole at time of surgery (Treat All Cesarean). Effectiveness was defined as avoidance of postpartum surgical site infection (SSI).

STUDY DESIGN

 A decision analytic cost-effectiveness model was designed from a third-party payer perspective using clinical and cost estimates obtained from the literature, American College of Surgeons National Surgical Quality Improvement Program participant use file (2005-2019), 2019 National Vital Statistics, Medicare costs, and wholesale drug costs. Cost estimates were inflated to 2020 U.S. dollars. For this study, effectiveness was defined as avoidance of postpartum SSIs.

RESULTS

 The base case analysis that is the current standard of care of not routinely testing and treating patients for BV (Treat None) was the most expensive and least effective strategy, with a mean cost of $59.16 and infection rate of 3.71%. Empirically treating all patients for BV without testing (Treat All Cesarean) was the most effective and the least expensive strategy, with a mean cost of $53.50 and an infection rate of 2.75%. Testing all patients for BV and treating those positive for BV (Test Treat) was also relatively inexpensive and effective, with an infection rate of 2.94% and mean cost of $57.05. Compared with Treat None, we would expect the Treat All Cesarean strategy to reduce the infection rate by 26%.

CONCLUSION

 These findings suggest that treating pregnant patients with intravenous metronidazole at time of cesarean delivery could be an effective and cost-saving strategy. Testing and treating for BV could also be considered a reasonable strategy, as it has the added benefit of preserving antibiotic stewardship. In no analysis was the standard of care strategy of neither testing nor treating for BV before delivery the preferred strategy.

KEY POINTS

· BV colonization may increase surgical site infection risk after cesarean section.. · Treatment of BV before or during delivery may be cost-saving strategies as treatment could prevent costs associated with infection.. · Further study is needed to best balance the risk of surgical site infection with antibiotic stewardship..

Analysis of surgical site infection and tumour-specific survival rate in patients with renal cell carcinoma after laparoscopic radical nephrectomy

Surgical site infections (SSIs) may pose a significant risk to patients undergoing surgery. This study aims to explore the risk factors for SSIs in patients undergoing laparoscopic radical nephrectomy for renal cell carcinoma and the impact of infection on tumour-specific survival (CSS) after nephrectomy for renal cell carcinoma. To explore the risk factors for SSIs in patients undergoing laparoscopic radical nephrectomy for renal cell carcinoma and the impact of infection on tumour-specific survival (CSS) after nephrectomy for renal cell carcinoma. A retrospective analysis was conducted on 400 patients in our hospital from June 2021 to June 2023. This study divided patients into two groups: those with SSI and those without SSI. Collect general data and information related to the operating room. Clearly defined inclusion and exclusion criteria. Select surgical time, laminar mobile operating room use, and intraoperative hypothermia as observation indicators. Perform statistical analysis using SPSS 25.0 software, including univariate, multivariate, and survival analyses of wound-infected and uninfected patients. Out of 400 patients, 328 had no SSIs, 166 died during follow-up, 72 had SSIs, and 30 died during follow-up. There was no statistically significant difference (p > 0.05) in comparing primary data between individuals without SSIs and those with SSIs. There were statistically significant differences (p < 0.05) in surgical time, nonlaminar flow operating room use, and intraoperative hypothermia. The postoperative survival time of SSI patients with a tumour diameter of 7.0-9.9 cm was significantly longer than that of SSI patients, and the difference was statistically significant (p < 0.05). The occurrence of severe infection in patients with other tumour diameters did not affect postoperative survival, and the difference was not statistically significant (p > 0.05). After multiple factor analysis, it was found that severe infection can prolong the postoperative survival of patients with tumour diameter exceeding 7 cm (HR = 0.749, p < 0.05). This study identified nonlaminar flow operating rooms, prolonged surgical time, and intraoperative hypothermia as significant risk factors for SSIs. After nephrectomy for renal cell carcinoma patients with a tumour diameter of 7-9.9 μ m, perioperative infection can prolong their survival. However, it has no significant effect on patients with other tumour diameters.

Predictive value of preoperative neutrophil to lymphocyte ratio and platelet to lymphocyte ratio combined with operating room factors for surgical site infection after laparoscopic radical nephrectomy in renal cell carcinoma patients

BACKGROUND

Surgical site infections (SSIs) can pose significant risks to patients undergoing surgical procedures. This study aimed to investigate the risk factors and diagnostic value of neutrophil to lymphocyte ratio (NLR) and platelet to lymphocyte ratio (PLR) for SSIs in patients undergoing laparoscopic radical nephrectomy for renal cell carcinoma.

METHODS

A retrospective analysis of 866 patients at our hospital was conducted between June 2016 and June 2022. The study divided patients into two groups: those with SSIs and those without. General data and operative room-related information were collected. Inclusion and exclusion criteria were clearly defined. Peripheral blood indicators were analysed, and observation indicators were meticulously selected, including surgery time, usage of a laminar flow operating room and intraoperative hypothermia. Statistical analysis was performed using SPSS 25.0 software, including univariate, multivariate analysis and receiver operating characteristic (ROC) curve analysis.

RESULTS

Thirty-six out of 866 patients developed SSIs. Statistically significant differences were found for surgery time, usage of non-laminar flow operating rooms and intraoperative hypothermia (p < 0.05). ROC curve analysis showed an AUC of 0.765 (95% CI: 0.636-0.868) for serum NLR and PLR, with optimal cut-off values at NLR 4.8 and PLR 196, indicating moderate to strong discriminative ability for SSIs.

CONCLUSIONS

The study identified non-laminar flow operating rooms, extended surgery time, and intraoperative hypothermia as significant risk factors for SSIs. Serum NLR and PLR were found valuable as biomarkers for SSIs diagnosis, holding potential for preoperative risk assessment and improved patient safety in renal cell carcinoma care.

Resident microbes shape the vaginal epithelial glycan landscape

Epithelial cells are covered in carbohydrates (glycans). This glycan coat or "glycocalyx" interfaces directly with microbes, providing a protective barrier against potential pathogens. Bacterial vaginosis (BV) is a condition associated with adverse health outcomes in which bacteria reside in direct proximity to the vaginal epithelium. Some of these bacteria, including Gardnerella, produce glycosyl hydrolase enzymes. However, glycans of the human vaginal epithelial surface have not been studied in detail. Here, we elucidate key characteristics of the "normal" vaginal epithelial glycan landscape and analyze the impact of resident microbes on the surface glycocalyx. In human BV, glycocalyx staining was visibly diminished in electron micrographs compared to controls. Biochemical and mass spectrometric analysis showed that, compared to normal vaginal epithelial cells, BV cells were depleted of sialylated N- and O-glycans, with underlying galactose residues exposed on the surface. Treatment of primary epithelial cells from BV-negative women with recombinant Gardnerella sialidases generated BV-like glycan phenotypes. Exposure of cultured VK2 vaginal epithelial cells to recombinant Gardnerella sialidase led to desialylation of glycans and induction of pathways regulating cell death, differentiation, and inflammatory responses. These data provide evidence that vaginal epithelial cells exhibit an altered glycan landscape in BV and suggest that BV-associated glycosidic enzymes may lead to changes in epithelial gene transcription that promote cell turnover and regulate responses toward the resident microbiome.

Metronidazole for Prevention of Pelvic Cellulitis and Abscess after Laparoscopic Hysterectomy: A Triple-blinded, Randomized, Placebo-controlled Clinical Trial

STUDY OBJECTIVE

To determine whether a postoperative 5-day treatment schedule with vaginal metronidazole added to conventional antibiotic prophylaxis with 2 g cefazolin modifies the risk of pelvic cellulitis (PC) and pelvic abscess (PA) after total laparoscopic hysterectomy (TLH).

DESIGN

A randomized, controlled, triple-blind, multicenter clinical trial.

SETTING

Two centers dedicated to minimally invasive gynecologic surgery in Colombia.

PATIENTS

A total of 574 patients were taken to TLH because of benign diseases.

INTERVENTION

Patients taken to TLH were divided into 2 groups (treatment group, cefazolin 2 g intravenous single dose before surgery + metronidazole vaginal ovules for 5 days postoperatively, control group: cefazolin 2 g intravenous single dose + placebo vaginal ovules for 5 days postoperatively).

MEASUREMENTS AND MAIN RESULTS

The absolute frequency (AF) of PC and PA and their relationship with the presence of bacterial vaginosis (BV) were measured. There was no difference in AF of PC (AF, 2/285 [0.7%] vs 5/284 [1.7%] in the treatment and placebo groups, respectively; risk ratio, 1.75; 95% confidence interval, 0.54-5.65; p = .261), nor for PA (AF, 0/285 [0%] vs 2/289 [0.7%]; p = .159, in the treatment and placebo groups, respectively). The incidence of BV was higher in the metronidazole group than the placebo group (42.5% vs 33.4%, p = .026).

CONCLUSION

The use of vaginal metronidazole ovules during the first 5 days in postoperative TLH added to conventional cefazolin prophylaxis does not prevent the development of PC or PA, regardless of the patient's diagnosis of BV.

Bacterial vaginosis: a review of approaches to treatment and prevention

Bacterial vaginosis (BV) is a common cause of vaginitis worldwide and is associated with serious reproductive health outcomes, including increased risk of preterm birth, sexually transmitted infections, and pelvic inflammatory disease. The current and only FDA-approved treatment regimens for BV are antibiotics, such as metronidazole and clindamycin. Antibiotics provide a short-term cure for bacterial vaginosis; however, fail to provide a consistent long-term cure for many women. Fifty to eighty percent of women experience a BV recurrence within a year of completing antibiotic treatment. This may be because after antibiotic treatment, beneficial strains of Lactobacillus, such as L. crispatus, do not recolonize the vagina. In the absence of an effective long-term cure, patients, providers, and researchers are exploring different approaches to treatment and prevention, resulting in a rapid evolution of perspectives on BV pathogenesis and approaches to management. Current areas of investigation for BV management include probiotics, vaginal microbiome transplantation, pH modulation, and biofilm disruption. Behavioral modifications that may help include smoking cessation, condom use and hormonal contraception. Additional strategies considered by many people include dietary modification, non-medical vaginally applied products, choice of lubricant, and treatments from medical practices outside of allopathic medicine. This review aims to provide a comprehensive and up to date outline of the landscape of ongoing and potential treatment and prevention strategies for BV.

Bacterial Vaginosis and Post-Operative Pelvic Infections

Bacterial vaginosis (BV) represents a condition in which the normal protective Lactobacilli, especially those that produce H₂O₂, are replaced by high quantities of facultative anaerobes, leading to gynecologic and obstetric post-operative complications. BV is an important cause of obstetric and gynecological adverse sequelae and it could lead to an increased risk of contracting sexually transmitted infections such as gonorrhea, genital herpes, Chlamydia, Trichomonas, and human immunodeficiency virus. Herein, we reviewed bacterial vaginosis and its association with post-operative pelvic infections. In Obstetrics, BV has been associated with increased risk of preterm delivery, first-trimester miscarriage in women undergoing in vitro fertilization, preterm premature rupture of membranes, chorioamnionitis, amniotic fluid infections, postpartum and postabortal endomyometritis as well as postabortal pelvic inflammatory disease (PID). In gynecology, BV increases the risk of post-hysterectomy infections such as vaginal cuff cellulitis, pelvic cellulitis, pelvic abscess, and PID. BV is often asymptomatic, can resolve spontaneously, and often relapses with or without treatment. The American College of Obstetricians and Gynecologists recommends testing for BV in women having an increased risk for preterm delivery. Women with symptoms should be evaluated and treated. Women with BV undergoing gynecological surgeries must be treated to reduce the frequency of post-operative pelvic infections. Metronidazole and clindamycin are the mainstays of therapy. Currently, there is no consensus on pre-surgery screening for BV; decisions are made on a case-by-case basis.

Preventive effect of metronidazole vaginal tablets on vaginal bacteria-related postoperative complications with total laparoscopic hysterectomy

BACKGROUND

The use of total laparoscopic hysterectomy is increasing. However, as with conventional abdominal hysterectomy, vaginal bacteria-related postoperative complications need to be managed in total laparoscopic hysterectomy. Therefore, we started to combine metronidazole vaginal tablets with intravenous administration of cephem antibiotics immediately before starting surgery to reduce complications. To evaluate the effect of this combination, and to determine the risk factors for these complications, we retrospectively collected medical records from our hospital and performed a multivariate analysis.

METHODS

We reviewed the medical records of 520 patients who underwent total laparoscopic hysterectomy from 1 January 2015 to 31 December 2021. Among these cases, we identified 16 cases as having vaginal bacteria-related postoperative complications, defined as needing more than one additional day for treatment of postoperative complications, namely postoperative infection (10 cases) and vaginal dehiscence (6 cases). First, we evaluate the effect of metronidazole vaginal tablets by dividing the patients into two groups according to whether metronidazole vaginal tablets were used, and comparing the vaginal bacteria-related postoperative complication rates and other indices. Second, we performed a multivariate logistic regression analysis to assess the influence of each of 17 representative factors, including patient characteristics and symptoms, uterus and leiomyoma sizes, concomitant procedures such as laparoscopic cystectomy and pelvic lymphadenectomy, and others.

RESULTS

In the multivariate analysis of the 520 cases, we confirmed that the use of metronidazole vaginal tablets could reduce the vaginal bacteria-related postoperative complications rate by more than half (odds ratio, 0.36). In addition to metronidazole vaginal tablets use, concomitant laparoscopic cystectomy and blood transfusion were associated with significant increases in the vaginal bacteria-related postoperative complication rate.

CONCLUSIONS

The effect of the addition of metronidazole vaginal tablets to pre- and postsurgical treatment on the reduction of vaginal bacteria-related postoperative complications was confirmed. This easy, safe, and low-cost method may improve the management of total laparoscopic hysterectomy.

Prophylaxis Effect of Metronidazole Vaginal Gel in Decreasing the Risk of Surgical Site Infections after Elective Hysterectomy

Objective

Infections are an important cause of morbidity and mortality after hysterectomy. Here, we aimed to investigate and evaluate the beneficial effects of metronidazole vaginal gel on the rate of surgical site infections in women undergoing elective abdominal hysterectomy.

Methods

This is a randomized prospective, double-blind controlled clinical trial performed in 2020 in Isfahan on 108 candidates for elective hysterectomy. At the beginning of the study, we completed a checklist of the patient's characteristics (patient age, body mass index [BMI], and history of medical conditions such as diabetes, hypertension, anemia, and immune deficiency) and the cause of hysterectomy. All patients were randomized into two groups. The first group received a lubricant vaginal gel single dosage, and the second group received a 0.75% metronidazole vaginal gel single dosage the night before surgery. Patients were visited up to 6 weeks after surgery, and the frequency of infection at the surgical site was determined.

Findings

The rates of infection were lower in patients who received metronidazole vaginal gel (5.8%) compared to the control group (11.6%) (P = 0.03). Patients with an estimated blood loss volume of more than 500 mL had higher rates of infection (13.46%) compared to patients with a bleeding volume of fewer than 500 mL (1.9%) (P = 0.001). We also found that patients with diabetes (13.5%) and patients with BMI more than 30 kg/m2(13.5%) had higher rates of infection compared to patients without diabetes (5.8%) and patients with BMI <30 kg/m2 (11.5%) (P = 0.001 for both). Patients with higher hospitalization duration had higher infection rates (P = 0.009).

Conclusion

Administration of a single dosage of metronidazole vaginal gel before abdominal hysterectomy may reduce surgical site infection and have clinical values.

Anaerococcus ihuae sp. nov. and Mediannikoviicoccus vaginalis gen. nov., sp. nov., two new bacteria isolated from human vaginal samples

Strains Marseille-Q5893 (= CSUR Q5893 = CECT 30496) and Marseille-Q5883 (= CSUR Q5883 = CECT 30497) were isolated from vaginal samples using the culturomics approach. The 16S rRNA gene sequences of each strain were sequenced and then compared by BLASTn to the NCBI database. Strains Marseille-Q5893 and Marseille-Q5883 were most closely related to Anaerococcus obesiensis and Finegoldia magna, with identities of 98.5% and 90.0%, respectively. Strain Marseille-Q5893 is strictly anaerobic, while strain Marseille-Q5883 is facultative anaerobic. Both strains are Gram-positive, coccus-shaped, oxidase- and catalase-negative. The most abundant fatty acid for both strains is hexadecanoic acid, followed by 9-octadecenoic acid and tetradecanoic acid. Strain Marseille-Q5893 has a genome size of 1,831,271 bp with a G+C content of 29.4 mol%, whereas strain Marseille-Q5883 has a genome of 1,997,945 bp with a 33.6 mol% G+C content. The genomic comparison of closely related species with strains Marseille-Q5893 and Marseille-Q5883 showed that all digital DNA–DNA hybridization (dDDH) and orthologous average nucleotide identity (OrthoANI) values were lower than the published species thresholds (70% and 95–96%, respectively). Based on these data, we conclude that strain Marseille-Q5893 belongs to a new species in the family Peptoniphilaceae and strain Marseille-Q5883 belongs to a new genus in the family Peptostreptococcaceae. For these two new bacterial species, the names Anaerococcus ihuae sp. nov. and Mediannikoviicoccus vaginalis gen. nov., sp. nov., were proposed.

The Chitosan-Based System with Scutellariae baicalensis radix Extract for the Local Treatment of Vaginal Infections

Scutellarie baicalensis radix, as a flavone-rich source, exhibits antibacterial, antifungal, antioxidant, and anti-inflammatory activity. It may be used as a therapeutic agent to treat various diseases, including vaginal infections. In this study, six binary mixtures of chitosan with stable S. baicalensis radix lyophilized extract were obtained and identified by spectral (ATR-FTIR, XRPD) and thermal (TG and DSC) methods. The changes in dissolution rates of active compounds and the significant increase in the biological properties towards metal chelating activity were observed, as well as the inhibition of hyaluronic acid degradation after mixing plant extract with chitosan. Moreover, the combination of S. baicalensis radix lyophilized extract with a carrier allowed us to obtain the binary systems with a higher antifungal activity than the pure extract, which may be effective in developing new strategies in the vaginal infections treatment, particularly vulvovaginal candidiasis.

Surgical site infections in gynecology: the latest evidence for prevention and management

PURPOSE OF REVIEW

Surgical site infection (SSI) remains one of the most common postoperative surgical complications. Prevention and appropriate treatment remain paramount.

RECENT FINDINGS

Evidence-based recommendations include recognition and reduction of preoperative risks including hyperglycemia and smoking, treatment of preexisting infections, skin preparation with chlorhexidine gluconate, proper use of preoperative antibiotics, and implementation of prevention bundles. Consideration should be given to the use of dual antibiotic preoperative treatment with cephazolin and metronidazole for all hysterectomies.

SUMMARY

Despite advancements, SSI in gynecologic surgery remains a major cause of perioperative morbidity and healthcare cost. Modifiable risk factors should be evaluated and patients optimized to the best extent possible prior to surgery. Preoperative risks include obesity, hyperglycemia, smoking, and untreated preexisting infections. Intraoperative risk-reducing strategies include appropriate perioperative antibiotics, correct topical preparation, maintaining normothermia, and minimizing blood loss. Additionally, early recognition and prompt treatment of SSI remain crucial.

Pathogenic Spectrum and Resistance Pattern of Bloodstream Infections Isolated from Postpartum Women: A Multicenter Retrospective Study

PURPOSE

Bloodstream infections (BSIs) cause morbidity and mortality in postpartum patients, resulting in poor prognosis for both mother and neonate. Gram-negative bacteremia is a public health threat, with high mortality among vulnerable populations and significant global economic costs. Gram-negative bacteremia and antimicrobial resistance are increasing. This study retrospectively analyzed the pathogen distribution and drug sensitivity among postpartum patients with BSIs to identify appropriate antibacterial agents for perioperative therapy.

MATERIAL AND METHODS

All bacteremia cases between January 2015 and December 2020 from three Health Centers for Women and Children in Chongqing, China, were retrospectively reviewed. Clinical data were collected from medical records and charts. Blood samples were cultured by BD BACTEC FX200. Bacterial and fungal species and bacterial susceptibility were identified by a BD PhoenixTM M50 automatic detection machine.

RESULTS

In total, 274 pathogenic strains were isolated from 272 blood samples. Excluding 25 suspected contamination strains, 248 blood samples yielded 249 microorganisms, including 214 gram-negative bacteria (85.9%), 34 gram-positive bacteria (13.6%), and 1 fungus (0.5%). Escherichia coli (E. coli) was the most frequently isolated pathogen, both overall and among gram-negative bacilli (73.5%). Streptococcus agalactiae represented 3.6% of gram-positive cocci (n = 9). Laboratory-confirmed anaerobic infections comprised 9.2% of cases (n = 23). Additionally, 47.4% of postpartum patients with BSIs suffered premature rupture of membranes (PROM), a suspected infection risk factor. Drug sensitivity levels remained unchanged for less commonly used drugs, but resistance increased against commonly used drugs. Specifically, E. coli resistance against fourth-generation cephalosporins increased during this study period.

CONCLUSION

E. coli is the most common gram-negative bacillus in postpartum patients with BSIs, and increased anaerobic bacterial detections suggest genital tract inflammation control before delivery is necessary. Effective drug resistance monitoring remains necessary to alleviate bacterial resistance, such as preventing inappropriate antibiotic applications.

Clinical comparative study of optimized metronidazole loaded lipid nanocarrier vaginal emulgel for management of bacterial vaginosis and its recurrence

The main focus of the current work was to design, evaluate and clinically compare the efficiency of novel metronidazole (MTD) loaded solid lipid nanoparticles (SLNs) vaginal emulgel with the marketed vaginal gel (Metron^®) against Bacterial vaginosis (BV). Eight formulations were fabricated using 2³ full factorial design and prepared by stearic acid and tween 80 as solid lipid and surfactant, respectively. Lipid and surfactant concentrations in addition to sonication amplitude were chosen as the independent variables (X₁–X₃). Then, the prepared MTD loaded SLNs were evaluated based on the dependent variables which were particle size, polydispersity index, zeta potential, entrapment efficiency, and cumulative % drug release for 24 h (Y₁–Y₅). The in vitro release study exhibited a sustained release of MTD from the SLNs up to 24 h. The optimal MTD loaded SLNs showed nanosized particles (256 nm) with EE% (52%), and an acceptable ZP value (−29.5 mV). Also, the optimized MTD-SLNs formulation was incorporated into Carbopol emulgel and investigated clinically for its effect against BV. Clinical studies recorded significant enhancement in therapeutic response of MTD from optimized SLNs vaginal emulgel formulation regarding the clinical treatment (p < .05) and low recurrence rate (p < .001) against the marketed product. In conclusion, our findings recommend that the fabricated MTD loaded SLNs vaginal emulgel have significant therapeutic effect in terms of BV management over commercially obtainable marketed vaginal gel (Metron^®).

Clinical research on traditional Chinese medicine treatment for bacterial vaginosis

Bacterial vaginosis (BV) is a common disease among women of reproductive age, with a serious impact on their daily life and health. At present, the most common treatment for BV is to take antibiotics, which results in good short-term treatment effects, but poor long-term effects. Traditional Chinese medicine (TCM) has been used to treat BV for over a millennium, with little risk of triggering drug resistance and adverse effects. Based on syndrome differentiation, there are three oral TCM treatment strategies for BV, including invigorating spleen, clearing dampness and heat, and nourishing kidney. The oral TCM prescriptions, such as Yi Huang decoction, Longdan Xiegan decoction, Zhibai Dihaung decoction, and so on are commonly used. Topical TCM treatment is also popular in China. According to the research results of pharmacological effects of active TCM ingredients, the most potential mechanisms of TCM for BV treatment are immune-enhancement effects, antibacterial activity, and estrogen-liked effects. Nonetheless, the multi-constituent of herbs may result in possible disadvantages to BV treatment, and the pharmacological mechanisms of TCM need further study. Here, we provide an overview of TCM compounds and their preparations used for BV, based on the pathogenesis and the potential therapeutic mechanisms, therefore providing a reference for further studies.

Asymptomatic Bacterial Vaginosis: To Treat or Not to Treat?

Purpose of Review

The purpose of this review is to summarize current evidence for and against the treatment of asymptomatic bacterial vaginosis (BV) in women.

Recent Findings

Asymptomatic BV is common although its pathogenesis remains incompletely understood. In favor of treating asymptomatic BV is the large body of data supporting that it is sexually transmitted. Along these lines and similar to other STIs, treatment of BV, regardless of symptom status, should be considered to reduce adverse outcomes of infection (i.e. adverse birth outcomes, infertility, post-gynecologic surgery infections, etc.) and prevent further sexual transmission of BV pathogen(s) to sexual partners. One study has found that treatment of women with asymptomatic BV led to a significant reduction in incident chlamydial infections over a 6 month follow-up period, compared to observation-only women. Additionally, some women with asymptomatic BV actually have symptomatic BV but do not recognize these symptoms as an infection. Nevertheless, limitations of the trial regarding treatment of asymptomatic BV as well as the 2020 United States Preventative Task Force recommendation against screening and treatment of asymptomatic BV in pregnant women dampen enthusiasm for recommending treatment in this setting.

Summary

Treatment of asymptomatic BV remains controversial. Additional studies are needed to further investigate the pathogenesis of BV, which will directly influence advances in its diagnosis, treatment, and prevention.

Vaginal microbiota and the potential of Lactobacillus derivatives in maintaining vaginal health

Human vagina is colonised by a diverse array of microorganisms that make up the normal microbiota and mycobiota. Lactobacillus is the most frequently isolated microorganism from the healthy human vagina, this includes Lactobacillus crispatus, Lactobacillus gasseri, Lactobacillus iners, and Lactobacillus jensenii. These vaginal lactobacilli have been touted to prevent invasion of pathogens by keeping their population in check. However, the disruption of vaginal ecosystem contributes to the overgrowth of pathogens which causes complicated vaginal infections such as bacterial vaginosis (BV), sexually transmitted infections (STIs), and vulvovaginal candidiasis (VVC). Predisposing factors such as menses, pregnancy, sexual practice, uncontrolled usage of antibiotics, and vaginal douching can alter the microbial community. Therefore, the composition of vaginal microbiota serves an important role in determining vagina health. Owing to their Generally Recognised as Safe (GRAS) status, lactobacilli have been widely utilised as one of the alternatives besides conventional antimicrobial treatment against vaginal pathogens for the prevention of chronic vaginitis and the restoration of vaginal ecosystem. In addition, the effectiveness of Lactobacillus as prophylaxis has also been well-founded in long-term administration. This review aimed to highlight the beneficial effects of lactobacilli derivatives (i.e. surface-active molecules) with anti-biofilm, antioxidant, pathogen-inhibition, and immunomodulation activities in developing remedies for vaginal infections. We also discuss the current challenges in the implementation of the use of lactobacilli derivatives in promotion of human health. In the current review, we intend to provide insights for the development of lactobacilli derivatives as a complementary or alternative medicine to conventional probiotic therapy in vaginal health.

Comparative analysis of Bacterial Vaginosis microbiota among pregnant and non-pregnant females and isolation of phages against Enterococcus faecalis, Enterococcus faecium, and Shigella flexneri strains

BACKGROUND AND OBJECTIVES

Bacterial vaginosis (BV) is the most common vaginal infection in women of reproductive age. It shifts the paradigms of the vagina from healthy, beneficial microbiota to facultative and strict anaerobes. BV remains one of the most arduous and controversial challenges in modern-day clinical microbiology because of its high prevalence and relapse rates. A lot of research has been carried out on it. Still, its etiology is unknown, which gave this infection global importance. The current study was designed to investigate and compare the microbiota of pregnant and non-pregnant females suffering from BV, and phages were isolated against BV microbiota.

MATERIAL AND METHODS

The samples were collected from the vagina by using a speculum, and swabs were streaked on different media to isolate bacteria. The microbiological analysis was performed by microscopy, biochemical testing, and antibiotic susceptibility was determined by using Metronidazole and Clindamycin. Furthermore, the phages were isolated and characterized against BV strains.

RESULTS AND CONCLUSION

The Gram staining showed high prevalence of Staphylococcus (36% vs. 33%), followed by Streptococcus (31% vs. 14%) and Enterococcus (7% vs. 14%) in non-pregnant and pregnant females' respectively. However, the exception was observed in non-pregnant BV positive females, who had Shigella flexneri in their samples. The antibiotic sensitivity showed Metronidazole was resistant against all BV microbiota, and Clindamycin showed susceptibility against 3 strains. Phages were isolated against three bacterial strains, i.e. E. faecalis, E. faecium, and S. flexneri. Bacterial reduction assay showed bacterial growth decreases in the presence of phage suspension, pH stability showed phages' maximum lytic activity at pH 7 for E. faecalis and E. faecium and pH 9 for S. flexneri. However, the thermal stability showed phages' highest lytic activity at 55 °C for E. faecalis, 70 °C for E. faecium, and 40 °C for S. flexneri. Phage genome isolation showed that all phages nucleic acid was DNA in nature and between 15 and 20kbp. SEM analysis showed they were circular in shape and might belong to the Podoviridae family. This study provides an understanding of pathogens involved in BV and helps the doctors to treat the patients accordingly. Furthermore, this study showed that Bacterial Vaginosis and BV secondary bacteria have associations. BV secondary microbiota is also involved in the pathogenesis of this infection, whereas bacteriophage therapy has the potential to be used as an alternative treatment to antibiotics.

Dual antibiotic prevention bundle is associated with decreased surgical site infections

BACKGROUND

Gynecologic oncology surgery is associated with a wide variation in surgical site infection risk. The optimal method for infection prevention in this heterogeneous population remains uncertain.

STUDY DESIGN

A retrospective cohort study was performed to compare surgical site infection rates for patients undergoing hysterectomy over a 1-year period surrounding the implementation of an institutional infection prevention bundle. The bundle comprised pre-operative, intra-operative, and post-operative interventions including a dual-agent antibiotic surgical prophylaxis with cefazolin and metronidazole. Cohorts consisted of patients undergoing surgery during the 6 months prior to this intervention (pre-bundle) versus those undergoing surgery during the 6 months following the intervention (post-bundle). Secondary outcomes included length of stay, readmission rates, compliance measures, and infection microbiology. Data were compared with pre-specified one-sided exact test, Chi-square test, Fisher's exact test, or Kruskal-Wallis test as appropriate.

RESULTS

A total of 358 patients were included (178 PRE, 180 POST). Median age was 58 (range 23-90) years. The post-bundle cohort had a 58% reduction in surgical site infection rate, 3.3% POST vs 7.9% PRE (-4.5%, 95% CI -9.3% to -0.2%, p=0.049) as well as reductions in organ space infection, 0.6% POST vs 4.5% PRE (-3.9%, 95% CI -7.2% to -0.7%, p=0.019), and readmission rates, 2.2% POST vs 6.7% PRE (-4.5%, 95% CI -8.7% to -0.2%, p=0.04). Gram-positive, Gram-negative, and anaerobic bacteria were all prevalent in surgical site infection cultures. There were no monomicrobial infections in post-cohort cultures (0% POST vs 58% PRE, p=0.04). No infections contained methicillin-resistant Staphylococcus aureus.

CONCLUSION

Implementation of a dual antibiotic infection prevention bundle was associated with a 58% reduction in surgical site infection rate after hysterectomy in a surgically diverse gynecologic oncology practice.